Kadima Rehabilitation & Nursing At Washington

Based on review of personnel records and staff interview it was determined that the facility failed to complete annual performance evaluations for five of five nurse aides (NA Employee E13, E15, E16, E17 and E18). Findings include:Review of personnel files revealed that Nurse Aide Employee E13 hire date was 10/21/98, there was no performance evaluation completed.Review of personnel files revealed that Nurse Aide Employee E15 hire date was 7/31/23, there was no performance evaluation completed.Review of personnel files revealed that Nurse Aide Employee E16 hire date was 9/11/24, there was no performance evaluations completed.Review of personnel files revealed that Nurse Aide Employee E17 hire date was 11/25/24, there was no performance evaluations completed.Review of personnel files revealed that Nurse Aide Employee E18 hire date was 11/27/24, there was no performance evaluations completed.During an interview on 1/30/26, at 10:15 a.m., the Director of Nursing confirmed that the facility failed to complete annual performance evaluations for five of five nurse aides (NA Employee E13,…

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, observations and staff interview, it was determined that the facility failed to properly store food products in the walk-in cooler and freezer which created the potential for cross contamination (Main Kitchen). Findings include:Review of facility policy Food Storage dated 1/9/26, indicated foods shall be received and stored in a manner that all foods in the freezer and refrigerators will be stored above the floor on shelves to facilitate thorough cleaning.During an observation of the main kitchen on 1/27/26, from 9:00 a.m., through 9:42 a.m., the following was observed:Walk in cooler and freezer had food stored to the ceiling and under the fan encasement allowing potential cross contamination. During an interview on 1/27/26, at 9:42 a.m., Dietary Manager Employee E21 confirmed that the facility failed to properly store food products which created the potential for food borne illness and cross contamination in the Main Kitchen.28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa. Code: 201.18(b)(3) Management.

Based on review of Quality Assurance attendance records, and staff interview, it was determined that the facility failed to conduct Quality Assessment and Assurance (QAA) meetings at least quarterly with all the required committee members for four of four quarterly meetings (2/12/25, 3/19/25, 4/23/25, 5/28/25, 6/25/25 ,7/30/25, 8/27/25, 9/24/25,10/28/25, 11/18/25, and 12/16/25).Findings Include:Review of Quality assurance and Performance Improvement sign in sheets and attendance records for 2/12/25, 3/19/25, 4/23/25, 5/28/25, 6/25/25 ,7/30/25, 8/27/25, 9/24/25,10/28/25, 11/18/25, and 12/16/25, failed to reveal the Lab Representative and Community Member, one of whom must be the facility's administrator, owner, board member, or other individual in a leadership role who has knowledge of facility systems and the authority to change those systems.During an interview on 1/30/26, at 10:20 a.m. the Nursing Home Administrator confirmed that the facility failed to conduct Quality Assessment and Assurance (QAA) meetings at least quarterly with all the required committee members for four 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 review of facility policy, personnel in-service training records, and staff interview, it was determined that the facility failed to provide training on resident rights for three of ten staff members (Employees E9, E10 and E15).Findings include:Review of the Facility Assessment most recently reviewed 1/7/26, listed under the training topics Residents rights is identified.Review of the facility policy Staff Development Program last reviewed on 1/7/26, with a previous review date of 1/9/25, identified resident rights as a topic for orientation and annual trainings required.Physical Therapy Aide Employee E9 had a hire date of 9/15/16, failed to have Resident Rights in-service between 1/17/25, and 1/30/26.Environmental Services Employee E10 had a hire date of 2/22/06, failed to have Resident Rights in-service education between 2/22/25 and 1/30/26.Nurse Aide Employee E15 had a hire date of 7/31/23, failed to have Resident Rights in-service education between 1/17/25, and 1/30/26.During an interview on 1/30/26, at 10:15 a.m., the Director of Nursing confirmed that 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.

Based on review of personnel records, and staff interview it was determined that the facility failed to ensure that five of five sampled Nurse Aides (NA) received a minimum of 12 hours of in-service education per year (NA Employees E13, E15, E16, E17 and E18). Findings include:Review of facility nurse aide training records revealed that NA Employee E13 did not receive 12 hours of in-service training in the last year.The facility was unable to provide documented evidence that NA Employee E13 had received a minimum of 12 hours of in-service training yearly.Review of facility nurse aide training records revealed that NA Employee E15 did not receive 12 hours of in-service training in the last year.The facility was unable to provide documented evidence that NA Employee E15 had received a minimum of 12 hours of in-service training yearly.Review of facility nurse aide training records revealed that NA Employee E16 did not receive 12 hours of in-service training in the last year.The facility was unable to provide documented evidence that NA Employee E16 had received a minimum of 12 hours of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the facility policy and clinical records and staff interviews, it was determined that the facility failed to provide the opportunity to formulate an advance directive (written instructions for when the individual is incapacitated) or conduct periodic review of instructions, for two of six residents reviewed (Resident R8, and R36).Findings Include: A review of the facility policy Advance Directives last reviewed 17/26 with a prior review date of 1/9/25, indicated procedures for periodic review of DNROrders will occur at least annually. This facility will allow revocations or amending DNR orders by the resident, the attorney in fact, the representative or treating physician. Such changes will be documented in the medical record. Physician Orders for Life-Sustaining Treatment (or POLST) paradigm form is a form designed to improve patient care by creating a portable medical order form that records patients' treatment wishes so that emergency personnel know what treatments the patient wants in the…

