Ridgeview Healthcare & Rehab Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of clinical records, 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 demonstrated the knowledge, skills, and documented competencies necessary to safely care for a resident with a central tunneled line catheter for one out of 26 residents reviewed (Resident 7). 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 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. A clinical record review revealed Resident 7 was admitted to the facility on [DATE], with diagnoses that included heart failure (a condition that develops when the heart doesn't pump enough blood to meet the body'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 observations, review of clinical records, select facility policies, and staff and resident interviews, it was determined the facility failed to ensure the resident environment was free from potential accident hazards related to unsecured medications on two out of two nursing units reviewed (Units 2 and 3) and for three out of eight residents sampled (Residents 1, 5, and 13). Findings include: A review of the facility policy titled Administering Medications, last reviewed July 28, 2025, revealed it is the facility's policy that medications are administered in a safe and timely manner and only as prescribed.A review of the facility policy titled Self-Administration of Medications, last reviewed July 28, 2025, revealed it is the facility's policy that medications permitted for self-administration are stored in a safe and secure manner and are not accessible to other residents. The policy further states that if safe storage is not possible in the resident's room, medications are to be stored on a central…

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 the facility failed to provide care in a manner that promotes each resident's quality of life by failing to respond timely to residents' requests for assistance, including experiences reported by three residents out of 19 residents sampled (Residents 5, 68, and 80) and one resident representative (Resident 11).Findings include: A clinical record review revealed Resident 68 was admitted to the facility on [DATE], with diagnoses that include peripheral vascular disease (a condition in which narrowed arteries reduce blood flow to the arms or legs). A review of a quarterly Minimum Data Set assessment (MDS-a federally mandated standardized assessment process conducted periodically to plan resident care) dated September 11, 2025, revealed that Resident 68 was cognitively intact with a BIMS score of 13 (Brief Interview for Mental Status-a tool within the Cognitive Section of the MDS that is used to assess the resident's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of clinical records, facility policy, and resident representative and staff interviews, it was determined that the facility failed to timely notify the resident's representative of a hospitalization after a fall for one resident out of 19 sampled (Resident 11).Findings include:A review of the facility policy titled Change in a Resident's Condition or Status, last reviewed by the facility on July 28, 2025, revealed the facility shall promptly notify the resident, his or her attending physician, and representative of changes in the resident's medical or mental condition or status. The policy indicates the nurse will notify the resident's representative when the resident is involved in any accident or incident that results in an injury or when it is necessary to transfer the resident to a hospital or treatment center.A clinical record review revealed Resident 11 was admitted to the facility on [DATE], with diagnoses that include cerebral infarction (brain damage that results from a lack of blood)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of clinical records, select facility policy review, and staff interview it was determined that the facility failed to ensure that one resident (Resident 53) of an 18 resident sample was free of chemical restraints that were not necessary to treat the resident's medical symptoms, were without justification, and did not demonstrate individualized, nonpharmacological approaches to careFindings include:A review of the facility policy, Identifying Involuntary Seclusion and Unauthorized Restraint, last reviewed on April 15, 2025, defines a chemical restraint as any drug used for discipline or staff convenience, and not required to treat medical symptoms. The policy further indicated residents must be free from chemical restraints not used to address medical conditions. According to the facility policy, psychotropic medications (drugs that affect one ' s mental state) will not be administered without documented indication for use and without evaluating for potential underlying causes for distressed…

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 19 sampled (Resident 5).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 5 was admitted to the facility on [DATE]. A review of a quarterly Minimum Data Set assessment…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, facility policy review, observation, and staff and resident interviews, it was determined the facility failed to incorporate and address an identified resident preference and behavior into the care planning process for one of 19 sampled residents (Resident 1).Findings include:The clinical record review indicated Resident 1 was admitted to the facility on [DATE], with a diagnosis of Anoxic Brain Damage (a condition that occurs when oxygen flow to the brain is cut off or severely reduced, causing brain cell injury and impaired neurological function).The clinical record also revealed Brief Interview for Mental Status assessment (BIMS, a tool to assess the residents attention, orientation and ability to register and recall new information) dated August 13, 2025, with a score of 12, indicating moderate cognitive impairment (moderate impairment means the resident has some loss of memory, reasoning, or judgment but retains partial decision-making ability and may need staff assistance 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, select facility policy, observation, and staff and resident interviews, it was determined the facility failed to ensure oxygen therapy was administered per physician's orders for one resident out of 19 sampled (Resident 70).Findings include: A review of the facility ' s policy titled Oxygen Administration, last reviewed on July 28, 2025, revealed that the purpose of the policy was to provide guidelines for safe oxygen administration. The policy directed staff to check the oxygen delivery system, including the mask, oxygen tank, and humidifier bottle (also known as humidifier reservoir, the container that holds sterile or distilled water through which oxygen passes to add moisture before being delivered to the resident) to ensure they were in good working order and securely fastened. The policy further required staff to verify that there was an adequate water level in the humidifier bottle so that the water bubbled as oxygen flowed through, and to periodically re-check 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 observation, review of facility policy, and staff interviews, it was determined that the facility failed to ensure biologicals were stored within their manufacturer ' s expiration date in one of two medication storage areas (third-floor nursing unit).Findings include:A review of the facility ' s policy titled Storage of Medications, last reviewed on [DATE], revealed that drugs and biologicals (defined as substances derived from living organisms and used in medical treatment, such as vaccines, nutritional formulas, and immunotherapies) are to be stored safely, securely, and in an orderly manner. The policy further indicated that discontinued, outdated, or deteriorated drugs or biologicals are to be returned to the dispensing pharmacy or destroyed.An observation conducted on [DATE], at 1:10 PM, in the presence of Employee 2 (Licensed Practical Nurse), revealed fourteen individual cartons of Glucerna CarbSteady 1.2 Cal (medically prescribed therapeutic nutritional biological formula designed for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of select facility policies, the facility diet manual, clinical records, and staff interviews, it was determined that the facility failed to assess, evaluate, and monitor the nutritional parameters of residents with significant weight loss for two of 18 residents reviewed (Residents 27 and 69). Findings include: Review of a facility policy titled Weight Monitoring Standards, last reviewed by the facility in October 2024, revealed if the monthly weight shows more than a 5% gain or loss, the resident is re-weighed within 24 hours. If there is an actual 5% or more gain or loss in one month, the resident, family, physician, and the Dining Services Director are notified by the Nursing Department. Documentation of the date notified should be documented in the nursing progress section of the medical record. The Dining Services Director/designee reviews the resident's nutritional status and makes recommendations for intervention in the nutrition progress notes if a significant change is noted. Review…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, a review of clinical records, the Resident Assessment Instrument, and staff interviews, it was determined the facility failed to ensure the Minimum Data Set Assessments accurately reflected the status of two residents out of 18 sampled (Residents 9 and 31). 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 9 was admitted to the facility on [DATE]. A review of a quarterly Minimum…

