Chestnut Hill Rehabilitation and Healthcare Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of clinical records and staff interviews, it was determined the facility failed to provide nursing services consistent with professional standards of quality to ensure that licensed nurses administered medications as prescribed to three residents out of 14 sampled (Resident 1, 2, and CR1). Findings included: According to the Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.11 (a)(1)(2)(4) indicates that the Registered Nurse (RN) was to collect complete ongoing data to determine nursing care needs, analyze the health status of individuals and compare the data with the norm when determining nursing care needs, and carry out nursing care actions that promote, maintain, and restore the well-being of individuals. The Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.145 Functions of the Licensed Practical Nurse (LPN) (a) The LPN is prepared to function as a member of the health care team by exercising sound…

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 clinical records, controlled drug records, and staff interviews, it was determined the facility failed to implement procedures to promote accurate accounting and the administration of controlled medications for one of 14 residents sampled (Resident 1). Findings include: A review of a facility policy titled Administering Medications, last reviewed on January 22, 2025, revealed that medications are administered in accordance with prescriber orders, including any required time frame, and are administered within one hour of their prescribed time unless otherwise specified. As required or indicated for a medication, the individual administering the medication records in the resident's medical record the date and time the medication was administered. A review of Resident 1's clinical record revealed a physician's order dated March 21, 2025, for Oxycodone 10 mg (an opioid pain medication used to treat moderate to severe pain), with instructions to administer one tablet three times a day for back pain. A review of the controlled substance record for Resident 1's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, a review of select facility policies, the facility's infection control log, and staff interviews, it was determined the facility failed to maintain and implement a comprehensive infection prevention and control program and failed to implement transmission-based precautions to mitigate the spread of infectious disease for one out of the 27 residents sampled (Resident 56). Findings included: A review of a facility policy titled Respiratory Syncytial Virus (RSV) Prevention, last reviewed by the facility on January 22, 2025, revealed it is the facility policy to ensure that residents diagnosed with RSV are placed on contact precautions for the duration of the illness. A review of a facility policy titled Isolation-Categories of Transmission-Based Precautions, last reviewed by the facility on January 22, 2025, revealed that contact precautions are implemented for residents known or suspected to be infected with microorganisms that can be transmitted by direct contact with the resident 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 a review of clinical records, select facility policies, documentation provided by the facility, and staff interviews, it was determined the facility failed to ensure that four residents out of 27 sampled (Residents 18, 104, 108, and 224) were free from abuse perpetrated by another resident (Residents 37 and 49) and failed to ensure one resident out of 27 sampled was free from neglect (Resident 57). Findings include: A review of the facility policy titled Abuse, Neglect, Exploitation, and Misappropriation Prevention Program, last reviewed by the facility on January 22, 2025, revealed it is the facility's policy that residents have the right to be free from abuse and neglect. The policy indicated the facility's resident abuse and neglect prevention program consists of a facility-wide commitment and resource allocation to support the following objectives: (1) protect residents from abuse and neglect by anyone, including, but not necessarily limited to, facility staff and other residents. A clinical record…

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

Based on observation, clinical record review, and staff interview it was determined the facility failed to ensure respiratory care including tracheostomy (surgical procedure where a hole is created in the neck and a tube is inserted into the trachea or windpipe to help a person breathe) care was provided in accordance with physician orders for one of three sampled residents (Resident 2). Findings include: Review of the clinical record revealed Resident 2 had diagnoses which included chronic respiratory failure (condition that occurs when the lungs cannot get enough oxygen into the blood or eliminate enough carbon dioxide from the body) with tracheostomy and cerebral palsy (brain disorder that appears in infancy or early childhood and permanently affects body movement and muscle coordination). A physician order dated February 3, 2025, was noted for a Pulmonary Consult on February 17, 2025. Review of the Pulmonary Consult dated February 17, 2025, revealed that Resident 2 was weaned to room air (normal air without supplemental oxygen) during the appointment. The plan/medical decision…

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 the facility failed to accurately identify a resident's request for future health care and advance directives (a written instruction such as a living will or durable power of attorney for health care for when the individual is incapacitated) as evidenced by one resident (Resident 173) out of 27 residents sampled. Findings include: A review of the clinical record of Resident 173, revealed the resident was admitted to the facility on [DATE], with diagnoses that included osteoarthritis (type of arthritis that causes joints to become painful and stiff) and atrial fibrillation (an irregular heart rate that commonly causes poor blood flow). Review of Resident 173's clinical record revealed a completed and signed POLST (Physician Orders for Life-Sustaining Treatment a medical order form used to communicate a resident's preferences for life-sustaining measures across care settings) dated [DATE]. The POLST indicated that the resident elected DNR status…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, clinical record review, review of facility policy, investigative documentation, and staff and resident interviews, it was determined the facility failed to thoroughly investigate an incident involving a fall with minor injury to determine whether neglect occurred and failed to identify that planned fall interventions were not in place for one of 27 sampled residents (Resident 57). The findings include: A review of the facility policy titled Abuse, Neglect, Exploitation, and Misappropriation Prevention Program, last reviewed by the facility on January 22, 2025, revealed it is the facility's policy that residents have the right to be free from abuse and neglect. The policy indicated the facility's resident abuse and neglect prevention program consists of a facility-wide commitment and resource allocation to support the following objectives: (1) protect residents from abuse and neglect by anyone, including, but not necessarily limited to, facility staff and other residents. Further review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of clinical records and the Resident Assessment Instrument (RAI) and staff interviews, it was determined the facility failed to ensure the Minimum Data Set Assessments (MDS - a federally mandated standardized assessment conducted at specific intervals to plan resident care) accurately reflected the status of three residents out of 27 sampled (Residents 2, 40, and 47). Findings included: A review of Resident 2's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses that included chronic respiratory failure (a condition that occurs when the lungs cannot get enough oxygen into the blood or eliminate enough carbon dioxide from the body) and atrial fibrillation (an irregular heart rate that commonly causes poor blood flow). A current physician order initially dated January 28, 2025, noted an order for Warfarin Sodium (an anticoagulant medication also known as a blood thinner) 4 mg via PEG-tube (percutaneous endoscopic gastrostomy- feeding tube placed directly…

