Shenandoah Senior Living Community

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of the facility's abuse prohibition policy, select investigative reports and clinical records, and staff interview, it was determined the facility failed to ensure the provision of care and services necessary to prevent a fall and maintain the physical health of one resident out of 23 residents reviewed (Resident 30). Findings include: A review of the facility policy titled Abuse Policy last reviewed by the facility on June 13, 2025, revealed it is the facility's policy that the resident has the right to be free from abuse, neglect, misappropriation or resident property, and exploitation. The policy defines neglect as the failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. A clinical record review revealed that Resident 30 was admitted to the facility on [DATE], with diagnoses that included above-the-knee right leg amputation, 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 the review of the facility's abuse prohibition policy, clinical records, select facility investigations, and staff interview, it was determined the facility failed to timely report an instance of resident neglect to the State Survey Agency for one out of the 23 residents reviewed (Resident 30). Findings include: A review of the facility policy titled Abuse Policy indicated as last reviewed by the facility on June 13, 2025, revealed all reports of abuse, neglect, exploitation, misappropriation of resident property, mistreatment, and/or injuries of unknown source shall be promptly reported to local, state, and federal agencies. The policy indicates that the nature of the allegations and the names of the resident(s) and individual(s) implicated will be reported to the appropriate agencies within five (5) working days of the incident. A clinical record review revealed that Resident 30 was admitted to the facility on [DATE], with diagnoses that included above-the-knee right leg amputation, dementia (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, select facility policy, and staff interviews, it was determined the facility failed to provide nursing services consistent with professional standards of quality to ensure that licensed nurses properly evaluated and provided nursing care according to physician orders for 2 residents out of 23 residents sampled (Resident 56 and 80). According to the Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.11 (a)(1)(2)(4) indicates that the Registered Nurse (RN) was to collect complete ongoing data to determine nursing care needs, analyze the health status of individuals and compare the data with the norm when determining nursing care needs, and carry out nursing care actions that promote, maintain, and restore the well-being of individuals. The Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.145 Functions of the Licensed Practical Nurse (LPN) (a) The LPN is prepared to function as a member…

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, employee files, and staff interview it was determined that the facility failed to timely train one agency employee out of four employees reviewed on the facility's abuse prohibition policy and procedures. Findings include: A review of the facility policy titled Abuse Policy last reviewed by the facility on June 13, 2025, revealed the facility's abuse prevention program provides training for mandated staff and others that includes topics such as abuse prevention, identification, and reporting requirements and to support an environment in which covered individuals report a reasonable suspicion of a crime, freedom from retaliation or reprisal, stress management, dealing with violent behavior or catastrophic reactions, etc. training is provided at the time of hire, annually, and as needed. A review of Employee 1's personnel file, who was employed as an agency licensed practical nurse (LPN) with a documented start date of November 19, 2022, revealed no evidence that the facility provided the required training on the facility's abuse prohibition…

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 controlled drug records, observation, and staff interview, it was determined the facility failed to implement pharmacy procedures for the reconciliation of controlled drugs on two of three medication carts reviewed (A, and C hall). Finding include: A review of facility policy entitled Controlled Substances last reviewed by the facility on June 21, 2024, states that nursing staff must count controlled medications at the end of each shift. The nurse coming on duty and the nurse going off duty must make the count together. They must document and report any discrepancies to the Director of Nursing Services. Any discrepancies in the controlled substance count are documented and reported to the director of nursing (DON) services immediately. An observation of the medication pass on September 10, 2024, at approximately 11:40 AM, revealed Employee 1 Licensed Practical Nurse (LPN), working the Medication Cart C. A review of a document entitled Shift Change Narcotic Audit, identified by Employee 1 (LPN), as the change of shift controlled count…

