Patriot Village

Based on review of the facility's plans of correction for previous surveys, and the results of the current survey, it was determined that the facility's Quality Assurance Performance Improvement (QAPI) committee failed to correct quality deficiencies and ensure that plans to improve the delivery of care and services effectively addressed recurring deficiencies. Findings include:.The facility's deficiencies and plans of corrections for a State Survey and Certification (Department of Health) survey ending January 9, 2025, revealed that the facility developed plans of correction that included quality assurance systems to ensure that the facility maintained compliance with cited nursing home regulations. The results of the current survey, ending January 8, 2026, identified repeated deficiencies related to accuracy of MDS ( Minimum Data Sets) assessments, revision of residents' care plans, quality of care, and food stored, prepared and served in a sanitary manner.The facility's plan of corrections for deficiencies regarding accuracy of MDS assessments cited during the survey ending…

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

Based on review of facility policy and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that a resident's care plan was updated/revised to reflect the resident's specific care needs for five of 31 residents reviewed (Residents 46, 54, 65, 73, 77). Findings include: A facility policy regarding plans of care, dated August 28, 2024, indicated that resident assessments are ongoing and care plans are revised as information about the resident and their condition changes. The interdisciplinary team reviews and updates the care plan when there has been a significant change in the resident's condition; when the desired outcome is not met; when the resident has been readmitted to the facility from a hospital stay; and at least quarterly, in conjunction with the required quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs). An annual MDS assessment for Resident 46, dated October 17, 2024, revealed that the resident was cognitively intact, was understood and able to understand others, 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, as well as staff interviews, it was determined that the facility failed to provide care and treatment in accordance with professional standards of practice by failing to follow physician's orders for three of 31 residents reviewed (Residents 27, 50, 77), and failed to ensure that bowel protocols were followed as ordered by the physician for one of 31 residents reviewed (Resident 69). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 27, dated December 2, 2024, revealed that the resident was understood and could understand others, and had a diagnosis which included hypertension (high blood pressure). A care plan for the resident, dated August 8, 2024, revealed that the resident had an altered cardiovascular (relating to the heart and blood vessels) status related to hypertension and that staff were to administer the resident's medications per orders. Physician's orders for Resident 27, dated April 22, 2024, included an order for the resident to receive one…

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

Based on resident and staff interviews, and a meal test tray, it was determined that the facility failed to serve food items that were palatable to the residents. Findings include: Interview with Resident 73 on January 7, 2025, at 10:47 a.m. revealed that when she receives her meal tray, the food is not as warm as she likes it to be, and the taste of the food has a lot to be desired. Interview with Resident 74 on January 7, 2025, at 10:33 a.m. revealed that the food is cold. Interview with Resident 77 on January 7, 2025, at 11:12 a.m. revealed that the food is terrible and she only drinks milk. Interview with a group of residents on January 8, 2025, at 10:07 a.m. revealed that food is an ongoing issue. The food is cold, food is dry, and they always have pork and chicken. Interview with Resident 45 on January 8, 2025, at 12:07 p.m., while she was eating sweet and sour pork for lunch, revealed that she could not taste the sweet and sour. Observations in the kitchen of the tray line for the East Side Third floor cart on January 8, 2025, at 11:38 a.m. and First cart for East Side Third…

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

Based on review of policies, as well as observations and staff interviews, it was determined that the facility failed to ensure that food was stored and served in accordance with professional standards for food service safety. Findings include: The facility's policy regarding food preparation, dated August 28, 2024, revealed that the dinning services director/cook is responsible to ensure that proper practice is utilized in thawing frozen foods. One method is that frozen foods are completely submerged under cold water (70 degrees or below) that is running fast enough to agitate and float off loose ice particles. Observations in the kitchen on January 7, 2025, at 8:49 a.m. revealed a large bag of chicken in a sealed plastic bag in the kitchen sink submerged in water. No running water was observed. Observations in the kitchen on January 7, 2025, at 9:06 a.m. revealed a large bag of chicken in a sealed plastic bag in the kitchen sink submerged in water. No running water was observed. Interview with the Food Service Director at that time indicated that they usually put the frozen…

