Greenwood Center For Nursing And Rehab

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of clinical records, select facility policy, state professional nursing standards, and staff interview, it was determined the facility failed to ensure nursing services were provided in accordance with professional standards of quality by not ensuring licensed nurses accurately administered a prescribed medication within the physician-ordered parameters for one of four sampled residents (Resident 1).Findings include:According to the Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.11 (a)(1)(2)(4) indicates the registered nurse was to 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 of the health-care team by exercising sound judgement based on preparation, knowledge, skills, understandings and past…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of clinical records, select facility policy, pharmacy records and staff and resident interviews, it was determined that the facility failed to ensure a resident's medication regime was free from significant medication errors for one of four residents reviewed (Resident 2). Findings include: Review of the facility policy titled Administering Medications last reviewed by the facility on June 1, 2025, revealed that medications are administered as prescribed and in a safe and timely manner. The policy required staff to verify medication allergies and obtain vital signs, as applicable, prior to administering medications. A review of the clinical record revealed Resident 2 was admitted to the facility on [DATE], with diagnoses to include Type 2 Diabetes (a chronic condition in which the body has difficulty controlling blood sugar and using it for energy), congestive heart failure (weakness of the heart that leads to build-up of fluid in the lungs and surrounding body tissues), and nausea and vomiting.…

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 facility's abuse policy, clinical records, and select investigative reports and staff interview it was determined the facility failed to assure that one resident (Resident 2) was free from sexual abuse/harassment perpetrated by another resident (Resident 1) and out of 9 residents sampled.Findings included: A review of the current facility policy titled Abuse Policy, last reviewed by the facility on September 2024, revealed the resident has the right to be free from abuse, neglect, and misappropriation of resident property. Residents must not be subject to abuse by anyone, including but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies, family members or legal guardians, or other individuals. Further review defined sexual abuse as non-consensual sexual contact of any type with a resident including sexual harassment, sexual assault. A review of Resident 1's clinical record revealed admission to the facility on April 22, 2024, with diagnoses to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of select facility policy, facility investigative reports, clinical records and staff interviews it was determined the facility failed to ensure a complete and accurate investigation into sexual abuse was completed for one resident out of 9 sampled (Resident 2). Findings included: A review of the current facility policy titled Abuse Policy, last reviewed by the facility on September 2024, revealed the resident has the right to be free from abuse, neglect, and misappropriation of resident property. Further review of the facility abuse policy revealed under the area of investigation all reports of resident abuse, neglect, exploitation, misappropriation, shall be promptly reported to local, state and federal agencies as defined by current regulations, and thoroughly investigated by the administrator and or designee. The administrator or his/her designee will provide appropriate agencies or individuals within five working days of the occurrence of the incident. 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of the facility's plan of correction from the survey ending July 24, 2025, the outcome of the activities of the facility's quality assurance committee, a review of clinical records, and staff interviews, it was determined the facility failed to maintain compliance with nursing home regulations and ensure that plans to improve the delivery of care and services effectively addressed recurring deficiencies for one of six residents reviewed related to ensuring residents are free from sexual abuse (Resident 3) perpetrated by another resident (Resident 1). Findings include: As a result of the deficiencies cited under the requirements related to ensuring residents are free from sexual abuse during the survey of July 24, 2025, the facility developed a plan of correction to serve as their allegation of compliance, which included a quality assurance monitoring component to ensure that solutions were sustained. This corrective plan was to be completed and functional by August 19, 2025. However, during 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 resident and staff interviews, it was determined that the facility failed to ensure that written notice, including the reason for a room change, was provided to residents and/or their resident representatives prior to a facility-initiated room change for three of eight residents reviewed (Residents CR1, 3, and 4). Findings include: Federal regulatory guidance under §483.10(e)(6) notes that moving to a new room or changing roommates is challenging for residents. A resident's preferences should be taken into account when considering such changes. When a resident is being moved at the request of facility staff, the resident, family, and/or resident representative must receive an explanation in writing of why the move is required. The resident should be provided the opportunity to see the new location, meet the new roommate, and ask questions about the move. At the time of the survey ending June 17, 2025, all beds in the facility were licensed and dually certified for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of clinical records, medication error reports, and staff interview it was determined that the facility failed to provide nursing services consistent with professional standards of practice by failing to follow physician's orders and assure that two residents out of eight reviewed were free of significant medication errors (Resident CR1 and Resident 2). Findings include: The Principles of Medication Administration, The Five Rights of Medication Administration indicate that when you are giving medication, regardless of the type of medication, you must always follow the five rights. Each time you administer a medication, you need to be sure to have the: 1. Right individual 2. Right medication 3. Right dose 4. Right time 5. Right route According to the Pennsylvania Code Title 49, Professional and Vocational Standards Department of State, Chapter 21 State Board of Nursing, Chapter 21.145 Functions of the LPN (Licensed Practical Nurse) requires the following: 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of clinical records, facility-initiated transfer notices, and staff interview, it was determined the facility failed to provide copies of written notice of facility-initiated hospital transfer notces for residents to a representative of the Office of the State Ombudsman for three out of 12 residents reviewed (Residents 1, 23, and 90). Findings include: A review of the clinical record revealed that Resident 1 was transferred to the hospital on February 10, 2025, and was readmitted to the facility on [DATE], Although written notices were provided to the resident and resident representative of the facility-initiated transfer, there was no documented evidence the facility sent copies of written notices of these facility-initiated transfers to the representative of the Office of the State Long-Term Care Ombudsman. A review of the clinical record revealed that Resident 23 was transferred to the hospital on November 5, 2024, and was readmitted to the facility on [DATE]. Although written notices were…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, clinical record review, resident and staff interviews, and a review of nurse staffing data, it was determined the facility failed to provide sufficient nursing staff to ensure timely and quality care for 5 of 28 residents sampled (Residents 11, 17, 25, 59, and 97), and failed to ensure adequate response times and care provision as reported by 3 of 6 residents interviewed during a group resident interview (Residents 7, 21, and 41). Findings included: A review of the clinical record revealed that Resident 59 was admitted to the facility on [DATE], with diagnoses to include multiple sclerosis (an immune-inflammatory disease that attacks and damages cells in the central nervous system and causes neurological impairment) and dysphagia (difficulty swallowing). A quarterly Minimum Data Set assessment (MDS-a federally mandated standardized assessment process conducted periodically to plan resident care) dated January 31, 2025, revealed that Resident 59 is moderately cognitively impaired with a BIMS…