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, a review of clinical records and staff interview, it was determined the facility failed to develop and implement a comprehensive person-centered care plan that included specific and individualized interventions to address dental needs for one out of 18 residents sampled (Resident 31). Findings include: A clinical record review revealed Resident 31 was admitted to the facility on [DATE], with diagnoses that included Parkinson's disease (disorder of the central nervous system that affects movement, often including tremors) and dementia (condition characterized by the loss of cognitive functioning such as thinking, remembering, and reasoning, to such an extent that it interferes with a person's daily life and activities). Observation on May 20, 2025, at 11:50 AM revealed that Resident 31 was edentulous (lacking teeth). Further review of the clinical record revealed a Dental Consult dated December 23, 2024, which indicated the resident had seven teeth extracted. A Dental Consult dated April 1,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of clinical records, observation, and staff interviews, it was determined the facility failed to provide nursing services consistent with professional standards of practice by not ensuring the consistent application of physician-ordered preventative measures for safety for one of 18 residents sampled (Resident 39). Findings include: A review of the clinical record revealed Resident 39 was admitted to the facility on [DATE], with diagnoses to include dementia (a chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning) and Parkinson's disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination). A review of a quarterly Minimum Data Set assessment (MDS-a federally mandated standardized assessment process conducted periodically to plan resident care) dated February 26, 2025, revealed that Resident 39…

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 the facility's accounts payable ledger and staff interviews, it was determined the facility failed to comply with Federal, State, and Local laws and professional standards by not ensuring timely payment for goods and services necessary for daily operations. Findings include: The 28 PA Code Commonwealth of Pennsylvania Long Term Care Licensure Regulations, subsection 201.14(g), dated July 1, 2023, revealed a facility owner shall pay in a timely manner bills incurred in the operation of a facility that are not in dispute and that are for services without which the resident's health and safety are jeopardized. A review of the current outstanding accounts payable ledger revealed outstanding balances as of January 1, 2025, exceeding 121 days past due, including but not limited to: Allstate Pest Management: $3,438.64 American Express Shenandoah: $359,551.27 Aplus Staffing LLC (nurse staffing agency): $558,269.78 [NAME] foods: $63,349.93 [NAME] of Shenandoah-Sewer: $2577.32 CMS: $157,209.00 Eshyft (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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, observation, and interview it was determined, the facility failed to implement effective infection prevention and control practices regarding activities of daily living (ADLs), including toileting, bathing, and bed maintenance, for one of 20 sampled residents (Resident 34). Findings include: Clinical record review revealed that Resident 34 was admitted to the facility on [DATE] with diagnosis to include, morbid obesity, acute and chronic respiratory failure, Chronic obstructive pulmonary disease ( COPD type of obstructive lung disease characterized by long-term poor airflow. The main symptoms include shortness of breath and cough with sputum production.), diabetes, heart disease and anxiety. A quarterly Minimum Data Set assessment (MDS - a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated February 19, 2025, revealed a BIMS score of 15 (brief interview for mental status, a tool to assess the residents attention, orientation and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, a review of clinical records, and select facility policy and staff interview, it was determined the facility failed to ensure the self-administration of medications was clinically appropriate for one of the 20 residents sampled (Resident 63). Findings include: A review of facility policy titled Self-Administration of Medications, last reviewed by the facility in October 2024, revealed residents have the right to self-administer medications if the interdisciplinary team has determined it is clinically appropriate and safe for the resident. If it is deemed safe and appropriate for a resident to self-administer medications, this is documented in the medical record and care plan. A clinical record review revealed Resident 63 was admitted to the hospital on [DATE], with diagnoses that included chronic obstructive pulmonary disease (COPD is a condition caused by damage to the airways or other parts of the lung that blocks airflow and makes it hard to breathe) and dementia (a condition…