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

Based on review of facility policy, observations, and resident and staff interviews, it was determined that the facility failed to make certain, residents who voice grievances can do so without fear of discrimination or reprisal for twelve of sixteen residents (R77, R200, R201, R500, R501, R502, R503, R504, R505, R506, R507, and 508).Findings include: The resident has the right to voice grievances to the facility or other agency or entity that hears grievances without discrimination or reprisal and without fear of discrimination or reprisal. Such grievances include those with respect to care and treatment which has been furnished as well as that which has not been furnished, the behavior of staff and of other residents, and other concerns regarding their LTC facility stay. A review of the facility policy Grievances last reviewed 1/7/26 with a prior review date of 1/9/25, indicated Voice grievances without discrimination or reprisal. Such grievances include those with respect to treatment which has been furnished as well as that which has not been furnished. During a group interview,…

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, clinical record reviews and staff interviews, it was determined that the facility failed to initiate a thorough investigation for potential abuse for one of three residents (Residents R400). Findings include:Review of the facility policy Abuse Protection last reviewed on 1/7/26. with a previous review date of 1/9/25, indicated that each resident has a right to be free from abuse, corporal punishment, neglect, etc. The reporting and filing of accurate documents are required and necessary.Review of clinical record indicated Resident R400 was admitted [DATE], with diagnoses which included a stroke with left sided weakness (non-dominant side), heart flutter, epilepsy and kidney disease. A MDS (Minimum Data Set-a periodic assessment of resident care needs), dated 9/17/25, indicated diagnoses remained current. Review of facility provided documentation indicated a submitted event that indicated Resident R400 allegation of abuse from the Activity Director Employee E20, which had…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of facility policy, clinical records, and staff interview, it was determined that the facility failed to develop care plans that included instructions to provide person centered care for one of two residents (Resident R18).Findings include: Review of facility's policy MDS/RAI/Care Planning dated 1/6/26, indicated the facility will develop a written plan of care individualized for each resident, which identifies through an assessment process his/her strengths, problems and needs. Review of the clinical record face sheet revealed that Resident R18 was admitted to the facility on [DATE], with a diagnosis that included PTSD (Post Traumatic Stress Disorder). Review of a psychiatry note dated 12/10/25, indicated Resident R18 had a diagnosis of chronic PTSD with extensive trauma history. Review of Resident R18's care plan dated 9/9/25, failed to reveal a care plan with goals and interventions for PTSD. During an interview on 1/30/26, at 11:00 a.m. the Director of Nursing confirmed that 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.

Based on review of facility assessment, facility policy, employee file and staff interview, it was determined that the facility failed Prevention of Abuse and Neglect in-service education for two of ten employees (Employees E9and E15) Findings include:Review of the Facility Assessment most recently reviewed 1/7/26, listed under the training topics Abuse Training is identified.Review of the facility policy Staff Development Program last reviewed on 1/7/26, with a previous review date of 1/9/25, identified abuse as a topic for orientation and annual trainings required.Physical Therapy Aide Employee E9 had a hire date of 9/15/16, failed to have Abuse training in-service between 1/17/25, and 1/30/26.Nurse Aide Employee E15 had a hire date of 7/31/23, failed to have Abuse Training in-service education between 1/17/25, and 1/30/26.During an interview on 1/30/26, at 10:15 a.m., the Director of Nursing confirmed that the facility failed to provide training on abuse for two of ten staff members.28 Pa Code: 201.14 (a) Responsibility of licensee.28 Pa Code: 201.18 (b)(1) Management.28 Pa Code:…

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 assessment, facility policy, personnel in-service training records, and staff interview, it was determined that the facility failed to provide training on Compliance and Ethics for ten of ten staff members (Employee E9, E10, E11, E12, E13, E14, E15, E16, E17 and E18).Findings include:Review of the Facility Assessment most recently reviewed 1/7/26, listed under the training topics Code of Ethical Conduct is identified.Review of the facility policy Staff Development Program last reviewed on 1/7/26, with a previous review date of 1/9/25, identified corporate compliance as a topic for orientation and annual trainings required.Physical Therapy Aide Employee E9 had a hire date of 9/15/16, failed to have Compliance and Ethics training in-service between 1/17/25, and 1/30/26.Environmental Services Employee E10 had a hire date of 2/22/06, failed to have Compliance and Ethics training in-service between 2/22/24, and 1/30/26. Registered Nurse Employee E11 had a hire date of 11/4/19, failed to have Compliance and Ethics training in-service between 11/4/24, and…