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, clinical record review, and resident and staff interviews, it was determined the facility failed to maintain residents' rights to privacy and confidentiality by placing health care information in a place compromising the resident's privacy for one out of the 28 residents sampled (Resident 205) and failed to ensure that mail was delivered unopened to one of the 28 residents interviewed (Resident 3). Findings include: A clinical record review revealed Resident 205 was admitted to the facility on [DATE], with diagnoses that included acute respiratory failure (a condition where the lungs fail to adequately exchange oxygen and carbon dioxide). A physician's order to maintain standard and transmission-based precautions due to SARS-CoV-2 (COVID-19) precautions was implemented on April 8, 2025. Further clinical record review revealed a care plan focus indicating Resident 205 has altered respiratory status and difficulty breathing related to a COVID-positive diagnosis initiated on April 9, 2025.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of clinical records, the Resident Assessment Instrument (RAI), and staff interview, it was determined the facility failed to ensure the Minimum Data Set Assessments (MDS - a federally mandated standardized assessment conducted at specific intervals to plan resident care) accurately reflected the status of two residents out of 28 sampled (Residents 101 and 102). Findings include: According to the Resident Assessment Instrument (RAI) User's Manual (an assessment tool utilized to gather definitive information on a resident's strengths and needs, which must be addressed in an individualized care plan, and the RAI also assists staff to evaluate goal achievement and revise care plans accordingly by enabling the facility to track changes in the resident's status) dated October 2024, Section A2105: Discharge Status indicates to review the medical record, including the discharge plan and discharge orders, for documentation of discharge location. A clinical record review revealed Resident 102 was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of select facility policy, clinical records, facility-provided documentation, and staff interviews, it was determined the facility failed to provide services in accordance with professional standards of practice by failing to follow physician orders for wound treatments for one resident out of 28 residents reviewed. (Resident 255) Findings include: A review of the facility policy titled Wound Care, last reviewed March 2025, revealed that all dressing changes must be marked with the date, time, and initials of the staff applying the treatment. The policy further directed that all wound care treatments must be documented in the clinical record at the time they are completed to ensure accurate and timely documentation of care provided. A review of Resident 255's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses which include pneumonia (an infection in one or both lungs) and venous insufficiency (a condition where blood flow through the veins is impaired,…