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, facility policy review, and staff interview, it was determined the facility failed to ensure that nursing services met professional standards of quality according to the Pennsylvania Code Title 49, Professional and Vocational Standards, by failing to implement nursing practices for the administration of intravenous medication via a peripheral IV (thin, flexible plastic tube inserted into a peripheral vein to allow for the administration of fluids, medications, and other therapies into the bloodstream and used for short-term intravenous therapy) for one of 27 residents reviewed (Resident 101). Findings include: According to the Pennsylvania Code Title 49, Professional and Vocational Standards Department of State, Chapter 21 State Board of Nursing, Chapter 21.145 Functions of the LPN (Licensed Practical Nurse) requires the following: The LPN is prepared to function as a member of the health care team by exercising sound nursing judgement based on preparations, knowledge, skills,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of clinical records, resident, and staff interviews, it was determined the facility failed to develop and implement an individualized person-centered plan to render trauma informed care to a resident with a diagnosis of Post-Traumatic Stress Disorder for one out of 27 residents reviewed (Resident 55). Findings include: A review of Resident 55's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses that included Post Traumatic Stress Disorder (PTSD a mental health condition that's caused by an extremely stressful or terrifying event, either being part of it or witnessing it. Symptoms may include flashbacks, nightmares, severe anxiety, and uncontrollable thoughts about the event). A review of the clinical record also revealed a physician's order dated March 12, 2025, for Prazosin HCL (a medication that decreases levels of norepinephrine in the central nervous system thereby reducing nightmares related to PTSD), with instructions to administer 1 mg tablet by…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of clinical records, select facility policy, and staff interviews, it was determined the facility failed to ensure that a resident's drug regimen was free of unnecessary antibiotics for one out of 27 residents sampled (Resident 47). Findings included: A review of the facility policy titled Antibiotic Stewardship, last reviewed by the facility on January 22, 2025, revealed it is the facility's policy that antibiotics will be prescribed and administered to residents under the guidance of the facility's antibiotic stewardship program. The policy indicates when a resident is admitted from an emergency department, the admitting nurse will review discharge and transfer paperwork for current antibiotic and anti-infective orders. When a culture and sensitivity (C&S) is ordered, lab results and the current clinical situation will be communicated to the prescriber as soon as available to determine if antibiotic therapy should be started, continued, modified, or discontinued. A clinical record 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and resident and staff interviews, it was determined that the facility failed to show adequate monitoring of symptoms and potential adverse consequences of psychoactive drug use for one resident out of 27 residents sampled (Resident 45). Findings include: A review of clinical records revealed Resident 45 was admitted to the facility on [DATE], with diagnoses to include schizoaffective disorder (a mental health disorder that is marked by a combination of schizophrenia symptoms, such as hallucinations or delusions, and mood disorder symptoms, such as depression or mania), bipolar type (a mental health disorder that causes unusual shifts in a person's mood, energy, activity levels, and concentration), and Parkinson's (progressive neurological disorder that affects movement) without dyskinesia (involuntary movement disorder characterized by uncontrolled and jerky movements). A review of a facility policy titled Psychotropic Medication Use, last reviewed by the facility on January 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of clinical records, CDC (centers for disease control) infection control guidance, facility's infection control policy and COVID-19 testing logs, and staff interview it was determined he facility failed to promptly implement infection control practices for cohorting like respiratory infections and testing for COVID-19 to prevent the spread of COVID-19 infections in the facility placing at least 12 residents (Residents 4, 6, 8, 10, 14, 16, 2, 20, 22, 24, 26 and 28) at increased risk for contracting COVID-19 and failed to implement effective interventions to prevent the spread of COVID-19 virus. Findings include: A review of the Pennsylvania Department of Health 2023-PAHAN-694-5-11-2023 update: Interim Infection Prevention and Control Recommendations for COVID-19 in healthcare settings dated May 11, 2023, revealed, this PA HAN (Pennsylvania Health alert Network) provides comprehensive information regarding infection prevention and control for COVID-19 in healthcare settings based on changes made…