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

Based on review of the grievance policy, facility documents, and staff interviews it was determined that the facility policy does not include all required elements and that the facility failed to document, resolve, and provide response to residents and/or their responsible parties for eleven of thirteen residents (Resident R2, R3, R4, R5, R6, R7, R8, R9, R10, and R11). Findings include: Review of the facility policy Grievances dated 1/31/24, indicated the facility will support each resident's right to voice grievances (e.g., those about treatment, care, management of funds, lost clothing, or violation of rights) and to assure that after receiving a complaint/grievance, the facility actively seeks a resolution and keeps the resident appropriately appraised of its progress toward resolution. Further review of the policy Grievances revealed that the policy failed to contain information related to: -The right to file grievances anonymously. -Identification of a Grievance Official responsible for overseeing the grievance process. -The right to obtain a written decision regarding his or…

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 federal and state laws, facility policies, clinical records, and staff interviews, it was determined that the facility failed to implement policies and procedures to report allegations of abuse and neglect for five of twelve residents (Resident R1, R3, R8, R9 and R10). Findings include: Review of the Older Adult Protective Services Act of 11/6/87, amended by Act 1997-13, Chapter 7, Section 701, requires any employee or administrator of a facility who suspects abuse is mandated to report the abuse. All reports of abuse should be reported to the local area agency on aging and licensing agencies. Review of the facility's policy Abuse Reporting and Investigation dated 1/31/24, indicated anyone who witnesses an incident of suspected resident abuse is to intervene immediately and stop the abuse. They are to report it to the charge nurse or supervisor immediately. The policy further stated the Department of Health will be notified of the alleged event by the Administrator or designee per regulation.…

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

Based on review of facility documents, observations, and resident and staff interviews it was determined that the facility failed to provide Activity of Daily Living (ADL) assistance for eight of 16 residents (Residents R1, R3, R5, R8, R9, R10, R12, and R13). Findings include: Review of the facility policy Flow of Care/ADL dated 1/31/24, indicated Care will be provided to residents, as needed 24-hour a day to attain and maintain the highest level of functioning. During an interview on 4/12/25, at 11:12 a.m. Resident R10 stated that staff tell her she pulls the call light too much, they don't care for all her needs, and that she hears the staff speak about being short-staffed. During an interview on 4/12/25, at 11:20 a.m. Resident R13 stated that fresh water isn't passed, and many times she has to get it herself. During an interview on 4/12/25, at 11:37 a.m. Resident R8 stated that the aides are short-staffed and the call lights can be long. During an interview on 4/12/25, at 11:40 a.m. Resident R12 stated that call lights seem like they take a long time. During an interview on…

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

Based on a review of facility policy, federal regulation, and staff interview, it was determined that the facility failed to provide transfer notices to representatives of the Office of the Long-Term Care Ombudsman Division for 12 of 12 months (January 2024 through December 2024). Findings include: Review of the facility policy Transfer and Discharge 1/31/24, indicated no resident will be discharged without timely notification of the resident, responsible party, or authorized representative. Review of Title 42 Code of Federal Regulations §483.15(c)(3) Notice Before Transfer: indicates, before a facility transfers or discharges a resident, the facility must (i) Notify the resident and the resident's representative(s) of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand. The facility must send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman. Federal Regulations further define emergency transfers as, When a resident is temporarily transferred on an emergency basis to an acute care…

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

Based on review of facility policies, job descriptions, clinical records, and staff interviews, it was determined that the facility failed to adhere to acceptable standards of practice related to participation in interdisciplinary meetings, monitoring of Food Service operations, resident interviews, and participation in the Quality Assurance and Performance Improvement (QAPI), by the Registered Dietitian. Findings include: The Pennsylvania Code, Title 49, Chapter 21, Professional and Vocational Standards: Responsibilities of the Licensed Dietitian/ Nutritionist Section 21.711 Professional Conduct indicated that the Licensed Dietitian/ Nutritionist shall provide information which will enable patients to make their own informed decisions regarding nutrition and dietetic therapy, including the reasonable expectations of the professional relationship. Review of the Registered Dietitian's Job Description, states that dietitian encourages the resident/family to participate in the development and review of the residents' plan of care, maintains an adequate liaison with families and…

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

Based on policy review, documentation and review of Centers for Disease Control (CDC) guidelines for Legionella (bacteria that causes disease found in contaminated water) control, and staff interviews it was determined that the facility failed to maintain a comprehensive program for water management to monitor the potential development and spread of Legionella and failed to implement control measures for Legionella within the facility for twelve of twelve months (December 2023 through December 2024). Finding include: Review of the facility policy Legionella Policy dated 1/9/25, previously dated 1/31/24, indicated Specific actions should be taken for prevention of Legionella and for investigation should a case occur. Core Elements of the Water Management Plan are: 1. Establish Water Management Plan team. 2. Describe Center's water system using text and flow diagram. 3. Risk assessment with control methods and corrective actions. 4. Monitoring control measures. 5. Corrective actions. 6. Verification and validation. 7. Documentation and communication. Review of Department of Health and…

