Wallingford Skilled Nursing And Rehabilitation Cen

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, observations, and interviews with residents and staff it was determined that the facility failed to maintain personal dignity for two of six residents observed (Resident R1, R2) Findings Include: Facility policy titled Residents Rights Under Federal Law , revised 2023, revealed the facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his/her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident. Clinical record revealed Resident R1 was admitted to the facility on [DATE] with a diagnosis that included fracture of upper end of left humerus, schizophrenia (mental health condition that affects how people think, feel, and behave), and muscle weakness. Review of Resident R1's Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs), dated June 06, 2025, revealed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of select facility policies and procedures, clinical record review, observation, and staff interview, it was determined that the facility failed to implement enhanced barrier precautions for four out of 35 residents reviewed (Resident 11, Resident 59, Resident 64, and Resident 164). Findings include: Review of facility policy titled Enhanced Barrier Precautions, revision date January 8, 2024, states Enhanced Barrier Precautions (EBP) is based on the Centers of Disease Control & Prevention (CDC) guidance, Implementation of Personal Protective Equipment (PPE) use in nursing homes to prevent spread of multidrug-resistant organisms (MDROs). Review of Resident 11's clinical record revealed the resident was admitted [DATE], with an admitting diagnosis of sepsis (occurs when your immune system has a dangerous reaction to an infection, resulting in tissue damage and organ failure). Additional review of Resident 11's clinical record revealed an active order for indwelling foley catheter due 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 a review of the facility's policy, clinical records review, and staff interview, it was determined that the facility failed to notify the physician of a significant weight change for one of the 35 residents reviewed (Resident 114). Findings include: A review of the facility's policy titled Weights and Heights, last revised on February 1, 2023, revealed, that if the body weight is not expected, re-weigh the patient. A significant weight change is defined as 5% in one month and 10% in six months. Significant weight changes will be reviewed by the licensed nurse for assessment. The physician and Dietitian will be notified, and notification of the physician and Dietitian will be documented in the Weight Change Progress Note. Clinical records review revealed Resident 114 had a diagnosis of Congestive Heart Failure (CHF weakened heart condition that causes fluid buildup in the feet, arms, lungs, and other organs). A review of Resident 114's weights and vitals revealed a weight of 131.2 pounds on November 4, 2024, and 150.2 pounds on December 5, 2024, a 19 pounds (14.48%)…

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 employee interview it was determined that the facility failed to ensure physician's orders were followed for one of 35 residents reviewed (Resident 19). Findings include: Review of Resident 19's physician's orders revealed an order dated October 3, 2023, for oxygen 2 liters via nasal cannula (tubing that wraps around the ears that supplies oxygen via the nose). Further review of Resident 19's physician's orders revealed an order dated March 7, 2024, to maintain ear protectors on oxygen tubing at all times. Review of Resident 19's Treatment Administration Records revealed staff were signing off that the ear protectors were maintained on the oxygen tubing. Review of Resident 19's progress notes revealed a practitioner note dated August 28, 2024, which stated: this is [an acute] visit per nurse request. Patient has [significant] redness and swelling behind left ear. Patient has oxygen and per nurse she injures area with oxygen tubing. The practitioner prescribed doxycycline (antibiotic) 100 milligrams twice daily for seven days, hydrocortisone cream…

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 records review, and staff interview, it was determined that the facility failed to ensure adequate assistance was provided to prevent a fall for one of the 35 residents reviewed (Resident 156). Findings include: A review of Resident 156's diagnosis list includes cerebral infarction (a condition that occurs when blood flow to the brain is blocked, resulting in brain tissue death), contracture (a permanent tightening of the muscles, tendons, and ligaments that prevents normal movement of a joint or body part), falls, and intellectual disabilities. A review of the Quarterly Minimum Data Set (MDS- A standardized assessment tool that measures health status in long-term care residents) dated November 8, 2025, revealed Resident 156 had a moderate cognitive impairment. The same MDS revealed that the resident had impairment to one side of the upper and lower extremities. The resident was dependent on toileting and personal hygiene. State MDS dated [DATE], revealed that the resident required…