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 and staff interviews, it was determined the facility failed to provide adequate housekeeping services to maintain a clean, sanitary, and homelike environment in one of the two nursing halls (second-floor nursing unit). Findings Include: An observation conducted on March 13, 2025, at approximately 9:00 AM, in room [ROOM NUMBER] revealed Resident 34 sitting in urine and feces-soaked linens that had leaked onto the floor. The floor beneath the bed and surrounding area was visibly soiled with brown and yellow liquid, emitting a foul, overpowering odor. The unsanitary conditions were immediately apparent from the hallway, creating an environment that was both demeaning and hazardous to the resident's dignity and well-being. A second observation on March 13, 2025, at approximately 1:30 PM, conducted with Employee 4, Registered Nurse, confirmed the yellow liquid remained present beneath the bed and in the surrounding area, still emitting a strong foul odor, indicating that no corrective action had…

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, observation, and resident and staff interviews, it was determined the facility failed to provide nursing services consistent with professional standards of practice by failing to thoroughly assess, obtain physician orders, and develop and implement a person-centered comprehensive care plan in accordance with standards of practice for one resident out of 20 sampled residents. (Resident 34) 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's EHR (electronic health 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…

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 clinical records, select facility investigative reports, and resident and staff interviews, it was determined the facility failed to implement effective safety measures and sufficient staff supervision to prevent falls for one out of 20 sampled residents (Resident 35) and maintain a safe environment for three out of 20 sampled residents (Residents 52, 55, and 56). Findings include: A clinical record review revealed Resident 35 was admitted to the facility on [DATE], with diagnoses that included dementia (a condition characterized by the loss of cognitive functioning such as thinking, remembering, and reasoning, to such an extent that it interferes with a person's daily life and activities) and chronic kidney disease (gradual loss of kidney function). A review of a quarterly Minimum Data Set assessment (MDS-a federally mandated standardized assessment process conducted periodically to plan resident care) dated February 3, 2025, revealed that Resident 35 was severely cognitively…

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

Based on staff interview and a review of employee credentials, it was determined the facility failed to employ a full-time qualified director of food and nutrition services and failed to ensure the registered dietitian (RD) provided the required on-site oversight of the food and nutrition services department. Findings include: An interview with the facility's Nursing Home Administrator (NHA) on March 13, 2025, at approximately 3:00 PM, revealed Employee 1 was appointed as the dietary supervisor on October 28, 2024. However, Employee 1 did not possess the regulatory qualifications for the role, as she was not a Certified Dietary Manager (CDM) and had not yet completed the required CDM program. Additionally, the NHA was unable to provide a definitive timeline for Employee 1's program completion or when she would obtain certification. The NHA further confirmed the full-time registered dietitian (RD) resigned on January 23, 2025. The NHA stated that since that time, the facility had not employed an in-house RD and instead relied on a corporate dietitian who provided services exclusively…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and resident and staff interviews, it was determined the facility failed to provide an ongoing program of activities designed to meet the needs, interests, preferences,and functional abilities of four residents out of 18 sampled residents (Residents 18, 16, 19, and 13). Findings include: A review of the facility census at the time of survey ending December 20, 2024, revealed a census of 90 residents. Review of the average age of residents indicated that 18 residents were under the age of 60. Review of the facility assessment revealed that 80-85 of 90 residents had some mental health diagnoses. A review of Resident council meeting minutes revealed during the November 2024 meeting, residents had voiced a concern with the Activities program. Specifically, residents stated the facility plays bingo but that instead of prizes they are given bingo bucks which then can be redeemed for prizes. Residents stated the prizes were used items and not what they would like. Further residents were…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of clinical records, select facility investigative reports, and staff interview, it was determined the facility failed to implement effective interventions, including staff supervision, to promote resident safety and prevent repeated falls for one resident (Resident 52) and further failed to implement effective interventions to prevent a fall for one resident (Resident 49) of four sampled residents and failed to maintain a safe environment in one of 3 resident shower rooms on the third floor. Findings include: A review of the clinical record revealed that Resident 52 was admitted to the facility on [DATE], with diagnoses to include Huntington's disease (an inherited condition that affects brain cells and causes physical and emotional changes that get worse over time). A quarterly Minimum Data Set assessment (MDS- a federally mandated standardized assessment process conducted periodically to plan resident care) dated August 9, 2024, indicated the resident exhibited a severe cognitive impairment…

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 the facility's accounts payable ledger and staff interviews, it was determined the facility failed to comply with Federal, State, and Local laws and professional standards by not ensuring timely payment for goods and services necessary for daily operations. Findings include: The 28 PA Code Commonwealth of Pennsylvania Long Term Care Licensure Regulations, subsection 201.14(g), dated July 1, 2023, revealed a facility owner shall pay in a timely manner bills incurred in the operation of a facility that are not in dispute and that are for services without which the resident's health and safety are jeopardized. A review of the current outstanding accounts payable ledger revealed outstanding balances as of December 20, 2024, for greater than 121 days beyond terms of payment which include: Allstate Pest Management: $1,969.48 Commonwealth of Pennsylvania: $16,000.00 Concept Medical: $2,681.31 E. Copier Solutions: $1,372.66 [NAME] Medical Center: $2,576.65 General Healthcare Resources: $19,771.26 Geri Medix:…