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

Based on review of facility policy, observations, and resident and staff interviews, it was determined that the facility failed to provide concern forms and grievance boxes to residents and visitors on the nursing units and failed to provide an opportunity for anonymous grievances (Resident group). Findings include: A review of the facility policy Grievances reviewed 1/31/24 and 1/9/25, indicated it is the policy of the facility to support each resident's right to voice grievances without discrimination, reprisal, or fear of discrimination. A grievance may include a formal, written grievance process or a resident's verbalized complaint to facility staff. During an interview on 1/14/25, at 10:30 a.m. the Resident Group stated, you cannot file an anonymous grievance, the only box and forms are in front of the Nursing Home Administrator's (NHA) office. During an observation on 1/14/25, at 11:45 a.m. revealed the grievance box in the front lobby is in front of the NHA's office and within sight of the receptionist. During an observation on 1/14/25, at 1:45 p.m. revealed no grievance…

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, clinical records, and staff interviews, it was determined that the facility failed to assess, document, and notify physicians of increased and decreased Capillary Blood Glucose (CBG) levels for five of seven residents reviewed (Residents R13, R26, R28, R29, and R46). Findings include: The Centers for Disease Control defines diabetes as: Diabetes Mellitus is a chronic (long-lasting) health condition that affects how your body turns food into energy. Most of the food you eat is broken down into sugar (also called glucose) and released into your bloodstream. When your blood sugar goes up, it signals your pancreas to release insulin. Insulin acts like a key to let the blood sugar into your body's cells for use as energy. If you have diabetes, your body either doesn't make enough insulin or can't use the insulin it makes as well as it should. When there isn't enough insulin or cells stop responding to insulin, too much blood sugar stays in your bloodstream. Over time, that can…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility documents, facility policy, clinical records, and staff interviews, it was determined that the facility failed to assess a resident for safe smoking for three of five residents reviewed (Residents R4, R10, and R54). Findings include: Review of the facility policy Smoking Policy dated 1/31/24, indicated that smokers will be reviewed on admission, at least quarterly, and as necessary depending on individual circumstances and changes in the resident's condition. Review of Resident R4's clinical record indicated an admission date of 9/19/09. Review of resident R4's MDS (Minimum Data Set- a periodic assessment of resident care needs) dated 11/8/24, indicated the diagnoses of atrial fibrillation (arrhythmia of the heart), seizures, and cognitive communication deficit. Review of resident R4's care plan dated 2/6/24 indicated the resident goes outside to smoke, is at risk for side effects and injury form smoking due to limited range of motion, and a smoking safety screen will be reviewed per…

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 facility policy review, personnel file review, and staff interview, it was determined that the facility failed to ensure that residents were protected from potential for abuse by failing to perform criminal history background checks prior to hire for two of five personnel files reviewed (Employee E7 and E12). Findings Include: Review of facility policy Abuse: Protection From Abuse reviewed 1/31/24 and 1/9/25, revealed the resident has the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, involuntary seclusion, neglect, and misappropriation of property. The facility conducts background checks and will not knowingly employ any individual who has been convicted of abusing, neglecting, or mistreating individuals. Review of facility policy Criminal Background Check reviewed 1/31/24 and 1/9/25, indicated a request for a criminal background check must be submitted to the Pennsylvania State Police prior to the start of active employment. Applicants may not be hired or attend orientation until such time as the criminal background clearance 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, observations, manufacturers recommendations, clinical records, and staff interview, it was determined that the facility failed to make certain that residents are free of significant medication errors for one of two residents observed (Resident R3). Findings include: A review of the facility policy Medication Administration dated 1/31/24, indicated medications are administered, as prescribed, in accordance with good nursing principles and practices to ensure the safe, accurate and timely administration of medications. A review of the manufacturer's guideline for glargine insulin (Lantus-long acting type of insulin that works slowly, over about 24 hours) Solostar prefilled pen, November 2000, specified to perform a safety test before each injection. Select a dose of two units, hold the pen with the needle pointing upwards, gently tap the reservoir to remove air bubbles, press the injection button all the way in and check if insulin comes out of the needle tip. A review of a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy review, clinical and facility record review, facility submitted documents, and staff interviews, it was determined that the facility failed to provide adequate supervision to prevent elopement for one of four residents (Resident R1). Review of the facility policy Resident Elopement dated 1/31/24, indicated cognitively impaired residents at risk for elopement will be appropriately monitored to reduce the potential for injury. Elopement is defined as a resident leaving the physical structure of the facility without knowledge of facility staff. Review of the Resident Assessment Instrument 3.0 User's Manual effective October 2023, indicated that a Brief Interview for Mental Status (BIMS) is a screening test that aides in detecting cognitive impairment. The BIMS total score suggests the following distributions: 13-15: cognitively intact 8-12: moderately impaired 0-7: severe impairment Review of the clinical record indicated Resident R was admitted to the facility on [DATE]. 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 review of facility documentation and staff interviews, it was determined that the facility failed to provide documentation of an effective training program, that included training topics based on the resident population for one of four residents (Resident R1). Findings include: Review of the facility policy, Staff Development dated 1/31/24, indicated, the facility must ensure that facility employees are competent in skills and techniques necessary to care for residents' needs and/or complete assigned job tasks. There shall be an ongoing coordinated education program which is planned and conducted for the development and improvement of skills of the facility personnel including training related to problems, needs and rights of the residents. Review of the Facility Assessment dated November 2023, indicated the facility will maintain an adequately trained and competent staff. Review of the Resident Assessment Instrument 3.0 User's Manual effective October 2023, indicated that a Brief Interview for Mental…