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

Based on review of facility procedure, observation, and clinical record review, it was determined that the facility failed to provide documented evidence that consistent, adequate catheter care was provided to one of five residents reviewed for catheters (Resident 167). Findings include: Review of facility procedure, Catheter: Indwelling Urinary - Care of, last revised February 1, 2023, revealed that catheter care is to be performed twice daily and as needed, and the catheter care is to be documented in the clinical record. Observation of Resident 167 on December 10, 2024, at approximately 9:00 a.m. revealed the resident had a Foley catheter (a thin, flexible tube placed in the bladder through the urethra to drain urine). Review of Resident 167's physician's orders, Medication Administrator Records, Treatment Administration Record, and care plan failed to reveal evidence that the resident was receiving routine catheter care. The above findings were discussed and confirmed with the Nursing Home Administrator on December 12, 2024, at approximately 9:50 a.m. 28 Pa Code 211.12(d)(5)…

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 procedure and clinical record review, it was determined that the facility failed to adequately monitor and address significant weight loss in one of nine residents reviewed for nutrition (Resident 130). Findings include: Review of facility procedure Weights and Heights, last revised February 1, 2023, revealed: If the body weight is not as expected, re-weigh the patient. The policy further stated: Significant weight changes will be reviewed by the licensed nurse for assessment. The licensed nurse would then notify the provider and dietitian of significant weight changes, document notification, and notify the physician of recommendations made by the dietitian. Review of Resident 130's weights revealed on September 6, 2024, the resident was documented as weighing 131.5 pounds (lbs.) On October 3, 2024, the resident was documented as weighing 123.8 lbs., a 5.86% loss in one month. The next documented weight in Resident 130's clinical record was not obtained until November 8. 2024, where the resident was documented as weighing 117.4 lbs., a 5.45% loss in one…

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

Based on clinical records review and staff interview, it was determined that the facility failed to ensure medication to treat Diabetes (A group of metabolic disorders characterized by a high blood sugar level over a prolonged period of time) was made available for one of 35 residents reviewed (Resident 13). Findings include: A review of Resident 13's physician order dated August 28, 2024, revealed an order for Trulicity (A medication used to help lower blood sugar levels in people with type 2 diabetes) 4.5mg/0.5ml Inject 4.5 mg subcutaneously one time a day every Wednesday for Diabetes. A review of the October and November 2024, Medication Administration Record revealed Trulicity was not administered on October 9, 30, and November 13, 2024. Nursing progress notes dated October 9, 2024, October 30, 2024, and November 13, 2024, all indicated medication Trulicity (not administered), pharmacy notified. A review of the laboratory report dated April 10, 2024, revealed an HbA1c (A hemoglobin A1C test is a blood test that shows what your average blood sugar level was over the past two 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 clinical records review and staff interview, it was determined that the facility failed to provide a consistent non-pharmacological intervention (NPI) and failed to provide an appropriate indication for the use of as-needed psychotropic medication for one of five residents reviewed (Resident 164). Findings include: A review of Resident 164's physician's order dated October 21, 2024, revealed an order for Lorazepam (A medication used to treat Anxiety) 0.5 mg one tablet two times daily. An order for Lorazepam 0.5 mg one tablet by mouth every six hours PRN (as needed) for Anxiety was also made on the same day. A review of the December 2024, Medication Administration Record revealed that from [DATE], until December 12, 2024, aside from the schedule two times daily Lorazepam order, Resident 164 was administered with PRN Lorazepam order six times in 12 days. Clinical records review revealed that from December 1, 2024, until December 12, 2024, Resident 164 was administered with PRN Lorazepam four times with no…