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 policy review, and staff interviews, it was determined the facility failed to ensure the ready availability of necessary emergency dialysis supplies for one of two residents reviewed who received hemodialysis (Resident 48). Findings include: According to the National Kidney Foundation, patients receiving hemodialysis, (a life-sustaining treatment for individuals with kidney failure that removes waste and excess fluids from the blood) must have access to emergency supplies, such as clamps and pressure dressings, in the event of complications such as hemorrhage or catheter dislodgement. A review of the facility policy titled Care of Resident with End Stage Renal Disease, last reviewed in March 2025, indicated that nursing staff will be trained to provide care to dialysis residents, including the ability to recognize and respond to medical emergencies such as hemorrhage or infection. A review of Resident 48's clinical record revealed the resident 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, clinical record review, select facility policy, and staff and resident interviews, it was determined the facility failed to ensure the correct installation of bed rails was implemented for one out of the 28 residents sampled (Resident 33). Findings include: A review of facility policy titled Use of Bed Rails, last reviewed by the facility in March 2025, revealed it is the facility's policy to ensure the safe use of bed rails as resident mobility aids and prohibit the use of bed bedrails as restraints unless necessary to treat a resident's medical condition. The policy indicates manufacturer's instructions for the operation of bed rails will be adhered to. A clinical record review revealed Resident 33 was admitted to the facility on [DATE], with diagnoses that included morbid obesity (a chronic disease that's characterized by a body mass index of 40 or higher, or a body mass index of 35 or higher with obesity-related health issues) and bradycardia (a condition where the heart beats slower…

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 implement procedures to ensure the timely acquisition and administration of a prescribed medication for one of 28 sampled residents (Resident 74). Findings include: A clinical record review revealed Resident 74 was admitted to the facility on [DATE], with diagnoses that included cerebral infarction (brain damage that results from a lack of blood). Review of an inter-facility transfer after-visit summary dated April 7, 2025, indicated Resident 74 was admitted to the community hospital on April 6, 2025, and discharged back to the facility on April 7, 2025. The discharge summary included a recommendation for the resident to begin taking gabapentin 100 mg capsules (an anticonvulsant and nerve pain medication), one capsule by mouth three times a day, for pain and discomfort. A review of the resident's medication administration record (MAR) for April 2025 revealed that Resident 74 did not receive any doses 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 observation, a review of the facility's planned menus, and resident and staff interviews, it was determined that the facility failed to accommodate individual food preferences, to the extent possible, to increase resident satisfaction with meals for residents, which included two residents out of the 28 residents sampled (Residents 11 and 60), as expressed by one out of six residents during a resident group interview (Resident 21). Findings include: During an interview on April 13, 2025, at 12:15 PM, Resident 11 indicated that he is consistently served meals that do not match his preferences. He explained that he does not like eggs or Brussels sprouts, but the facility does not honor his preferences. He explained that he has refused his breakfast many times because eggs were served. Resident 11 indicated when they serve Brussels sprouts, he is not offered an alternative vegetable. During an observation on April 13, 2025, at 12:30 PM, Resident 11's lunch meal tray was observed with brussels sprouts. Resident 11's tray had a meal ticket indicating the resident disliked…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, clinical record review, and staff interview, it was determined the facility failed to ensure the provision of adaptive dining equipment as prescribed to support safe eating for one of 28 sampled residents (Resident 59). Findings include: A review of the clinical record revealed that Resident 59 was admitted to the facility on [DATE], with diagnoses to include multiple sclerosis (an immune-inflammatory disease that attacks and damages cells in the central nervous system and causes neurological impairment) and dysphagia (difficulty swallowing). A review of Resident 59's comprehensive plan of care dated March 2, 2020, indicated a focus on aspiration precautions. The care plan was revised on September 26, 2024, following a documented choking episode, to include staff-assisted feeding using a small maroon dysphagia spoon (a spoon with a narrow, shallow bowl that promotes more efficient food transfer). The care plan stated that this specific adaptive dining utensil was to be provided on all trays…