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, observations, and staff interview it was determined that the facility failed to maintain the confidentiality of residents' medical information in one area (storage shed). Findings include: Review of the facility policy Confidentiality dated 1/31/24, indicated that residents have the right to personal privacy and confidentiality of his or her personal and clinical records. Review of the facility policy Medical Records Storage dated 1/31/24, indicated that all medical records will be stored in a secure, fire-protected, waterproof area. During an observation of a unsecured storage shed behind the facility on 6/4/24, at 8:15 a.m., approximately 75 boxes of loose paper, with resident information observed throughout the shed. During an interview on 6/4/24, at 8:17 a.m., Maintenance Director Employee E1 confirmed that the paperwork was stored in the storage shed due to lack of space, and the shed is left unsecured all the time. During an interview on 6/4/24, at 9:20 a.m., the Nursing Home Administrator confirmed that the facility failed to maintain 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 observations, and resident and staff interviews, it was determined that the facility failed to maintain a safe, clean, homelike environment on one of two nursing units(North Wing), and in the main dining room. Findings include: During observations on 6/4/24, from 8:45 a.m., through 9:45 a.m., the following was identified: Residents R1 and R2 had hole in he floor near baseboard by the bathroom. Residents R3 and R4 had areas of chipped paint under the window surrounding the heater. Residents R5 and R6 had a cracked ceiling above bed 2, Resident R6 stated the ceiling may leak through the hole, but I haven't seen any water. Resident room [ROOM NUMBER] currently empty had a broken wall plug plate in the bathroom. Residents R7 had unfinished drywall with spackling behind beds. The main dining room floor has multiple spots of brown substance and appears soiled with food debris. During an interview on 6/4/24, at 10:00 a.m., the Nursing Home Administrator and the Maintenance Director Employee E1 confirmed that…

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, facility documentation, and staff interviews, it was determined that the facility failed to protect residents from neglect for one of two residents (Resident R8), by failing to follow physicians orders during incontinence pad change and linen change. This was identified as past non-compliance. Findings include: Review of the United States Code of Federal Regulations (CFR), 42 CFR §483.12. Freedom from Abuse, Neglect, and Exploitation defined neglect as the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. Review of the facility policy Abuse Protection dated 1/31/24, with a previous review date of 1/26/23, indicated that all resident have a right to be free from abuse, neglect, etc. and the facility is committed to protecting the residents from abuse by anyone providing services to the residents. Review of the clinical record indicated…

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, clinical records, facility documentation, and resident and staff interviews, it was determined that the facility failed to provide adequate supervision and implement effective bed mobility interventions as per physician order to promote resident safety, for one of two residents (Resident R8). This deficiency is cited as past non-compliance. Findings include: Review of facility policy entitled Accidents and Incidents- Investigating and Recording, dated 1/31/24, indicated that all incidents and accidents occuring on the premises must be investigated and reported to the administrator. Regardless of the incident/accident, staff are to render immediate assistance, conduct an initial assessment and provide emergency interventions and if necessary, call 911. An employee witnessing an accident or incident involving a resident must report such occurrence to his or her supervisor immediately. Do not leave the victim unattended unless necessary to summon assistance. A witness statement…

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, water testing logs and staff interview, it was determined that the facility failed to implement an effective Water Management Program for the prevention and control of water-borne contaminants, such as Legionella (a bacteria that may cause Legionnaires' Disease, a serious type of pneumonia). That the facility failed failed to provide surveillance data and analysis and provide documentation of the I/C program must include, at a minimum, a system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, and visitors for three of eleven months (Mar, April, and May 2023). Findings include: The facility Water Management Program last reviewed on 1/26/23, indicated that the plan is to minimize risk for Legionella associated with the building water systems at Grove of [NAME]. Based on framework outlined in ASHRAE Standards. During an interview on 11/20/23, at 12:55 p.m., Maintenance Director Employee E1 and…

