Oak Ridge Rehabilitation & Healthcare Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, review of facility policy, investigative documentation, and staff interviews, it was determined the facility failed to thoroughly investigate an incident involving a resident being left unattended while at an outside medical appointment to determine whether neglect occurred for one of 22 sampled residents (Resident 1).Findings include: A review of the facility policy titled Abuse Policy last reviewed by the facility on April 8, 2025, revealed it is the facility's policy that residents have the right to be free from abuse and neglect. The policy indicated it is the expectation that any allegation of abuse or neglect is to be reported to the Nursing Home Administrator and other officials. The policy further indicates that an investigation into the allegation will be initiated immediately and include complete statements and interviews from staff and residents involved in the allegation within time frames required by federal regulations. A review of Resident 1's clinical record…

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

Based on clinical record review, interview, and policy review, it was determined the facility failed to provide residents and/or their representatives with the required written notice of Medicare coverage termination, including an explanation of the Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNF-ABN) and the right to appeal, prior to the end of Medicare Part A services for two of three sampled residents reviewed for Medicare coverage notices (Resident 1 and Resident 2).Findings Include: A review of Resident 1's clinical record revealed admission to the facility on May 14, 2025, with diagnoses to include Parkinsons disease (a progressive, neurological disease), muscle weakness and diabetes. Review of the resident's Medicare coverage documentation revealed the last day of covered Medicare Part A services was June 5, 2025. Further review of the Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNF-ABN) form dated June 3, 2025, which is a standardized written notice that facilities are required to issue to a Medicare beneficiary when services…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of clinical records and select facility investigative reports and staff interview it was determined the facility failed to fully develop and implement person-centered comprehensive care plans to meet the individualized toileting and safety needs of two residents (Residents 18 and 11) out of 27 sampled. Findings included: A review of Resident 18's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses that included hemiplegia (paralysis on one side of the body) and hemiparesis (one-sided muscle weakness that occurs due to disruptions in brain, spinal cord, or the nerves that connect to the affected muscles) following cerebral infarction (also known as an ischemic stroke, is the pathologic process that results in an area of necrotic tissue in the brain (cerebral infarct) that is caused by disrupted blood supply (ischemia) and restricted oxygen supply), abnormalities of gait (walking [NAME]) and mobility, lack of coordination, and narcolepsy (a neurological…

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

Based on a review of the facility's abuse prohibition policy, employee personnel files and staff interviews, it was determined the facility failed to fully develop and implement its established abuse prohibition procedures by not adequately screening two of five employees for employment (Employee 2 and 3). Findings include: A review of the facility's Resident Abuse policy last reviewed by the facility April 2025, revealed the requirement for screening potential employees included obtaining references from the most recent or previous employer. Review of employee personnel files revealed the following: Employee 2 (Dietary Manager): Hired on March 3, 2025. The application listed previous employers, but there was no documentation showing the facility had contacted the most recent former employer. Employee 3 (Housekeeping): Hired on January 10, 2025. The application listed prior employers, yet no evidence was found to verify that the facility obtained references or employment information from previous employers. Interview with the Nursing Home Administrator (NHA) on April 25, 2025, at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of clinical records and the Resident Assessment Instrument (RAI) and staff interviews, it was determined the facility failed to conduct a significant change Minimum Data Set Assessments (MDS - a federally mandated standardized assessment process conducted at specific intervals to plan resident care) for one of 27 residents reviewed (Resident 76). Findings include: According to the RAI User's Manual dated October 2023 a Significant Change in Status MDS assessment is required within 14 days of the determination of the significant change when: A resident enrolls in a hospice program; or A resident changes hospice providers and remains in the facility; or A resident receiving hospice services discontinues those services; or A resident experiences a consistent pattern of changes, with either two or more areas of decline or two or more areas of improvement, from baseline (as indicated by comparison of the resident's current status to the most recent CMS-required MDS). A review of the clinical record…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, a review of select facility policy, review of clinical records and staff and resident interviews it was determined the facility failed to provide nursing services consistent with professional standards of quality to ensure that licensed nurses follow physician's orders and ensure accurate medication administration as prescribed for one resident (Resident 31) out of one sampled. Findings include: The Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing 21.11 (a)(1)(2)(4) indicated the registered nurse is responsible for assessing human responses and plans, implementing nursing care, analyzing/comparing data with the norm in determining care needs, and carrying out nursing care actions that promote, maintain and restore the well-being of individuals. According to the Pennsylvania Code Title 49, Professional and Vocational Standards Department of State, Chapter 21 State Board of Nursing, Chapter 21.14 Functions of the RN (Registered Nurse) requires 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 and select facility policy review and staff interview, it was determined the facility failed to attempt non-pharmacological interventions to alleviate pain prior to the administration of a narcotic pain medication prescribed on an as needed (PRN) basis for one resident out of twenty-seven sampled (Resident 52). Findings include: Review of the facility policy titled Pain Assessment and Management, last reviewed by the facility on April 8, 2025, revealed non-pharmacological interventions may be appropriate alone or in conjunction with medications to manage pain. Examples of non-pharmacological interventions included environmental adjustments (such as adjusting room temperature or providing pressure-reducing surfaces), physical interventions (such as ices packs or warm compresses), exercise (such as range of motion exercises), and cognitive or behavioral strategies (such as relaxation techniques, music, or diversional activities). The policy indicated that while pharmacological…

