Edenbrook At Hampton

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of clinical records and staff interview, it was determined the facility failed to provide therapeutic social services to promote the mental and psychosocial well-being of one resident out of 21 sampled (Resident 31). Findings include: A review of the clinical record revealed that Resident 31 was admitted to the facility on [DATE], with diagnoses to include major depressive disorder (a mood disorder characterized by persistent low mood and anxiety (feelings of worry and unease). Review of a quarterly Minimum Data Set Assessment (MDS- a federally mandated standardized assessment process completed at specific intervals to plan resident care) dated April 14, 2025, indicated the resident had a BIMS score of 15 (brief interview for mental status, a tool to assess the residents attention, orientation and ability to register and recall new information, a score of 13-15 equates to being cognitively intact). Further review of the clinical record revealed a progress note dated June 7, 2025, at 6:33 PM,…

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

Based on observation, review of select facility policy and clinical records, and staff interviews, it was determined the facility failed to adhere to acceptable storage and labeling for multi-dose medications in one of two medication carts observed (C Hall). Findings include: Review of the facility policy titled Medication Labeling and Storage last reviewed by the facility March 1,2025, indicated that multi-use medication vials/bottles that have been opened or accessed (e.g. seal broken) are to be labeled with the date they were opened to ensure proper tracking for expiration purposes. An observation of the medication cart located on C Hall unit on June 11, 2025, at 8:22 AM, in the presence of Employee 2 (Licensed Practical Nurse ) of the medication stored in the medication cart, revealed one (1) multi-dose insulin pen of Insulin Lispro (a fast acting insulin medication used to lower blood sugar) and two (2) multi-dose pens of Insulin Glargine (a long acting insulin medication used to lower blood sugar) that had been opened and available for use, but not dated when initially opened.…

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 Resident Council Meeting minutes and maintenance work orders, observation, and resident and staff interviews, it was determined the facility failed to ensure all residents had access to a resident-only telephone for one of 20 residents sampled (Resident 1) and failed to provide privacy for residents when having telephone calls on three out of three clinical nursing units. Findings include: Interview with Resident 1 on January 29, 2025, at 11:40 AM revealed that the resident-only telephone, located in the B-Wing Resident Lounge, was non-operational. Resident 1 stated that for three months, the facility had informed him that the guy isn't available to fix it. He reported the issue during the January 22, 2025, Resident Council Meeting, but the facility had not addressed his concern. Observation of the B-Wing Resident Lounge on January 29, 2025, at 12:06 PM revealed a landline telephone on a countertop without a dial tone. Further observation showed the phone jack pulled out from the wall with exposed phone cable wires. Interview with Employee 2 (licensed practical…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, a review of clinical records, review of facility grievances, Resident Council Meeting minutes, and resident and staff interviews, it was determined the facility failed to provide sufficient staff, providing direct services to residents, who possess the necessary competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident as evidenced the facility's inability to appropriately manage and supervise the wandering and aggressive behaviors of two residents (Residents 4 and 20) out of 20 sampled. Findings include: Review of clinical record of Resident 4 revealed that the resident was admitted to the facility on [DATE], with diagnoses to include dementia with other behavioral disturbances (a condition characterized by progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with…

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

Based on review of facility policy, observation and staff interview, it was determined the facility failed to maintain acceptable practices for the storage and service of food to prevent the potential for contamination and microbial growth in food, which increased the risk of food-borne illness in the food and nutrition services department. Findings include: Food safety and inspection standards for safe food handling indicate that everything that comes in contact with food must be kept clean and food that is mishandled can lead to foodborne illness. Safe steps in food handling, cooking, and storage are essential in preventing foodborne illness. You cannot always see, smell, or taste harmful bacteria that may cause illness according to the USDA (The United States Department of Agriculture, also known as the Agriculture Department, is the U.S. federal executive department responsible for developing and executing federal laws related to food). A review of a facility policy entitled Cleaning Dishes: Manual Dishwashing last reviewed by the facility on April 17, 2024, indicated that sink…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of clinical records and staff interview, it was determined the attending physician failed to act upon pharmacist identified irregularities in the medication regimen of four of 20 residents sampled (Resident 12, 47, 86, and 46). Findings include: A review of the clinical record revealed Resident 12 was admitted to the facility on [DATE], and had diagnoses that included bipolar disorder (serious mental illness characterized by extreme mood swings, a mood disorder that causes radical emotional changes and mood swings, from manic, restless highs to depressive, listless lows. Most bipolar individuals experience alternating episodes of mania and depression). A review of an April 2024 Note to Attending Physician/Prescriber revealed the consultant pharmacist indicted the resident was recently admitted with an order for Quetiapine Fumarate (antipsychotic medication) oral tablet 25mg three times a day related to bipolar disorder and the medication needed to be evaluated for the effectiveness and if a GDR…