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

Based on review of facility records and staff interview, it was determined that the facility failed to ensure the designated Infection Preventionist was qualified with specialized training in infection prevention and control. Findings include: Review of the individual identified as the facility Infection Control (I/C) Preventionist Registered Nurse (RN)Employee E7's personnel file documentation did not include indication of the specialized training required to be in the position. RN Employee E7 had been indicated as the I/C Preventionist since October. The prior Infection Control Preventionist was the current Director of Nursing (DON) who also had not attended specialized training in infection control. During an interview on 11/21/23, at 9:06 a.m., the DON and the current I/C Preventionist RN Employee E7 stated that neither of them have the credentials to be I/C Preventionist at this time. I/C Preventionist RN Employee E7 is currently working on getting the credentials. 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 211.10(d) Resident care policies. 28 Pa. Code 211.12(d)(1)(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 observations, and resident and staff interviews, it was determined that the facility failed to maintain a clean, homelike environment on three of three nursing units (South, North, and Middle Nursing Units). Findings include: During observations on 11/21/23, from 8:16 a.m., through 11:50 a.m., the following was identified: Residents R34 and R40 had hole under the window. Residents R58 and R8 had holes behind Resident R58's bed. Residents R29 and R13 had broken wall areas behind the toilet. Residents R22 and R4 had broken tiles by the door and by the bathroom. Residents R1 and R27 toilet had appeared to have leaked and the flooring was stained and the toilet was in disrepair. Resident R1 stated that the toilet leaked and had not been replaced the facility has known about it. Residents R50 and R44 had broken areas of wall by the bathroom entrance. Residents R17 and R3 walls behind both beds had broken walls with holes and missing floor trim. Resident R53 had a empty bed in A bed with a soiled heavily soiled mattress. Residents R64 had a broken wall by the bathroom. Residents…

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 personnel records and staff interview it was determined that the facility failed to provide nursing staff annual performance evaluations based on the date of hire for four of four nurse aides (NA Employee E3, E4, E5, and E6). Findings include: During an interview on 11/21/23, at 10:45 a.m. Human Resource/Scheduler Employee E10 confirmed that the facilty has not completed annual performance reviews for NA Employee E3, E4, E5, and E6. During an interview on 11/22/23, at 11:30 a.m. the Nursing Home Administrator confirmed the facility failed to provide nursing staff annual performance evaluations based on the date of hire for four of four nurse aides. 28 Pa Code: 201.20 (a)(b)(c)(d) Staff development 28 Pa Code: 201.14 (a) Responsibility of licensee

Based on review of facility policy, observation and staff interview, it was determined that the facility failed to make certain that refrigerated medications are stored at proper temperatures and failed to monitor the medication refrigerator temperatures daily in one of one medication rooms. Findings include: Review of the facility policy Storage of Medications last reviewed on 1/26/23, indicated that medications are stored in the refrigerator at temperatures between 36 and 46 degrees and are monitored daily. During an observation of the Medication Room refrigerator on 11/20/23, at 8:30 a.m., the thermometer indicated the refrigerator was 50 degrees. During an interview on 11/20/23, at 8:30 a.m., Registered Nurse Employee E2 confirmed the refrigerator felt warm and would contact Maintenance to monitor the temperature after turning it down. During a review of the Medication Room Refrigerator temperature logs, the Director of Nursing stated that the facility only had logged temperatures for October 2023, and November of 2023, and there were dates of missed temperature 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 review of the facility's admission agreement and staff interviews, it was determined that the facility failed to ensure a neutral and fair arbitration process by ensuring both the resident or his or her representative, and the facility agree on the selection of a neutral arbitrator. Findings include: Review of facility's admission Agreement packet, which contained the document Voluntary Arbitration Agreement indicated that Accordingly, any dispute arising out of relating to the provision of services by the Facility to the Resident, Resident's admission to the Facility, Resident's contracts with the Facility or the subject matter thereof, any breach of contract, including any dispute regarding the execution, validity or scope of this Arbitration Agreement or any of its clauses, will be resolved through arbitration administered by [name of arbitrator services company which the facility utilizes] and conducted pursuant to the [arbitrator] Rules of Procedure for Arbitration. The facility's arbitration agreement failed to provide for the selection of a neutral arbitrator agreed…

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 and interviews with staff, it was determined that the facility failed to develop, implement, and maintain an effective training program that was sufficient to meet the requirement for facility-provided annual nurse aide education. Findings include: Review of the Facility Assessment dated November 2023, indicated the facility will maintain an adequately trained and competent staff. The assessment further stated, Mandatory education is delivered and tracked by the Director of Education to ensure compliance with state and federal regulations. Review of the facility policy Staff Development Program dated 1/26/23, indicated all employees receive mandatory in-services annually. Review of the facility education calendar, with a listing of all scheduled in-services, included the following: -Abuse/Neglect/Elder Justice Act -Infection Control/Personal Protective Equipment -Psychosocial Needs -Dementia -Trauma Informed Care -Bloodborne Pathogens -Covid-19 -Customer Service -Resident ' s Rights -Accidents -Fire/Safety/Disasters -Hazard Communication…

