Bradford Hills Nursing & Rehabilitation Center

Based on clinical record review and staff interview, it was determined that the facility failed to provide the highest practical care related to bowel management for one of one resident reviewed (Resident 11).Findings Clinical record review revealed the facility admitted Resident 11 on February 21, 2025. Further review of Resident 11's clinical record revealed the following physician ordered medications initiated February 21, 2025, to promote Resident 11's bowel movements: Milk of Magnesia (MOM, laxative that pulls water into bowel to soften bowel contents) give 30 ml (milliliters) by mouth as needed (PRN) for bowel management if no bowel movement in two days (evening shift). Dulcolax suppository (a laxative medication used to relieve constipation) insert one suppository rectally as needed for constipation, if MOM is ineffective and as needed for bowel management on day three (evening shift). Review of bowel elimination records for Resident 11 revealed that staff documented no bowel movements for July 5, 6, 7, 8, and 9, 2025 (5 days). There was no indication that staff offered (as…

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

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 provide comprehensive skin assessments that are consistent with professional standards of practice to promptly identify and promote healing of a pressure ulcer for one of four residents reviewed for pressure ulcers (Resident 1).Findings include: Clinical record review for Resident 1 revealed a quarterly Minimum Data Set Assessment (MDS, an assessment completed at specific intervals to determine care needs) dated November 11, 2025, that noted facility staff assessed the resident as having a BIMS (Brief Interview for Mental Status) of 7, which indicated cognitive impairment. The MDS revealed that the resident had a pressure ulcer. The MDS dated [DATE], also revealed the resident had a pressure ulcer. Current physician orders for Resident 1 dated August 21, 2025, at 8:00 AM instructed staff to treat the resident's sacral region wound every day shift every other day. A review of the Treatment Administration 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 observation, clinical record review, and staff interview, it was determined that the facility failed to ensure an environment free from potential accident hazards for one of one resident reviewed for smoking concerns (Resident 33).Findings include: Review of the facility policy reviewed on August 14, 2025, titled Tobacco Product Usage and Smoking Policy Posting, revealed that the facility maintains a resident's rights to smoke while ensuring activities remain safe and do not infringe upon the health, safety, welfare, or rights of others. The policy further noted that the safety delivery of quality health care is the goal of each and every employee and in order to provide for an optimum, safe environment in which to meet the goal, the facility will observe a tobacco usage and smoking policy for all residents, staff, visitors, and volunteers. Section L noted that, Smoking aprons will be worn by all residents while smoking. The smoking policy was signed and dated by Resident 33 and social services staff on September 9, 2025. Clinical record review for Resident 33 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.

Based on a review of select facility policies and procedures, observation, and staff interview, it was determined that the facility failed to ensure an environment free from the potential spread of infection related to hand hygiene for one of 27 residents reviewed (Resident 13).Findings include: The facility policy entitled, Handwashing/Hand Hygiene, last reviewed without changes on April 2, 2025, revealed that all personnel will follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. Use an alcohol-based hand rub containing at least 62 percent alcohol; or, alternatively, soap and water after removing gloves. Hand hygiene is the final step after removing and disposing of personal protective equipment (PPE). The use of gloves does not replace hand washing/hand hygiene. Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare-associated infections. The procedural steps in the policy included performing hand hygiene before applying non-sterile gloves…

