Embassy Of East Mountain

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of clinical records, facility policy, resident representative and staff interviews, it was determined the facility failed to ensure residents maintain acceptable parameters of nutritional status, such as usual body weight, unless the resident's clinical condition demonstrates that is not possible for one out of four residents sampled (Resident CR1).Findings include: A facility policy titled Weight Monitoring, dated October 1, 2024, revealed it is the facility's policy that based on the resident's comprehensive assessment, the facility will ensure that all residents maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range, unless the resident's clinical condition demonstrates that this is not possible or resident preferences indicate otherwise. The resident and/or resident representative will be involved in the development of the care plan to ensure it is individualized and meets personal goals and preferences. Interventions will be…

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 residents' financial account records and staff interview, it was determined the facility failed to return the personal funds of one discharged resident (Resident CR1) within 30 days of discharge, for one of 12 residents reviewed. Findings include: Clinical record review revealed that Resident CR1 was admitted to the facility on [DATE], and discharged on January 2, 2025. A review of the resident's financial account statement, provided by the facility and dated June 1, 2025, revealed a credit balance of $12,743.00 remained on the account, indicating funds belonging to Resident CR1 had not been disbursed within 30 days of the resident's discharge. Further review included an email, provided to the surveyor, from the Regional Business Office Manager (RBOM) dated May 29, 2025, which stated the facility's Business Office Manager was terminated on March 4, 2025, due to poor performance. The RBOM subsequently assumed responsibility for financial operations at this facility and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of clinical records and resident and staff interviews it was determined the facility failed to develop and implement an individualized discharge plan for two of 21 residents reviewed (Residents 252 and 81) to reflect the residents' discharge goals. Findings Include: Clinical record review revealed that Resident 251 was admitted to the facility on [DATE], with diagnoses to include alcoholic cirrhosis of the liver (a degenerative disease of the liver resulting in scarring and liver failure). Review of an admission Minimum Data Set Assessment (MDS- a federally mandated standardized assessment process completed at specific intervals to plan resident care) dated December 17, 2024, indicated the resident had a BIMS (brief interview mental screener that aids in detecting cognitive impairment) score of 15 indicating he was cognitively intact. A review of Resident 251's social service notes, revealed a note dated December 11, 2024, indicating the resident would like to be discharged home when able. This…

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 interview, it was determined the facility failed to maintain an environment free of accident hazards to the extent possible in three of three resident hallways Findings include: During an observation conducted on March 4, 2025, at 10:00 AM, the following environmental hazards were identified: In the 200 hallway, three linen carts were positioned at the end of the hallway on the same side, obstructing access to the handrails. Additionally, four linen carts were lined up against the wall in the hallway connecting the 100 and 200 hallways, further occluding the handrails. A floor cleaning machine was also present in this hallway, on the same side, blocking access to the handrails. This hallway included access to the resident dining room, an area of frequent resident traffic. In the 100 resident hallway, plastic storage bins with three drawers, containing Personal Protective Equipment (PPE) such as face masks, gloves, and gowns, were observed in front of resident rooms [ROOM NUMBERS]. 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 observation, review of select facility policy and staff interview, the facility failed to store Oxygen in a safe and secure manner. Findings include: A review of a select facility policy for Oxygen safety, last reviewed January 1, 2025, revealed it is the policy of the facility to provide a safe environment for residents, staff and the public. This policy addresses the use and storage of oxygen equipment. Oxygen storage locations shall be in an enclosure or within an enclosed interior space of non-combustible or limited combustible construction, with doors or gates that can be secured against unauthorized entry. Precautionary signs readable from 5 feet shall be maintained on the door or gate where oxygen is used or stored. (Example: OXYGEN STORED WITHIN-NO SMOKING) On March 4, 2025, at 9:00 A.M., seven full oxygen cylinders were observed in a multi-tank rack on wheels (not secured to the wall or floor) positioned on the right side of the hallway. Five empty oxygen tanks were stored in a similar multi-tank rack on wheels (not secured to the wall or floor) on the left side 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 clinical record reviews and staff interviews, it was determined that the facility failed to ensure the provision of pharmacy services to assure the timely receipt and administration of physician-prescribed medications for three (3) of twenty-one (21) residents reviewed (Residents 90, 64, and 201). The facility also failed to implement a process for providing pharmacy services, including access to emergency medications when not available onsite, and failed to maintain oversight of the facility's medication dispensing system. Findings include: Review of clinical record revealed that Resident 90, was admitted to the facility on [DATE], at 10:45 AM with diagnoses to include chronic obstructive pulmonary disease (COPD- group of lung diseases that block airflow and make it difficult to breathe), dysphagia (difficulty swallowing), depression, and anxiety. A physician order dated February 4, 2025, documented an order for Clonazepam (an antianxiety medication) 1 mg by mouth twice daily for a diagnosis of…