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

Based on a review of facility personnel, select facility policy, and staff interview, it was determined the facility did not have one or more individuals serving as the Infection Preventionist (IP) responsible for the facility's infection prevention plan. Findings included: According to regulatory guidance the facility must designate one or more individual(s) as the infection Preventionist(s) (IP)(s) who are responsible for the facility's IPCP (infection prevention and control program). The IP must: Have primary professional training in nursing, medical technology, microbiology, epidemiology, or other related field; Be qualified by education, training, experience or certification; Work at least part-time at the facility; and Have completed specialized training in infection prevention and control. Review of the facility Infection Control Policy last reviewed June 3 2024, failed to mention the need or role of the Infection Preventionist. Review of current staffing positions during the survey on September 10, 2024, at approximately 9:15 AM revealed the facility did not currently employ…

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, CDC infection control guidance, facility's infection control policy and COVID-19 testing logs, and staff interview it was determined that the facility failed to promptly implement infection control practices for cohorting like respiratory infections and testing for COVID-19 to prevent the spread of COVID-19 infections in the facility placing at least four residents (Residents 61, 73, 63 and 77) at increased risk for contracting COVID and failed to implement effective interventions to prevent the spread of COVID-19 virus. Findings include: A review of the Pennsylvania Department of Health 2023-PAHAN-694-5-11-2023 update: Interim Infection Prevention and Control Recommendations for COVID-19 in healthcare settings dated May 11, 2023, revealed, this HAN provides comprehensive information regarding infection prevention and control for COVID-19 in healthcare settings based on changes made by the Centers for Disease Control and Prevention (CDC) on May 8, 2023. A review of 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, minutes from Residents' Council meetings, and grievances filed with the facility, and resident and staff interviews, it was determined that the facility failed to provide care in a manner and environment that promotes each resident's quality of life by failing to respond timely to residents' requests for assistance for six residents out of the 25 sampled (Residents 2, 20, 29, 33, 75, and 84) and experiences reported by three out of the five residents during a resident group interview (Residents 1, 26, and 83). Findings include: Clinical record review revealed that Resident 29 was admitted to the facility on [DATE]. A review of a quarterly Minimum Data Set assessment (MDS - a federally mandated standardized assessment process conducted periodically to plan resident care) dated June 10, 2024, revealed that Resident 29 is cognitively intact with a BIMS score of 15 (Brief Interview for Mental Status- a tool within the Cognitive Section of the MDS that is used to assess 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 and resident and staff interviews, it was determined that the facility failed to provide housekeeping and maintenance services to maintain a clean and orderly environment in two of the two nursing halls (Nursing Units 2 and 3). Findings include: An observation on July 23, 2024, at 10:46 AM, in resident room [ROOM NUMBER] revealed an unlabeled clear urine collection graduate hanging on an the grab assist bar adjacent to the toilet. A call bell cord was wrapped around the grab assist bar, was coated with black and brown discoloration stains. An observation on July 23, 2024, at 11:01 AM, revealed a foul urine smell outside of resident room [ROOM NUMBER]. An observation on July 23, 2024, at 11:18 AM, in resident room [ROOM NUMBER] revealed a foul urine smell. An observation on July 23, 2024, at 11:23 AM, in resident room [ROOM NUMBER] revealed that the window blinds that do not close and missing slats. An observation on July 23, 2024, at 12:29 PM, in resident room [ROOM NUMBER] revealed tan…

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 scheduled facility mealtimes and select facility policy, and resident and staff interviews, it was determined that the facility failed to consistently provide snacks as desired by residents including four out of the 25 residents sampled (Residents 2, 20, 29, and 84) and experiences reported by residents during a group interview (Residents 1, 26, 27, 83, and 89). Findings include: A review of the facility's policy titled Nourishment: Serving Between Meals and Bedtime Snacks, last reviewed on June 3, 2024, indicated that it is the facility policy to serve residents with extra nourishment to provide energy. A review of the facility's scheduled mealtimes revealed that the time between dinner and breakfast the next day exceeds 14 hours. A clinical record review revealed that Resident 29 was admitted to the facility on [DATE]. A review of a quarterly Minimum Data Set assessment (MDS - a federally mandated standardized assessment process conducted periodically to plan resident care) dated June 10,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of clinical records, the facility's abuse prohibition policy, and facility investigation reports, and staff interviews, it was determined the facility failed to timely and accurately report allegations of resident abuse for one resident out of 25 sampled (Resident 29) perpetrated by another resident (Resident 2) to the State Survey Agency. Findings include: A facility policy titled Abuse Prevention Policy and Procedure Manual, reviewed last by the facility on June 3, 2024, indicated it is the facility policy that abuse, neglect, and/or mistreatment of residents will not be tolerated in any manner. The purpose of the policy indicated all necessary steps shall be taken to ensure the provision of a safe and secure environment. The policy indicates that all allegations of abuse will be reported to all local and state agencies within the required time frames as mandated by the Department of Health and Act 13. For allegations of physical abuse, notify the state regional licensing agency (DOH) of any…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of clinical records, and staff interviews, it was determined that the facility failed to implement individualized interventions to address a resident's decline in bowel continence in an effort to restore normal bowel function to the extent possible for one resident out of three sampled (Resident 1). Findings include: Review of Resident 1's clinical record admission to the facility on December 19, 2023, with diagnoses that included Parkinson's disease (a long-term neurodegenerative disease of mainly the chronic obstructive pulmonary disease (COPD), multiple sclerosis, chronic respiratory failure, and hypertension. The resident's Quarterly Minimum Data Set Assessments (MDS - a federally mandated standardized assessment completed at specific intervals to define resident care needs) dated December 11, 2023, and Annual MDS dated [DATE], Section H Bladder and Bowel, both indicated that the was always continent of bowels. A physician order was noted March 27, 2023, to check and change every (Q) 2 hours…