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, information submitted by the facility, select facility reports, and staff interviews it was determined the facility failed to provide a resident who sustained repeated falls the necessary supervision and/or effective fall interventions to prevent a fall with a monor injury for one out of five sampled residents for accidents (Resident 7). Findings include: A review of a facility policy entitled Falls Management that was last reviewed by the facility on June 21, 2024, indicated that each resident is assisted in attaining or maintaining their highest practicable level of function through providing the resident adequate supervision, assistive devices, and functional programs, as appropriate, to prevent accidents. It is the policy of this center to provide each resident with appropriate evaluation and interventions to prevent falls and minimize complications if a fall occurs. A review of Resident 7's clinical record revealed that the resident was admitted to the facility on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, a review of clinical records, a review of nurse staffing, and interviews with staff and residents, it was determined the facility failed to provide sufficient nursing staff to provide timely and quality care for residents that sustained falls, for three residents out of 20 sampled (Residents 7, 70, and 90) and failed to provide timely care expressed by residents during a resident group interview (Residents 1, 35, 52, 65, and 71). Findings included: The facility failed to provide sufficient supervision and implement effective fall prevention interventions for two residents at high risk for falls, Resident 7 and Resident 70, both of whom experienced repeated falls despite being identified as high fall risks. A review of Resident 7's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses that included dementia and severe cognitive impairment. Resident 7 has a documented history of falls from her Broda chair, often accompanied by agitation and behaviors.…

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, observations, and staff interview, it was determined the facility failed to maintain infection control practices to prevent potential spread of infection for two out of 20 residents sampled (Resident 77 and 83) and failed to offer and/or provide SARS-CoV-2 (COVID-19) immunization, unless the immunization was medically contraindicated or the resident has already been immunized, to one of five residents reviewed (Resident 2). Findings include: A review of facility policy titled Coronavirus Disease (COVID-19)-Infection Prevention and Control Measures, last reviewed by the facility on June 21, 2024, revealed the facility follows infection prevention and control practices recommended by the Centers for Disease Control and Prevention to prevent the transmission of COVID-19 within the facility. A review of the CDC ' s Use of an Additional Updated 2023-2024 COVID-19 Vaccine Dose for Adults Aged greater than or equal to 65 Years: Recommendations of the Advisory Committee on Immunization…

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 the facility failed to accommodate residents' need and preference for access to the call bell system in order to request staff assistance for one resident (Resident 79). Findings include: A review of Resident 79's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses that included cerebral infarction (also known as an ischemic stroke, is the pathologic process that results in an area of necrotic tissue) with hemiplegia (is a symptom that involves one-sided paralysis. Hemiplegia affects either the right or left side of your body) and hemiparesis (is one-sided muscle weakness and occurs due to disruptions in the brain, spinal cord or the nerves that connect to the affected muscles) to the right dominant side, dysphagia (difficulty swallowing), and muscle weakness. A quarterly Minimum Date Set assessment (MDS - a federally mandated standardized assessment conducted at specific intervals to plan resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of clinical records and the Resident Assessment Instrument and staff interview, 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 resident out of 20 sampled (Residents 95). Findings included: A review of Resident 95's clinical record revealed that the resident was admitted to the facility on [DATE], and discharged from the facility on August 16, 2024. A review of Resident 95's Discharge MDS assessment dated [DATE], revealed in Section A2105 Discharge Status that Resident 95 was discharged to a short term general hospital. A review of the skilled nursing note dated August 14, 2024, at 1429 hours (2:29 PM) indicating the resident is being discharged on August 16, 2024. A review of the resident's Discharge Plan and Instructions revealed the resident was discharged home, on August 16, 2024. Review of physician…