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

Based on a review of the facility's automated emergency medication system, applicable state regulations, facility policies, and staff interviews, it was determined that the facility failed to comply with Federal, State, and Local laws and professional standards by not ensuring pharmacy services necessary for daily pharmacy operations according to state requirements of Pa. Code title 49. Findings include: A review of Pennsylvania Code title 49, part I, subpart A, chapter 27 - STATE BOARD OF PHARMACY, 49 Pa. Code § 27.204 - Automated medication systems revealed: (a) This section establishes standards applicable to licensed pharmacies that utilize automated medication systems which may be used to store, package, dispense or distribute prescriptions. (b) A pharmacy may use an automated medication system to fill prescriptions or medication orders provided that: (1) The pharmacist manager, or the pharmacist under contract with a long-term care facility responsible for the dispensing of medications if an automated medication system is utilized at a location which does not have a pharmacy…

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 interview, it was determined the facility failed to ensure the Minimum Data Set Assessment (MDS - a federally mandated standardized assessment conducted at specific intervals to plan resident care) accurately reflected the status of one resident out of 21 sampled (Resident 25). Findings included: A review of Resident 25's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses which 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) and oropharyngeal dysphagia (difficulty swallowing). A current physician order initially dated April 30, 2024, noted an order for Nutren 1.5 (liquid nutritional supplement) 45 ml/hour via peg tube (percutaneous endoscopic gastrostomy tube- feeding tube surgically placed through the abdomen into the stomach, allowing direct…

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 interviews, it was determined the facility failed to refer residents with newly evident or possible serious mental disorder, intellectual disability, or a related condition for a Preadmission Screening and Resident Review (PASRR) level II resident review for one out of 21 residents (Resident 81). Findings include: Preadmission Screening and Resident Review (PASRR) is a federal requirement to help ensure that individuals are not inappropriately placed in nursing facilities for long-term care. The PASRR process requires that all applicants to Medicaid-certified nursing facilities be given a preliminary assessment to determine whether they might have serious mental illness before admission. This is called a PASRR Level I screen. Those individuals who test positive for PASRR Level I are then evaluated in-depth; this is called PASRR Level II. The results of this evaluation result in a determination of need, a determination of an appropriate setting, and a set 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 clinical record review, information submitted by the facility, and staff interview, it was determined the facility failed to ensure that a resident's comprehensive care plan was reviewed and revised as needed to accurately reflect the resident's current needs and services required by one of 21 residents reviewed (Resident 81). Findings include: Review of the clinical record of Resident 81 revealed the resident was admitted to the facility on [DATE], with diagnoses to include depression, and anxiety. On September 26, 2024, at 3:00 PM, nursing documentation indicated that Resident 81 expressed suicidal thoughts and, when asked if he would act upon them, responded, it all depends. The resident was offered emotional support and was asked if he would seek staff assistance before harming himself, to which he responded that he could not make any promises. The physician assistant was contacted, and an order was obtained to transfer the resident to the hospital for psychiatric evaluation. The resident, as his…

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, select facility policy, and resident and staff interview, it was determined the facility failed to consistently provide restorative nursing services as planned to maintain mobility for one resident (Resident 85) out of 21 residents sampled. Findings include: Review of the facility Restorative Nursing Services Policy last reviewed January 16, 2025, indicated a Restorative Nursing Program is utilized to assist residents to achieve and/or maintain their optimal functional level consistent with their capabilities, goals, and preferences. Restorative nursing care consists of nursing interventions that may or may not be accompanied by formalized rehabilitative services (physical, occupational, or speech therapies). Residents may be started on a restorative nursing program upon admission, during the course of a stay or when discharge from rehabilitative care. Restorative goals and objectives are individualized and resident-centered and are outlined in the resident's plan of care.…