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 interview, it was determined the facility failed to maintain acceptable practices for the storage and service of food to prevent the potential for contamination and microbial growth in food, which increased the risk of food-borne illness in the food and nutrition services department. Findings include: Food safety and inspection standards for safe food handling indicate that everything that comes in contact with food must be kept clean and food that is mishandled can lead to foodborne illness. Safe steps in food handling, cooking, and storage are essential in preventing foodborne illness. You cannot always see, smell, or taste harmful bacteria that may cause illness according to the USDA (The United States Department of Agriculture, also known as the Agriculture Department, is the U.S. federal executive department responsible for developing and executing federal laws related to food). Observation during the initial tour of the kitchen conducted with the facility's dietary manager on April 13, 2025, at 9:30 AM revealed the following unsanitary practices…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of select facility policy, clinical record review, and staff interviews, it was determined the facility failed to afford a resident and their designated representative the right to participate in the development of the resident's plan of care for one resident out of seven residents sampled (Resident 3). Findings include: A review of the facility policy titled, Resident Participation- Assessment/Care Plans, last revised February 2021, revealed the resident and his or her representative are encouraged to participate in the resident's assessment and in the development and implementation of the resident's care plan. Furthermore, the policy indicated facility staff support and encourage resident and resident representative participation in the care planning process by providing sufficient notice in advance of the care plan meeting and planning for enough time for exchange of information and decision-making. The social services director or designee is responsible for notifying the resident 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 review of select facility policy and reports and clinical records and resident and staff interviews, it was determined that the facility failed to demonstrate the implementation of ongoing QAPI programs, to include the use of systems for investigating and analyzing the root cause of adverse events as evidenced by one resident out of six sampled (Resident B1). Findings include: Review of the facility policy titled Quality Assurance and Performance Improvement last reviewed in January 2024, revealed that the facility shall develop, implement and maintain an effective, comprehensive, data-driven QAPI program that is focused on indicators of the outcomes of care and quality of life for the residents. The policy guidance of the QAPI program is to: (1) Maintain documentation and demonstrate evidence of its ongoing QAPI program which may include but is not limited to: a. systems and reports demonstrating systematic identification, reporting, investigation, analysis, and prevention of adverse events; and b.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and resident and staff interviews, it was determined that the facility failed to provide care in a manner and environment that promotes each resident's quality of life by failing to respond timely to residents' requests for assistance as evidenced by four residents out of 18 sampled (Residents 3, 26, 40 and 79). Findings include: A clinical record review revealed that Resident 40 had diagnoses, which included congestive heart failure (a chronic condition in which the heart does not pump blood as well as it should) and diabetes mellitus. A review of a quarterly Minimum Data Set assessment (MDS - a federally mandated standardized assessment process conducted periodically to plan resident care) dated April 12, 2024, revealed that Resident 40 is cognitively intact with a BIMS score of 15 (Brief Interview for Mental Status- a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; 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 observations and staff interview, it was determined that the facility failed to maintain a clean and orderly environment in resident areas on two of two resident units (West and East Nursing Units). Findings include: Observations on May 14, 2024, at approximately 11:10 AM of the [NAME] Nursing Unit revealed the following: Resident room [ROOM NUMBER] gouges in the surface of the wall were observed behind the resident's nightstand. Multiple small holes were in the wall by the resident's dressers. The paint on the wall was bubbling behind the toilet in the bathroom in this resident room and two holes in the hall near the toilet paper holder. Resident room [ROOM NUMBER] observations revealed that resident's dinner tray from the prior evening, Monday May 13, 2024, remained on the nightstand. There were dirty used gloves atop the dinner tray. The resident's breakfast tray from that morning was also still in the room on the over the bed table. There were food particles and wrappers on the floor. [NAME] stains…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, a review of clinical records, and staff interviews, it was determined that the facility failed to provide supplemental oxygen administration as ordered for one of 18 residents reviewed (Resident 64). Findings include: A review of Resident 64's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses which included shortness of breath and chronic respiratory failure with hypoxia (low levels of oxygen in your body). The resident had physician's orders as follows: Oxygen at 2 liters per minute per nasal cannula every shift for shortness of breath initially dated March 8, 2023; Check oxygen humidification water level and replace as needed initially dated March 8, 2024; Change oxygen tubing, humidification bottle, clean oxygen filter, and inspect easy foam wraps every Saturday on night shift initially dated March 8, 2024. Observation of Resident 64 on May 14, 2024, at approximately 11:15 AM revealed the resident was in bed with his supplemental oxygen in…