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 the facility failed to develop and implement an individualized person-centered plan to address a resident's dementia-related behavioral symptoms for one out of 27 residents (Resident 115). Findings include: A review of Resident 115's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses which included dementia (a chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning). A review of Resident 115's Quarterly Minimum Data Set Assessment (MDS - a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated April 2, 2025, revealed the resident was severely cognitively impaired. A review of Resident 115's nursing progress notes for the month of April 2025, revealed the resident had increased behaviors, almost daily, of self rising and increased anxiety…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff interview, the facility failed to ensure that non-pharmacological interventions were attempted by staff prior to administering a PRN antianxiety medication, for Resident 129. Findings include: A review of Resident 129's clinical record revealed that the resident was admitted to the facility on [DATE], with diagnoses that included dementia (a group of symptoms affecting memory, thinking and social abilities and symptoms interfere with activities in daily lives), anxiety (a feeling of worry, nervousness, or unease, typically about an imminent event or something with an uncertain outcome), and insomnia (a common sleep disorder that can make it hard to fall asleep or stay asleep). A review of Resident 129's clinical record revealed a progress note dated April 2, 2025, at 3:15 PM, completed by the facility's contracted psychiatric Certified Registered Nurse Practitioner (CRNP). The note indicated that the resident's behaviors may have been associated with underlying…

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 interviews, it was determined that the facility failed to ensure proper labeling and storage of medications and failed to prevent significant medication errors for one resident (Resident 31) out of 27 residents sampled. Specifically, a registered nurse administered a medication that was both expired and not prescribed, resulting in a significant medication error. Findings include: A clinical record review revealed that Resident 31 was admitted to the facility on [DATE], with diagnoses including Type 2 Diabetes Mellitus (a condition in which the body does not use insulin normally and cannot control blood glucose levels) and parkinsonism (a neurological disorder that affects movement and muscle control). A review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], identified that Resident 31 was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 14. A BIMS score of 13-15 indicates intact cognition, meaning the resident is…

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, observation, and staff interview, it was determined that the facility failed to maintain acceptable practices for the storage and service of food to prevent the potential for contamination and microbial growth in food, which increased the risk of food-borne illness, in the dietary department and the second floor and Memory Care Unit resident food storage areas. Findings include: Food safety and inspection standards for safe food handling indicate that everything that comes in contact with food must be kept clean and food that is mishandled can lead to foodborne illness. Safe steps in food handling, cooking, and storage are essential in preventing foodborne illness. You cannot always see, smell, or taste harmful bacteria that may cause illness according to the USDA (The United States Department of Agriculture, also known as the Agriculture Department, is the U.S. federal executive department responsible for developing and executing federal laws related to food). A review of a facility policy entitled Food Storage and was last reviewed by…

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 documents and staff interviews, it was determined that the facility failed to ensure that the Medical Director or designee was in attendance at monthly Quality Assurance Process Improvement (QAPI) Committee meetings for four of four months (January 2024 through April 2024) Findings include: A review of QAPI Committee meeting sign-in sheets for the period of January 2024 through April 2024, revealed that the Medical Director or other physician was not in attendance, virtually or in-person, at the QA meetings held from January 2024 through April 2024, missing 4 monthly meetings (January 2024 through April 2024). Interview with the administrator on May 9, 2024, at 12:00 PM confirmed that the a physician failed to attend the facility's QAPI meetings on a monthly/quarterly basis. 28 Pa. Code 211.2(d)(5)(6)(7)(8)(10) Medical director 28 Pa. Code 201.18 (e)(2)(3)(4) Management.