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 observations, review of monitoring logs and reference information, and staff interview it was determined the facility failed to maintain acceptable practices for the storage a of food to prevent the potential for microbial growth in food, which increased the risk of food-borne illness. Findings include: According to the U.S. Department of Agriculture Foods (USDA) and The Food Establishment Plan Review Guide, Section III and current standards of practice as referenced in HACCP (Hazard Analysis Critical Control Point) dry storage of food guidelines indicate: Many items such as canned goods, baking supplies, grains, and cereals may be held safely in dry storage areas. The guidelines below should be followed: Keep dry storage areas clean with good ventilation to control humidity and prevent the growth of mold and bacteria. Store dry foods at 50°F for maximum shelf life. However, up to 70°F is adequate for dry storage of most products. Place a thermometer on the wall in the dry storage area. Check the temperature of the storeroom daily. Store foods away from sources of heat and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and resident and staff interview, it was determined the facility failed to provide housekeeping and maintenance services necessary to maintain a safe and orderly environment on the second and third floor units of the facility. Findings include: During an observation and interview with Resident 1 at 10:30AM on June 26, 2024, the resident reported a concern that his toilet seat has been broken for a long time. Observation of the toilet seat in the bathroom of the resident's room, that is shared with his roommate and the residents residing in the adjoining room revealed that the seat was very loose and not secured to the toilet. The seat widely moved from side to side causing a potential fall hazard. The toilet (porcelain) was also cracked underneath the toilet seat on both sides where the seat came in contact with the base. There was a dark substance observed accumulated inside these cracks in the toilet. Observations on June 26, 2024, during a tour of resident bathrooms at 2:45 PM 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of clinical records, and staff interview, it was determined the facility failed to promptly provide recommended and/or prescribed pressure relieving measures to prevent pressure sore development and promote healing for two of six residents sampled with pressure sores (Resident 2 and Resident 3). Findings include: According to the US Department of Health and Human Services, Agency for Healthcare Research & Quality, the pressure ulcer best practice bundle incorporates three critical components in preventing pressure ulcers: Comprehensive skin assessment, Standardized pressure ulcer risk assessment and care planning and implementation to address areas of risk. ACP (The American College of Physicians is a national organization of internists, who specialize in the diagnosis, treatment, and care of adults. The largest medical-specialty organization and second-largest physician group in the United States) Clinical Practice Guidelines indicate that the treatment of pressure ulcers should involve multiple…

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. 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). A tour of the facility's kitchen dish room was conducted on April 24, 2024, at approximately 10:00 AM, revealing the following unsanitary practices with the potential to introduce contaminants into food and…

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

Based on clinical record and facility policy review and staff interview, it was determined the facility failed to ensure that in preparation for room change each resident/resident representative received written notice, including the reason for the change before the resident's room was changed for four of 24 room changes completed by the facility from April 2, 2024, through April 24, 2024 (Residents B1, B2, B3 and B4). Findings include: Federal regulatory guidance under §483.10(e)(6) notes that moving to a new room or changing roommates is challenging for residents. A resident's preferences should be taken into account when considering such changes. When a resident is being moved at the request of facility staff, the resident, family, and/or resident representative must receive an explanation in writing of why the move is required. The resident should be provided the opportunity to see the new location, meet the new roommate, and ask questions about the move. A review of an undated facility policy provided to the survey team during the survey of April 24, 2024, entitled Transfer:…

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

Based on review of select facility polity, the minutes from Resident Council Meetings and grievance logs and resident and staff interviews, it was determined that the facility failed to demonstrate timely action to resolve resident grievances raised at resident group meetings and keep the residents apprised of the status of the facility's decisions and efforts toward grievance resolution. Findings include: A review of the minutes from the Resident Council Meeting held during the month of March 2024, revealed that the number of residents in attendance at the meeting was not noted. During that meeting, the residents present voiced concerns about activities programming and that the Nursing Home Administrator should come to the resident floors and see residents. At the time of the survey ending April 24, 2024, there was no documented evidence that the facility had addressed the residents' concerns and responded to the residents with the facility's efforts to resolve their concerns. A review of the minutes from the Resident Council Meeting held during the month of April 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 observations, the facility failed to maintain a clean and homelike environment on two of two resident units (Second and Third Floor). Findings include: Observations during a tour of the second floor resident unit on April 24, 2024, at 10:00 AM, 11:45AM, 12:30 PM and 2:15 PM revealed a very strong pungent urine-like odor. The pervasive offensive urine-like odor lingered on the unit at the time of each observation throughout the day. Observations during a tour of the third floor resident unit on April 24, 2024, at 9:45 AM, 11:30 AM, 12:15 PM and 2:00 PM. revealed a very strong pungent urine-like odor. The pervasive offensive urine-like odor lingered on the unit at the time of each observation throughout the day. 28 Pa. Code 201.18 (e)(2.1) Management