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 policy, observations, and staff interview, it was determined that the facility failed to ensure medications were properly stored and labeled for one of the two units observed (1 North). Findings include: A review of the facility policy titled Medication Storage undated, revealed medications and biologicals are stored properly, following manufacturers' or provider pharmacy recommendations to keep their integrity and to support safe, effective drug administration. The provider pharmacy dispenses medications in containers that meet state and federal labeling requirements. Medications are to remain in these containers and stored in a controlled environment. An observation on the 1 North short hall med cart was conducted on December 10, 2024, at 9:30 a.m., with the presence of licensed Employee E6. Observation of the top drawer of the medication cart revealed the following: five white tablets in a medication cup; 12 loose Allegra tablets (A medication used to treat allergies) tablets; and five loose Famotidine tablets (A medication used to treat…

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 upon clinical record review, it was determined that the facility failed to ensure that medication irregularities were acted upon by a physician for four of five residents reviewed (Resident 16, 29, 77, and 137). Findings include: Review of Resident 16's Consultation Report for the Medication Regimen Review completed on September 1, 2023, revealed a recommendation to consider a trial dose reduction of Aripiprazole (anti-psychotic medication) to 2 mg at night. Review of Resident 16's clinical record failed to reveal that the above recommendation was addressed by the physician. Interview with the Director of Nursing on June 25, 2024, at 1:00 p.m., confirmed that the pharmacy recommendation made on September 1, 2024, was not addressed by the physician. Review of Resident 29's Consultation Report for the Medication Regimen Review completed on February 1, 2024, revealed a recommendation for a dose reduction evaluation for the medications Clonazepam (Anti-anxiety medication), Haloperidol (Anti-psychotic…

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 upon clinical record review, it was determined that the facility failed to ensure residents were free from unnecessary psychotropic medications by attempted dosage reductions and periodical reevaluation of psychotropic drug usage for three of five residents reviewed (Residents 16, 29, and 137). Findings include: Review of the facility's policy titled Psychotropic Medication Use dated December 1, 2007, revealed the facility should ensure that the ordering physician reviews the medication plan and considers a Gradual Dose Reduction (GDR) of psychotropic medications to find the lowest effective dose unless a GDR is clinically contraindicated. The physician should document the clinical rationale for why any additional attempted dose reduction at that time would be likely to impair the resident's function or increase distressed behavior. Review of Resident 16's physician order dated September 1, 2023, revealed an order for Aripiprazole (anti-psychotic medication) 5 mg (milligram) given by mouth at bedtime for…

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

Based on job description reviews, it was determined that the Nursing Home Administrator and Director of Nursing failed to effectively manage the facility of ensuring that the beverage temperature policy/guidelines included parameters identifying safe beverage temperatures for hot liquids and failed to protect residents from potentially suffering a medical emergency related to hot beverage burns. Findings include: Review of the Nursing Home Administrator's (NHA) job description includes the following responsibilities: Managing all business-related activity to achieve the facility's vision and supporting strategies and assures ethical and high-quality provider of health services is maintained; Knowing and respecting resident rights; Safety-follows established safety policies, ensures potential safety/health hazards are eliminated, and demonstrate job-specific knowledge of disaster procedures; Staff development-participates in QAA program communicates new policy and regulations to staff to ensure compliance; Administration Provision and Services Responsibilities-drives quality…

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 the clinical records review interview with staff and physician, it was determined that the facility failed to notify the physician of an abnormal blood result for one of the three residents reviewed (Resident R1). Findings include: A review of Resident 1's physician order dated July 31, 2024, revealed an order for Coumadin 5 mg one tablet one time a day on Tuesday, Wednesday, Thursday, Friday, Saturday, and Sunday for A-Fib (Irregular heartbeat). Clinical records review revealed a blood work for INR (International Normalized Ratio- A standardized measurement of prothrombin time, which is the test that measures how long it takes blood to clot. An INR for healthy people is between 0.8 and 1.2.) was done on August 13, 2024t, with a result of 4.1 indicating a critical high result. The laboratory result revealed that the result was reported on August 13, 2024. Clinical records review failed to reveal that the physician was notified of the critical high INR result. A review of Resident 1's Medication Administration Record revealed that the resident was administered with Coumadin…