Based on observation, facility pest service records and resident and staff interview, it was determined that the facility failed to maintain an effective pest control program. Findings include: During the initial tour of the kitchen that was conducted on May 7, 2024, at 9:40 a.m., inside of the dish room several small black flies (three or more) were observed flying around a large metal wire storage rack of clean cooking equipment and supplies. The CDM confirmed the observations and stated that drain flies are frequently observed in the area due to the damp environment. Observations of the 2nd floor dining area on May 9, 2024, at 9:57 a.m., revealed small dead black bugs on floor, on the windowsills, and the air-conditioning units. The windowsill was loose and gaps to the outside were present. A dead, large-winged insect was observed on the floor below an unoccupied wheelchair. An interview with the facility's Director of Maintenance on May 9, 2024, at 10:40 a.m., revealed that pest treatments were performed to floor drains in the dietary department, but the employee was unable 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 observation and staff interview, it was determined that the facility failed to provide housekeeping services to maintain a clean environment on one of three resident units (third floor dementia unit). Findings include: An observation May 8, 2024, at 10 AM in the large dining room floor on the third floor dementia unit revealed that the floor was sticky, dirty and soiled with dried liquid stains. Dirt, dried liquid stains and food crumbs were observed on the window sills in the dining room. The floor in resident room [ROOM NUMBER] was dirty and sticky. A strong urine odor emanated from the resident's mattress. In resident room [ROOM NUMBER] B, there was a broken floor tile under the resident's bed. On the wall next to the door was damaged with deep gouges in the surface and the wallpaper was heavily soiled. The floor in resident room [ROOM NUMBER] was dirty and sticky. The floor in resident room [ROOM NUMBER], was dirty, with dirt accumulated around the perimeter of the room. During an interview May 9,…

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 grievances filed with the facility and resident and staff interviews, it was determined that the facility failed to demonstrate timely and adequate efforts to resolve resident grievances including those voiced by two out of 23 residents sampled (Residents 76 and 90). The findings include: A review of clinical record revealed that Resident 76 was admitted to the facility on [DATE], with diagnoses that include gastroesophageal reflux disease ([GERD] occurs when stomach acid frequently flows back into the esophagus) with esophagitis (inflammation or irritation of esophagus, the pipe that carries food from mouth to stomach) and muscle weakness. An annual Minimum Data Set assessment (MDS - a federally mandated standardized assessment process conducted at specific intervals to plan resident care) dated February 14, 2024, revealed that the resident was cognitively intact, requiring moderate assistance with activities of daily living (ADL). A Grievance/Concern Form filed by…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of clinical records, select facility policy and investigative reports and staff interviews it was determined that the facility failed to assess and implement individualized measures planned to meet the toileting needs of one resident out of three residents sampled with a decline in continence (Resident 27). Findings included: A review of a facility policy entitled Urinary Incontinence - Clinical Protocol that was last reviewed by the facility on November 27, 2023, indicated that as part of the initial assessment, the physician will help identify individuals with impaired urinary continence. The staff and physician will review the progress of individuals with impaired continence until continence is restored or improved as much as possible, or if it is identified that further improvement is unlikely. This should include documentation of a resident's response to attempt interventions such as scheduled toileting, prompted voiding, or medications used to treat incontinence. A review of Resident 27's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of clinical records and resident and staff interview it was determined that the facility failed to ensure each resident was provided with the necessary behavioral health care and services to meet the needs of two residents out of 23 sampled (Residents 90 and 28) to maintain the residents' highest practicable physical, mental, and psychosocial well-being). Findings include: A review of clinical record revealed that Resident 90 was admitted to the facility on [DATE], with diagnoses that include adjustment disorder (a short-term condition arising due to difficulty in managing stressful changes that can lead to significant impairment in functioning) with mixed anxiety, depression (mood disorder with experiences of persistent symptoms of sadness), major depressive disorder (mental health disorder having episodes of depression that can be dangerous or life threatening if untreated), and acute stress reaction (occurs after an unexpected life crisis or traumatic event). A quarterly Minimum Data Set…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of clinical records and select incident reports, observations, and staff interviews, it was determined that the facility failed to ensure that staff possessed the necessary skills and competencies to implement person-centered dementia care approaches planned to decrease the potential for further escalation of dementia-related behaviors for one resident out of six residents sampled with dementia (Resident A1). Findings include: A review of Resident A1's clinical record revealed that the resident was admitted to the facility on [DATE], with diagnoses that included encephalopathy [is a medical term used to describe a disease that affects brain structure or function and causes altered mental state and confusion], amnesia (a condition characterized by the inability of a person to recall facts or previous experiences), and cerebrovascular disease [is a term for conditions that affect blood flow to your brain that can result in stroke, brain bleed, aneurysm (a bulge in the wall of an artery that can…