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, staff interview, and review of facility documentation, it was determined that the facility failed to maintain an effective pest control program so that the facility is free from pests in the main kitchen area. Findings include: Observation of the facility's main kitchen on June 20, 2025, at 10:28 AM with Employee 1 (dietary clerk) and Employee 2 (dietitian) revealed the following: The dishwashing area had multiple smaller winged insects flying around. Two dead cockroach appearing insects were observed in the overhead wooden cupboards in the dishwashing area. These cupboards contained several loose unused trash bags and multiple boxes of surgical masks. An opening between the wall splash guard and the underlying wall was observed. This opening was located under the stainless-steel counter in the dishwashing area. Further observation of this area revealed the plastic splash guard was not securely affixed to the wall as noted while pushing in the center of the splash guard. While tapping on the splash guard, there was obvious insect activity noted as evidenced 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 select facility policies and procedures, clinical record review, and resident and staff interview, it was determined that the facility failed to ensure dependent residents received bathing assistance for four of six residents reviewed (Residents 1, 3, 4, and 6). Findings include: The facility policy entitled, Preferences Requests Policy, issued December 1, 2024, revealed that it is the nursing staff's responsibility to obtain a resident's bathing preferences (such as shower or bath, morning or afternoon, and how many times a week). Clinical record review for Resident 1 revealed a quarterly MDS (Minimum Data Set, an assessment tool completed at specific intervals to determine resident care needs) dated March 20, 2025, that assessed him as being dependent upon staff for shower/bathing assistance. Review of electronic task documentation dated April and May 2025, revealed that facility staff determined Resident 1's preference was to receive a shower one time a week in the evening. Review of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of select facility policies and procedures, closed clinical record review, and staff interview, it was determined that the facility failed to implement procedures to exercise reasonable care for the protection of residents' property from loss for three of five residents reviewed (Residents CR1, CR3, and CR4). Findings include: The facility policy entitled, Personal Property, last reviewed/revised [DATE], revealed that a documented inventory of all residents' personal belongings will be completed upon admission by the nursing department, or another department identified by the facility. The inventory sheet will be updated when new items are acquired if the facility has been notified by the responsible party. The resident's personal belongings and clothing will be inventoried and documented upon admission and as such items are replenished. Missing items should be reported immediately to a staff member on the unit and placed on a concern/grievance form with follow through based on the concern…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of select facility policies and procedures, closed clinical record review, review of personnel certifications, and staff interview, it was determined that the facility failed to ensure properly certified personnel provided basic life support, including cardiopulmonary resuscitation (CPR), to a resident who required emergency care (Employee 1; Resident CR2). Findings include: Review of the facility policy POLST (Physician Orders for Life Sustaining Treatment, form used to document a resident/responsible party wishes in the event of a medical emergency such as the absence of a heart rate or respirations), last revised [DATE], revealed that the facility assists the resident/responsible family member (RP) in completing a POLST upon admission. If the resident/responsible family member is not ready to complete the POLST, the facility informs the resident/RP that until a decision is made, the resident will be considered a Full Code (CPR, medical intervention such as chest compression and artificial…

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 and resident interview, it was determined that the facility failed to ensure self-determination for resident's choices related to shower preference for bathing for one of four residents reviewed (Resident 1). Findings include: A review of the census revealed that Resident 1 was admitted to the facility on [DATE]. An interview with Resident 1 on February 18, 2025, at 12:20 PM revealed that the resident stated that he had not received a shower since arrival in the facility and he and staff utilize wipes to bathe him. Clinical record review for Resident 1 revealed an admission Minimum Data Set Assessment (MDS, an assessment completed at specific intervals to determine care needs) dated January 8, 2025, that noted facility staff assessed the resident as having a BIMS (Brief Interview for Mental Status) of 14, which indicated no cognitive impairment. The MDS revealed that the resident was dependent on staff for bathing. Further review of the MDS noted 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 clinical record review, observation, and staff interview, it was determined that the facility failed to ensure complete and accurate clinical documentation for one of seven residents reviewed (Resident CR1). Findings include: Closed clinical record review for Resident CR1 revealed the resident was admitted to the facility on [DATE], at 4:30 PM and signed out of the facility against medical advice on January 26, 2025, at 9:13 PM. Closed clinical record review for Resident CR1 revealed a diagnosis list that included Type Two Diabetes Mellitus (a condition where the body cannot properly regulate blood sugar which results in an abnormally high blood sugar levels). Clinical record review for Resident CR1 revealed a physician's order on the Medication Administration Record and Treatment Administration Record (MAR/TAR where staff document the administration of medications and treatments) dated January 26, 2025, at 9:00 AM that instructed staff to obtain a blood sugar four times a day for diabetes monitoring.…

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 store food and maintain food service equipment in a safe and sanitary manner and prevent the potential for food contamination in the facility's main kitchen and on two of five nursing units (Second Floor East, Third Floor West) Findings include: Observation of the facility's main kitchen on November 19, 2024, at 11:00 AM revealed the following: Handwashing sinks located inside the kitchen entrance, beside the three-compartment sink area, snack preparation are, and dishwashing area were observed with brown staining, and with dust, dirt, and debris buildup on the surrounding faucet area. Small tan colored trashcans located beside the above noted handwashing sinks were observed with dried liquid spills and buildup of dust/dirt on the exteriors. The wall area behind the trash receptacle by the handwashing sink in the three-compartment sink area was observed with multiple areas of dried liquid/food splatter. The frame of the linen cart stored beside the handwashing sink upon entrance to the kitchen…

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 and resident interview, it was determined that the facility failed to provide adequate housekeeping and maintenance services to ensure a clean, safe, and orderly environment on two of five nursing units (2E and 2W Nursing Units, Residents 15, 32, 73, 84, and 134). Findings include: Observation of the 2 E Nursing Unit on November 19, 2024, at 9:45 AM revealed that there was a damp odor upon entry to the unit's shower room. Observation of the 2 W Nursing Unit on November 19, 2024, at 12:31 PM revealed that there was a damp odor and fecal material upon entry to the unit's shower room. There was a one-half tile piece missing and another tile that was cracked on the corner of the wall near the sink and entry door. On the lower part of the tiled wall and floor in the shower area, there was a black substance in the grout lines of the tile. The surveyor reviewed the above information during an interview with the Nursing Home Administrator and Director of Nursing on November 20, 2024, at 1:45 PM. Observation of Resident 15's room on November 19, 2024, at 11:18…