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

Based on review of facility policy and procedure, clinical record, and staff interview it was determined the facility failed to thoroughly investigate an injury of unknown origin for one of 24 residents reviewed. (Resident 264) Findings include: Review of Facility policy and procedure titled Accidents/Incidents, last revised on March 1, 2024 revealed, When conducting an investigation the Administrator, DON, or designee will make every effort to ascertain the cause of the accident/incident .Conduct witness interviews from all staff and visitors who may have knowledge of the accident/incident. Review of Resident 264 progress notes revealed a nursing entry dated February 21, 2024 at 1:44 p.m. stating, during rounds resident grimacing and moaning when left lower extremity moved, resident have limited to no movement of left leg, NP (Nurse Practitioner) seen and examined and resident with new order for stat (immediate) x-ray of the left hip, pelvis, and femur and knee. Further review of Resident 264 progress notes revealed a nursing entry on February 21, 2024 at 4:48 p.m. stating x-ray…

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

Based on clinical records review and staff interview, it was determined that the facility failed to ensure medication ordered by the physician was followed for one of the 33 residents reviewed (Resident 70). Findings include: Review of Resident 70's diagnosis list includes Chronic Kidney Failure and Dependence on Hemodialysis (A process of purifying the blood of a person whose kidneys are not working normally). Review of Resident 70's clinical record revealed the resident goes for dialysis services every Tuesday, Thursday, and Saturday at 10:00 a.m. Review of the Resident 70's blood work dated June 4, 2024, revealed a Phosphorus level of 6.8 mg/dl (normal range 2.5- 4.5) Review of Resident 70's physician's orders dated June 2, 2024, and June 13, 2024, revealed an order for Calcium Acetate (Phosphate binder) 667 mg one tablet by mouth with meals for elevated phosphorus. The medication was scheduled for 8:30 a.m., 12:30 p.m., and 5:00 p.m. Review of Resident 70's medication administration record revealed that the medication was not administered on June 4, 6, 15, 18, and 20, 2024, at…

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

Based on clinical record review, it was determined that the facility failed to monitor and address significant weight changes in a timely manner for two of six residents reviewed for nutrition (Residents 54 and 60). Findings include: Review of Resident 54's weights revealed the resident had not been weighed since April 24, 2024. Review of Resident 54's progress notes revealed a dietitian entry dated May 20, 2024 stating No updated weight this month. Rt refused to be weighed Attempted to get weight again today but sit to stand scale is broken. Review of Resident 54's clinical record revealed there was no other documentation of resident refusing to be weighed and there was no care plan developed for the resident related to refusals. Interview with the Director of Nursing confirmed Resident 54 had not been weighed since April 24, 2024 and there was no other documented evidence Resident 54 had refused weights. Interview with the Nursing Home Administrator on June 24, 2024 at 1:15 p.m. revealed the maintenance director had inspected the scale used for Resident 54 and it was in working…

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 the facility failed to provide enteral nutrition (feeding delivered through a feeding tube) as ordered by the physician for one of five residents reviewed. (Resident 54) Findings include: Review of Resident 54's clinical record revealed the resident returned from the hospital on February 28, 2024 with a PEG tube (feeding tube- tube surgically inserted into the stomach when oral intake is not adequate). Review of the physician orders revealed an order dated April 24, 2024 for Jevity 1.5 (tube feeding) running at 65 ml per hour starting at 5 p.m. and ending at 9 a.m. for a total of 1040 ml per day. Review of resident 54's Medication Administration Record (MAR) for the months of April, May and June 2024 revealed there were no days where it was documented the resident received a total of 1040 ml per day as ordered by the physician. Interview with the Director of Nursing on June 24, 2024 at 11:15 a.m. confirmed there was no documented evidence Resident 54 had received the amount of tube feeding as ordered 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, it was determined that the facility failed to ensure non-pharmalogical interventions (NPIs) were attempted prior to the administration of as-needed narcotic pain medication for one of thirty-three residents reviewed (Resident 98). Findings include: Review of Resident 98's physician's orders revealed an order dated October 25, 2023, for oxycodone (narcotic pain reliever) 5 milligrams (mg) give every 4 hours as needed, and document all NPIs prior to administering the medication. Review of Resident 98's April 2024 Medication Administration Record (MAR) revealed the resident received as-needed oxycodone 5 mg a total of 21 times. Review of Resident 98's May 2024 MAR revealed the resident received as-needed oxycodone 5 mg a total of 20 times. Review of Resident 98's June 2024 revealed the resident received as-needed oxycodone 5 mg a total of 26 times as of June 21, 2024. Further review of Resident 98's April 2024, May 2024, and June 2024 MARs and progress notes failed to reveal NPIs were documented prior to administering the resident's oxycodone 5mg.…