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 interviews, it was determined that the facility failed to attempt a gradual dose reduction of psychoactive medications for two residents out of 23 sampled (Resident 52 and 77). Findings include: A review of Resident 52's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses to include dementia. The resident had a physician order initially dated April 25, 2018, for Trazadone 100 mg (antidepressant) by mouth at hour of sleep (HS) for insomnia. The resident also had a physician order dated dated April 28, 2018, for Lexapro 10 mg (antidepressant) one time a day for depression . A review of a pharmacist consult to the physician dated December 1, 2023 reveled a request for a gradual dose reduction (GDR) for the Lexapro and Trazadone. There was no physician documentation of the clinical necessity of the duplicate antidepressant drug therapy. The physician's response was solely to disagree with the recommendation with no explanation of the…

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

Based on a review of select facility policy and manufacturer's directions for use, observations, and staff interview, it was determined that the facility failed to ensure adherence to pharmacy supplies expiration/use by dates on two of three resident units (First and Second Floor). Findings include: A review of facility policy entitled Storage of Medications with a review date of November 27, 2023, revealed that medications and biologicals are stored in the packaging and nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe and sanitary manner. If the facility has discontinued, outdated, or deteriorated medications or biologicals the dispensing pharmacy is contacted for instructions regarding returning or destroying these items. Medication refrigeration are stored in a refrigerator located in the medication room at the nurse's station or other secured location separately from food with temperature ranges 36 degrees Fahrenheit to 46 degrees Fahrenheit. Multi-dose vials that have been opened or accessed are dated and discarded within 28…

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, review of facility scheduled meal times and select facility policy, and resident and staff interviews the facility failed to ensure the provision of a nourishing (satisfying to the resident) evening snack when greater than 14 hours elapsed from the supper meal to breakfast the next day for residents including four residents of 23 sampled (Residents 72, 5, 64, and 41). Findings include: Review of the facility's Snacks Policy last reviewed by the facility February 2024, indicated that it is the facility policy to provide the resident with adequate nutrition. Review of the facility's scheduled (not exact times may fluctuate +/- 15 minutes) meal times revealed 15 hours between the evening meal and the next day's breakfast meal. During a group interview with six alert and oriented residents on May 8, 2024, at 10:00 AM, all four residents (Residents 72, 5, 64, and 41) in attendance stated that snacks are not routinely offered to them in the evenings. The residents stated they would like to receive an evening/bedtime snack. Residents reported that when they have…

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

Based on staff interviews and a review of documentation provided by the facility, it was determined that the facility failed to timely review and update its facility wide assessment in order to identify the specific personnel and resources presently available and/or required, which are necessary to care for its current resident population. Findings include: At the time of the survey ending May 10, 2024, the facility had reviewed its facility assessment on April 15, 2024, to determine the specific and unique needs of its resident population and the available and accessible resources to meet these needs on a daily basis and during emergent situations. The facility provided a facility assessment tool to the survey team on May 7, 2024. There was no documentation on the form that identified and addressed the needs of the locked third floor unit, Dementia/Memory care unit. The form did not include any focus on the care and needs of the 61 residents with documented diagnosis of Dementia/Alzheimers disease and 43 residents residing on the locked dementia unit. A review of the results of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of clinical records and select facility policy, observation and staff and resident interviews it was determined that the facility failed to provide care in a manner that maintains the personal dignity, privacy and quality of life of two residents out of 23 sampled (Resident 49 and 90). Findings include: A facility policy entitled Dignity with a review date of November 27, 2023, revealed that residents are always treated with dignity and respect. The facility culture supports dignity and respect for resident's by honoring resident goals, choices, preferences values, and beliefs. This begins on admission and continues throughout the resident's facility stay. Demeaning practices and standards of care that compromise dignity are prohibited staff are expected to promote dignity and assist residents by helping to promptly response to a resident's request for toileting assistance. An observation on May 8, 2024 at 9 AM, revealed no curtains, shades or blinds on the windows in resident room [ROOM…