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 resident and staff interview, it was determined that the facility failed to ensure resident grievances were addressed timely for four of six residents (Residents 22, 24, 65, and 95 ). Findings include: Review of resident grievances revealed the following: Resident 24 filed a grievance on August 6, 2024, and August 13, 2024. Resident 95 filed a grievance on August 7, 2024. Resident 65 filed a grievance regarding a concern on September 24, 2024. There was no documentation available that the facility investigated and addressed Resident 24, 65, and 95's concerns until November 13, 2024. The surveyor reviewed the above information during an interview with the Nursing Home Administrator and the Director of Nursing on November 20, 2024, at 1:45 PM. Review of a grievance filed by Resident 22 on September 15, 2024, revealed that there was no evidence that the facility addressed the concern until November 13, 2024. Interview with the Nursing Home Administrator on November 21, 2024, at 2:15 PM confirmed that Resident 22's grievance was not addressed in a timely manner.…

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

Based on clinical record review and staff interview, it was determined that the facility failed to provide care and services identified to reduce a resident's decline in ADL's (activities of daily living) for five of five residents reviewed (Residents 47, 66, 73, 80, and 108). Findings include: Clinical record review for Residents 47 revealed a current task for staff to provide: nursing rehab for dressing and grooming, staff to encourage resident to assist with all dressing and grooming every shift nursing rehab eating and swallowing, staff to encourage resident to eat 50 to 75 percent of all meals Review of task documentation for Resident 47 revealed that staff did not document completion or documented NA (Not Applicable) of the nursing rehab grooming task on the following dates: Day Shift: October 7, 13, 24, and 27 2024 November 1, and 7, 2024 Evening Shift: October 2, 5, 6, 12, 14, 16, 19, and 25, 2024 November 3 and 17, 2024 Review of task documentation for Resident 47 revealed that staff did not document completion or documented NA (Not Applicable) of the nursing rehab eating…

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

Based on clinical record review and staff interview, it was determined that the facility failed to provide the highest practicable care regarding physician ordered treatments and medications for three of 29 residents reviewed (Residents 52, 131, and 300). Findings include: Clinical record review for Resident 131 revealed a diagnosis list that included sepsis (a systemic response to infection) and resistance to multiple antimicrobial drugs. Observation of Resident 131 on November 20, 2024, at 11:00 AM revealed the resident was sitting in a wheelchair at the foot of the bed. The resident had a PICC line (peripherally inserted central catheter; a thin, soft, flexible tube inserted through a vein in the arm and passed through to the larger veins near the heart for the administration of fluids or medication) in the left arm. Current physician orders for Resident 131 revealed an order dated November 19, 2024, that noted the resident was to receive Meropenem (an antibiotic) two grams intravenously every eight hours for sepsis related to a thigh abscess (a tender mass filled with pus caused…

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 provide appropriate respiratory care and services for three of three residents reviewed (Residents 73, 122, and 300). Findings include: Clinical record review for Resident 73 revealed a current physician's order for staff to provide oxygen at 4 liters per minute (LPM) via NC (nasal canula, tubing to deliver oxygen to the nose), monitor (Resident 73's) oxygen saturation (the amount of oxygen in the blood) every shift and ensure the appropriate flow rate every day and evening shift. Observation of Resident 73's oxygen concentrator on November 19, 2024, at 12:47 PM revealed that their oxygen level was set at 6 LPM. Observation on November 20, 2024, at 10:52 AM revealed that Resident 73's oxygen level set was at 6.5 LPM. On November 21, 2024, at 2:26 PM revealed Resident 73's oxygen level was set at 6.5 LPM. Concurrent interview with Employee 2, nurse aide, confirmed the observation. During each observation, Resident 73's oxygen concentrator was located at the head of their…