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 ensure that physician orders for individual pain management regimens were followed for five of 18 residents reviewed for pain management (Resident 54, 86, 64, 17 and 190). Findings include: A review of the clinical record revealed Resident 54 was admitted to the facility on [DATE], with diagnoses to include chronic pain disorder, rheumatoid arthritis ([RA] an autoimmune disorder that attack the joints and causes pain) and progressive neuropathy (nerve pain). A physician order dated February 6, 2024, at 3:27 PM was noted for Tramadol (pain medication) 50 milligrams (mg) by mouth every six hours as needed for severe pain related to chronic pain with a pain level 8-10. Review of the resident's Medication Administration Record (MAR) for the month of April 2024 revealed that nursing administered the prn opioid pain medication, Tramadol, to the resident on the following dates for pain rated lower than the 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 a review of clinical records and controlled drug medication sheets, and staff interview, it was determined that the facility failed to implement procedures to promote accurate accounting of controlled medications for three of four residents sampled (Resident 64, 54, and 52). Findings include: A review of Resident 64's clinical record revealed that the resident was admitted to the facility on [DATE], with diagnoses which included lower back pain and abdominal pain. A review of the resident's clinical record revealed that Resident 64 had a physician order initially dated March 27, 2024, and revised on April 4, 2024, for Oxycodone HCL (a narcotic opioid pain medication) 5 mg tablet every 6 hours as needed for pain level 8 to 10. A review of the resident's controlled substance records accounting for the above controlled medication revealed on April 8, 2024, at 12:00 AM, April 18, 2024, at 12:00 AM, and May 10, 2024, at 11:00 PM revealed that nursing staff signed out a dose of the resident's supply 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 observation, resident and staff interviews, and test tray results it was determined that the facility failed to serve meals that are palatable, attractive, and at a safe and appetizing temperature. Findings include: According to the federal regulatory guidance at 483.60(i)-(2) Food safety requirements - the definition of Danger Zone, found under the Definitions section, is food temperatures above 41 degrees Fahrenheit and below 135 degrees Fahrenheit that allow rapid growth of pathogenic microorganisms that can cause foodborne illness. During an interview with Resident 40 on May 14, 2024, at 11:00 AM the resident stated that the food is often not hot enough when served. During an interview with Resident 45 on May 14, 2024, at 11:33 PM the resident states that the food served in the facility could taste better. During an interview with Resident 79 on May 14, 2024, at 11:51 PM the resident states that the food tastes lousy here and is never hot when served. During an interview with Resident 3 on May 14, 2024, at 12:02 PM the resident stated that the food is not served hot 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 observation, a review of the facility's planned menus and grievances submitted to the facility, and resident and staff interview it was determined that the facility failed to provide preferred food as planned and accommodate individual food preferences to the extent possible to increase satisfaction with meals for seven residents out of 18 sampled (Residents 40, 3, 28, 69, 45, and 19). Findings include: A review of the facility's 2 Gram Sodium Diet revealed that this diet is a strict sodium restriction omitting the use of saltshaker at the table and cooking. Salted food items and foods of sodium content are eliminated or replaced with a low-sodium alternate unless otherwise calculated into the diet by the dietitian. The diet can be individualized. Review of Grievance/Concern Form dated March 25, 2024, revealed that Resident 3 had a concern related to her lunch. She had selected a steak sub on her meal ticket but received baked ziti. The resident indicated that the kitchen said I knew they did not have steak subs left, but I was not informed of this, I also did not get a tea…