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 and investigative reports resident and staff interview, it was determined that the facility failed to ensure that one resident was free from physical abuse out of 23 sampled residents (Resident 85). Findings including A review of the current facility policy titled Abuse Policy, last reviewed by the facility November 27, 2023, revealed that residents have the right to be free from abuse. Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting in physical harm, pain, or mental anguish. Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. The facility's goal is to achieve and maintain an abuse-free environment. A review of Resident 85's clinical record revealed that she was admitted to the facility on [DATE], with diagnoses that included Alzheimer's disease [is a gradually…

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

Based on a review of the facility's abuse prevention policy and clinical records and staff interview, it was determined that the facility failed to implement their established abuse prohibition policy and procedures for responding to incidents of resident abuse for one resident out of 23 sampled (Resident 85). Findings include: A review of the current facility policy titled Abuse Policy, last reviewed by the facility November 27, 2023, revealed that the facility's abuse prevention/intervention program included training all staff and practitioners' ways to resolve conflicts appropriately. Assessing, care planning, and monitoring residents with needs and behaviors that may lead to conflict or neglect and assessing residents with signs and symptoms of behavior problems and developing and implementing care plans to address behavioral issues. The facility's response to abuse includes an assessment and assessment data will include injury assessment, signs of recent fall, pain assessment, current behavior, all current medications, vital signs, behaviors over the past 24-hours, all active…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of clinical records, select facility incident reports, and the facility's abuse prohibition policy and staff interview it was determined that the facility failed to thoroughly investigate potential neglect of five residents out of 23 sampled (Residents 99, 43, 17, 46, and 97). Findings included: A review of the facility's policy, entitled Abuse Policy last reviewed by the facility November 2023, indicated that a complete investigation will be conducted. Neglect is defined as the failure of the facility, its employees or service providers to provide goods and services to a resident that necessary to avoid physical harm, pain, mental anguish or emotional distress. Neglect occurs when the facility is aware of or should have been aware of goods or services that a resident requires but the facility fails to provide them to the resident, that has resulted in or may result in physical harm, pain, mental anguish, or emotional distress. A review of medication errors in the facility for the month 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, clinical record review and staff interview, it was determined that the facility failed to identify a resident's need for monitoring of the resident's respiratory status and oxygen use on the resident's comprehensive care plan for one resident out of 23 sampled (Resident 102). Findings include: According to the American Thoracic Society, oxygen (O2) is a medication that requires a prescription from a healthcare provider. The provider will prescribe your O2 at a specific flow rate and a specific number of hours per day. It is very important that O2 is used as prescribed. Using too little O2 may put a strain on the heart and brain, causing heart failure, fatigue, or memory loss. Using too much O2 can also be a problem. For some patients, using too much O2 can cause them to slow their breathing to dangerously low levels. It is important to wear O2 as your provider ordered it. If the patient starts to experience headaches, confusion, or increased sleepiness after using supplemental O2, the patient may be getting too much. A review of the clinical record of 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.