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

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 two residents out of 21 sampled (Resident 251 and Resident 81). Findings include: A review of the clinical record revealed that Resident 251 was admitted to the facility on [DATE], with diagnoses to include alcoholism and a history of suicidal ideations. Review of a quarterly Minimum Data Set Assessment (MDS- a federally mandated standardized assessment process completed at specific intervals to plan resident care) dated January 15, 2025, indicated the resident had a BIMS (brief interview mental screener that aids in detecting cognitive impairment) score of 15 indicating he was cognitively intact. Further review of the clinical record indicated the resident expressed a strong desire to be discharged home, but his wife opposed the discharge. The resident frequently voiced frustration and agitation about wanting to leave the…

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

Based on review of clinical records and resident payor source data, and staff interview, it was determined the facility failed to offer routine annual dental services for two private payor source residents (Residents 60 and 39) out of four residents sampled for dental services. Findings include: Review of Resident 60's clinical record revealed admission to the facility on January 15, 2021, with diagnoses to include Alzheimer's disease (a progressive brain disease that destroys memory and other important mental functions) and COPD (chronic obstructive pulmonary disease-lung disease that blocks airflow and makes it difficult to breathe). The resident was identified as private payor source. Review of Resident 60's quarterly Minimum Data Set assessment (MDS-standardized assessment completed at specific intervals to identify specific resident care needs) dated February 9, 2025, indicated that the resident was severely cognitively impaired. There was no documented evidence in the clinical record at the time of the survey ending March 7, 2025, that Resident 60's responsible party 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.

Based on review of clinical records and resident payor source data, and staff interview, it was determined the facility failed to offer routine annual dental services for one Medicaid payor source resident (Resident 64) out of four residents sampled for dental services. Findings include: Review of Resident 64's clinical record revealed admission to the facility on December 21, 2023 with diagnosis to include dementia (a chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning), and congestive heart failure (weakness of the heart that leads to build-up of fluid in the lungs and surrounding body tissues). The resident was identified as Medicaid payor source. Review of Resident 64's Annual Minimum Data Set assessment (MDS-standardized assessment completed at specific intervals to identify specific resident care needs) dated November 18, 2024, indicated that the resident was moderately cognitively impaired. There was no documented evidence in the clinical record at the time of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, and staff interview, it was determined the facility failed to ensure coordination of Hospice services with facility services to meet each individual residents' needs daily for the management of a terminal illness of one of two residents reviewed receiving hospice services. (Resident 54 and 61). Findings include: A review of the clinical record revealed that Resident 54 was admitted to the facility on [DATE], with diagnoses of cerebral infarct (stroke). The resident was admitted to hospice services on February 5, 2025, for cerebral infarct. Review of Resident 54's plan of care, during the survey ending March 7, 2025, revealed no evidence the resident's plan of care was integrated with hospice services to demonstrate coordination of care and services to meet the resident's needs related to the care of the resident's terminal illness daily. A review of the clinical record revealed that Resident 61 was admitted to the facility on [DATE], with diagnoses of dementia, chronic…

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 minutes from Resident Council and Food Committee meetings and resident and staff interviews it was determined that the facility failed to put forth sufficient efforts to promptly resolve continued resident complaints/grievances expressed during Resident Council and Food Committee Meetings and submitted grievances, including those voiced by four of 4 residents (Residents 16, 37, 81, and 50). Findings include: Review of the facility's current Grievance policy indicated that it is the facility's policy to provide an opportunity for residents to express concerns at any time. The facility's goal is to resolve resident and family concerns in a timely basis. Review of the minutes from the December 2023, through March 2024, Resident Council and Food Committee meetings revealed that residents in attendance at these resident group meetings voiced their concerns regarding resident care and facility services during the meetings. During the December 2023, Resident Council meeting the residents relayed concerns that the shower water temperature 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 select facility policy and clinical records and resident and staff interviews, it was determined that the facility failed to ensure that dependent residents were provided with the necessary services to maintain good personal hygiene, by failing to provide showers as scheduled and personal grooming for three of 23 residents sampled (Residents 5, 7 and 47). Findings include: Review of a facility policy entitled Shower/Bathing Policy last reviewed by the facility on February 15, 2024, indicated the purpose of the policy was to cleanse and refresh the resident. If the resident refuses a shower, a bed bath will be offered and provided as per the resident's preference. Care plan documentation guidelines include list the amount of assistance the resident needs with bathing and any resident preferences, precautions, special soap, or lotion to be used. A review of the clinical record revealed that Resident 7 was admitted to the facility on [DATE], and had diagnoses which included multiple sclerosis ([MS] immune…