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 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 18 sampled (Resident 17). Findings include: According to the RAI User's Manual dated October 2023, Section J0100 Pain Management reflects pain medication the resident received in the last 5 days. The quarterly MDS Assessment of Resident 17 dated March 12, 2024, revealed Section J0100 indicated the resident did not receive scheduled pain medication or as needed pain medication in the last 5 days. A review of Resident 17's March 2024 Medication Administration Record revealed that the resident received physician prescribed Acetaminophen as needed pain medication 5 times in the last 5 days. Review of Section J Other Orthopedic Surgery indicated under J2500 that Resident 17 had…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of clinical records and staff interview, it was determined that the facility failed to revise the residents' comprehensive plan in response to a change in condition for two residents out of 18 reviewed (Resident 77 and 17). Findings include: A review of Resident 77's clinical record revealed that the resident was admitted to the facility on [DATE], with diagnoses which included malignant neoplasm of the prostate and obstructive and reflex uropathy. A review of the resident's comprehensive plan of care, last revised by the facility March 19, 2024, revealed that the resident had an indwelling catheter, a 16 French Foley catheter (a medical device place through your urethra into your bladder to drain urine) with a 30 cc balloon. A review of a progress note dated April 5, 2024 at 3:54 PM indicated the resident had a suprapubic catheter (a medical device that helps drain urine from your bladder. It enters your body through a small incision in your abdomen) placed. A review of physician's orders dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of clinical records, and staff interview, it was determined that the facility failed to accurately assess bowel and bladder function and implement individualized approaches to restore normal bowel and bladder function to the extent possible for one out of 18 sampled residents (Resident 86). Findings include: A review of the clinical record revealed that Resident 86 was admitted to the facility on [DATE], with diagnoses which included chronic kidney disease, unsteadiness on feet, and muscle weakness. A review of the resident's three day bowel and bladder diary completed April 29, 2024, revealed that the resident was frequently incontinent of urine. However, a review of the resident's admission bowel and bladder assessment dated [DATE], indicated that the resident was continent of bowel and bladder. A review of Resident 86's admission Minimum Data Set assessment (MDS- a federally mandated standardized assessment process conducted periodically to plan resident care) dated May 2, 2024, revealed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, review of clinical records, and staff interview, it was determined that the facility failed to provide person-centered care for one resident receiving hemodialysis services out of 18 sampled (Resident 80). Findings include: A review of the clinical record revealed that Resident 80 was admitted to the facility on [DATE], with diagnoses to include stage 4 chronic kidney disease and dependence on renal dialysis (a procedure to remove waste products and excess fluid from the blood when the kidneys stop working properly). A review of a progress note dated May 6, 2024, at 10:00 AM revealed that the resident was on a leave of absence from the facility to go to dialysis. A review of a progress note dated May 8, 2024, at 10:30 AM indicated the resident left for dialysis in stable condition. A review of a progress note dated May 10, 2024, at 9:50 AM revealed the resident left the facility in stable condition to go to dialysis services. A review of a progress note dated May 15, 2023, at 10:00 AM…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of select facility reports and clinical records and staff interview it was determined that the facility failed to assure that nursing staff possessed the necessary knowledge, competencies, and skill sets to provide care to meet a resident's individualized needs as identified in the resident's current plan of care for one resident out of 18 sampled (Resident 22). Findings include: A review of the clinical record of Resident 22 revealed admission to the facility on March 11, 2013, with diagnoses including Lennox-Gas taut Syndrome (a rare and severe form of epilepsy (seizure - a period of abnormally excessive neuronal activity in the brain) that starts in childhood and causes multiple types of seizures), intractable with status epilepticus, localization -related (focal)(partial) symptomatic epilepsy and epileptic syndromes with simple partial seizures, intractable with status epilepticus and anoxic (without oxygen) brain damage. A quarterly MDS assessment dated [DATE], revealed that 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 a review of clinical records and staff interview, it was determined that the facility failed to develop and implement an effective individualized person-centered plan to address a resident's dementia-related behavioral symptoms for one out of 18 residents reviewed (Resident 20). Findings include: A review of Resident 20's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses to include vascular dementia (A condition caused by the lack of blood that carries oxygen and nutrient to a part of the brain. It causes problems with reasoning, planning, judgment, and memory.) A review of Resident 20's Quarterly Minimum Data Set Assessment (MDS - a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated April 17, 2024, revealed the resident was severely cognitively impaired. A review of progress notes in the resident's clinical record dated from February 01, 2024 to May 16, 2024, revealed that the resident exhibited behaviors 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 clinical record review and staff interview it was determined that the facility failed to ensure accurate medication labeling for one of 18 residents sampled (Resident 54). Findings include: Review of Pa Code Chapter 27. State Board of Pharmacy, 27.18 Standards of Practice, (d) The container in which a prescription drug or device is sold or dispensed to the ultimate consumer shall bear a label which shall be written in ink, typed or computer generated and shall contain the following information: (1) The name, address, telephone number and DEA number of the pharmacy. (2) The name of the patient. (3) Full directions for the use of its contents. (4) The name of the prescriber. (5) The serial number of the prescription and the date originally filled. (6) The trade of brand name of the drug, strength, dosage form and quantity dispensed, the manufacturer's name shall also be shown. (7) On controlled substances, the statement: Caution: Federal law prohibits the transfer of this drug to any person other than 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 18 sampled (Resident 39). Findings included: A review of clinical record revealed Resident 39 was admitted to the facility on [DATE], with diagnoses, which included dementia. A CRNP (certified registered nurse practitioner) note dated May 10, 2024, revealed that the CRNP examined the resident. The CRNP noted that the resident was complaining of burning upon urination and had increased agitation. The CRNP was requesting a repeat U/A C&S (urinalysis and culture and sensitivity) before starting Bactrim (antibiotic). Review of Resident 39's clinical record during survey ending May 17, 2024, revealed no documented evidence that the CRNP's request for a repeat U/A C&S had been completed. There was no documented evidence that the facility completed the lab studies as the CRNP had requested. During an interview with the Director of Nursing (DON) on May 16,…