Based on observation, clinical record review and staff interview it was determined that the facility failed to consistently administer oxygen (O2) as ordered for one out of 23 sampled residents (Resident 7). Findings included: According to the American Thoracic Society, O2 is a medication that requires a prescription from a healthcare provider. The provider will prescribe your O2 at a specific flow rate and a specific number of hours per day. It is very important that O2 is used as prescribed. Using too little O2 may put a strain on the heart and brain, causing heart failure, fatigue, or memory loss. Using too much O2 can also be a problem. For some patients, using too much O2 can cause them to slow their breathing to dangerously low levels. It is important to wear O2 as your provider ordered it. If the patient starts to experience headaches, confusion, or increased sleepiness after using supplemental O2, the patient may be getting too much. A review of the clinical record of Resident 7 revealed admission to the facility on October 14, 2020, with diagnoses that include a history of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of clinical records and select facility policy, observations, and staff interviews it was determined that the facility failed to provide person-centered care and coordination of individualized resident services for one of one residents sampled receiving hemodialysis (Resident 51). Findings include: A review of a facility policy entitled Care of a Resident with End-Stage Renal Disease that was last reviewed by the facility on November 27, 2023, indicated that a resident's compressive care plan would reflect the resident's needs related to end stage renal disease [(ESRD) is a condition where the kidney reaches advanced state of loss of function. This causes changes in urination, fatigue, swelling of feet, high blood pressure, and loss of appetite]. A review of Resident 51's clinical record revealed that he was most recently admitted to the facility on [DATE], with diagnoses that included end stage renal disease with hemodialysis [is a procedure where a dialysis machine and a special filter called…

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, observation and staff interviews it was determined that the facility failed to maintain and accurate and complete clinical records for two out of 23 residents reviewed. Findings included: 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 experiences in nursing situations. The LPN participates in the planning, implementation, and evaluation of nursing care in settings where nursing takes place. 21.148 Standards of nursing conduct (a) A licensed practical nurse shall: (5) Document and maintain accurate records. According to the American Nurses Association Principles for Nursing Documentation, nurses document their work and outcomes and provide an integrated, real-time method of informing the health care team about…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and staff interviews it was determined that the facility failed to ensure call bells were accessible to one of 23 residents sampled (Resident 52). Findings include: Observation on May 9, 2024, at 9 AM revealed that in resident room [ROOM NUMBER], in which Resident 52, a severely, cognitively impaired resident resided, but was not in the room at the time of the observation there was no call bell connected to the wall outlet or anywhere these in the room. There was no alternate method for use as a call bell, such as a tap bell noted in the resident's room. There were 2 plugs placed into the wall outlet call bell unit. The plugs were utilized to circumvent the alarm when the outlet is unplugged. Interview with Employee 4 (licensed practical nurse) on May 9, 2024, at 9:05 AM confirmed the observation that Resident 52 did not have access to a call bell to summon staff assistance while in bed and verified that call bells are to be placed within reach of the residents and each resident's bedside.…

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 select facility policy and clinical records, and staff interview, it was determined that the facility failed to implement established procedures to assure safe smoking ability for one resident out of one resident identified as a current smoker (Resident 34). Findings include: During an onsite survey beginning May 7, 2024, a policy was observed on facility bulletin board indicating that the facility was a non-smoking facility that smoking is not permitted within the facility or on facility grounds. During entrance conference on May 7, 2024, at 9:30 a.m. the Nursing Home Administrator stated that one resident, Resident 34 was a current smoker. Review of Resident 34's clinical record revealed that the resident was admitted to the facility on [DATE], with diagnoses to have included chronic obstructive pulmonary disease (COPD). Review of Resident 34's plan of care, reviewed during the survey ending May 10, 2024, revealed no care plan to address the resident's smoking until surveyor…

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, guidance issued by the Centers for Medicare and Medicaid Services and facility documentation, and staff interview, it was determined that the facility failed to develop and implement policies and procedures designed to protect residents from unacceptable practices of disenrolling residents from their Medicare health plans by ensuring all risks of disenrolling are explained, both verbally and in writing, and the residents are found to be competent to make informed decisions for four of four reviewed disenrolled from Medicare health plans (Resident 11, 16.17, 21). Finding include: A review of a CMS guidance entitled Memo to Long Term Care (LTC) Facilities on Medicare Health Plan Enrollment dated October 2021 revealed that CMS continues to hear reports of the unacceptable practice of nursing facilities or skilled nursing facilities (collectively, long-term care or LTC facilities) disenrolling beneficiaries from Medicare health plans (Medicare Advantage plans with and without…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of clinical records and select reports, observations, and staff interview, it was determined that the facility failed to develop and implement individualized plans to manage residents' dementia related behavioral symptoms to promote resident safety and the residents' highest practicable physical and mental well-being for two residents (Resident 14 and 19) out of 21 sampled. Findings include: A review of the clinical record revealed that Resident 14 was admitted to the facility on [DATE], with a diagnoses of dementia (irreversible, progressive degenerative disease of the brain, resulting in loss of reality contact and functioning ability), behavioral disturbance (globally described as agitation, wandering, and hoarding), unsteadiness on feet and lack of coordination (refers to abnormal motor planning and execution, disturbed negotiation with obstacles or the environment), and had a history of falls. A quarterly Minimum Data Set assessment (Minimum Data Set - a federally mandated standardized…