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

Based on review of clinical records, as well as observations and staff interviews, it was determined that the facility failed to maintain dignity for one of 33 residents reviewed (Resident 34) who had an indwelling urinary catheter. Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 34, dated December 19, 2024, indicated that the resident was understood and able to understand others, and had an indwelling urinary catheter (a flexible tube used to drain urine from the bladder into a drainage collection bag). A care plan for the resident, dated April 29, 2024, revealed that the resident had an indwelling urinary catheter. Staff were to cover the urinary drainage bag with a dignity cover and position the catheter bag and tubing below the level of the bladder and away from entrance room door. Physician's orders for Resident 34, dated August 22, 2024, included an order for the resident to have an indwelling urinary catheter for a diagnosis of obstructive uropathy (a condition that occurs when urine…

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

Based on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that the resident and/or resident representative had an opportunity to develop an advance directive (instructions regarding the provision of health care when the resident is incapacitated) or assist in formulating an advance directive for two of 31 residents reviewed (Residents 10, 46). Findings include: The facility policy regarding advance directives, dated August 28, 2024, indicated that prior to or upon admission of the resident, the social services director or designee inquires of the resident, his/her family members, and/or his or her legal representative about the existence of any written advance directive. The resident or representative is provided with written information concerning the right to refuse or accept medical or surgical treatment and to formulate an advance directive if he or she chooses to do so. If the resident or resident representative indicates that he or she has not established advance directives, the facility staff…

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 staff interviews, it was determined that the facility failed to provide a homelike environment for three of 31 residents reviewed (Residents 19, 69, 84). Findings include: Observations of Resident 19 on January 8, 2025, at 8:50 a.m. revealed that the resident was sitting in her room in a facility recliner that had the leather covering on the arms, seat and back of the chair heavily shredded and torn. In order to provide comfort, the resident had her own blanket covering the back of the chair. When asked if she minded the torn upholstery, the resident indicated that she would rather it had a brown slipcover like her roommate's recliner. Observations of Resident 69 on January 7, 2025, at 10:22 a.m. and January 8, 2025, at 8:57 a.m. revealed that the resident was sitting in his room in a facility recliner that had the leather covering on the arms, seat and back that was very heavily shredded and torn. Observations of Resident 84's facility recliner on January 8, 2025, at 8:53 revealed that the arms and back of the leather-type covering was shredded and torn.…

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

Based on clinical record reviews and staff interviews, it was determined that the facility failed to ensure that a written notice regarding emergency transfer to the hospital was provided to the Office of the State Long-Term Care Ombudsman, and failed to ensure that a written notice was provided to the resident and the resident's responsible party regarding the reason for transfer to the hospital for two of 31 residents reviewed (Residents 61, 73). Findings include: A significant change Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 61, dated December 6, 2024, indicated that the resident was cognitively intact, was understood, and could understand others. A nursing note, dated November 29, 2024, at 1:18 p.m., revealed that Resident 61 was diaphoretic (sweating), slurring words, and hypoxic. The resident began to vomit brown liquid and was then sent to the emergency room for evaluation and treatment. There was no documented evidence that a written notice of Resident 61's transfer to the hospital was provided to the…

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

Based on review of the Resident Assessment Instrument User's Manual and clinical records, as well as staff interviews, it was determined that the facility failed to complete accurate Minimum Data Set assessments for two of 31 residents reviewed (Residents 61, 74). Findings include: The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which provides guidance and instructions for the completion of Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October, 2024, indicated that the intent of Section N was to record the number of days, during the seven day assessment period, that any type of injection, insulin, and/or select medications were received by the resident. Section N0300 was to indicate if the resident received any type of injection during the last seven days and Section N0415B Antianxiety Medications was to be coded if the resident took the medication during the seven-day look-back period. Physician's orders for Resident 61, dated December 3, 2024, included an order for the resident to receive…