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

Based on clinical records review and staff interview, it was determined that the facility failed to perform laboratory services for one of the 33 residents reviewed (Resident 29). Findings include: Review of Resident 29's clinical records revealed Resident 29 had a diagnosis of Epilepsy (disorder in which nerve cell activity in the brain is disturbed causing seizures). Review of Resident 29's physician order dated August 26, 2022, revealed an order for Depakote 750 mg in the morning and 500 mg at bedtime. Review of Resident 29's physician's notes dated April 29, 2024, at 9:30 a.m., revealed Today's order: TSH, CBC, CMP, and Depakote level for May 1, 2024. Review of Resident 29's physician's notes dated May 22, 2023, at 3:49 p.m., revealed the Depakote level was ordered but not completed on May 1, 2024, then reorder for May 2023. Clinical records review failed to reveal that Depakote level was completed on May 1, 2024, and/or May 23, 2024. An interview conducted with the Director of Nursing on June 24, 2024, at 1:00 p.m., confirmed Depakote level was not completed until June 22,…

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, it was determined that the facility failed to ensure the radiological diagnostic studies were done in a timely manner for one of thirty-three residents reviewed (Resident 101). Findings include: Review of Resident 101's progress notes revealed a nurse's note dated April 2, 2024, which stated: Resident return from schedule [doctor] appointment. Per [doctor] recommendation to check vitamin D level, increased vitamin D to 2000, Calcium 600 mg, Prolia [(medication used to treat bone loss)] injection [every] six months. Next office visit May 2024 for Dexa scan [(low-dose x-ray that measures bone density and risk for osteoporosis and fractures.)] Further review of Resident 101's progress notes revealed a nurse's note dated May 20, 2024, which stated: Resident was supposed to go out on appointment this afternoon, transport did not show- up. Further review of Resident 101's progress notes revealed a late entry nurse's note effective date May 20, 2024, which stated: Resident was scheduled for a dexascan today. The order was placed for stretcher transport,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy and facility documentation, and staff interview, it was determined that the facility failed to ensure one of three residents reviewed was free from abuse (Resident CL1). Findings include: Review of facility policy, Abuse Prohibition, last reviewed [DATE], revealed that Centers prohibit abuse, mistreatment, neglect, misappropriation of resident/patient property, and exploitation for all patients. Review of Resident CL1's clinical record revealed the resident was admitted to the facility on [DATE], with a diagnosis of lung cancer with metastasis to the brain and expired on [DATE]. Review of Resident CL1's comprehensive Minimum Data Set (MDS - periodic assessment of resident care needs) dated [DATE], revealed the resident's Brief Interview for Mental Status (BIMS) score was 13, indicating the resident was cognitively intact. Review of Resident CL1's roommate's clinical record, Resident CL2, revealed a comprehensive MDS dated [DATE], with a BIMS score of 15, indicating that the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff interview it was determined that [NAME] Skilled Nursing and Rehabilitation Center failed to ensure that residents were assessed and monitored to prevent pressure ulcers for one of one residents reviewed (Resident R72). Findings include: Review of Resident R72's clinical record revealed resident was admitted on [DATE]. Further review of clinical record revealed Resident 72's diagnoses include; Diabetes Mellitus (failure of the body to produce insulin to enable sugar to pass from the blood stream to cells for nourishment), Vascular Dementia (lack of blood carrying oxygen and nutrient to a part of the brain, causing problems with reasoning, planning, judgment, and memory); Malnutrition; and Abnormalities of gait. Review of Resident R72's clinical record revealed most recent Braden Scale (assessment of risk of developing pressure ulcers) dated June 15, 2023 which indicated resident was considered High Risk to develop pressure ulcer/wound. Review of Resident R72's clinical…