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 plan of correction from the survey of January 25, 2024, and the findings of the survey ending February 27, 2024, it was determined that the facility's Quality Assurance Performance Improvement (QAPI) committee failed to correct quality deficiencies related to abuse and dementia care and to ensure that plans designed to improve the delivery of care and services were consistently implemented to effectively deter future quality deficiencies. Findings include: A review of the facility's plan of correction for the deficiencies cited under abuse and dementia care during the survey ending January 25, 2024, revealed the facility developed a plan of correction that included quality assurance monitoring systems to ensure that solutions were sustained, which were to be functional by December 12, 2024. The results of the current survey ending February 27, 2024, identified repeat quality deficiencies in prevention of resident abuse and dementia care. In response to the deficiency cited related to resident abuse during the survey of January 25, 2024, 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 a review of facility's abuse policy, clinical records, and select reports and staff interviews it was determined that the facility failed to assure that one resident (Resident 18) out of four sampled was free from sexual abuse perpetrated by another resident (Resident 19). Findings included: A review of the current facility policy titled Abuse Policy, provided by the facility during the survey of February 27, 2024, revealed it is the policy of the facility that the residents have the right to be free from abuse, neglect, misappropriation of resident property, corporal punishment and involuntary seclusion. Sexual abuse is defined as non-consensual, sexual harassment, sexual coercion, contact or sexual assault. Residents have the right to engage in consensual sexual activity. However, anytime the facility has reason to suspect that a resident may not have the capacity to consent to sexual activity, the facility must take steps to ensure that the resident is protected from abuse. These steps should include evaluating whether the resident has the capacity to consent to sexual…

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

Based on review of clinical records and staff interview it was determined that the facility failed to ensure that one resident out of 21 sampled was free of chemical restraints used to most readily control the resident's behavior and not required to treat the resident's medical symptoms (Resident 19). Findings include: A review of Resident 19's clinical record revealed admission to the facility on December 18, 2023, with diagnoses to include Parkinsonism (brain conditions that cause slowed movements, stiffness and tremors), dementia with behavioral disturbances (a condition characterized by progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change) and adult failure to thrive (a syndrome of decline in older adults that affects their physical, mental, and social well-being). An admission Minimum Data Set assessment (a federally mandated standardized assessment completed periodically to plan resident care) dated December 25, 2023, indicated that the resident was severely cognitively…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, a review of clinical records, facility investigations, and staff interview, it was determined that the facility failed to provide sufficient staff, providing direct services to residents, who possess the necessary competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident as evidenced by five residents out of six sampled (Residents 1, 2, 3, 4 and CR1). Findings include: A review of Resident 1's clinical record revealed that the resident was admitted to the facility on [DATE], with diagnoses, which included alcohol induced dementia (a chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning. A review of the resident's Quarterly Minimum Data Set Assessment (MDS - a federally mandated standardized assessment conducted at specific intervals 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 observations, resident and staff interview, a review of grievances lodged with the facility, and test tray results, it was determined that the facility failed to provide meals that are served at safe and palatable temperatures for a test tray completed during the lunch meal for in-room tray service. Findings include: According to the federal regulation 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. A review of a Grievance/Concern Form completed by on behalf of Resident A1's by her spouse dated January 18, 2024, at 12:15 PM, revealed that the resident complains of cold food during lunch. A review of a Grievance/Concern Form completed during Resident B2's care plan meeting held on January 19, 2024, no time noted, revealed that the resident complained that his food was often cold. During on-site survey ending January 25, 2024, a test tray 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 observation, a review of facility pest service records and staff interview, it was determined that the facility failed to maintain an effective pest control program. Findings include: A review of the facility's contracted pest control report dated January 8, 2024, at 2:37 PM, revealed that during a common inspection that the third-floor kitchenette floor drain had build up of organic matter that allowed drain flies to breed and noted that the drain needed to be cleaned to prevent unsanitary conditions and attractions of pests. Drain flies were found in the third-floor kitchenette and that sealing an open drain would resolve the fly problem. During a tour of the 3rd Unit Resident Pantry/Kitchenette on January 25, 2024, at 9:17 AM, revealed that inside of the ice scoop storage container there were two small black flies floating in the pooled water on the bottom of the container. Further observations revealed that upon opening the stainless-steel refrigerator, there were several small black flies that flew out and there small flying insects on the resident food items 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, clinical records, and investigative reports, and staff interview, it was determined that the facility failed to ensure that two residents (Resident 1 and 2) out of six sampled were free from physical abuse perpetrated by other residents, Residents 2 and 3). Findings include: A review of the current facility policy entitled Abuse Prevention Program, last reviewed by the facility June 6, 2023, revealed it is the policy of the facility that the residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. As part of the resident abuse prevention program, the administration will protect the residents from abuse by anyone including, but not necessarily limited to facility staff, other residents, consultants, volunteers, staff from other agencies, family members,…