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

Based on observation and staff interview, it was determined that the facility failed to maintain acceptable practices for the storage and service of food to prevent the potential for contamination and microbial growth in food, which increased the risk of food-borne illness in the food and nutrition services department. Findings include: Food safety and inspection standards for safe food handling indicate that everything that comes in contact with food must be kept clean and food that is mishandled can lead to foodborne illness. Safe steps in food handling, cooking, and storage are essential in preventing foodborne illness. You cannot always see, smell, or taste harmful bacteria that may cause illness according to the USDA (The United States Department of Agriculture, also known as the Agriculture Department, is the U.S. federal executive department responsible for developing and executing federal laws related to food). Observation during the initial tour of the kitchen conducted with the facility's dietary manager on May 14, 2024, at 9:00 AM revealed the following unsanitary…

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 afford a resident's designated representative the right to make health care decisions on the resident's behalf for one resident out of six sampled (Resident CR1). Findings include: A review of the clinical record revealed that Resident CR1 was admitted to the facility on [DATE], with diagnoses that included ascites [is the buildup of fluid in your belly, often due to severe liver disease], chronic kidney disease 3A [moderate kidney damage and noticeable loss of kidney function], unspecified dementia [confusion or mild cognitive impairment can't be clearly diagnosed as a specific type of dementia], and cognitive communication deficit [deficits result in difficulty with thinking and how someone uses language]. A readmission Minimum Data Set Assessments (MDS -a federally mandated standardized assessment completed at specific intervals to define resident care needs) dated November 10, 2023, indicated that Resident CR1…

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 and select facility policy review and staff interview, it was determined that the facility failed to provide effective individualized pain management consistent with professional standards of practice, administer pain medication as prescribed by the physician and attempt non-pharmacological interventions to alleviate pain prior to the administration of a pain medication prescribed on an as needed basis for two residents out of 18 residents sampled (Resident 3 and 30). Findings include: Review of a facility policy entitled Pain - Clinical Protocol and reviewed by the facility on August 8, 2023, indicated that the physician will order appropriate non-pharmacologic and medication interventions to address the individual's pain and that staff will provide the elements of a comforting environment and appropriate physical and complementary interventions, for example local heat or ice, and repositioning. The staff will evaluate and report the resident's use of standing and PRN (as needed)…