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

Based on Clinical record review and staff interview it was determined the facility failed to accurately code Minimum Data Set assessments for five of 24 residents reviewed. (Residents 4, 72, 78, 85, 92,) Findings Include: Review of Resident 4's Significant Change Minimum Data Set (MDS- periodic assessment of resident needs) dated June 6, 2023 revealed sections C Cognitive Patterns and D Mood were all dashed indicating they were not completed at the time of submission of the MDS. Review of Resident 72's Modification of Quarterly Minimum Data Set (MDS- periodic assessment of resident needs) dated May 11, 2023 revealed sections C Cognitive Patterns and D Mood were all dashed indicating they were not completed at the time of submission of the MDS. Review of Resident 78's Quarterly Minimum Data Set (MDS- periodic assessment of resident needs) dated July 20, 2023 revealed sections C Cognitive Patterns and D Mood were all dashed indicating they were not completed at the time of submission of the MDS. Review of Resident 85's Quarterly Minimum Data Set (MDS- periodic assessment 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 upon review of facility policy and procedure and clinical record review, it was determined that the facility failed to follow physician orders for the administration of medication for two of 31 residents reviewed (Resident 69 and Resident 142). Findings include: Review of facility policy titled General Dose Preparation and Medication Administration, revised January 1, 2022, revealed Facility staff should comply with Facility policy, Applicable Law and the State Operations Manual when administering medications. Further review of the facility policy revealed Facility staff should verify that the medication name and dose are correct when compared to the medication order on the medication administration record. Further review of the facility policy revealed Verify each time a medication is administered that it is the correct medication, at the correct dose, at the correct route, at the correct rate, at the correct time, for the correct resident, as set forth in facility's medication administration schedule. Clinical records review revealed Resident 69's diagnosis list includes…

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 the facility failed to have a consultant pharmacist provided a monthly medication review or a physician respond to the recommendations made by the pharmacist during the monthly medications review for five of 5 residents reviewed (30, 33, 35, 68, 92) Findings include: Review of Resident 30's clinical record revealed diagnoses including but not limited to Vascular Dementia with psychosis (Memory loss with loss of reality in higher brain functions) Review of Resident 30's clinical record revealed a physician's orders for various medications including antipsychotics, anticonvulsants, opioids, antidepressant, and antianxiety medications. Review of Resident 30's pharmacy monthly consultation report dated February 22, 2023, and July 4, 2023, revealed that irregularities were found by the pharmacist, but the irregularities were not documented. Interview with the DON on August 3, 2023, at 11AM confirmed that pharmacy irregularity reports were not received by the facility and was therefore not provided to the attending…

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, a review of medication manufacturer's guidelines, and staff interviews, it was determined that the facility failed to ensure that medications were properly labeled and stored in two of six medication carts observed (1 North long hall and 1 North short hall medication cart). Findings include: Review of the manufacturer's storage guidelines for Insulin Lispro (Humalog-fast-acting insulin), revealed that the medication must be stored at room temperature and must be discarded within 28 days after opening. Review of manufacturers' storage guidelines for Insulin Gargline (long-acting insulin) revealed that the medication may be stored at room temperature and must be discarded within 28 days after opening. Review of the manufacturer's guidelines for Basaglar Insulin Kwikpen (a long-acting insulin) revealed that the medicine should be discarded 28 days after opening or removal from refrigeration. Review of the manufacturer's storage guidelines for Levemir FlexTouch (long-acting insulin), revealed in-use Levemir insulin must be discarded 42 days after opening. Review…