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 Pennsylvania Nurse Practice Act and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that physician's orders were clarified when needed for two of 31 residents reviewed (Residents 29, 73). Findings include: The Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.11 (a)(1)(2)(4) indicated that the registered nurse was to collect complete and ongoing data to determine nursing care needs, analyze the health status of individuals and compare the data with the norm when determining nursing care needs, and carry out nursing care actions that promote, maintain and restore the well-being of individuals. An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 29, dated December 2, 2024, revealed that the resident was understood, could understand others, had diagnoses that included end-stage renal disease (ESRD - a permanent condition that occurs when the kidneys are no longer able to function properly), 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, as well as staff interviews, it was determined that the facility failed to ensure that treatments and preventative measures for pressure ulcers were provided as ordered by the physician for two of 31 residents reviewed (Residents 19, 50). Findings include: An admission MDS assessment for Resident 19, dated December 6, 2024, revealed that the resident had mild cognitive impairment, was understood and able to understand others, had impaired mobility with deconditioning, had one pressure area, two unstageable and three Stage 3 pressure ulcers (pressure wound with skin loss) upon admission, and received pressure ulcer care. A care plan for Resident 19, dated December 8, 2024, revealed that staff was to administer treatments as ordered. Physician's orders for Resident 19, dated December 8, 2024, included an order to apply skin prep (protectant) to the purple area on the left lateral heel and cover with comfort foam (an absorbent dressing). Physician's orders, dated December 10, 2024, included an order to cleanse the right buttocks with wound cleaner,…

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 clinical records, as well as resident and staff interviews, it was determined that the facility failed to ensure that restorative nursing programs to maintain or improve physical abilities were provided as ordered and/or care planned for one of 31 residents reviewed (Resident 10). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 10, dated December 19, 2024, revealed that the resident was cognitively impaired, was usually understood and usually able to understand others, had functional limitation in range of motion (ROM - extend or limit to which a joint can be moved) to his bilateral upper and lower extremities, was dependent with care needs, and had diagnoses that included muscle contractures (a permanent shortening and tightening of muscle fibers that reduces flexibility and makes movement difficult) of multiple sites, contracture to right hand, and a personal history of traumatic brain injury. A care plan for Resident 10 addressing his decreased ROM and contractures,…

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

Based on review of clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that residents received proper care for indwelling urinary catheters for one of 31 residents reviewed (Resident 34). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 34, dated December 19, 2024, indicated that the resident was understood and able to understand others, and had an indwelling urinary catheter (a flexible catheter used to drain urine from the bladder into a drainage collection bag). A care plan for the resident, dated April 29, 2024, revealed that the resident had an indwelling urinary catheter and staff was to position the indwelling urinary catheter bag and tubing below the level of the bladder. Observations of Resident 34 on January 7, 2025, at 10:41 a.m. and 11:33 a.m. revealed that the resident was lying in bed with his indwelling urinary catheter drainage bag and tubing lying on the floor. Interview with Licensed Practical Nurse 1 on…

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

Based on review of policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that residents received oxygen as ordered by the physician for one of 31 residents reviewed (Resident 29). Findings include: The facility's policy regarding oxygen therapy, dated August 28, 2024, indicated that oxygen was to be administered in accordance with physician's orders. A admission Minimum data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 29, dated December 2, 2024, revealed that the resident was cognitively intact and had diagnoses that included congestive obstructive pulmonary disease (a lung disease causing restricted airflow and breathing problems) and heart failure (a condition in which the heart does not pump blood as well as it should). Resident 29's care plan, dated January 6, 2025, indicated that she had difficulty breathing related to chronic respiratory failure. Physician's orders for Resident 29, dated January 1, 2025, included an order for the resident to…