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, facility investigation reports, and staff interviews, it was determined the facility failed to develop and implement a person-centered care plan to meet the specific needs of one resident out of 20 sampled (Resident 70). Findings including: A clinical record review revealed Resident 70 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). Resident 70 has a documented history of falls, as noted in facility investigations and a clinical record review, occurring on the following dates: February 24, March 2, March 29, and June 2, 2024. Resident 70's care plan initiated September 26, 2023, indicated he is deficient in his ability to carry out activities of daily life, such as eating and personal hygiene, related to a lack of coordination, and his diagnoses 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 resident and staff interviews, it was determined that the facility failed to provide restorative nursing services planned to maintain mobility and functional abilities of one of the 20 residents sampled (Resident 77). Findings included: A clinical record review revealed Resident 77 was admitted to the facility on [DATE], with diagnoses that include unsteadiness on feet (walking that is unstable), muscle weakness, and difficulty in walking. A review of an admission Minimum Data Set assessment (MDS - a federally mandated standardized assessment process conducted periodically to plan resident care) dated August 18, 2024, revealed that Resident 77 is moderately cognitively impaired with a BIMS score of 10 (Brief Interview for Mental Status- a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 8-12 indicates cognition is intact). A review of Resident 77'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 review of select facility policy, clinical records and staff interview, it was determined the facility failed to consistently and accurately monitor resident weights to timely identify changes in nutritional parameters for a resident with an identified significant weight loss and gain for 1 of 20 residents sampled (Resident 31). Findings include: A review of the policy titled Weight Assessment and Intervention Policy Statement, last reviewed by the facility on April 21, 2024, revealed the nursing staff will weigh the resident on admission, then weekly for four weeks. If there are any weight changes, the weight will be retaken for confirmation. Any weight change of five pounds or greater since the last weight assessment will be retaken for confirmation. A review of the residents' clinical record revealed the resident was admitted on [DATE], with the diagnosis to include paroxysmal fibrillation (a type of abnormal heart rate), cerebral vascular disease (a disease that affects the blood vessels and 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 a review of clinical records and staff interviews, it was determined the facility failed to ensure the resident's drug regimen was free of unnecessary antibiotic medication for one out of 20 residents sampled (Resident 2). Findings included: A clinical record review revealed Resident 2 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). A progress note dated June 24, 2024, at 9:30 PM indicated a urine sample was obtained from Resident 2 directly from her Foley catheter (an indwelling catheter is a flexible tube used for draining urine from the bladder and having an inflatable part at the bladder end that allows the tube to be kept in place for variable time periods). The urine sample was placed in refrigeration, while awaiting transfer to the laboratory. A review of Resident 2's clinical…

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 employee personnel records and staff interview, it was determined the facility failed to have an Infection Preventionist (IP) that worked at least part time at the facility. Findings Include: A review of facility policy review and observations determined the facility failed to ensure infection control practices were maintained to prevent the spread of infection as evidenced by the transmission of the COVID-19 virus between two residents on September 5, 2024. During an interview on September 13, 2024, at approximately 10:30 AM the Nursing Home Administrator (NHA) confirmed that the facility did not currently have an infection preventionist. The NHA explained that the Director of Nursing (DON) has been covering the duties of the infection preventionist since July 18, 2024. A review of the DON's infection preventionist credentials revealed a certification titled Training Plan Proof of Completion that acknowledges the DON successfully completed the Nursing Home Infection Preventionist Training Course on August 27, 2024. The NHA confirmed the DON was not certified as…

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 clinical records 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 staff assistance as evidenced by experiences reported by six residents out of eight interviewed (Residents 21, 62, 81, 39, 49, 69, 101, and 61). Findings include: A review of resident clinical records and a facility provided BIMS (brief interview mental status - a tool that assesses cognitive status) report and random interviews conducted on May 15, 2024, with 8 alert and oriented residents, revealed that 6 of the 8 residents interviewed voiced concerns regarding staff's failure to respond to their requests for assistance from staff and provide requested and needed care and services in a timely manner. During interviews, the residents relayed that they feel the facility is not adequately staffed because they wait extended periods of time for staff to respond to their requests for assistance, including untimely responses to their…