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 resident and staff interviews, it was determined that the facility failed to provide care in a manner and environment that promotes each resident's quality of life by failing to respond timely to residents' requests for assistance, including experiences reported by nine out of the 11 residents during a resident group interview (Residents 6, 18, 24, 37, 41, 51, 83, 107, and 114). Findings include: During a resident group interview with alert and oriented residents on June 12, 2024, at 10:00 AM, the residents in attendance expressed concerns regarding the long wait times for staff to provide assistance with their care when requested/needed. During the resident group interview, Resident 6 stated that when she needs assistance for care, she waits 15 to 20 minutes for staff to provide the needed care. During the resident group interview, Resident 18 stated that she waits a very long time for staff to provide needed assistance with care. She explained that staff will sometimes initially respond to her calls…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of clinical records, select facility policy and investigative reports, and staff interviews, it was determined that the facility failed to ensure that four residents out of 30 sampled were free from physical abuse (Residents 62, 85, 97, and 119). Findings include: A facility policy titled Abuse Prevention Program, reviewed on April 18, 2024, revealed it is facility policy that residents have the right to be free from abuse, including physical abuse. Further policy review revealed that the administration will implement protocols to protect residents from abuse by anyone, including other residents. A clinical record review revealed Resident 62 was admitted to the facility on [DATE] with diagnoses that include dementia (a condition characterized by the loss of cognitive functioning such as thinking, remembering, and reasoning, to such an extent that it interferes with a person's daily life and activities). A review of a quarterly Minimum Data Set assessment (MDS - a federally mandated standardized…

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

Based on a review of clinical records and select facility policy, staff, and resident interviews, it was determined the facility failed to provide written notice of the facility's bed hold policy to a resident and the resident's representative upon the resident's transfer to the hospital for eight residents out of the 27 sampled (Residents 7, 114, 101, 9, 63, 112, 2, and 106). Findings include: A review of facility policy titled Bed-Holds and Returns, last reviewed on April 18, 2024, revealed it is the facility's policy to inform all residents and/or resident representatives in writing of the facility and state bed-hold policies. The policy indicates that all residents and resident representatives, regardless of payor source, are provided written information regarding the facility and state bed-hold policies, which address holding or reserving a resident's bed during periods of absence at least twice: (1) on admission and (2) at the time of transfer (if the transfer was an emergency, within 24 hours). A clinical record review revealed that Resident 114 was transferred to the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of select facility policy and clinical records and staff interview, it was determined that the facility failed to provide restorative nursing services planned to maintain mobility and functional abilities of four of 27 residents sampled (Residents 63, 114, 72, and 2). Findings included: A review of facility policy titled Restorative Nursing Services, last reviewed by the facility on April 18, 2024, revealed that it is the facility policy that residents will receive restorative nursing care as needed to help promote optimal safety and independence. The policy indicates restorative goals and objectives are individualized and resident-centered and are outlined in the resident's plan of care. A review of the clinical record of Resident 63 revealed admission to the facility on September 13, 2023, with diagnoses to include cerebrovascular disease (stroke), hemiplegia (one sided paralysis - weakness) and hemiparesis (one sided weakness) following cerebral infarction affecting left non-dominant side,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of clinical records and select facility policy, and staff and resident interviews it was determined that the facility failed to ensure that physician ordered intravenous antibiotics were administered as prescribed for two residents out of 27 sampled (Resident 86 and 72). Findings include: Review of a facility policy titled Administering Medications last reviewed by the facility on April 18, 2024, indicated that medications are administered in a safe and timely manner. It indicated that medications are administered in accordance with prescriber orders, including any required time frame. Medication errors are documented, reported, and reviewed by the QAPI committee to inform process changes and/or the need for additional staffing. Prescribed medications are to be administered within one hour of their prescribed time, unless otherwise specified. Review of Resident 86's clinical record revealed that the resident was admitted to the facility on [DATE], with diagnoses to include quadriplegia (paralysis…

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 documents of QA meeting attendance and staff interview, it was determined that the facility failed to ensure that the Medical Director or designee attended quarterly Quality Assurance Process Improvement (QAPI) Committee meetings for two of three quarters reviewed (August 2023 through June 2024). Findings include: A review of QAPI Committee meeting sign-in sheets for the period of August 2023 through June 2024, revealed that the Medical Director or other physician was not in attendance, virtually or in-person, at the QA meetings held from October 2023 through April 2024 missing 2 quarterly meetings (October 27, 2023, and December 5, 2023). An interview with the Nursing Home Administrator (NHA) on June 14, 2024, at 9:00 AM, revealed that the facility was unable to provide documented evidence that the physician attended the facility's QAPI meetings on a quarterly basis as required. 28 Pa. Code 211.2 (d)(3)(4)(5)(6) Medical Director 28 Pa. Code 201.18 (e)(1)(3) Management

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, a review of clinical records and select facility policy, staff and resident interviews, it was determined that the facility failed to ensure the self-administration of medications was clinically appropriate for one of the 27 residents sampled (Resident 7). Findings include: A review of facility policy titled Self-Administration of Medications, provided by the facility on April 18, 2024, indicated residents have the right to self-administer medications if the interdisciplinary team has determined that is clinically appropriate and safe for the resident. If it is deemed safe and appropriate for a resident to self-administer medications, this is documented in the medical record and care plan. A clinical record review revealed Resident 7 was admitted to the hospital on [DATE], with diagnoses that include acute respiratory failure (a condition where the respiratory system is unable to remove carbon dioxide from or provide oxygen to the body) and chronic kidney disease (gradual loss of kidney…