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

Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to maintain accountability for controlled medications (drugs with the potential to be abused) for one of 31 residents reviewed (Resident 50). Findings include: The facility's policy regarding documentation of medication administration, dated August 28, 2024, indicated that the nurse was to document all medications administered to each resident on the resident's medication administration record (MAR). An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 50, dated December 9, 2024, revealed that the resident had mild cognitive impairment, was understood and able to understand others, had pain, and was administered routine and as needed pain medications. Physician's orders for Resident 50, dated December 3, 2024, included an order for the resident to receive 5 milligrams (mg) of Oxycodone HCL (a narcotic drug used to treat moderate to severe pain) every four hours as needed for moderate to…

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

Based on review of manufacturer's instructions and clinical records, as well as observations and staff interviews, it was determined that the facility failed to maintain a medication administration error rate of less than five percent. Findings include: Observations during medication administration on January 8, 2025, at 8:19 a.m. and at 11:51 a.m. revealed that two medication administration errors were made during 36 opportunities for error, resulting in a medication administration error rate of 6.25 percent. Physician's orders for Resident 27, dated April 22, 2024, included an order for the resident to receive one 10 milligram (mg) tablet of Hydralazine (used to treat high blood pressure) three times a day. Staff was to hold the medication if the resident's systolic blood pressure (the top number of a blood pressure) was less than 100 millimeters of mercury (mmHg) or if the resident's heart rate was less than 60 beats per minute. Observations during the medication administration on January 8, 2025, at 8:19 a.m. revealed that Licensed Practical Nurse 7 prepared and administered…

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 facility policies, as well as observations and staff interviews, it was determined that the facility failed to properly date medications after they were opened in one of three medication carts reviewed (First floor cart), failed to discard expired medical supplies, and failed to sign out routine narcotics on the appropriate narcotic medication card (Residents 37, 69). Findings include: The facility's policy regarding medication storage and disposal, dated [DATE], revealed that the facility would properly date medication vials after they were opened and remove outdated supplies from the facility inventory. Observations in the First floor medication cart on [DATE], at 11:01 a.m. revealed that there was one 10 ml (milliliter) bottle of Systane (medication used to relieve dry, irritated eyes) eye drops opened and undated. Interview with Licensed Practical Nurse 6 on [DATE], at 11:10 p.m. confirmed that the Systane eye drops were open and should have been labeled with the date it was opened.…

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

Based on clinical record reviews, observations, and staff interviews, it was determined that the facility failed to provide adaptive eating equipment as ordered by the physician for one of 31 residents reviewed (Resident 69). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 69, dated November 20, 2024, indicated that the resident was cognitively intact and required set-up assistance from staff with eating. Physician's orders for Resident 69, dated November 4, 2024, included an order for built-up utensils for all meals. A care plan, dated June 20, 2024, indicated that the resident was to utilize built-up utensils. Observations of Resident 69 during the breakfast meal on October 9, 2024, at 8:26 a.m. revealed that the resident was in his room eating his meal with regular utensils and did not have built-up utensils. The resident's meal ticket included built-up utensils. Interview with Nurse Aide 9 at that time confirmed that Resident 69 did not have built-up utensils and should have had them.…

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

Based on review of the facility's plans of correction for previous surveys, and the results of the current survey, it was determined that the facility's Quality Assurance Performance Improvement (QAPI) committee failed to correct quality deficiencies and ensure that plans to improve the delivery of care and services effectively addressed recurring deficiencies. Findings include: The facility's deficiencies and plans of corrections for a State Survey and Certification (Department of Health) survey ending February 29, 2024, revealed that the facility developed plans of correction that included quality assurance systems to ensure that the facility-maintained compliance with cited nursing home regulations. The results of the current survey, ending January 9, 2025, identified repeated deficiencies related the accuracy of Minimum Data Set (MDS) assessments (mandated assessment of a resident's abilities and care needs), to care plan timing and revision, the failure to provide quality of care, issues with the accountability of controlled medications (drugs with the potential to be abused),…