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

Based on observation, clinical record review, review of select manufacturer's guidelines, and staff interview, it was determined that the facility failed to ensure a medication error rate below five percent (Residents 1 and 94). Findings include: The facility's medication error rate was 16 percent based on 25 medication opportunities with four medication errors. Observation of a medication administration pass on November 19, 2024, at 9:30 AM revealed Employee 1, licensed practical nurse (LPN), preparing to administer Insulin Lispro (helps regulate blood sugars) 60 units, Dulera (used to control symptoms of asthma) inhaler, and Flonase (used to help with nasal allergies) nasal spray to Resident 1. Review of Resident 1's clinical record revealed a physician's order dated October 22, 2024, that indicated nursing staff are to administer the Insulin Lispro before meals. Employee 1 administered the Insulin Lispro almost 90 minutes after Resident 1 ate her breakfast. Review of the manufacturer's guidelines for the use of Dulera revealed that once the administration is complete, the user 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 review of the facility meal schedule, observation, and resident and staff interview, it was determined that the facility failed to ensure that meals were served at regularly scheduled times in accordance with resident needs on three of five nursing units (Resident 9 and 108; Second Floor East, Second Floor West, and Third Floor East) Findings include: Review of the facility's resident food committee minutes dated October 17, 2024, revealed the residents indicated dinner is late. Observation on the Second-Floor East nursing unit on November 19, 2024, at 12:28 PM revealed staff passing lunch meal trays on the unit. Several trays remained in the cart waiting to be passed. Resident 9 who resides on the unit was observed being served lunch during an interview with the resident at 12:40 PM. Resident 9 indicated meals are often late and never when they are told they are going to be, stating she was supposed to get her lunch around noon. Resident 9 requested an alternate entrée at the time the meal tray was served to her. The alternate entrée was observed being served to the…

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

Based on clinical record review, facility documentation, and staff interview, it was determined that the facility failed to ensure complete and accurate clinical documentation for four of five residents reviewed for restorative nursing services (Residents 47, 66, 80, and 108). Findings include: Review of the facility's meal service times revealed that the breakfast meal tray carts for the 2W Nursing Unit were to be delivered to the unit at 7:50 AM and 8:00 AM respectively. Clinical record review for the following residents revealed that staff documented that they provided nursing rehab for eating and swallowing and encouraging residents to eat 50-75 percent of the meal prior to the facility delivering their breakfast tray. Review of Resident 47's October and November 2024 Task documentation (a document staff use to indicate the Resident's self-performance and staff support needed while completing a task and/or receiving care) revealed staff documentation prior to 7:50 AM that they provided nursing rehab for eating and swallowing on: October 1, 28, and 30, 2024 November 13, 14, 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 observations and resident and staff interview, it was determined that the facility failed to ensure that residents could make choices about aspects of their lives that were significant to them, such as rising for the day, for one of four residents reviewed (Resident 108). Findings include: Clinical record review for Resident 108 revealed an initial MDS (Minimum Data Set, an assessment tool completed at specific intervals to determine resident care needs) dated May 26, 2024, that indicated Resident 108 believed that it was very important to care for her personal belongings, choose between a bed bath, shower, or a sponge bath, choose the clothes to wear, to have snacks available between meals, and choose a bedtime, and have a family member or close friend involved in care discussion(s). Interview with Resident 108 on November 19, 2024, at 10:41 AM revealed that she preferred to get up at 7:00 AM and go to bed between 7:00 PM and 7:30 PM. She revealed that there were some days when she was still in bed at 12:00 PM and did not get to bed until 9:00 PM or 9:30 PM, due to late…

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 establish clear advance directives for one of five residents reviewed (Resident 15). Findings include: A review of the census for Resident 15 revealed the resident was admitted to the facility on [DATE]. Current physician orders for Resident 15 revealed an order dated [DATE], that indicated the resident was a Full Code (attempt resuscitation and CPR when the person has no pulse and is not breathing). Nursing documentation for Resident 15 dated [DATE], at 1:19 PM revealed the resident is a full code. Facility documentation titled, Code Status for Resident 15 and dated [DATE], indicated the resident was marked with a check indicating Do Not Resuscitate (do not attempt CPR when the person has no pulse and is not breathing). The form was signed by Resident 15 and the medical provider and dated [DATE], by both. The above discrepancy between the resident's signed wishes and the physician order was reviewed in a meeting…

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, review of select policies and procedures, and staff interview, it was determined that the facility failed to implement their abuse policy regarding completion of an investigation of an unknown injury for one of six residents reviewed (Resident 118) and background check screening for one of five newly hired employees (Employee 4 ). Findings include: The policy entitled Resident Abuse and Neglect Prevention Program last reviewed on May 28, 2024, indicates that the facility will investigate bruises and/or marks of unknown origin. An incident/accident report will be initiated by the charge nurse and an investigation is initiated to rule out the possibility of abuse. The policy does not indicate how other injuries will be investigated to rule out abuse, such as fractures. The policy indicates to refer to the policy entitled Incident/Accident Investigative Reports. The policy indicates that the facility will conduct a criminal background check on all prospective staff utilizing the State Police and Federal Bureau of Investigation if required. The criminal…