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 select facility incident reports and staff and resident interview, it was determined that the facility failed to ensure that mail was delivered unopened to one of 11 residents interviewed during a resident group interview (Resident 106). Findings include: Definitions under the regulatory guidance for §483.10(h)(2) The facility must respect the residents right to personal privacy, including the right to privacy in his or her oral (that is, spoken), written, and electronic communications, including the right to send and promptly receive unopened mail and other letters, packages and other materials delivered to the facility for the resident, including those delivered through a means other than a postal service. During a resident group interview on June 12, 2024, at 11:40 AM, Resident 106 stated that he does not receive his incoming mail and packages unopened. Resident 106 stated in the past there was a mix-up with prescription medication arriving in a package from a healthcare facility addressed to him instead of being sent directly to the facility. 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.

Based on a clinical record review and staff interview, it was determined that the facility failed to ensure that the necessary resident information was communicated to the receiving health care provider for one resident out of 27 residents sampled with facility-initiated transfers (Residents 7). Findings include: A clinical record review revealed that Resident 7 was transferred to a community hospital on June 8, 2024, and returned to the facility on June 10, 2024. A nursing progress note dated June 8, 2024, at 2:09 PM indicated that Resident 7 was sent to the receiving provider and sent with all appropriate paperwork. There was no documented evidence that the facility had communicated specific information to the receiving health care provider for the residents transferred and expected to return, including contact information of the practitioner responsible for the care of the resident, resident representative information including contact information, advance directive information, all special instructions or precautions for ongoing care, as appropriate, and any other documentation,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of the Resident Assessment Instrument Manual and clinical records, and staff interview, it was determined that the facility failed to timely submit Minimum Data Set (MDS) assessments to the required electronic system, the CMS Quality Improvement and Evaluation System (QIES) Assessment Submission and Processing (ASAP) System, for one of eight sampled (Resident 72). Findings Include: The Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, which provides instructions and guidelines for completing the Minimum Data Set (MDS) dated [DATE], requires that discharge assessments-return anticipated (non-comprehensive) be completed no longer than the resident's discharge date + 14 calendar days. A clinical record review revealed that Resident 72 was transferred to the hospital on April 30, 2024. A progress note dated May 3, 2024, revealed that Resident 72 returned to the facility. Further review of the clinical record revealed no documented evidence that an MDS discharge…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, review of clinical records, and staff interview it was determined that the facility failed to address a resident's active diagnoses and treatment and individualized communication methods and needs on the resident's care plan for one resident out of 27 sampled (Resident 112). Findings included: A review of Resident 112's clinical record revealed he was admitted to the facility on [DATE], with diagnosis to include diabetes, Parkinson's disease (a long-term neurodegenerative disease of mainly the central nervous system), and peripheral vascular disease (a slow, and progressive disorder of the blood vessels - PVD). A review of the admission Minimum Data Set assessment (MDS-a federally mandated standardized assessment process conducted at specific intervals to plan resident care) dated December 5, 2023, revealed that the resident is Hispanic, Latino/a, or Spanish in origin, and that Resident 112's preferred language is Spanish (Espaniol and ) and that the resident does need - wants an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of clinical records, and staff interviews, it was determined that the facility failed to thoroughly assess and evaluate bladder function and implement individualized interventions to restore bladder function to the extent possible for one resident (Residents 47), andprovide care and services to prevent potential complications with the use of an indwelling foley catheter (a flexible tube which is placed into the bladder to drain urine) for one resident out of two sampled with a foley catheter (Resident 101). Findings include: Department of Health & Human Services, USA. Centers for Disease Control and Prevention, Guideline for Prevention of Catheter-Associated Urinary Tract Infections 2009, last updated June 6, 2019, III Proper Techniques for Urinary Catheter Maintenance, B. Maintain unobstructed urine flow. 2. Keep the collecting bag below the level of the bladder at all times. Do not rest the bag on the floor. Review of Resident 47's clinical record revealed admission to the facility on August 9,…

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

Basedonobservation, clinicalrecordreview, andstaffinterview itwasdeterminedthatthefacilityfailedtofailedtotimelyimplementanutritionalsupportregimentomeetthenutritionalneedsandpreventweightlossforoneresident (Resident 90) and failed toaccuratelymonitorafluidrestrictionprescribedtoaddressaresidentsclinicalconditionandmaintainfluidbalanceandadequatehydrationstatusforoneresident(Resident178) outof27 sampled. Findingsinclude AreviewofafacilitypolicyWeightAssessmentandIntervention lastreviewedbythefacilityApril18, 2024, indicatedthatresidentweightsaremonitoredforundesirableorunintendedweightlossorgain Residentsareweigheduponadmission weeklyx4 weeks andthenmonthlyorperphysicianorders Iftheweightlossis5-pounddifferencefromthelastweight areweightwillbeobtainedandvalidated Thedieticianwillreviewtheweightrecordtofollowindividualweighttrends Thethresholdforsignificantunplannedandundesiredweightlossisbasedonthefollowingcriteria a 1 month- 5% weightlossissignificant greaterthan5% issevere b 6 months- 10% weightlossissignificant greaterthan10% issevere Thepolicyfurther…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, a review of clinical records, and staff interview it was determined that the facility failed to ensure the ready availability of necessary emergency supplies for one resident out of two sampled receiving hemodialysis (Resident 59). Findings include: According to the National Kidney Foundation, patients receiving hemodialysis should keep emergency care supplies on hand. A review of the clinical record revealed that Resident 59 was admitted to the facility on [DATE], with a diagnosis to include end stage renal disease, and dependence on renal dialysis (process of removing waste products and excess fluid from the body when the kidneys are not able to adequately filter the blood). Resident 59's clinical record indicated he was receiving hemodialysis through a right upper chest Tesio port (dialysis access site) for dialysis access every Tuesday, Thursday and Saturday. Resident 59's clinical record revealed a physician order dated June 11, 2024, for an emergency kit at bedside for the dialysis…