Based on observation and staff interview it was determined the facility failed to maintain an environment free of potential accident hazards and obstacles to safe mobility and use of mobility assistance devices on two of the two nursing units. Findings include: Observations of the second floor resident hallway, on April 24, 2024, at 10:00 AM, 11:45AM, 12:30 PM and 2:15 PM revealed three-drawer plastic bins containing boxes of gloves, disposable protective gowns, plastic bags and other items. These bins were located on both sides of the hallway against the wall, obstructing unimpeded access to the handrails, in front of rooms 209, 211, 213, 215, 214, 216, 219, 221, and 222. Observations of the third floor resident hallway on April 24, 2024, at 9:45 AM, 11:30 AM, 12:15 PM and 2:00 PM. revealed three drawer plastic bins positioned on both sides of the hallway in front of rooms 302, 303, 304, 307, 309, 310, 317, 318 and 320, obstructing access to the handrails. Interview with Director of Nursing on April 24, 2024, at 2:30 PM revealed that the plastic bins are for those residents…

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, review of the facility's planned written menus and menu extensions, and staff interviews, it was determined that the facility failed to follow planned written menus and failed to ensure that the facility's dietitian periodically reviewed the always available menu for appropriateness of the corresponding menu extensions for residents prescribed a therapeutic diet, including Resident A1. Findings included: A review of the current facility census at the time of the survey on April 24, 2024, revealed 104 residents were currently residing in the facility. Review of the facility's Week 4 lunch menu for Wednesday April 24, 2024, revealed that the planned menu included spaghetti and meat sauce (8 oz), mashed broccoli (4 oz.), pound cake (4 oz.) milk (4 oz) and coffee or tea (8 oz). The Week 4 lunch meal, Renal diet extension for the lunch menu on April 24, 2024, revealed that meal to be served to those residents prescribed a renal therapeutic diet was spaghetti and meatballs with [NAME] sauce (8 oz), carrots (4 oz.), diet vanilla pudding (4 oz.), milk (4 oz) and…

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

Based on review of the minutes from Residents' Council meetings, and resident and staff interviews, it was determined that the facility failed to routinely offer evening snacks to residents including Residents A2, A3, A4, and A5). Findings include: During an interview on April 24, 2024 at 12:30 P.M., Resident A2, who was alert and oriented, the resident stated that the facility does not consistently offer snacks at bedtime, and when they do provide a snack, it's only a cookie and there is no variety of snacks offered. During an interview on April 24, 2024 at 12:35 P.M., Resident A3, who was alert and oriented, the resident stated that the facility does not consistently offer snacks at bedtime and there is no variety of snacks. During an interview on April 24, 2024 at 12:40 P.M., Resident A4 stated that the facility does not offer snacks at bedtime and there is no variety of snacks available for residents. During an interview on April 24, 2024 at 12:45 P.M., Resident A5, a cognitively impaired resident stated that the facility does not offer snacks at bedtime and there is no variety…

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 plan of correction from the survey ending January 26, 2024, the outcome of the activities of the facility's quality assurance committee, current staffing of the facility's food and nutrition services department, menus and menu extensions, observations and interviews it was determined that the facility's procedures failed to effectively identify ongoing deficient practices related to the facility's food and nutrition services department, and its lack of effective oversight, and implement effective plans to correct and prevent further quality deficiencies related to menus, snacks and food service sanitation. Findings included During the survey ending January 26, 2024, deficient facility practice was cited for the facility's failure to assure qualified full time staff responsible for the oversight of the food and nutrition services department. In response to that deficiency the facility developed a plan of correction, that included a quality assurance monitoring program, indicated that the facility will take the following steps: In coordination 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 observations and resident and staff interviews, it was determined that the facility failed provide care in a manner that promotes each resident's quality of life by failing to respond timely to residents' requests for assistance including one resident out of 19 sampled (Residents A2) Findings included: An interview conducted on April 24, 2024, at approximately 12:15 PM with Resident A1, who was alert and oriented, revealed that the resident stated that staff do not respond timely to resident call bells. The resident stated that the staff are wonderful but there is not enough staff to care for the residents in the facility in a timely manner. The resident stated residents wait 30 minutes or longer for staff to answer their call bells when they request assistance. He stated that he requires staff assistance with his activities of daily living and it is sometimes very hard to wait a long time for assistance from staff. An interview with the Nursing Home Administrator and Director of Nursing on April 24, 2024, at approximately 2 PM, confirmed that the staff are expected to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of clinical records and staff interviews, it was determined that the facility failed to develop and implement an individualized person-centered plan to provide trauma-informed care to a resident with a diagnosis of Post Traumatic Stress Disorder (PTSD) for one resident out of three sampled with a diagnosis of PTSD (Resident M1). Findings include: A review of the clinical record revealed that Resident M1 was admitted to the facility on [DATE], with diagnoses to include major depression, anxiety, suicidal ideations, and Post Traumatic Stress Disorder (PTSD). A quarterly Minimum Data Set assessment (MDS- a federally mandated standardized assessment process conducted at specific intervals to plan resident care) dated May 26, 2024, Section I, Active Diagnoses, Psychiatric/Mood Disorder, question I6100, indicated the resident has post-traumatic stress disorder (PTSD). A review of Resident M1's current care plan, initially dated September 14, 2023, and revised January 26, 2024, indicated that the…