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

Based on observations, a review of facility pest service records and staff interview, it was determined the facility failed to maintain an effective pest control program throughout multiple areas of the facility. Findings include: An observation of the A hall nursing unit medication room on August 22, 2024, at approximately 9:05 AM revealed a strong mildew and sewage smell throughout the room. A flying bug was seen in the med room. An observation of the A hall nursing unit shower room on August 22, 2024, at approximately 9:15 AM revealed a large amount of sewer flies in the shower room. These flies were noted to be covering the walls of the shower room. They were noted by the tub and in both shower stalls. There was multiple dead flies noted on the floor, in the tub, or flattened on the wall. An interview with Employee 1 LPN (license practical nurse) on August 22, 2024, at approximately 9:25 AM revealed the employee stated the bugs have been an ongoing issue in the facility. She stated that they have been a problem for at least four months and have become worse over the summer. The…

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

Based on observation, and staff interviews it was determined the facility failed to provide housekeeping and maintenance services to maintain a clean and safe resident environment. Findings include: An observation on August 20, 2024, at approximately 1:30 PM revealed in Room B14 Resident 25's tube feeding pump and pole were soiled with dried tube feeding solution dried to the pump and pole. In addition there were dried spots of tube feeding solution on the floor. An observation of the A hall nursing unit medication room on August 22, 2024, at approximately 9:05 AM revealed there was dirt and debris on the floor. A strong mildew and sewage smell was noted throughout the room. A flying bug was observed flying around in this medication room. An observation of the A hall nursing unit shower room on August 22, 2024, at approximately 9:15 AM revealed a large amount of sewer flies in the shower room. These flies were noted to be covering the walls of the shower room. They were observed by the tub and in both shower stalls. There were multiple dead flies noted on the floor, in the tub, 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 clinical record review and staff interviews, it was determined the facility failed to develop person-centered care plans that include individual medication therapy for one resident out of 20 sampled (Resident 12). Findings include: A review of the clinical record revealed Resident 12 was admitted to the facility on [DATE], with diagnoses to include hypertension (high blood pressure). A review of a physician order, initially dated April 30, 2024 revealed the resident was receiving Eliquis Oral Tablet 2.5 MG (anticoagulant medication-commonly known as a blood thinner, chemical substance that prevents or reduces the coagulation of blood, prolonging the clotting time) give twice a day for history of pulmonary embolism (blood clot in the lung). A review of the current resident's plan of care revealed the resident's care plan failed to identify the resident's anticoagulant therapy and interventions to monitor for bleeding. Interview with the Nursing Home Administrator and Director of Nursing on August 23,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of clinical records, and staff interview, it was determined the facility failed to provide nursing services consistent with professional standards of practice by failing to ensure physician ordered medication, an antibiotic, and additive were timely obtained and administered to treat a urinary tract infection for one resident (Resident 93) out of 20 sampled residents. Findings include: According to the American Nurses Association Principles for Nursing Documentation, nurses document their work and outcomes and provide an integrated, real-time method of informing the health care team about the patient status. Timely documentation of the following types of information should be made and maintained in a patient's EHR (electronic health record) to support the ability of the health care team to ensure informed decisions and high-quality care in the continuity of patient care: • Assessments • Clinical problems • Communications with other health care professionals regarding the patient • 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of select facility policy, clinical records, and staff interview, it was determined the facility failed to implement individualized approaches for inontinence to provide maintenance care to the extent possible for one out of 20 sampled residents (Resident 25). Findings include: A review of facility policy entitled Urinary and Bowel Incontinence Evaluation and Management last reviewed April 17, 2024, indicated if a resident is not a candidate for a schedule, they will be placed on Incontinence Care and Comfort (checked and changed every two to three hours). A review of Resident 25's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses which included dementia (a decline in cognitive abilities that can affect a person's ability to perform everyday activities) and muscle wasting. A review of the resident's bladder and bowel evaluation dated July 21, 2024, revealed the resident was always incontinent of bowel and bladder, has poor a potential for a toileting…

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 policies and staff interview, it was determined the facility failed to consistently and accurately monitor resident weights to timely identify changes in nutritional parameters for two of 20 sampled residents (Residents 40 and 91). Findings include: The facility policy Weight Policy dated as revised June 2024, indicated that any resident with weight changes of five or more pounds will be re-weighed within 72 hours post the original weight by the assigned CNA/designee and nurse. The Dietician will review the medical record of residents with significant weight changes (greater than or equal to 5% in 1 month, greater than or equal to 7.5% in 3 months, and greater than or equal to 10% in 6 months). Interventions will be recommended, as needed. Interventions that are initiated in response to a weight change will be reflected in the care plan. Residents with significant weight loss/gain will be further reviewed by the IDCPT (interdisciplinary care plan team)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of clinical records and staff interview, it was determined the facility failed to develop and implement an effective individualized person-centered plan to address a resident's dementia-related behavioral symptoms for one out of 20 residents reviewed (Resident 86). Findings include: A review of Resident 86's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses to include dementia (a progressive brain disorder that affects memory, thinking, and behavior) A review of Resident 29's Quarterly Minimum Data Set Assessment (MDS - a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated May 13, 2024, revealed the resident was severely cognitively impaired. A review of progress notes in the resident's clinical record dated from February 01, 2024 to August 24, 2024, revealed the resident exhibited behaviors of intrusive wandering, striking out, screaming, and agitation. The resident's current care plan in effect at…