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 select facility policy and grievances lodged with the facility and staff interviews it was determined that the facility failed to put forth timely and sufficient efforts to promptly resolve grievances for two residents out of 22 sampled. (Resident CR1 and 11) Findings include: Review of the facility's Grievance policy and procedure provided by the facility during the survey on April 12, 2024, indicated that residents and their representatives have the right to file grievances, either orally or in writing, to the facility staff or to the agency designated to hear grievances. The administrator and staff will make prompt efforts to resolve grievances to the satisfaction of the resident and/or representative. Upon receipt of a grievance and/or complaint, the grievance officer with review and investigate the allegations and submit a written report of such findings to the administrator. The grievance office, administrator and staff will take immediate action to prevent further potential violations of resident rights while the alleged violation is being investigated. The…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff interview it was determined that the baseline care plan failed to fully address the resident's immediate individual needs for care and services upon admission of one of 22 residents sampled (Resident 111). Findings: A review of Resident 111's clinical record revealed that she was admitted to the facility on [DATE], with above of the knee amputations of the left and right legs. Review of the Resident 111's baseline care plan, conducted at the time of the survey ending April 12, 2024, revealed that the resident's baseline care plan did not identify the resident's bilateral above the knee amputations and resident's needs for assistance with activities of daily living as a result of the amputations, present upon admission. The resident's baseline care plan, initiated April 3, 2024, revealed that the resident was at risk for falls related to gait/balance problems with planned interventions of to be sure my call light is within reach and encourage me to use it for assistance…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of clinical records and incident reports, resident and staff interviews it was determined that the facility failed to consistently provide care and services, consistent with professional standards of practice, to prevent the development of pressure ulcers for one resident out of four sampled residents (Resident 110). Findings: According to the US Department of Health and Human Services, Agency for Healthcare Research & Quality, the pressure ulcer best practice bundle incorporates three critical components in preventing pressure ulcers: Comprehensive skin assessment, Standardized pressure ulcer risk assessment and care planning and implementation to address the areas of risk. The American College of Physicians (ACP) is a national organization of internists, who specialize in the diagnosis, treatment, and care of adults. The largest medical-specialty organization and second-largest physician group in the United States) Clinical Practice Guidelines indicate that the treatment of pressure ulcers…

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

Based on observation and resident and staff interviews, it was determined that the facility failed to reasonably accommodate residents' need for call bell accessibility for 5 out of 7 residents sampled (Residents 86, 89, 111, 118, and 119). Findings include: Observation on November 7, 2023, at 10:35AM revealed Resident 111 seated in a wheelchair along the left side of her bed. The resident's call bell was observed tucked under the mattress on the right side of her bed, out of sight and reach of the resident. During an interview at the time of the observation, Resident 111 stated that she was unable to locate her call bell to request staff assistance when needed. An interview with Employee 3 (RN nurse consultant) on November 7, 2023, at 10:40 AM confirmed the observation that Resident 111 did not have access to a call bell to summon staff assistance. Observation on November 7, 2023, at 10:45 AM revealed that Resident 119 was lying in bed unable to reach or access her call bell. The resident's call bell was wrapped around the bed frame and out of reach of Resident 119. Observation on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of clinical records, select investigative reports and facility policy, and resident and staff interviews, it was determined that the facility failed to consistently implement sufficient measures to protect three residents (Residents 45, 55, and 82) out of 18 sampled from physical abuse perpetrated by other residents. Findings included: A review of the current facility policy titled Abuse Prevention Program, dated as revised in December 2016, revealed that it is the facility's policy that residents have the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. The policy indicated that as part of resident abuse prevention, the administration will protect residents from abuse by anyone, including, but not necessarily limited to: facility staff, other residents, consultants, volunteers, staff from other agencies, family members, legal representatives, friends, visitors, or any other individual. A clinical record review revealed that Resident 18 was admitted…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of clinical records, facility investigative reports, and resident and staff interviews, it was determined that the facility failed to provide therapeutic social services to assess the psychosocial status and needs of residents following incidents of abuse perpetrated by other residents to promote the psychosocial well-being of two of 18 residents sampled (Resident 45 and 82). Findings include: A clinical record review revealed that Resident 82 was admitted to the facility on [DATE], with diagnoses to include lymphocytic leukemia (a type of cancer in which the bone marrow makes too many white blood cells) and chronic obstructive pulmonary disease (COPD). A review of a quarterly Minimum Data Set assessment (MDS - a federally mandated standardized assessment process conducted periodically to plan resident care) dated September 11, 2023, revealed that Resident 82 was moderately cognitively impaired with a BIMS score of 11 (Brief Interview for Mental Status- a tool to assess cognitive function; a…