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 on one of three resident pantries areas (3rd Resident Pantry/ Kitchenette). 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). During a tour of the 3rd Unit Resident Pantry/Kitchenette on January 25, 2024, at 9:17 AM, observation of the inside of 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.

Based on a review of grievances lodged with the facility and the minutes from Residents' Council meetings 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 reported by seven alert and oriented residents out of 15 interviewed (Residents 7, 27, 38, 47, 72, 98, and 14). Findings include: A review of the minutes from the Resident Council meeting on October 26, 2023, revealed that the residents in attendance voiced concerns that staff do not answer their requests for assistance, via the nurse the call bell system, in a timely manner. A review of grievances lodged with the facility revealed a grievance filed anonymously on November 2, 2023, on behalf of a resident, indicating that the resident's call bell was on for an extended period of time with no response from staff. A grievance was filed on November 4, 2023, on behalf of 12 residents, indicating that their call bells were not being answered timely…

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 and two of three resident pantries. 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). During the initial tour of the food and nutrition services department conducted on December 12, 2023, at 9:00 AM revealed 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 clinical record review and interviews with staff, it was determined that the facility failed to provide and/or obtain radiology/diagnostic services to meet the needs of one of eight residents' clinical record reviewed (Resident 2). Findings include: Review of Resident 2's clinical record revealed that the resident was admitted to the facility on [DATE], with the diagnoses to include unspecified dementia. Review of Resident 2's clinical record revealed a progress note dated August 26, 2023, indicating the resident had a fall and was complaining of left wrist pain after the fall. An x-ray was completed in the facility on August 27, 2023, and no fracture was noted. Progress notes revealed that the resident continued to have pain in the left wrist another x-ray was completed on August 28, 2023, and the results of this x-ray were inconclusive, and the radiology report recommended that resident see a hand specialist and receive a CT scan (diagnostic imaging test that uses several X-ray images and computer…

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, staff and resident interviews and a review planned menus, dietary staffing credentials, hours and job descriptions, it was determined that the facility failed to ensure effective management and execution of the duties and responsibilities of the facility's food and nutrition department to provide consistent planned meals and professional dietary and nutritional services to meet the nutritional needs of each resident. Findings include: An observation of the facility's main kitchen on August 7, 2023, at 9:50 AM revealed 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. The main walk-in refrigerator cooler was observed to be inoperable since July 25, 2023, as confirmed during interviews with Employee 1, Dietary Manager. When observed at the time of the survey on August 7, 2023, perishable food items were stored at a temperature of 61 degrees Fahrenheit, available for resident consumption, in this…

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 test tray results it was determined that the facility failed to serve food and beverages at palatable, safe and appetizing temperatures. Findings include: According to the federal regulation 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. A test tray was conducted, on August 7, 2023, on third floor, at 12:36 PM, at the time the last resident began eating, revealed the following: The lunch meal consisted of meat loaf with gravy, stuffed tomatoes, mashed potatoes with gravy, tomato soup, brownie, milk, and coffee. The food temperatures that were obtained in the kitchen tray-line prior to service that began at 11:45 AM were as follows: meatloaf 200 degrees Fahrenheit, mashed potatoes 182 degrees Fahrenheit and broiled half tomato 180 degrees Fahrenheit. The last cart, third floor cart left the kitchen at 12:30 PM and arrived on 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.