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

Based on observation and staff interview, it was determined that the facility failed to 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. 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). A tour of the facility's kitchen was conducted with Employee 3, Dietary Manager, on March 7, 2023, at approximately 10:00 AM, revealing the following unsanitary practices with the potential to introduce…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, review of clinical records, and resident and staff interviews, it was determined that the facility failed to provide reasonable accommodation of the needs of bariatric residents' for showering equipment for two of two bariatric residents reviewed (Residents 11 and 12). Findings include: Review of the clinical record revealed that Resident 11 was admitted to the facility on [DATE], with diagnoses of hemiplegia (paralysis of one side of the body) and hemiparesis (weakness on one side of the body) following a cerebral infarction (stroke), Type 2 diabetes (failure of the body to produce insulin), chronic obstructive pulmonary disease (lung disease that blocks airflow and makes it difficult to breathe), and morbid obesity (excess body fat with obesity related health condition). Review of the Resident 11's quarterly Minimum Data Set Assessment (MDS - a federally mandated standardized assessment completed at specific times to identify resident care needs) dated December 20, 2023, indicated 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.

Based on review of select facility policy and the minutes from Residents' Council meetings and staff interviews it was determined that the facility failed to put forth sufficient efforts to promptly resolve resident complaints/grievances expressed during Resident Council Meetings. Findings include: Review of the facility's Grievance policy and procedure provided by the facility on March 7, 2024, indicated that it is the facility's policy to notify residents of their right to file a grievance, and to ensure the prompt resolution of all filed grievances. A written response to all grievances will be issued to the party who filed the grievance. This written response will be issued within five (5) business days of the receipt of the grievance. Written responses to grievances will include the date the grievance was received, a summary statement of the resident's grievance, the steps taken to investigate the grievance, a summary of pertinent findings or conclusions regarding the resident's concern(s), a statement as to whether the grievance was confirmed or not confirmed, any corrective…

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 provide care in an manner that enhances each resident's quality of life by failing to assist residents in maintaining a dignified personal appearance as preferred by for one resident out of 25 sampled (Resident 11) and failed to respond timely to residents' requests for assistance as reported by two residents (Residents 11 and 12). Findings include: Review of the clinical record revealed that Resident 11 was admitted to the facility on [DATE], with diagnoses of hemiplegia (paralysis of one side of the body) and hemiparesis (weakness on one side of the body) following a cerebral infarction (stroke), Type 2 diabetes (failure of the body to produce insulin), chronic obstructive pulmonary disease (lung disease that blocks airflow and makes it difficult to breathe), and morbid obesity (excess body fat with obesity related health condition). Review of the Resident 11's 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.