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

Based on review of clinical records and controlled substance count records, resident and staff interviews, it was determined that the facility failed to implement procedures to promote accurate accounting and administration of controlled drugs for one of three residents sampled (Resident 57). Findings include: A review of Resident 57's clinical record revealed admission to the facility on September 20, 2023, with diagnoses of gastro-esophageal reflux disease (GERD), depression, chronic obstructive pulmonary disease (COPD), protein-calorie malnutrition, and diabetes. An admission Minimum Data Set assessment (MDS - a federally mandated standardized assessment process conducted periodically to plan resident care) dated September 24, 2023, revealed that the resident was moderately impaired with a BIMS (brief interview to assess cognitive status) score of 12 (a score of 8-12 indicates moderate impairment). The resident had a physician order dated September 29, 2023, for Adderall oral tablet 10 milligram (mg), give 2 tablets by mouth two times a day for attention deficit related 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 review of the facility's plan of correction from the surveys of September 28, 2023 and November 7, 2023, and the findings of the survey ending December 7, 2023, it was determined that the facility's Quality Assurance Performance Improvement (QAPI) committee failed to develop and implement corrective action plans to prevent continued quality deficiencies related to abuse prevention and pharmacy services and to ensure that plans designed to improve the delivery of care and services were consistently implemented to effectively deter future quality deficiencies. Findings include: The facility's deficiencies and plan of correction for the survey ending November 7, 2023, revealed the facility developed a plan of correction that included quality assurance monitoring systems to ensure that solutions were sustained. The results of the current survey ending December 7, 2023, revealed that two residents, Resident 1 and 2 were physically abused by Resident 3 and continued to deficient practice was identified in abuse. In response to the deficiency cited under resident abuse during the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of resident clinical records and medication error report and staff interview it was revealed that the facility failed assure that one of three residents reviewed was free of significant medication errors (Resident 23). Findings include: The Principles of Medication Administration, The Five Rights of Medication Administration indicate that when you are giving medication, regardless of the type of medication, you must always follow the five rights. Each time you administer a medication, you need to be sure to have the: 1. Right individual 2. Right medication 3. Right dose 4. Right time 5. Right route According to the Pennsylvania Code Title 49, Professional and Vocational Standards Department of State, Chapter 21 State Board of Nursing, Chapter 21.145 Functions of the LPN (Licensed Practical Nurse) requires the following: The LPN is prepared to function as a member of the health care team by exercising sound nursing judgement based on preparations, knowledge, skills, understandings and past…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and staff interview, it was determined that the facility failed to provide housekeeping services to maintain a clean and orderly environment in resident areas on three of three resident units (First, Second, and Third Floor Nursing Units) Findings include: Observations on The First Floor Nursing Unit revealed on September 28, 2023, at 9:50 AM revealed an accummulation of dead insects on the floor at the end of the hall by the heating/cooling unit. The insects included dead stink bugs, dead ants, a dead moth, and dead beetle/roach like bugs. In resident room [ROOM NUMBER] there was a dead stink bug observed. In the soiled utility room there were multiple dead roach-like bugs along with dead ants. Observations on The Third Floor Nursing Unit revealed on September 28, 2023, at 10:35 AM revealed dirt and debris on the floor in the hallway. A used blood glucose strip was observed on the floor in the hallway. The soiled utility room had a strong foul smell. In the soiled utility room there was a…

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

Based on clinical record review and staff interview it was determined that the facility failed to provide services necessary to maintain good personal hygiene and grooming of residents' requiring assistance with activities of daily living for two out of five residents reviewed. (Residents 15 and 17). Findings include: A review of Resident 15's clinical record revealed admission to the facility on May 3, 2023, with diagnoses which included dementia (persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change, resulting from organic disease of the brain). The resident required assistance with activities of daily living, including personal hygiene, showers and bathing. A review of the resident's clinical record revealed that the resident was to be showered on Monday and Thursdays during the 7 AM to 3 PM shift. A review of the resident's bathing record for September 2023 revealed that Thursday September 28, 2023, during the 7 AM to 3 PM shift staff provided the resident a bed bath instead of a shower.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of clinical records and staff interview, it was determined that the facility failed to consistently provide adequate supervision and follow physician's orders for measures planned to prevent accidents and promote resident safety three of 21 sampled (Resident 5, 15, and 16) Findings include: A review of the clinical record revealed that Resident 5 was admitted to the facility on [DATE], with diagnoses to include a history of falling and orthostatic hypotension (a condition in which your blood pressure suddenly drops when you stand up from a seated or lying position). A review of a physician's order initially dated September 15, 2023, indicated the resident was to receive 15 minute checks for safety. A review documentation titled Q 15 Minute Checks revealed that on September 26, 2023, the physician ordered checks were not completed 32 times throughout the day. On September 27, 2023, the physician ordered checks were not completed six times throughout the day. A review of the clinical record…