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

Based on review of established infection control guidelines, facility policy, and residents' clinical records, as well as observations and staff interviews, it was determined that the facility failed to follow infection control guidelines from the Centers for Medicare/Medicaid Services (CMS) and the Centers for Disease Control (CDC) to reduce the spread of infections and prevent cross-contamination for one of 31 residents reviewed (Resident 50). Findings include: CDC guidance on isolation precautions and Implementation of Personal Protective Equipment (PPE) use in Nursing Homes to Prevent Spread of Multidrug-Resistant Organisms (MDRO's - bacteria that have become resistant to certain antibiotics, and these antibiotics can no longer be used to control or kill the bacteria), dated July 12, 2022, indicates that MDRO transmission is common in skilled nursing facilities, contributing to substantial resident morbidity and mortality and increased healthcare costs. Enhanced Barrier Precautions (EBP) are an infection control intervention designed to reduce transmission of resistant organisms…

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

Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to provide medication as ordered by the physician, resulting in significant medication errors for one of 37 residents reviewed (Resident 7). Findings include: The facility's policy regarding medication administration, dated January 1, 2024, indicated that residents were to receive all medications as per the physician's order meeting the requirements of the right dose, right route, at the right rate, at the right time, and for the right resident. An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 7, dated December 19, 2023, indicated that the resident was alert and oriented, received insulin, and had diagnoses that included diabetes. Physician's orders for Resident 7, dated December 14, 2023, included an order for the resident to receive 5 units of Insulin Lispro (fast acting insulin) subcutaneously (beneath the skin) twice a day for diabetes and to hold the insulin if the resident's 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.

Based on review of manufacturer's instructions and clinical records, as well as observations and staff interviews, it was determined that the facility failed to store unopened (unused) multi-dose containers of insulin according to manufacturer's instructions for one of 37 residents reviewed (Resident 22), and failed to ensure that controlled refrigerated medications were stored in a separately-locked, permanently-affixed container in one of two medication refrigerators reviewed (third-floor east medication room refrigerator). Findings include: Manufacturer's directions for Insulin Lispro (Humalog - a fast-acting insulin used to lower blood sugar levels), dated July 2023, indicated to store unused pens in the refrigerator at 36 degrees Fahrenheit (F) to 46 degrees F. Unused pens may be used until the expiration date printed on the label if the pen has been kept in the refrigerator. Physician's orders for Resident 22, dated January 30, 2024, included an order for the resident to receive Insulin Lispro as per a sliding scale (the amount of Insulin given was determined by the 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 facility policies, as well as observations and staff interviews, it was determined that the facility failed to store food in accordance with professional standards for food service safety by failing to store food under sanitary conditions, failing to ensure that dietary staff wore appropriate hair coverings, and failing to ensure that a microwave was clean and free of deterioration, for one of three microwaves reviewed (first-floor pantry) Findings include: The facility's policy regarding uniform dress code, dated January 31, 2024, revealed to restrain all facial hair with a beard net/restraint. Observations in the outside walk-in freezer on February 26, 2024, at 8:53 a.m. and February 27, 2024, at 1:15 p.m. revealed that there was an accumulation of ice on the ceiling and floor, as well as on a plastic jug that contained water, a case of ham, and a case of roast beef that were stored on the shelves below the freezer condenser. Interview with the Dietary Manager on February 27, 2024, at 1:15…

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

Based on review of the Resident Assessment Instrument User's Manual and clinical records, as well as staff interviews, it was determined that the facility failed to complete accurate comprehensive Minimum Data Set assessments for two of 45 residents reviewed (Residents 30, 72). Findings include: The RAI User's Manual, dated October, 2023, indicated that Sections P0100A-P0100H were to capture physical restraint use, Section E0100A-H was to be coded (0) when restraints are not used, (1) when a restraint was used less than daily, and (2) when a restraint was used daily. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) (for Resident 30, dated November 24, 2023, revealed that section P0100F (limb restraint) was coded (1) used less than daily. Observations of Resident 30 in the dining room on February 26, 2024, at 12:29 p.m. revealed the resident was sitting in her broda chair with no restraints. Interview with Licenced Practical Nurse 1 on February 28, 2024, at 1:55 p.m. revealed that Resident 30 does not have a limb…