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 select facility policy and controlled drug records and staff interview, it was determined that the facility failed to implement procedures to promote accurate controlled medication records on three of three medication carts (East A, C and D hall) and accurate disposition of controlled drugs for one of 18 sampled residents (Resident CR1). Finding include: A review of facility policy entitled Controlled Substances, review date August 8, 2023, indicated that the facility shall comply with all laws, regulations, and other requirements related to handling, storage, disposal, and documentation of Schedule II and other controlled substances. 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. A review of the Shift Change Controlled Substance Count for the East A Hall medication cart on August 22, 2023, in the presence of Employee 3 Licensed Practical Nurse (LPN) at approximately…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of resident clinical record and medication error reports and staff interview it was revealed that the facility failed to assure that two of 18 residents reviewed were free of significant medication errors (Resident 42 and 24 ). Findings include: A review of the clinical record revealed that Resident 42 was admitted to the facility on [DATE], with diagnosis to include lung cancer, diabetes and dementia. The resident had a physician order, dated April 7, 2021, for Gabapentin (an antiseizure medication sometimes used for nerve pain) 400 mg, give one pill twice a day for neuropathy (nerve pain). A pharmacy recommendation to the physician dated February 10, 2023, revealed that the pharmacist recommended that the physician decrease the resident's dose of Gabapentin to 300 mg by mouth twice a day. The physician agreed and signed and an order written on March 1, 2023, to decrease the resident's Gabapentin to 300 mg BID. A review of a resident's March 2023 medication administration record (MAR) revealed…

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

Based on observation and staff interview it was determined that the facility failed to ensure the availability of a functioning bed for all current licensed and certified resident beds in 15 resident rooms observed (Rooms 186, 187, 188, 189, 190, 191, 192, 193, 194, 196, 197, 198, 199, 200 and 201). Findings include: Observations made during an environmental tour August 22, 2023 at 11 A.M. revealed multiple broken beds on the three hallways of an unoccupied unit in the facility. Observation of resident room: 186 A and B- a sign on the bed stating that the bed is broken 187 A and B- a sign on the bed, bed broken 188 A and B- a sign on the bed, bed broken 189 A and B- a sign on the bed, bed broken 190 A and B- a sign on the bed, bed broken 191 A bed broken 192 A and B- a sign on the bed, bed broken 193 A and B-a sign on the bed, bed broken 194 A and B- a sign on the bed, bed broken 196 A and B- a sign on the bed, bed broken 197 A and B- a sign on the bed, bed broken 198 A and B- a sign on the bed, bed broken 199 A and B- a sign on the bed, bed broken 200 A and B-a sign on the bed, bed…

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

Based on observation and staff interview, it was determined that the facility failed to maintain a safe and functional environment for residents, staff and the public. Findings include: Observations made of an unoccupied resident unit in the facility on August 22, 2023, at 10 A.M. revealed in that in licensed/certified resident rooms,188, 192, 193, 194, and 196 the P-TAC (heating and cooling units) were not functional. During an interview on August 23, 2023, at approximately 10 AM, the Nursing Home Administrator (NHA) confirmed the observation of the non-functioning heating/cooling units in the above licensed and certified resident rooms. The NHA stated that presently one of the two resident units observed were vacant. She stated that when the heating/cooling units on the currently occupied side of the facility needed repair, the maintenance department would take the part from a broken unit in an unoccupied room to perform the repair. She further stated that using the broken units for spare parts in an vacant room was the practice, instead of ordering new parts for the broken units…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, a review of clinical records, and staff interview it was determined that the facility failed to timely and consistently provide individualized care and services based on the resident's identified needs and risk factors to prevent the development of pressure ulcers for one resident out of three sampled residents with pressure sores (Resident 175). Findings include: According to the US Department of Health and Human Services, Agency for Healthcare Research & Quality, the pressure ulcer best practice bundle incorporates three critical components in preventing pressure ulcers: Comprehensive skin assessment, Standardized pressure ulcer risk assessment and care planning and implementation to address areas of risk. ACP (The American College of Physicians is a national organization of internists, who specialize in the diagnosis, treatment, and care of adults. The largest medical-specialty organization and second-largest physician group in the United States) Clinical Practice Guidelines indicate…

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.