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 select facility policy, clinical records, the minutes from resident group meetings and grievances lodged with the facility, and resident and staff interviews, it was determined that the facility failed to demonstrate their response to resident complaints and grievances, including those raised at group meetings, including resident complaints and grievances raised during two of the two resident group meeting minutes reviewed (March 2024 and April 2024), Findings include: A review of the facility policy titled Grievances, last reviewed by the facility on June 30, 2023, revealed that the facility has a system in place to ensure the residents right to prompt efforts to resolve grievances. The policy specifies that residents can expect a completed review of the grievance within five to seven business days. The policy also indicates that all written grievance decisions include a summary statement of the resident's grievance, steps taken to investigate the grievance, a summary of…

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

Based on resident and staff interviews and a review of temperature logs and clinical records revealed that the facility failed to serve appetizing food at palatable temperatures as discerned by residents including five of eight residents interviewed (Resident 21, 101, 61, 81, and 69). Findings included: An interview with Resident 21 on May 15, 2024, at 11:15 AM revealed that the resident stated that the food served is not palatable and is often served cold. The resident stated that the vegetables are overcooked and often mushy. An interview with Resident 101 on May 15, 2024, at approximately 12:40 PM revealed that the resident stated that the food is served cold, and mostly the breakfast meal. An interview with Resident 61 on May 15, 2024, at approximately 1:02 PM revealed that the food could be warmer. A review of a Social Services note dated May 6, 2024, at 10:18 AM, indicated that meeting was held on May 6, 2024 from 9:30 - 10:00 AM with the Assistant Director of Nursing (ADON), therapy, Social Services, POA, and Resident 69 to address the concerns in regards to her care, the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of clinical records and the facility's grievance/concern log, staff and resident interviews it was determined that the facility failed to demonstrate prompt efforts to resolve resident grievances as evidenced by one resident out of eight sampled (Resident 69) and maintain accurate and complete evidence of the implementation of the facility's grievance process from receipt to resolution. Findings included A review of Resident 69's clinical record, indicated she was admitted to the facility on [DATE], and was cognitively intact. A Social Services note dated April 26, 2024, at 8:20 AM, indicated that Social Services spoke with the resident's power of attorney (POA) regarding an invitation to a care plan meeting scheduled for May 1, 2024. During the conversation, the POA voiced some concerns regarding complaints Resident 69 had shared with the POA about the resident's care and facility services. The resident's POA mentioned that Resident 69 had stated she was sitting on the bed pan for 1 hour 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 a review of clinical records, information submitted by the facility, and select facility reports, and staff interviews, it was determined that the facility failed to provide necessary supervision and effective safety measures to monitor the whereabouts and activities of one resident out of the 13 sampled (Resident CR1). Findings include: A clinical record review revealed that Resident CR1 was admitted to the facility on [DATE], with diagnoses that included cerebral infarction (brain damage that results from a lack of blood) and 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). An elopement assessment dated [DATE], indicated that Resident CR1 was alert and oriented, understands the need to be in nursing home placement for short term rehabilitation, and is a low risk for elopement. A physician's order indicated that Resident CR1 may go out on a leave of absence with medications initiated…

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, facility contracts and select policies and procedures and interview with facility staff, it was determined that the facility failed to provide residents with timely intravenous fluids as prescribed and consistent with professional standards of practice for one resident (Resident C1) out of eight residents reviewed. Findings include: A review of Resident C1's clinical record revealed that the resident tested positive for COVID-19 on March 18, 2024, and displayed a progressive decline in medical status and meal intakes during the month of February 2024. A nursing progress note completed by Employee 1, a Registered Nurse (RN), dated February 23, 2024, at 12:34 p.m., revealed that Resident C1 was assessed by Employee 1 and vital signs were obtained (blood pressure (BP) was Blood Pressure: BP 86/58, pulse P: 80, Pulse Oximetry: O2 82.0 %) and the resident was noted to have been hypotensive [is a blood pressure reading below the specified limit (90/60 mmHg) that can cause dizziness, blurred vision, and tiredness] and had incontinent episodes of foul…