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 facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that baseline care plans included the information and instructions needed to provide person-centered care for one of 37 residents reviewed (Resident 80). Findings include: The facility's policy regarding baseline care plans, dated January 31, 2024, indicated that within 24-48 hours of admission the facility was to coordinate the gathering, assessment, and evaluation of information from all sources (hospital, facility assessments and notes, resident/resident representative interview) and initiate the resident's care plan. No later than 48 hours after admission the Registered Nurse Assessment Coordinator (RNAC- a registered nurse who is often involved in the development of residents' care plans) or designated person would ensure that the baseline care plan was in place and all required items were addressed. admission information for Resident 80 revealed that he was admitted…

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

Based on clinical record reviews and staff interviews, it was determined that the facility failed to ensure that residents' care plans were reviewed and revised to reflect their current care needs for two of 37 residents reviewed (Residents 35, 42). Findings include: A significant change Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 35, dated December 18, 2023, revealed that the resident was cognitively intact and required extensive assistance for daily care tasks. The resident's care plan, dated November 14, 2023, revealed that the resident was medicated with an anticoagulant (blood thinner); however, the resident's anticoagulant was discontinued on December 13, 2023. There was no documented evidence that Resident 35's care plan was updated to reflect the discontinuation of the anticoagulant. Interview with the Director of Nursing on February 28, 2024, at 3:42 p.m. confirmed that Resident 35's care plan should have been updated to reflect the discontinuation of the anticoagulant and it was not. A significant change…

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

Based on clinical record reviews and staff interviews, it was determined that the facility failed to complete treatments as ordered by the physician for one of 37 residents reviewed (Resident 78). Findings include: An admission skin assessment, dated February 24, 2024, revealed that Resident 78 had scabs on his second, fourth, and fifth toes of the left foot. Physician's orders, dated February 25, 2024, included an order to apply skin prep (protective film) to the second, fourth, and fifth toe of the left foot every day shift. A comprehensive admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated June 26, 2021, revealed that the resident was able to make himself understood and could understand others, required supervision with daily care activities, had a surgical wound that required treatments, and had diagnoses that included a wound infection. Physician's orders, dated June 20, 2021, included an order to clean the resident's abdominal wounds with normal saline solution (medical grade salt water) and pack…

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

Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to maintain accountability for controlled medications (drugs with the potential to be abused) for one of 37 residents reviewed (Residents 42). Findings include: The facility's policy regarding controlled substances, dated January 31, 2024, indicated that accurate accountability of the inventory of all controlled drugs is maintained at all times. When a controlled substance was administered, the licensed nurse administering the medication was to immediately enter the following information on the accountability record and Medication Administration Record (MAR): date and time of administration, amount administered, remaining quantity, and the initials of the nurse administering the dose, completed after the medication is actually administered. A significant change Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 42, dated December 15, 2023, revealed that the resident was cognitively intact, required…

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

Based on clinical record reviews and staff interviews, it was determined that the facility failed to ensure that non-pharmacological (non-medication) interventions were attempted prior to the administration of anti-anxiety medications for one of 37 residents reviewed (Resident 53). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 53, dated January 30, 2024, indicated that the resident was cognitively impaired and had diagnoses that included anxiety. Physician's orders for Resident 53, dated January 28, 2024, included an order for the resident to receive 0.5 milligrams (mg) of Ativan (an antianxiety medication) every six hours as needed for anxiety. Resident 53's care plan, dated January 28, 2024, revealed that the resident used an antianxiety medication related to anxiety. Resident 53's Medication Administration Records (MAR's) for February 2024 revealed that staff administered as needed Ativan to the resident on February 1 at 12:41 a.m. and 9:30 p.m., February 2 at 5:21 a.m., February 5 at…