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

Based on observation and staff interviews, it was determined the facility failed to provide housekeeping and maintenance services necessary to maintain a safe, clean, and orderly environment in one of the three resident units (C Hall). Findings include: An observation on, July 2, 2024, at 8:22 AM of the wall at the C Hall nursing station revealed an area of missing floor strip molding that created a hole measuring 3 inches x 24 inches. An accummulation of rocks, dirt, metal, and other debris were observed on the floor near this hole. An ethernet outlet cover was detached from the wall, exposing the interior wiring. A small cut was observed the protective plastic exterior of a black phone wire, and an unused white phone wire was hanging from the wall. An observation on July 2, 2024, at 8:27 AM revealed dead bugs and debris inside the ceiling light fixture in the C Hall resident shower room. A thick layer of brown and gray dust was observed covering the ceiling vent and internal fan blades. An observation on July 2, 2024, at 8:32 AM in resident room C-16 revealed the floor molding was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of clinical records, and resident staff interview it was determined that the facility failed to ensure that residents dependent on staff for assistance with activities of daily living consistently were provided showers as planned to maintain good personal hygiene for five of 10 residents sampled (Resident B1, B2, B3, B4, and B5). Findings include: A review of Resident B1's clinical record revealed that the resident was admitted to the facility on [DATE], with diagnoses to include diabetes, and osteoarthritis (a degenerative joint disease that occurs when tissues that cushion the ends of bones within the joints break down), A quarterly Minimum Data Set Assessment (MDS - a federally mandated standardized assessment conducted at specific intervals to plan resident care) of Resident B1 dated May 2, 2024, indicated that the resident required substantial/maximal assistance for showering/bathing. The resident was cognitively intact with a BIMS score of 15 (brief interview for mental status, a tool to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of clinical records, select facility policy and investigative reports, and staff interviews, it was determined that the facility failed to ensure that one resident out of 15 sampled was free from verbal and mental abuse (Resident A1). Findings include: A facility policy titled Abuse, dated as reviewed by the facility April 17, 2024, revealed that that it is the facility policy that each resident will be free from abuse. Abuse can include verbal and mental abuse. The facility policy defines verbal abuse as the use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or their families or within their hearing distance, regardless of their age, ability to comprehend, or disability. Examples of verbal abuse include, but are not limited to: threats of harm; saying things to frighten a resident, such as telling a resident that he will never be able to see his family again. Mental abuse was defined as the use of verbal or nonverbal conduct 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 a review of clinical records, the facility's abuse prohibition policy, facility investigation reports, and resident and staff interviews, it was determined the facility failed to timely report the witnessed abuse of one resident out of 15 sampled (Resident A1) to the State Survey Agency. Findings include: A facility policy titled Abuse, dated as reviewed by the facility on April 17, 2024, indicated that abuse allegations are reported per federal and state law. The facility will ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment are reported immediately, but no later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials, including the State Survey Agency. Employees must always report any abuse or suspicion of abuse immediately to the administrator. Verbal abuse is defined as the use of oral, written, or gestured language that willfully…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of clinical records, select facility incident reports and the facility's abuse prohibition policy and resident and staff interviews, it was determined that the facility failed to timely and thoroughly investigate an injury of unknown source to rule out abuse, neglect or mistreatment for one of 15 residents sampled (Resident CR1) and failed to promptly conduct a thorough investigation into the witnessed abuse perpetrated by Employee 3, and failed to protect residents from the potential for further abuse during the course of the investigation into the abuse of one resident (Resident A1) out of the 15 sampled residents. The findings include: A review of the facility's Abuse Prohibition Policy last reviewed April 17, 2024, indicated that the objective of the abuse policy is to comply with the seven-step approach to abuse and neglect detention and prevention. Verbal abuse is defined as the use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of clinical records and select reports and resident and staff interviews it was determined that the facility failed to provide therapeutic social services to a resident following an incident of verbal and mental abuse perpetrated by staff for one resident out of 15 sampled (Resident A1). Findings included: According to regulatory requirements under 42 CFR Part 483 Subpart B, the intent of §483.40(d) is to assure that sufficient and appropriate social services are provided to meet the resident's needs. Situations in which the facility should provide social services or obtain needed services from outside entities include, but are not limited to the following: o Expressions or indications of distress that affect the resident's mental and psychosocial well-being, resulting from depression, chronic diseases (e.g., Alzheimer's disease and other dementia related diseases, schizophrenia, multiple sclerosis), difficulty with personal interaction and socialization skills, and resident to resident…