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 documentation, clinical record review, and staff interview, it was determined that the facility failed to identify the potential for, ensure a complete and thorough investigation of, and to ensure timely reporting of an incident involving the potential for neglect for one of 29 residents reviewed (Resident 65) Findings include: Clinical record review for Resident 65 revealed nursing documentation dated November 7, 2024, at 2:19 PM that indicated that staff was notified at 11:00 AM by Resident 65 that she had a fall. Resident 65 revealed that the fall occurred prior to the change of shift. She noted that she requested to be changed (receive incontinence care). The (nurse) aide came in and when I rolled to by side, I rolled out of the bed and landed on my knees. The (nurse) aide went and got another aide and helped me back into bed. Staff noted that Resident 65 was capable and sustained two small abrasions on both of Resident 65's knees and a scratch on her right elbow. Review of Resident 65's care plan revealed that on June 17, 2024, the facility…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, observation, and staff and resident interview, it was determined that the facility failed to ensure the availability of necessary emergency supplies for one of two residents reviewed receiving hemodialysis (Resident 52). Findings include: Clinical record review for Resident 52 revealed the resident was admitted to the facility on [DATE], and was receiving hemodialysis (a machine that performs a basic function of the kidney by cleansing the blood of impurities) three days a week. A nursing progress note dated November 1, 2024, at 7:28 PM noted the resident had a right chest tunnel catheter (a central line placed under the skin allowing long term access to a vein) for dialysis. An observation of Resident 52's room on November 20, 2024, at 10:25 AM did not reveal any emergency supplies in the resident 's room for the central line to include sterile gauze, hemostat (a tool used to control bleeding), needleless connector, or tape. The above information regarding Resident 52's central…

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

Based on clinical record review and resident and staff interview, it was determined that the facility failed to identify triggers related to a resident's diagnosis of Post-Traumatic Stress Disorder, to provide culturally, competent, trauma-informed care, and to eliminate or mitigate re-traumatization for one of four residents reviewed for mood/behavior (Resident 22). Findings include: Clinical record review revealed the facility admitted Resident 22 on November 2, 2015, with a diagnosis of Post Traumatic Stress Disorder (PTSD, a mental and behavioral disorder that develops related to a terrifying event). Review of Resident 22's annual MDS (Minimum Data Set Assessment, an assessment completed at least quarterly by the facility to determine the care needs of the resident) dated June 15, 2024, revealed that she had an active diagnosis of PTSD. Interview with Resident 22 on November 19, 2024, at 12:10 PM revealed that she has a diagnosis of PTSD and that she is triggered by people arguing and fighting, screaming, and doors slamming. She also indicated that she would pick at her…

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, review of facility documentation, and staff interview, it was determined that the facility failed to ensure an appropriate physician response to the consultant pharmacist's recommendation for one of five residents reviewed for potentially unnecessary medications (Resident 122). Findings include: Current physician orders for Resident 122 revealed an order for Oxycodone HCL (an opioid analgesic pain medication used to treat moderate to severe pain) dated September 10, 2024, that instructed staff to give one tablet by mouth every four hours as needed for moderate to severe pain (4-10) with a maximum daily amount of 30 milligrams (mg). Further review of the current physician orders revealed an order for Resident 122 for Acetaminophen (Tylenol; used to treat mild to moderate pain and/or reduce fever) tablet dated September 10, 2024, that instructed staff to give 650 mg every four hours as needed for mild pain rated 1-3 and not to exceed 3000 mg in 24 hours. A consultant pharmacist recommendation dated September 17, 2024, noted the following regarding…

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 appropriate medication security on one of five nursing units (Resident 83, Second Floor East) Findings include: Observation of Resident 83 on November 19, 2024, at 2:20 PM revealed the resident was in bed. A bottle of iodine solution was observed sitting on the resident's tray table in front of her amongst many personal belongings. A follow up observation on November 20, 2024, at 10:09 AM revealed the bottle was again observed on the resident's tray table in front of the resident in bed. The bottle was labeled Povidone-Iodine solution 10%. Resident 83 indicated she was applying it to a mole on her face and was to put it on daily, but she hasn't in a long time. Resident 83 indicated she purchased the solution herself, but they know about it, and that I have it. Clinical record review revealed no evidence of any iodine solution ordered for Resident 83, any order to self- administer the solution, or store it in her room. Resident 83 resided in a room with a roommate. In an interview with the…

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

Based on observation, review of facility documentation, and resident and staff interview, it was determined that the facility failed to serve food at a palatable temperature on one of five nursing units (Third Floor East, Resident 15). Findings include: Review of the Food Committee meeting minutes dated September 14, 2024, and October 17, 2024, noted that residents replied sometimes when asked if the hot food was hot and the cold food was cold. Interview with Resident 15 on November 19, 2024, at 11:20 AM revealed concerns that sometimes the food was not hot and a little on the colder side. Observation of meal service on the Third Floor East Nursing Unit on November 21, 2024, at 1:26 PM revealed that the food trays arrived on the unit and staff began immediately serving the meals. Further observation revealed that staff had passed the last resident food tray at 1:31 PM. The surveyor obtained a test tray at this time from the meal cart and began testing the food temperatures. The oven fried chicken entrée was tested at 111.2 degrees Fahrenheit. The plain white rice was tested at 119.2…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, clinical record review, and resident and staff interview, it was determined that the facility failed to implement appropriate enhanced barrier transmission-based precautions for three of 29 residents reviewed (Residents 52, 83, and 131). Findings include: Review of the memo entitled Enhanced Barrier Precautions (EBP, gown and glove use) in Nursing Homes to Prevent the Spread of Multi-drug Resistant Organisms released by the Center for Medicaid and Medicare Services (CMS) on March 20, 2024, with an implementation date of April 1, 2024, revealed that nursing care facilities are to use EBP for residents with chronic wounds or indwelling medical devices (i.e., indwelling urinary catheters) during high-contact resident care activities regardless of their multidrug-resistant organism status. High-contact activity would include things like dressing, transferring, changing linens, providing hygiene, changing briefs, wound care, or device care. Review of the facility policy titled, Infection Control…