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 investigation reports and staff interview, it was determined that the facility failed to develop and consistently implement a person-centered care plan to address a resident's known risk factors for falls for one resident out of 11 sampled. Findings include: Clinical record revealed that Resident B1 was admitted to the facility on [DATE], with diagnoses of dementia, difficulty walking and a history of falls in the facility. An admission Minimum Data Assessment (MDS - a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated March 4, 2024, revealed that the resident was cognitively impaired with a BIMS score of 7 and required staff assistance with activities of daily living. The resident's care plan, initiated October 14, 2022, indicated that the resident may be out of bed to the wheelchair with gel cushion, auto lock brakes and anti-tippers. On October 21, 2022, the resident's care plan noted that the resident was 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 clinical record review and staff interview, it was determined that the facility failed to timely identify and address a resident's decline in food and fluid consumption with significant weight loss for one resident out of eight sampled. Findings included: A review of clinical record revealed Resident C1 was admitted to the facility on [DATE], with diagnoses that included congestive heart failure [(CHF) is a weakened heart condition that causes fluid buildup in the feet, arms, lungs, and other organs with symptoms that include shortness of breath, fatigue, arrhythmias, and edema], cardiomyopathies [an acquired or inherited disease of the heart muscle which makes it difficult for the heart to pump blood to other parts of the body], dysphagia (difficulty swallowing), and cognitive communication deficit [may occur after a stroke, tumor, brain injury, progressive degenerative brain disorder, or other neurological damage that may result in deficits with thinking and how someone uses language]. A review of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff interview it was determined that the facility failed to timely obtain prescribed laboratory services for one resident out of eight residents sampled (Resident C1). Findings included: A review of clinical record revealed Resident C1 was admitted to the facility on [DATE], with diagnoses that included congestive heart failure (CHF) is a weakened heart condition that causes fluid buildup in the feet, arms, lungs, and other organs with symptoms that include shortness of breath, fatigue, arrhythmias, and edema), cardiomyopathies (disease of the heart muscle which makes it difficult for the heart to pump blood to other parts of the body), dysphagia (difficulty swallowing), and cognitive communication deficit (may occur after a stroke, tumor, brain injury, progressive degenerative brain disorder, or other neurological damage that may result in deficits with thinking and how someone uses language). Resident C1 tested positive for COVID-19 on [DATE]. A review of nursing health…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, observation, and resident and staff interviews, it was determined that the facility failed to consistently provide restorative nursing services as planned to maintain mobility, range of motion and to ensure the application of splinting devices for three residents of 20 sampled (Residents 1, 27, and 54). Findings include: A review of Resident 1's clinical record revealed that the resident was admitted to the facility on [DATE], with diagnoses to include multiple sclerosis, paraplegia (paralysis of the lower body), stiffness of elbow, and contracture of muscle (abnormal shortening of muscle tissue). A physician order dated May 27, 2021, was noted for the application of a bean bag splint to resident's knee when in bed, during hours of sleep. Alternate splint between right and left knee daily. Review of Resident 1's care plan revealed a restorative nursing program (RNP) to apply a splint or brace to resident's bilateral (both) elbows and knees during hours of sleep, with the resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of clinical records, information submitted by the facility, and select facility reports and staff interviews it was determined that the facility failed to provide effective safety measures planned to prevent falls for one resident out of four reviewed for falls (Resident 82). Findings included: A review of the clinical record revealed that Resident 82 was admitted to the facility on [DATE], with diagnoses to include cerebrovascular disease (condition that affects blood flow and blood vessels in the brain), cognitive communication deficit, difficulty in walking, and muscle weakness. A review of the quarterly Minimum Data Set Assessment (MDS - a federally mandated standardized assessment completed at specific times to identify resident care needs) dated September 21, 2023, indicated that the resident was moderately cognitively impaired with a BIMS (brief interview to assess cognitive status) score of 9 (8-12 represents moderate cognitive impairment), required extensive assist of two people 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.