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

Based on a review of clinical records and select facility policy, and staff interview it was determined that the facility failed to ensure that licensed nursing staff possessed the skills and competencies necessary to assure resident safety and administer antibiotics via a PICC line (peripherally inserted central catheter- long thin tube that is inserted through a vein in your arm and passed through to the larger veins near the heart and is used for long-term intravenous antibiotics, nutrition, or medication, and for blood draws) as evidenced by one resident out of 21 residents reviewed (Resident CR1). Findings Include: According to the Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.145 Functions of the Licensed Practical Nurse (LPN) (a) The LPN is prepared to function as a member of the health-care team by exercising sound judgement based on preparation, knowledge, skills, understanding and past experiences in nursing situations. The LPN participates in the planning, implementation, and evaluation of nursing care in settings where…

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 controlled drug shift count records and select facility policy and staff interview, it was determined that the facility failed to implement procedures to promote accurate controlled medication records on two of two medication carts observed. Finding include: A review of the current facility provided policy entitled Controlled Substances revealed controlled medications are counted at the end of each shift. The nurse coming on duty and the nurse going off duty determine the count together. The oncoming and off going nurse will view the medication together to validate the medication and count is correct. A review of the facility Narcotic Count Sheet from the first floor medication cart revealed the following: September 10, 2023, the 3 pm to 11 pm off going nurse failed to sign that the narcotic count to confirm completion of the count; September 17, 2023, the 3 pm to 11 pm oncoming and the 3 pm to 11 pm off going nurse failed to sign that the narcotic count was completed. September 20, 2023, the 7 am to 3 pm oncoming and the 7 am to 3 pm off going nurse failed 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 observation and staff interview, it was determined that the facility failed to maintain acceptable practices for the storage of food and supplements to prevent the potential for microbial growth in food or contamination, which increased the risk for foodborne illness. Findings include: An observation on September 28, 2023, at approximately 9:55 AM of the First Floor Nursing Unit dining room revealed a functioning drawer style refrigerator and a drawer style freezer. There was no thermometer in the refrigerator or freezer to monitor for proper temperature. Upon opening the freezer a large build up of ice that had dislodged fell to the dining room floor. The inside of the freezer was soiled with a dried sticky residue on the bottom shelf. In the refrigerator in the pantry located next to the dining room, there was an open gallon of milk that was not dated when it was opened, one open gallon of chocolate milk not dated when opened, four containers of ketchup not dated, a jar of homemade canned pickles not labeled with a resident's name or dated, a partially frozen half…

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

Based on observation and staff interviews, it was determined that the facility failed to consistently provide a fully functioning call system to provide direct communication from the resident to the caregivers for 4 of 21 residents sampled (15, 18, 25 and 26) Findings included: Observations on the third floor nursing unit on September 28, 2023, at approximately 2:00 PM revealed Resident 15's call bell was unplugged from the wall. The call bell was observed lying on the floor under the resident's bed. Observation revealed that Resident 18's call bell was unplugged from the wall. The call bell was not accessible to the resident and was found lying under the resident's bed. Resident 25's call bell was unplugged from the wall. The call bell was found under a chair in the room and not accessible to the resident. Resident 26's call bell was unplugged from the wall. The call bell could not be located in the resident's room. The call belly system was not functional for this resident's use. Interview with the nursing home administrator (NHA) on September 28, 2023, at approximately 4:00 PM…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of clinical records and staff interview, it was determined that the facility failed to timely notify the resident's interested representative of a change in condition for one resident out of 21 sampled (Resident CR1). Findings include: A review of the clinical record revealed that Resident CR1 was admitted to the facility on [DATE], with diagnoses which included diabetes mellitus, left hallux (big toe) amputation, partial first metatarsal ray resection of left foot (procedure used to help salvage the foot and maintain bipedal ambulation), and a right foot ulcer. A review of a nurses note dated September 11, 2023, noted resident with fluid filled blisters to bilateral shins approximately the size of a large grape and noting that the physician was aware. New orders were received and updated accordingly. The order was for Furosemide (a diuretic medication) to be given twice daily for three days. Antibiotic cream and dry sterile dressing to be put in place once sites open and begin draining. There…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff interview, it was determined that the facility failed to complete a discharge summary, which included a recapitulation of the resident's stay, the course of illness, corresponding treatment, discharge instructions, and a post-discharge care plan for one of one discharged resident record reviewed (Resident CR1). Findings include: A review of the closed clinical record revealed that Resident CR1 was admitted to the facility on [DATE], with diagnoses including diabetes mellitus, left hallux (big toe) amputation, partial first metatarsal ray resection of left foot (procedure used to help salvage the foot and maintain bipedal ambulation), and right foot ulcer. A closed clinical records review, conducted on September 28, 2023, revealed that Resident CR1 was discharged home with hospice services on September 15, 2023. A nurses note dated September 11, 2023, indicated that the resident had fluid filled blisters on both shins approximately the size of a large grape. The entry…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of clinical records and select facility policy, and staff interviews it was revealed that the facility failed to accurately monitor bowel activity to ensure a physician prescribed bowel protocol was timely implemented as needed for one resident out of 22 sampled residents (Resident 22). Findings include: According to the American Academy of Family Physicians {The American Academy of Family Physicians is one of the largest medical organizations in the US founded to promote the science and art of family medicine} the primary goal of constipation management should be symptom improvement, and the secondary goal should be the passage of soft, formed stool without straining at least three times per week). Review of facility policy entitled Bowel Regimen, last reviewed January 2023 indicated that the purpose of the bowel regimen was to achieve control of bowel evacuation on a regular basis, to avoid constipation, to prevent fecal impaction, and to establish psychological and social well-being.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and resident and staff interviews, it was determined that the facility failed to consistently provide services planned to maintain mobility for two of four sampled residents for mobility/range of motion (Resident 7 and 19). Findings include: A review of Resident 7's clinical record revealed that the resident was admitted to the facility on [DATE], with diagnoses to include intervertebral disc displacement of the lumbar region (degeneration of the disc that separate the bones of the spine, causing pain in the back and legs), and gout (complex form of arthritis). Resident 7 was discharged from physical therapy on August 15, 2023 with discharge recommendations that Resident 7 was to receive Restorative Nursing Services (RNP) to walk daily, 30-50 feet with a rolling walker, with assist of one person and a wheelchair to follow. Review of facility document titled Documentation Survey Report v2 dated August 2023, revealed that the daily restorative program for ambulation was not provided…