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

Based on review of facility documents and staff interview, it was determined that the facility failed to provide training on abuse, neglect, and exploitation for four of ten staff members (Employees E4, E6, E8, and E9). Findings include: Review of the Facility Assessment dated November 2023, indicated the facility will maintain an adequately trained and competent staff. The assessment further stated, Mandatory education is delivered and tracked by the Director of Education to ensure compliance with state and federal regulations. Review of the facility policy Staff Development Program dated 1/26/23, indicated all employees receive mandatory inservices annually. Review of the facility policy Abuse Protection dated 1/26/23, indicated that mandated training/orientation on abuse protection, identification and reporting of abuse, stress management, dealing with violent behavior or catastrophic reaction, etc.; training is provided at time of hire, annually, and as needed. Review of the facility provided staff list indicated Nurse Aide (NA) Employee E4 was hired on 3/12/12. Review of NA…

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

Based on review of facility documents, staff education records, and staff interviews, it was determined that the facility failed to conduct at least 12 hours of in-service education, within 12 months of their hire date anniversary, for nurse aides as required for four of four nurse aides (Employees E3, E4, E5, and E6). Finding include: Review of the Facility Assessment dated November 2023, indicated the facility will maintan an adequately trained and competent staff. The assessment further stated, Mandatory education is delivered and tracked by the Director of Education to ensure compliance with state and federal regulations. Review of the facility policy Staff Development Program dated 1/26/23, indicated nurse aides receive at least 12 hours of inservice per year. Review of Nurse Aide (NA) Employees E3, E4, E5, and E6's education records with hire date greater than 12 months revealed the following: NA Employee E3 had a hire date of 10/22/16, with 6.00 hours in-service education between 10/22/22, and 10/22/23. NA Employee E4 had a hire date of 3/12/12, with 6.00 hours in-service…

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 state laws, facility policies, clinical records, and staff interviews, it was determined that the facility failed to implement policies and procedures for covered individuals to report the suspicion and/or observation of staff to resident abuse or neglect for two of five residents reviewed (Resident R44 and R46). Findings include: Review of the Older Adult Protective Services Act of 11/6/87, amended by Act 1997-13, Chapter 7, Section 701, requires any employee or administrator of a facility who suspects abuse is mandated to report the abuse. All reports of abuse should be reported to the local area agency on aging and licensing agencies. Review of the facility's policy Abuse Protection dated 1/26/23, indicated Regardless of how minor an accident or incident may be, including injuries of unknown source, it must be reported to the department supervisor as soon as such accident/incident is discovered or when information of such accident/incident is learned. An investigation and witness statements…

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 Resident Assessment Instrument (RAI) User's Manual, clinical records, and staff interviews, it was determined that the facility failed to ensure that MDS assessments accurately reflected the resident's status for three of twelve residents (Resident R43, R48, and R61). Findings include: The Resident Assessment Instrument (RAI) User's Manual, which gives instructions for completing Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2023, indicated the following instructions: -Observation (Look-Back, Assessment) Period is the time period over which the resident's condition or status is captured by the MDS assessment. Most MDS items themselves require an observation period, such as 7 or 14 days, depending on the item. Since a day begins at 12:00 a.m. and ends at 11:59 p.m., the observation period must also cover this time period. A standard 7-day look-back period counts back from and includes the Assessment Reference Date (ARD+6…

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, facility document reviews, and staff interviews it was determined that the facility failed to make certain that equipment was in safe operating condition for one of one crash carts and one of one AEDs (Automatic External Defibrillators). Findings include: Review of facility AED Policy dated 1/26/23, indicated the facility will conduct a daily check for battery status and monthly and annual equipment maintenance. During an observation of the facility crash cart (cart maintained with equipment used in cardiac emergencies) on 9/11/23, at 1:20 p.m. revealed a three-ring binder on the cart containing daily crash cart check list sheets for January through September 2023. Review of the check list sheet documentation revealed the cart was check the following number of days: January 2023: Two of 31 days. February 2023: Zero of 28 days. March 2023: Zero of 31 days. April 2023: Zero of 30 days. May 2023: One of 31 days. June 2023: Three of 30 days. July 2023: Zero of 31 days. August 2023: Two of 31 days. September 2023: Zero of 10 days. During a review of the items…