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 an environment free of potential accident hazards on the East and [NAME] Hallways. Findings include: An observation of the 100 East hallway on April 9, 2024, at 9:16 AM and again on April 10, 2024, at 8:48 AM revealed 3 rollator walkers, 5 wheelchairs, a resident room armchair, a stool and a large linen cart were lined up blocking access to the handrails on the right side of the corridor. These items completely obstructed resident access to the hand railing on the right side of the hallway. Observations at that time revealed multiple residents self-propelling in wheelchairs in the hallway. During an interview April 12, 2024, at 12:00 PM the Nursing Home Administrator (NHA) confirmed that the handrails on the right side of hallway were obstructed and that residents did not have unimpeded access to the handrails on the right side of the corridor to assist with ambulation and mobility on that side of the hall. An observation conducted on April 10, 2024, at approximately 1:05 PM, revealed a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of select facility policy and clinical records, observation, and staff interview it was determined that the facility failed to consistently administer oxygen as ordered and maintain sanitary oxygen delivery systems for one out of two sampled residents (Resident 47). Findings included: According to the American Thoracic Society, O2 is a medication that requires a prescription from a healthcare provider. The provider will prescribe your O2 at a specific flow rate and a specific number of hours per day. It is very important that O2 is used as prescribed. Using too little O2 may put a strain on the heart and brain, causing heart failure, fatigue, or memory loss. Using too much O2 can also be a problem. For some patients, using too much O2 can cause them to slow their breathing to dangerously low levels. It is important to wear O2 as your provider ordered it. If the patient starts to experience headaches, confusion, or increased sleepiness after using supplemental O2, the patient may be getting too…

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 and service of food to prevent the potential for contamination and microbial growth in food, which increased the risk of food-borne illness. 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). Initial tour of the food and nutrition services department in the presence of the foodservice director (FSD) on April 9, 2024, at 8:00 AM, revealed the following sanitation concerns with the potential to…

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

Based on a review of clinical records and the Resident Assessment Instrument and staff interviews, it was determined that the facility failed to conduct a significant change Minimum Data Set Assessments (MDS - a federally mandated standardized assessment process conducted at specific intervals to plan resident care) for one of 23 residents reviewed (Resident 19). Findings include: According to the RAI User's Manual dated October 2023 a Significant Change in Status MDS assessment is required within 14 days of the determination of the significant change when: o A resident enrolls in a hospice program; or o A resident changes hospice providers and remains in the facility; or o A resident receiving hospice services discontinues those services; or o A resident experiences a consistent pattern of changes, with either two or more areas of decline or two or more areas of improvement, from baseline (as indicated by comparison of the resident's current status to the most recent CMS-required MDS). A review of the clinical record of Resident 19 revealed that the resident had experienced 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 a review of clinical records and the Resident Assessment Instrument and staff interviews, it was determined that 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 one resident out of 23 sampled (Residents 32). Findings include: According to the RAI User's Manual dated October 2023, Section A 1500 Preadmission Screening and Resident Review (PASRR) is to be completed if the type of assessment is an admission assessment, significant change, or annual assessment. The annual MDS Assessment of Resident 32 dated June 23, 2023, revealed Section A 1500 was coded as 0 indicating that the resident was not considered by the State to require a Level II PASRR process, to have serious mental illness, and/or intellectual disability or mental retardation or a related condition. A review of Resident 32's clinical record revealed a Level I PASRR was completed on June 1,…