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 resident's privacy on one of five nursing units (2 [NAME] Nursing Unit). Findings include: Observation of the 2 [NAME] nursing unit on October 31, 2024, revealed the following: At 12:21 PM, Employee 1 returned to the medication cart, poured resident medications, and left again to go down the hallway. Employee 1 left a resident clinical record open and in full view/access to anyone choosing to access said record. At this time, one non-licensed staff member was in the vicinity of the medication cart and several residents were congregated near the medication cart and nurse's station. At 12:22 PM, Employee 1 returned to the medication cart, poured resident medications, and immediately left the vicinity of the medication cart. Employee 1 again left a resident's clinical record open and in full view/access to anyone. At 12:24 PM, Employee 1 returned to the medication cart and poured resident medications. At 12:37 PM, Employee 1 left the medication cart, walked to a resident sitting near the…

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

Based on observation and staff interview, it was determined that the facility failed to ensure appropriate medication security on one of five nursing units (2 [NAME] nursing unit). Findings include: Observation of the 2 [NAME] nursing unit on October 31, 2024, revealed the following: At 11:12 AM upon arrival to the 2 [NAME] nursing unit the surveyor observed the unit's medication cart was unlocked while it was near the nurse's station. No licensed staff were observed in the vicinity. There were several residents congregated near the nurse's station. At 11:13 AM Employee 1, licensed practical nurse, returned to the medication cart from down the hallway and out of view of the medication cart. At 12:02 PM the surveyor observed the unit's medication cart unlocked in the same location as above. No licensed staff were observed in the vicinity. There were several residents congregated near the nurse's station. At 12:04 PM Employee 1 returned to the medication cart from down the hallway and out of view of the medication cart, removed medications, and left the vicinity of the medication…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and resident, family, and staff interview, it was determined that the facility failed to assist dependent residents with bathing, repositioning, and toileting care for two of seven residents reviewed (Residents 2 and 7). Findings include: Interview with Resident 2 and her husband on June 3, 2024, at 12:15 PM revealed that staff do not provide care every two hours as she is supposed to have. Resident 2 stated that she has discomfort sitting in the same position for long periods of time. Clinical record review of a quarterly MDS (Minimum Data Set, an assessment tool completed at specific intervals to determine resident care needs) dated May 5, 2024, revealed that staff assessed Resident 2 as needing the extensive assistance of two staff for bed mobility, and that she was dependent on the assistance of two staff for transfers. An active physician's order dated November 30, 2023, instructed staff to turn and reposition Resident 2 every two hours. A plan of care developed by 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 clinical record review and resident and staff interview, it was determined that the facility failed to provide services to maintain a resident's mobility for one of seven residents reviewed (Resident 6). Findings include: Interview with Resident 6 on June 3, 2024, at 12:50 PM revealed that staff have not walked with her per her walking program. Resident 6 stated that she believed that there were not enough staff to walk with her, and the facility restructured their nurse aide staffing to no longer have dedicated restorative nursing aides. Clinical record review for Resident 6 revealed a plan of care developed by the facility to address her deficit with self-care of activities of daily living (ADL) performance. Interventions for the plan of care included a nursing rehabilitation program to ambulate 200-250 feet twice with one staff assist, a roller walker, and a wheelchair following (as resident may get dizzy). Review of Task documentation (electronic system of nurse aide documentation of activities of daily living care) dated May 2024, and June 2024, revealed that staff…

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

Based on clinical record review and staff interview, it was determined that the facility failed to provide services to maintain a resident's range of motion (ROM) for three of three residents reviewed (Residents 54, 67, and 72). Findings include: Clinical record review for Resident 25 revealed a current care plan for staff to provide level two nursing rehabilitation of AROM (active range of motion, movement of the body in an attempt to maintain a resident's ability) to the RLE (right lower extremity) and PROM (passive range of motion) to the LLE (left lower extremity) for two sets of 15 repetitions in all planes daily and orange TheraBand (a stretchy band to help increase mobility) AROM to the RUE (right upper extremity) and PROM to the LUE (left upper extremity) two sets of 15 repetitions in all planes daily. Review of task documentation for Resident 25 for October, November, and December 2023, revealed that staff did not document completion of the restorative task on the following dates: AROM RLE and PROM LLE- October 21, 22, 27, and 31, 2023 November 1, 2, 3, 5, 6, 7, 9, 10, 11,…