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

Based on clinical records reviews, observations, and staff interviews, it was determined that the facility failed to maintain clinical records that were complete and accurately documented for two of 37 residents reviewed (Residents 7, 42). Findings include: An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 7, dated December 19, 2024, revealed that the resident was cognitively intact, had pressure ulcers (skin impairment caused by pressure), and received pressure ulcer care. Physician's orders, dated December 18, 2023, included an order for collagen (promotes wound healing, silver alginate (prevents infection) and a bordered foam covering be applied to the left heel every day shift. A wound note, dated February 20, 2024, revealed the resident had a Stage 3 pressure ulcer (a full thickness tissue loss where subcutaneous fat may be visible) on the left heel that measured 1.3 x 0.6 x 0.3 centimeters (cm). Resident 7's Treatment Administration Records (TAR's) for February 2024 revealed that there was no documented…

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

Based on review of the facility's plans of correction for previous surveys, and the results of the current survey, it was determined that the facility's Quality Assurance Performance Improvement (QAPI) committee failed to correct quality deficiencies and ensure that plans to improve the delivery of care and services effectively addressed recurring deficiencies. Findings include: The facility's deficiencies and plans of correction for the State Survey and Certification (Department of Health) survey ending March 2, 2023, revealed that the facility developed plans of corrections that included quality assurance systems to ensure that the facility-maintained compliance with cited nursing home regulations. The results of the current survey, ending February 29, 2024, identified repeated deficiencies related to a failure to complete Minimum Data Set (MDS) assessments (mandated assessments of residents' abilities and care needs) accurately, revision of care plans, following physician's orders, to prepare and store food under sanitary conditions, and to maintain complete and accurate 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 facility policies and residents' clinical records, as well as staff interviews, it was determined that the facility failed to honor a power of attorney's right to make informed choices and participate in treatment decisions for one of four residents reviewed (Resident 1). Findings include: The facility's policy regarding resident rights, dated March 22, 2023, revealed that residents and/or their representatives have the right to be fully informed of their medical condition in a language they can understand, and to participate in person-centered care planning and treatment, including the type of caregiver who provides services. The residents also have the right to refuse and/or discontinue medications and treatments and to formulate an advanced directive. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated August 29, 2023, revealed that the resident was sometimes understood, sometimes understands, required extensive assistance with her daily care tasks including with eating, was…

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

Based on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included specific and individualized interventions for two of six residents reviewed (Residents 1, 2). Findings include: The facility's policy regarding care planning, dated March 23, 2023, indicated that the interdisciplinary team is responsible to develop and implement a comprehensive person-centered care plan that includes measurable objectives and timeframes to meet the resident's medical, nursing, mental, and psychosocial needs that have been identified in the comprehensive assessment. The comprehensive care plan will meet professional standards of quality and services and will be provided by qualified persons. A quarterly MDS assessment for Resident 1, dated August 28, 2023, indicated that the resident was cognitively impaired, was independent with transfers and ambulation, had no behaviors, and had diagnoses that included dementia, anxiety and depression. 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.

Based on review of job descriptions and the deficiencies cited during the current survey, it was determined that the Nursing Home Administrator (NHA) and the Director of Nursing (DON) failed to assume responsibility for effective management of the facility to ensure that the residents' environment remained free of accident hazards, and for ensuring that each resident receives and is provided food prepared in a form designed to meet individual needs. Findings include: The job description for the NHA, dated March 8, 2023, indicated that the primary function of this position was to establish and direct the overall operation of the facility's operations in compliance with all federal, state, and local guidelines, standards and regulations as directed by the Senior [NAME] President and/or President so as to ensure that each resident receives the highest standard of care and services and to ensure the facility is operated in a prudent and fiscally responsible fashion. That the administrator has total responsibility for the nursing home's operation on a 24-hour/seven day per week basis,…

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.