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 job description reviews, it was determined that the Nursing Home Administrator and Director of Nursing failed to effectively manage the facility by implementing monitoring, supervision, and effective safety measures to for a resident who demonstrated physical aggression, which resulted in harm to Resident 141 as evidenced by laceration needing emergency medical treatment. The Administration failure resulted in an immediate jeopardy situation for 42 additional residents who resided on the same unit as Resident 88. Findings include: Review of the Nursing Home Administrator's (NHA) job description includes the following responsibilities: Managing all business-related activity to achieve the facility's vision and supporting strategies and assures ethical and high-quality provider of health services is maintained; Knowing and respecting resident rights; Safety-follows established safety policies, ensures potential safety/health hazards are eliminated, and demonstrate job-specific knowledge of disaster procedures; Staff development-participates in QAA program communicates new…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, observations and staff interview it was determined the facility failed to ensure the dignity of resident for two of 24 resident reviewed. (Residents 68 and 78) Findings Include: Review of resident 68's quarterly Minimum Data Set (MDS- periodic assessment of resident needs), dated July 5, 2023 revealed the resident had cognitive impairment. Observation of resident 68's room on July 31, 2023 at 9:45 a.m. and August 1, 2023 at 10:00 a.m. revealed a sign on the wall above the bed with instructions on how to use the resident's palm guard, ensure items are within resident's reach, and provide a scoop dish and handled mug at each meal. The sign was dated June 2023 and was signed by an occupational therapist. Review of Resident 78's quarterly MDS dated [DATE] revealed the resident had cognitive impairment. Observation of resident 68's room on July 31, 2023 at 9:45 a.m. and August 1, 2023 at 10:00 a.m. revealed a sign on the outside of the door and observable from the hallway with…

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, it was determined that the facility failed to ensure a comprehensive care plan was initiated for a resident receiving hospice services for one of 31 residents reviewed (Resident 4). Findings include: Review of Resident 4's clinical record revealed an order for hospice (end of life care) dated June 5, 2023. Review of Resident 4's care plan failed to reveal evidence of a care plan related to hospice or end of life care. Interview with the Director of Nursing on August 3, 2023, at 10:30 a.m. confirmed there was no care plan addressing Resident 4's hospice needs. 28 Pa. Code 211.11(a)(b)(c)(d) Resident care plan

Based upon review of facility documentation and clinical record review, it was determined the facility failed to ensure care plans were revised and updated after falls and an episode of aggression for two of 31 residents reviewed.(Resident 88 and Resident 100). Findings include: Review of Resident 88's clinical record revealed an admission date of November 1, 2018, which includes, but is not limited to schizophrenia, dementia, psychotic disturbance, mood disturbance, anxiety, and major depressive disorder. Review of Resident 88's clinical record revealed that on May 30, 2023, the resident struck another resident with a cane causing a laceration to the scalp. Review of Residents 88's current plan of care failed to reveal a revised and updated interventions to address the aggression displayed on May 20, 2023. Review of Resident 100's diagnosis list revealed diagnoses including seizure disorder. Review of Resident 100's clinical record and facility documentation revealed Resident 100 had sustained falls on May 4, 2023, May 11, 2023, May 18, 2023, and July 31, 2023. Review 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based upon review of facility policy and procedure, clinical record review, and interview it was determined the facility failed to obtain weights upon admission and failed to obtain weekly weights for nutrition maintenance for two of 31 residents reviewed. (Resident 68 and Resident 153). Findings include: Review of facility policy and procedure titled Weights and Heights, revised June 15, 2022 revealed Patients are weighed upon admission and/or re-admission, then weekly for four weeks and monthly thereafter. Additional weights may be obtained at the discretion of the interdisciplinary care team. Hospital weight will not serve as admission or re-admission weight. Review of Resident 68's demographic sheet revealed the resident was admitted to the facility on [DATE]. Review of Resident 68's weights revealed the first weight was not obtained until May 18, 2023. Interview with the Nursing Home Administrator and the Director of Nursing on August 3, 2023 at 12:30 p.m. confirmed there was no admission weights and weekly…