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

Based on observation and staff interview, it was determined that the facility failed to ensure that essential resident care equipment, a sit-to-stand lift, was in safe operating condition. Findings Include: Observation of the second floor B wing residents lounge area on July 2, 2024, at 10:35 AM, in the presence of the Director of Nursing (DON) revealed one out of the three facility sit-to-stand lifts was not operating properly. Observation revealed that the adjustable leg base of the sit-to-stand lift is designed to extend open to accommodate positioning around a toilet, recliner chair, wheelchairs and obstacles, and to provide a wider base of support when transferring a resident from one location to another. Observation revealed that the left leg of the base would not move when activated by the electronic controller. Interview with the DON on July 2, 2024, during the time of the observation, revealed that the facility failed to maintain essential resident equipment in a safe operating condition. 28 Pa. Code 201.18 (e)(2.1) Management

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, review of select facility policy and clinical records, and staff interview, it was determined that the facility failed to promptly act upon known risk factors, including immobility, for pressure sore development and timely implement individualized measures to prevent pressure sore development and promote healing for one of six residents sampled with pressure sores (Resident 1). Findings include: 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 areas of risk. ACP (The American College of Physicians 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…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of select facility policy and clinical records and staff interview, it was determined that the facility failed to administer pain medication as prescribed by the physician and attempt non-pharmacological interventions to alleviate pain prior to the administration of pain medication prescribed on an as needed basis for one of six residents reviewed (Resident D2). Findings include: A review of the facility policy entitled Pain Management Program dated October 24, 2022, indicated that the facility shall provide adequate management of pain to ensure that residents attain or maintain the highest practicable physical, mental, and psychosocial well-being. Residents will be evaluated for pain upon admission, during periodic scheduled assessments, and with change in condition or status (e.g., after a fall, with change in behavior or mental status). If the resident's pain is not controlled by the current treatment regimen, the practitioner should be notified. The interdisciplinary team and the resident…

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

Based on review of select facility polity, the minutes from Resident Council Meetings and grievance logs and resident and staff interviews, it was determined that the facility failed to demonstrate prompt action to resolve resident grievances raised at resident group meetings and keep the residents apprised of the status of the facility's decisions and efforts toward grievance resolution. Findings include: A review of the minutes from the Resident Council Meeting held during August 2023, revealed that 23 residents attended the meeting. During that meeting, the residents voiced concerns about nurse aides coming into their rooms and shutting off their call bells without meeting the needs of the residents for assistance. There was no documented evidence that the facility had addressed this concern. A review of the minutes from the Resident Council Meeting held during September 2023, revealed that 21 residents attended the meeting. During that meeting, the residents voiced the same concerns about the timeliness of assistance provided after ringing their call bells. There was no…

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

Based on observations and staff interview, it was determined that the facility failed to maintain a clean and orderly environment in resident areas on three of three resident units (A hall, B hall, and C hall Nursing Units) Findings include: Observations on November 16, 2023, at 9:30 AM of the C hall Nursing Unit revealed the following: In resident Room C17 the molding was peeling off from the wall. There was a hole in the wall in the bathroom. Feces was observed on the toilet. The floor next to the toilet was wet and had a black substance around the toilet. A strong odor of urine was present. The bathroom floor was sticky. Observation in the central shower room revealed a hole in the wall outside the door that was attempted to be patched but the patch was also damaged. There were holes in the wall in the shower room along with sticky drips running down the wall with hair stuck to the wall. There were missing heat lamp lights in the shower room. The tile in the bathroom was cracked and broken. There was hair in the shower drain. [NAME] spots and a black substance were observed the…

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

Based on clinical record review and staff and resident interview, it was determined that the facility failed to include the resident's preferences for showers/bathing on the comprehensive care plan of one resident out of five reviewed (Resident 1). Findings include: A review of the clinical record revealed Resident 1 was admitted to the facility July 14, 2023, with diagnoses to include heart disease. Review of the admission Minimum Data Set assessment (MDS-a federally mandated standardized assessment process conducted at specific intervals to plan resident care) dated August 3, 2023, revealed that the resident was cognitively intact, with a BIMS score (Brief Interview for Mental Status - a tool to assess cognitive function) of 15 and required extensive assist with ADLs including bathing. During an interview with Resident 1 on November 16, 2023, at approximately 9:20 a.m., the resident stated she had never been asked her preference for shower times and days to be showered. A review of Resident 1's comprehensive care plan, conducted on November 16, 2023, revealed that the resident'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.