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

Based on clinical record review and staff interview, it was determined that the facility failed to ensure that a resident received acceptable parameters of hydration for one of one resident reviewed (Resident 97). Findings include: Clinical record review for Resident 97 revealed the facility admitted him on September 26, 2023. On September 26, 2023, the physician ordered a fluid restriction of 1500 milliliters (ml) per day. On December 4, 2023, the physician changed the fluid restriction to 1800 ml per day. Review of Resident 97's care plan dated October 4, 2023, revealed he was at risk for a fluid-volume overload (making it harder for heart to pump when there is a fluid overload) related to congestive heart failure (chronic condition in which the heart doesn't pump blood as well as it should). The facility failed to verify what Resident 97's fluid intake totals were for each 24-hour period to determine if Resident 97 was within his restriction or getting enough fluids. The surveyor totaled Resident 97's fluid intakes from November 1-30, 2023, and December 1-7, 2023, which 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 clinical record review, review of select policies and procedures, and staff interview, it was determined that the facility failed to establish clear and consistent resident's wishes regarding advance directives (written instruction, such as a living will or durable power of attorney, relating to the provision of healthcare, for a time when a resident may be incapacitated and not able to make decisions) for one of two residents reviewed (Resident 66). Findings include: The policy entitled POLST, last reviewed on September 20, 2023, indicates that if a resident or their responsible party is not ready to complete a POLST (Pennsylvania Orders for Life Sustaining Treatment, a form that allows people with serious or chronic illnesses or the frailties of age to spell out what kinds of medical care they would want in potential future emergencies), nursing staff are to inform the resident and/or the RP (responsible party) that until a decision is made, the resident will be considered a full code. Review of Resident 66's clinical record revealed that the facility admitted him on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the facility policy, employee personnel records, and staff interview, it was determined that the facility failed to develop and implement an abuse prohibition policy that required a thorough investigation of prospective employee's employment history for three of five newly hired employees reviewed (Employees 3, 4, and 5). Findings include: The policy entitled Resident Abuse and Neglect Prevention Program last reviewed without changes on September 20, 2023, revealed that residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation as defined by the regulation. The facility will develop and implement written policies and procedures to prohibit and prevent abuse including screening of new/potential staff. The facility will conduct a criminal background investigation on all prospective staff utilizing the (Pennsylvania) state police (PSP) and the FBI (federal bureau of investigation) if the potential candidate has not resided in the state 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 clinical record review and staff interview, it was determined that the facility failed to ensure that the resident or resident representative received written notice of the facility's bed hold policy at the time of transfer for three of 10 residents reviewed for hospitalizations (Residents 25, 74, and 106). Findings include: Clinical record review for Resident 74 revealed that he was transferred to the hospital on November 3, 2023, for respiratory distress. There was no documentation available that the facility provided written notice regarding a bed hold to the resident and/or the resident's responsible party upon transfer out of the facility. Interview with the Nursing Home Administrator on December 8, 2023, at 9:45 AM confirmed that the facility did not provide a written bed hold notice to Resident 74 or his responsible party. Clinical record review for Resident 25 revealed that they were transferred to the hospital on November 2, 2023, after they had a change in condition. There was no documentation available that the facility provided written notice regarding a 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.

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 complete and accurate Minimum Data Set (MDS) assessments for two of 25 residents reviewed (Residents 51 and 113). Findings include: Review of Resident 51's clinical record revealed a Minimum Data Set Assessment (MDS, a form completed at specific intervals to determine care needs) dated October 23, 2023, that indicated the facility assessed him as having a psychotic disorder. There was no documented evidence in Resident 51's clinical record to support a diagnosis of psychotic disorder. Review of Resident 113's clinical record revealed an MDS dated [DATE], and September 26, 2023, that indicated the facility assessed him as having a psychotic disorder. There was no documented evidence in Resident 113's clinical record to support a diagnosis of psychotic disorder. Interview with Employee 2, MDS assessment coordinator, on December 8, 2023, at 9:47 AM, confirmed the above findings for Resident 51 and Resident 113…