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

Based on clinical records, and interviews with residents and staff, it was determined that the facility failed to make certain that the medications ordered were available and administered by the acceptable standards of care for one of the 31 residents reviewed (Resident 20). Findings include: Clinical records review revealed Resident 20's had a diagnosis of Chronic Pain Syndrome. Review of Resident 20's Physician's order sheet (POS) revealed an order for Oxycodone HCL (A medication to treat moderate to severe pain) 10mg tablet Give one tab every six hours for pain. Review of Resident 20's July 2023 Medication Administration Record (MAR) revealed that the Oxycodone was not administered on the following dates/times: July 9, 2023, at midnight, July 10, 2023, at noon, July 11, 2023, at 12:00 a.m., 6:00 a.m., and 12 noon, and July 12, 2023, at midnight. Resident 20 did not received her/his ordered Oxycodone medication six times on July 2023. Review of the nursing progress notes dated July 9, 2023, revealed that at midnight, the nurse called the pharmacy because Oxycodone 10mg was not…

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

Based on clinical records review and staff interview, it was determined that the facility failed to ensure that an appropriate indication was present and non-drug interventions were attempted before administering an as-needed anti-anxiety medication for two of the 31 residents reviewed (Resident 35 and Resident 69). Findings include: Clinical record review revealed Resident 35's diagnosis list includes Schizoaffective Disorder. Review of Resident 35's physician's order revealed Xanax (anti-anxiety medication) 0.25 milligrams by mouth every six hours as needed for anxiety. Review of Resident 35's Medication Administration Record (MAR) revealed the resident's behaviors and refusals should be documented every shift daily. Further review of Resident 35's MAR revealed that the resident's behaviors were only documented on the Medication Administration Record for three shifts from July 1,2023, until July 31, 2023. Interview with the Director of Nursing on August 3, 2023 at 11:00 a.m. confirmed that staff was not documenting the resident's behaviors because the system did not prompt them 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, review of facility policies and interviews with staff, it was determined that the facility failed to store food in accordance with professional standards for food service safety. Based on observation of the first-floor pantry refrigerator and cabinets on August 1, 2023, at 9:23 a.m. it was determined that there were six unlabeled 4 oz milk cartons that expired on June 26, 2023. Additional observation of the refrigerator showed four peanut butter and jelly sandwiches, two open loaves of bread, a pizza box, a container of macaroni and cheese and four bags of take-out food all of which were unlabeled and undated. Further observation of the refrigerator showed and an open 16 oz ginger ale soda that was unlabeled. Observation of the facility's Food from Outside Sources policy stated that food must be labeled with the resident's name and date it was brought to the facility. The policy further states that the nursing and dietary department is assigned responsibility for monitoring the designated refrigerator and discarding outdated foods once a day. Interview with…

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 interview with staff and clinical record review, it was determined that the facility failed to maintain complete and accurate medical records related to medications and treatments for one of six residents reviewed (Resident 35). Findings include: Review of facility policy Medication Pass Policy dated last revised June 14, 2017, revealed that After you have finished assisting with medication, it is very important that you immediately write in the MAR and record the following information: the vital signs if and required for the medication, your initials in the appropriate box, your name and title in the appropriate space, the resident refusal to take the medication if applicable. Clinical record review for Resident 35 revealed a physician's order for Paliperidone ER (antipsychotic medication used to treat Schizophrenia and Schizoaffective disorder) 3 milligrams every night at bedtime. Per the resident's notes dated July 15, 2023, the medication was on order. Per the resident's progress notes dated July 23, 2023, the medication was on order, progress notes for July 24, 2023,…

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.