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, observations, and staff interview it was determined that the facility failed to maintain the confidentiality of residents' medical information for two of two areas accessible to all staff (nutrition room and basement storage area). Findings include: Review of the facility policy Confidentiality dated 1/26/23, indicated that residents have the right to personal privacy and confidentiality of his or her personal and clinical records. During an observation of the nutrition room on 9/11/23, at 11:17 a.m. three boxes of loose paper, with resident information on them were observed on the floor. During an interview on 9/11/23, at 11:25 a.m. Registered Nurse Employee E3 confirmed that the paperwork was stored in the nutrition room due to lack of space, and the nutrition room door does not have a lock. During an observation of the basement storage area on 9/11/23, at 2:00 p.m. numerous boxes of loose paper, with resident information on them were observed on the floor. During an interview on 9/11/23, at 2:40 p.m. the Nursing Home Administrator confirmed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and resident and staff interviews, it was determined that the facility failed to provide a clean, sanitary, and homelike environment for two of two nursing units (North Wing and South Wing). Findings include: The facility Resident Environment policy dated 1/26/23, indicated the facility will provide and environment that is safe, clean, comfortable, and homelike. During multiple observations made on 9/11/23, from 9:30 a.m. through 2:30 p.m. indicated the following: 9:40 a.m. - Resident R1's call light cord was extremely soiled, his Flextouch (machine used to assist in preventing swelling) was placed directly on the floor, and the garbage can exterior was soiled. 9:45 a.m. the North Wing shower room near room [ROOM NUMBER] had refuse on the floor, boxes of supplies and sneakers in the tub, missing tiles surrounding the drain the shower area, four soap dispensers on the stacked up, with no usable soap dispenser on the wall. 10:40 a.m. - Resident R3' window screen is not installed correctly,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of resident clinical records and staff interviews it was determined that the facility failed to make certain that appropriate treatment and services were ordered and/or provided for two of three residents with a urinary catheter (Resident R1 and R2). Findings include: Review of the Centers for Disease Control guidance Guideline for Prevention of Catheter-Associated Urinary Tract Infections updated 6/6/19, indicated to not rest the collecting bag on the floor. Review of admission record indicated that Resident R1 was admitted on [DATE]. Review of Resident R1's Minimum Data Set Assessment (MDS, periodic assessment of resident care needs) dated 8/14/23, indicated diagnoses of chronic kidney disease (gradual loss of kidney function), neurogenic bladder (bladder problems due to disease or injury of the nervous system involved in the control of urination), and muscle weakness. Section H - Bladder and Bowel indicated the utilization of an indwelling catheter. During an observation on 9/11/23, at 9:40…

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 observations and staff interviews, it was determined that the facility failed to properly dispose of expired and/or opened medical supplies in one of one medication rooms and one of one basement storage areas. Findings include: During an observation of the facility medication room on [DATE], at 1:15 p.m. of the facility medication room, the following was observed: -Three suction catheter kits, with expiration dates of [DATE]. -Three nasal canula sets with expiration dates of [DATE], [DATE], and [DATE]. -Two IV start kits with expiration dates of [DATE]. -One [NAME] suction [NAME] with an expiration date of 8/2018. -One package of calcium alginate rope with an expiration date of 4/2022. -One container of topical yeast infection powder, open and undated. During an observation of the basement storage area on [DATE], at 2:00 p.m. the following was observed stored directly on the basement floor: -Boxes of COVID test kits. -Kangaroo e-pump sets (bag and tubing for tube-feeding). -Box of saline…

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 documents, clinical records and staff interviews, it was determined that the facility failed to schedule a neurosurgery follow-up appointment timely, which caused a delay in that .for one of two residents (Resident R1). Findings include: Review of the Resident Assessment Instrument 3.0 User's Manual effective October 2019, indicated that a Brief Interview for Mental Status (BIMS, a screening test that aides in detecting cognitive impairment). The BIMS total score suggests the following distributions: 13-15: cognitively intact 8-12: moderately impaired 0-7: severe impairment Review of Resident R1's admission record indicated she was admitted to the facility on [DATE]. Review of Resident R1's Minimum Data Set (MDS) assessment (mandated assessment of a resident's abilities and care needs) dated 4/21/23, indicated diagnoses of diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time), muscle weakness, and the need for assistance in personal…

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 interview, it was determined that the facility failed to make certain essential equipment was maintained properly for one of one ice makers and one of two shower rooms (Left-side) Findings include: During an observation of the ice maker room on 8/18/23, at 11:00 a.m. noted: -Numerous fruit flies in the room. -The ice access door not attached, and placed on top of the ice maker. A large black garbage bag was attached to the top of the opening to cover the access to the ice. -Water pitches, paper towels, plastic bags, and other refuse behind the ice maker. -Styrofoam cups, disposable gloves, food waste, and other debris under the ice maker. The ice maker drain was resting directly on a Styrofoam cup, preventing the required air gap. The water from the ice maker drain was prevented by the refuse from entering the drain, wetting the surrounding cabinets and debris. -The cabinet to the left of the ice maker was severely water damaged, with multiple areas broken away, including the cabinet door. Mildew was present on the remaining cabinet and the multiple broken…

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.