Based on clinical record review and resident and staff interview it was determined that the facility failed to develop and implement an individualized discharge plan for one of 25 residents sampled (Resident 11). Findings Include: A review of the clinical record of Resident 11 revealed admission to the facility on June 18, 2022. A quarterly Minimum Data Set Assessment (MDS- standardized assessment process conducted at periodic intervals to plan resident care) dated December 20, 2023, revealed that the resident had a BIMS (brief interview to aid in detecting cognitive impairment) score of 15, indicating that his cognition was intact. Review of Resident 11's care plan, initially dated December 9, 2022, indicated that that discharge planning was complete, and the resident will acclimate to nursing facility placement as skilled nursing facility placement remains appropriate. The resident's care plan was updated March 16, 2023, indicating that long term care remains appropriate for the resident. The intervention indicated that the resident be allowed the opportunity to verbalize goals…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and staff interview, it was determined that the facility failed to maintain respiratory and oxygen equipment in a manner to promote optimal functioning for one resident out of 25 sampled residents (Resident 1). Findings include: A review of the current facility policy, provided during the survey ending March 7, 2024, entitled Oxygen Concentrator revealed that staff will date and time humidification bottles. Staff will change the nasal cannula and tubing at least once a week. The tubing will be labeled with the current date and time. A review of Resident 1's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses, which included Chronic Obstructive Pulmonary Disease (COPD a group of lung diseases that block airflow and make it difficult to breathe). The resident had a current physician order initially dated January 5, 2024, for humidified oxygen at 3 liters a minute via nasal cannula continuously. An observation on March 7, 2024, at 10:58 AM, 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of clinical records and select facility reports, and staff interviews, it was determined that the facility failed to consistently implement planned individualized safety measures designed to prevent falls and injury and ensure that planned fall prevention approaches do not create a potential accident hazard for one resident identified at high risk for falls (Resident 60) out of 21 residents reviewed. Findings include: A review of Resident 60's clinical record revealed she was admitted to the facility on [DATE], with diagnoses schizoaffective disorder, major depression and difficulty walking. A quarterly MDS (minimum data set- a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated October 12, 2023, indicated that the resident was independent for transfers, bed mobility, ambulation and activities of daily living (ADLs) and uses a manual wheelchair. The resident was cognitively intact with a BIMS score of 15 (brief interview for mental status, 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 observation, a review of clinical records, resident and staff interviews it was determined that the facility failed to provide nursing services consistent with professional standards of practice by failing to follow physician's orders for treatment of one resident (Resident 83), medication administration for one resident (Resident 73) and failing to demonstrate ongoing monitor and assessment of a resident's edema for one resident (Resident 36) out of nine sampled. Findings include: A review of Resident 83's clinical record revealed that he was most recently admitted to the facility on [DATE], with diagnoses of an acquired absence of left leg above the knee, congestive heart disease, peripheral vascular disease (PVD), severe protein-calorie malnutrition, and anxiety. A health status note, dated September 7, 2023, indicated that the resident had a 2 centimeter (cm) x 2 cm x 1.5 cm open area, stage II to resident's left heel without drainage identified during wound rounds. A new order was obtained for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, a review of clinical records and incident reports, resident and staff interviews it was determined that the facility failed to consistently provide care and services, consistent with professional standards of practice, to prevent the development of pressure ulcers for one resident out of two sampled residents (Resident 36). Findings: According to the US Department of Health and Human Services, Agency for Healthcare Research & Quality, the pressure ulcer best practice bundle incorporates three critical components in preventing pressure ulcers: Comprehensive skin assessment, Standardized pressure ulcer risk assessment and care planning and implementation to address the areas of risk. The American College of Physicians (ACP) is a national organization of internists, who specialize in the diagnosis, treatment, and care of adults. The largest medical-specialty organization and second-largest physician group in the United States) Clinical Practice Guidelines indicate that the treatment 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, clinical record review, and staff interview, it was determined that the facility failed to ensure that medications were labeled according to accepted labeling requirements for one of four residents sampled (Resident 83). Findings include: A review of Resident 83's clinical record revealed he was most recently admitted to the facility on [DATE], with diagnoses of acquired absence of left leg above the knee, congestive heart disease, peripheral vascular disease (PVD), severe protein-calorie malnutrition, and anxiety. A physician order dated September 27, 2023, was noted for Percocet (Oxycodone - Acetaminophen) [an opioid pain medication] 5-325 milligram (mg), give 1 tablet by mouth every 4 hours as needed (PRN) for moderate pain (4-6), left above knee amputation (AKA), for 21 days. A physician order was noted October 20, 2023, for Percocet (Oxycodone - Acetaminophen) 5-325 mg, give 1 tablet by mouth every 12 hours for severe pain for 30 days. The resident's controlled substance record,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of clinical records and select facility policy and staff interviews it was revealed that the facility failed to provide quality care as evidenced by the facility's failure to administer physician prescribed medications within scheduled/prescribed timeframes for 11 residents out of 15 sampled (Residents 2, 3, 4, 5, 6, 7, 8, 9, 10, 12 and 13). Findings include: A review of the clinical record revealed that Resident 2 was admitted to the facility on [DATE], with diagnoses, which included anxiety and chronic pain. Resident 2 had a current physician order dated June 27, 2023, for Neurontin (an antiseizure medication sometimes used for neurological pain) 100 mg by mouth three times a day or thoracic back pain. The medication was scheduled for administration at 9 AM, 1 PM and 5 PM A review of Resident 2's Medication Administration Record dated September 2023 revealed that on September 28, 2023, nursing staff administered the Neurontin scheduled for 9 AM at 12:14 PM. and the 1 PM dose 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of resident clinical records and staff interview it was revealed that the facility failed to ensure that three of 15 residents reviewed were free of significant medication errors (Residents 14, 15 and 11). Findings include: A review of the clinical record revealed that Resident 14 was admitted to the facility on [DATE], with diagnoses to include diabetes. The resident had a physician order, dated January 1, 2023, for HumaLOG Solution 100 UNIT/ML Inject 8 unit subcutaneously with meals for diabetes. A review of the Medication Administration Record (MAR) for September 2023 revealed that Resident 14's insulin was scheduled for administration at 8 AM. Nursing staff administered the medication to the resident at 9:22 AM on September 28, 2023. The resident's breakfast was served at 7:15 AM. The insulin was not administered with the resident's breakfast meal as ordered. A review of the clinical record revealed that Resident 15 was admitted to the facility on [DATE], with diagnoses to include diabetes.…

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, observations and staff interviews it was determined that the facility failed to ensure the effective use of resources designed to maintain residents' highest practicable physical well-being by failing to efficiently implement procedures to continue resident care during a disruption in internet and telephone services, which resulted in significantly late medication administration for residents on one of two nursing units. Findings include: Review of facility policy for Emergency procedures for specific events last reviewed May 12, 2023 revealed that the loss of IT (internet technology) affects everything in the facility from medical records to ordering pharmaceuticals. As such, it is considered critical infrastructure component. With systems down, the facility will have to got to to Down Time procedures. Each department maintains its own Down Time procedures. Nursing/DON (Director of Nursing): - Electronic health records including Pharmacy and…

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

Based on review of clinical records and controlled drug records and staff interview, it was determined that the facility failed to implement procedures to promote accurate accounting and administration of controlled medications and maintenance of accurate controlled substance records as evidenced by two of four residents sampled (Residents 1 and 7) . Finding include: A review of the clinical record revealed that Resident 1 had a current physician order dated July 27, 2023, for Oxycodone (a narcotic opioid pain medication) 5 mg Tablet, by mouth every 8 hours, as needed for moderate pain. A review of the controlled substance record accounting for the above narcotic medication revealed that on the following dates nursing staff signed for the removal of a dose from the resident's supply of oxycodone 5 mg: August 1, 2023 at 3 P.M. August 1, 2023 at 11:15 P.M, August 2, 2023 at 11 P.M, August 5, 2023 at 11 P.M., August 7, 2023 at 10 P.M., August 8, 2023 at 11:30 P.M., August 9, 2023 at 11:30 P.M. August 10, 2023 at 11:30 P.M., August 13, 2023 at 11:30 P.M., August 14, 2023 at 11 PM.,…

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.