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 staff interview, it was determined that the facility failed to revise a comprehensive care plan in response to the discontinuation of Hospice services (a type of care and philosophy of care that focuses on the palliation of a chronically ill, terminally ill or seriously ill patient's pain and symptoms, attending to their emotional and spiritual needs) for one resident out of 23 reviewed (Resident 19). Findings include: A review of Resident 19's clinical record revealed that the resident had diagnoses which included chronic obstructive pulmonary disease (COPD- group of lung diseases that block airflow and make it difficult to breathe). A review of the resident's comprehensive plan of care initiated January 16, 2023, revealed that the resident was receiving Hospice services due to end stage COPD. Further review of the clinical record revealed that Hospice services were discontinued on February 25, 2024. The facility failed to revise and update the resident's care plan when Hospice services were discontinued. An interview with the director 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 staff interview, it was determined that 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 23 residents reviewed (Resident 34). Findings include: A review of Resident 34's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses to include dementia with agitation (a condition characterized by progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change). A review of Resident 34's Quarterly Minimum Data Set Assessment (MDS - a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated March 7, 2024, revealed the resident was severely cognitively impaired and displayed physical behavioral symptoms (hitting, kicking, pushing, scratching) and verbal behavioral symptoms (threatening,…

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 interviews, it was determined that the facility failed to provide housekeeping and maintenance services to maintain a clean and orderly environment in resident areas on three of three resident units (West Wing, East Wing and Alzheimer Care Unit). Findings included: An observation on January 9, 2024, at 9:45 AM of the [NAME] Wing front hallway revealed a weight scale on the floor littered with used disposable gloves, crumbled paper and used tissues. An observation on January 9, 2024, at 9:50 AM of the [NAME] Wing Day room revealed an unknown white substance splattered on two walls, the wall to left of entry and the wall by the sink, An unknown red substance was observed on the sink top, food particles were observed in the sink, an empty hand sanitizer dispenser and an unknown orange substance were observed on the floor and tabletop. An observation on January 9, 2024, at 10:10 AM, in resident room [ROOM NUMBER] revealed a pile of peas and carrots, a paper towel, a plastic cup, 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, observations and staff interview, it was determined that the facility failed to provide meal service in an environment that maintains each resident's dignity as evidenced by two residents out of six sampled (Residents 9 and 36). Findings include: An observation conducted on January 9, 2024, at approximately 11:50 AM revealed lunch delivery service in the [NAME] Wing Day room. Observation revealed multiple residents in the dining room awaiting the lunch meal service. Observation revealed that staff served meals and assisted all residents present with tray set-up, except Residents 9 and Resident 36, who continued to wait for their meals to be served and were watching the other residents eat. A review of Resident 9's clinical record revealed that the resident is moderately cognitively impaired and required setup assistance for her meals. Resident 9 was observed seated at a table with Resident 16. Resident 16 was served her tray and was eating her meal at 11:50 AM. Resident 9 did not have a meal tray and was observed asking staff repeatedly Where's my…

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, observation, and resident and staff interviews, it was determined that the facility failed to ensure that a resident's comprehensive care plan was reviewed and revised as needed to accurately reflect the resident's current needs and services required by one of 14 residents reviewed (Resident 73). Findings include: Review of the clinical record of Resident 73 revealed initial admission to the facility on February 1, 2023, with diagnoses to include diabetes, depression, and adjustment disorder with anxiety. A quarterly Minimum Data Set Assessment (MDS - federally mandated assessment of a resident's abilities and care needs) of Resident 73 dated November 16, 2023, indicated that the resident was cognitively intact with a BIMS (brief interview for mental status) score of 15 (13-15 represents intact cognitive responses). According to the assessment, Section D0150. Resident Mood Interview, the resident did not have thoughts that he would be better off dead or of hurting himself in some way during the assessment look back period. A review of Resident 73'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 pest control records, and staff interview it was determined that the facility failed to maintain an effective pest control program and act upon recommendations of the professional pest control services to prevent infestation. Findings include: Observation of resident room [ROOM NUMBER] (semi-private) on September 27, 2023, at approximately 10:30 AM, revealed what appeared to multiple mouse droppings, in the dresser drawer and behind the dresser located at the door side of the resident room. There was a rodent bait station placed on the floor behind the dresser in this room. A review of monthly pest control management service records revealed that services were provided to the facility as follows: On August 21, 2023- the interior and exterior of the facility were inspected. Interior and exterior rodent bait stations and snap traps were rebaited. Two mice captured inside. The service record identified a hole in the kitchen back door sweep that needs to be fixed as soon as…

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