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, clinical record, and staff interview it was determined that the facility failed to provide care and services designed to prevent potential complications associated with tube feedings for one resident receiving an enteral feeding out of 21 residents sampled (Resident 17). Findings include: A review of the clinical record of Resident 17 revealed admission to the facility on October 13, 2022, with diagnoses of cerebral infarction (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it) and dysphagia (difficulty swallowing). Resident 17 required a PEG tube [Percutaneous endoscopic gastrostomy (PEG) is an endoscopic medical procedure in which a tube (PEG tube) is passed into the patient's stomach through the abdominal wall, most commonly to provide a means of feeding when oral intake is not adequate [for example, because of dysphagia] for enteral feeding [enteral nutrition generally refers to any method of feeding that uses the gastrointestinal (GI) tract to deliver part or all of a person's caloric…

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 a staff interview, it was determined that the facility failed to provide housekeeping and maintenance services to maintain a clean, orderly, and homelike environment in resident areas on two of three resident units (Units 2 and 3). Findings included: An observation on August 15, 2023, at 10:30 a.m. of resident room [ROOM NUMBER] revealed a build-up of a white powdery substance covering the red electrical outlet, black electrical cord, and chair legs adjacent to the door-side bed. An observation on August 15, 2023, at 10:40 a.m., of resident room [ROOM NUMBER] revealed a tan floor mat, to left of the bed located by the door, that had black scuff marks, brown stains, and areas of build-up of black substance Observation of the residents' bathroom revealed a toilet cleaning brush hanging on the assist bar behind the toilet. An observation on August 15, 2023, at 10:45 a.m., of resident room [ROOM NUMBER] revealed brown and tans stains on the top and front cover of the heating and cooling…

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 grievances filed with the facility and the minutes from resident group meetings and staff interviews it was determined that the facility failed to put forth sufficient efforts to promptly resolve continued resident complaints and grievances expressed during Resident Council meetings, including those voiced by six (6) of the seven (6) residents (Residents 16, 20, 25, 52, 65, and 101). Findings included: A review of the minutes from the May 2023 through July 2023 Resident Council and Town Hall meetings revealed that residents in attendance at these meetings voiced their concerns regarding the facility's laundry services and long waits for staff to respond to their call bells. The minutes from several Resident Council meetings indicated that concerns with facility laundry services were referred to a laundry/housekeeping meeting (Town Hall). During the May 1, 2023, Resident Council Meeting, the residents voiced several concerns related to missing clothing articles. Individual grievances were…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of clinical records and staff interview it was determined that the facility failed to ensure that a resident dependent on staff for assistance with activities of daily living consistently received showers as planned to maintain good personal hygiene for one of four residents sampled (Resident 126). Findings include: A review of Resident 126's clinical record revealed that the resident was admitted to the facility on [DATE], with diagnoses that included dementia (chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning). An admission Minimum Data Set Assessment (MDS - a federally mandated standardized assessment conducted at specific intervals to plan resident care) of Resident 126 dated July 12, 2023, indicated that the resident was totally dependent on staff for bathing/showers. The resident was moderately cognitively impaired with a BIMS score of 8 (brief interview for mental status, 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 observation, a review of clinical records and select facility incident reports, and staff interview, it was determined that the facility failed to fully develop and implement an individualized person-centered plan to address a resident's dementia-related behavioral symptoms for one out of the 27 residents sampled (Residents 111). Findings included: A review of the clinical record revealed that Resident 111 was admitted to the facility on [DATE], and had diagnoses that included unspecified cerebrovascular disease (a group of conditions that affect blood flow and the blood vessels in the brain). A quarterly Minimum Data Set assessment (a federally mandated standardized assessment completed periodically to plan resident care) dated August 2, 2023, indicated that Resident 111 is severely cognitively impaired and exhibits inattention, disorganized thought, threatening, screaming, or yelling at others. A psychiatric evaluation and history dated June 1, 2023, indicated that Resident 111 during a psychiatric…

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.