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 and family interview, it was determined that the facility failed medically justify and evaluate the clinical necessity for a urinary catheter for one of two residents reviewed (Resident 43). Findings included: Clinical record review for Resident 43 revealed the facility admitted him on July 22, 2022. Resident 43 was admitted to the hospital from [DATE] to 17, 2023, for evaluation and treatment of his left second toe. An interview with Resident 43's family on December 5, 2023, at 2:06 PM revealed that Resident 43 had a catheter put in at the hospital. She stated that he did not have a urinary catheter (insertion of a tube into the bladder to remove urine) prior to Resident 43's hospitalization on November 13, 2023. A review of Resident 43's physician orders revealed a new order dated November 23, 2023, for staff to insert a Foley catheter16 French with a 5 milliliter (mL) balloon. A review of Resident 43's clinical record revealed no medical justification for the…

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

Based on observation, clinical record review, and staff interview, it was determined that the facility failed to provide appropriate respiratory care and services for one of five residents reviewed (Resident 21). Findings include: According to the American Association for Respiratory Care proper cleansing of respiratory (nebulizer) equipment reduces infection risk. The longer a dirty nebulizer sits and is allowed to dry, the harder it is to clean thoroughly. Parts of the aerosol drug delivery device should be rinsed and then washed with soap and hot water after each treatment. Once completely dry, store the nebulizer cup and mouthpiece in a zip lock bag. Clinical record review for Resident 21 revealed a current physician's order for staff to administer a CPAP (continuous positive airway pressure, a device to help treat sleep apnea) device at bedtime. Observation of Resident 21 revealed that there was a CPAP mask unbagged and lying on a shelf beside her bed or on the floor on the following dates and times: December 5, 2023, at 10:27 AM, on shelf by bed December 6, 2023, at 12:04 PM…

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

Based on clinical record review and resident and staff interview, it was determined that the facility failed to provide the highest practicable care regarding coordination of dialysis services and administration of physician ordered medications for one of one resident reviewed (Resident 14). Findings include: Clinical record review for Resident 14 revealed that she received kidney dialysis (a procedure to remove waste products and excess fluid from the blood when the kidneys stop working properly) on Mondays, Wednesdays, and Fridays at an outside provider. Further clinical record review revealed that her plan of care indicated the facility could administer her morning medications prior to leaving for dialysis on Mondays, Wednesdays, and Fridays. Interview with Resident 14 on December 6, 2023, at 11:41 AM indicated that she leaves for dialysis on Mondays, Wednesdays, and Fridays at 4:10 AM. She indicated that she eats her breakfast and takes her morning medications prior to going to dialysis. Resident 14 currently receives the following medications at 4:00 AM prior to leaving 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 clinical record review, select facility policies, and staff and resident interview, it was determined that the facility failed to obtain physician ordered medications for one of 25 residents reviewed (Resident 25). Findings include: The current facility policy entitled Medication Availability Policy, last reviewed without changes on September 20, 2023, revealed that when a medication was unavailable the LPN (licensed practical nurse) or RN (registered nurse) must check for overstock in the medication room, check central supply for possible availability, and call the supervisor and make them aware of the unavailable medication with the RN checking the emergency box/pyxsis (a medication dispensing system). If the medication was still unavailable, the RN will contact the pharmacy to send on the next run. If the medication was emergent, call the physician to obtain prescription from the backup pharmacy and notify the physician that the dose will be administered as soon as it was delivered and if ok per the physician. The RN will notify the LPN/RN on the cart, with documentation…

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 ensure a medication error rate less than five percent (Resident 58). Findings include: The facility's medication error rate was 8 percent based on 25 medication opportunities with two medication errors. Clinical record review for Resident 58 revealed current physician's orders for the nurse to administer the following medications: Lacosamide 150 milligram (mg) tablet one every 12 hours for seizures (a burst of uncontrolled electrical activity in the brain that causes temporary abnormal muscle tone or movements). Finasteride 5 mg tablet one time a day for urinary retention (difficulty urinating). The medication administration record indicated do not crush or split the tablet. Should not be handled by women of child-bearing age. Women who are pregnant or may get pregnant must not handle broken or crushed tablets. Observation of the medication administration pass for Resident 58 on December 7, 2023, at 9:45 AM revealed that Employee 7, licensed practical nurse, crushed 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, review of select facility policies and procedures, and staff interview, it was determined that the facility failed to provide the recommended pneumococcal immunizations for two of five residents reviewed for immunizations (Residents 18 and 37). Findings include: The policy entitled Infection Control-Immunization of pneumococcal vaccination of residents last reviewed September 20, 2023, indicates that all residents upon admission are offered the Pneumococcal vaccine, consent or declination will be maintained on the resident record. If a PCV15 (Pneumococcal conjugate vaccine) is used, this should be followed by a dose of PPSV23 (Pneumococcal polysaccharide vaccine) one year later. Prior administration of Pneumococcal vaccine shall be documented on the resident immunization record. Vaccines are administered per the CDC (Center for Disease Control) guidance as follows: Residents 19-[AGE] years old considered at risk, or 65 or older with one dose of PCV15 should be followed up with 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.