Edenbrook North

Based on observation, clinical record review, and staff interview, it was determined that the facility failed to implement the administration of supplemental oxygen per the physician's order for one of one resident reviewed for oxygen concerns (Resident 120).Findings include: Observation of Resident 120 on April 21, 2026, at 2:04 PM revealed him to be in his room with supplemental oxygen administration via a room concentrator set to two liters per minute. Observation of Resident 120 with Employee 8 (licensed practical nurse) on April 23, 2026, at 10:09 AM revealed that Resident 120 supplemental oxygen room concentrator was set to 1.5 liters per minute. Clinical record review revealed an active physician's order dated April 7, 2026, for staff to administer supplemental oxygen continuously at three liters per minute every shift. Review of Resident 120's plans of care developed by the facility to address Resident 120's care needs revealed no entries related to supplemental oxygen use until April 21, 2026. Interview with Employee 8 on April 23, 2026, at 10:26 AM confirmed active…

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 select facility policies and procedures, clinical record review, and staff interview, it was determined that the facility failed to offer, provide education regarding the benefits, risks, and potential side effects, or administer a COVID immunization for two of five residents reviewed for immunizations (Residents 30 and 36).Findings include: The policy entitled Covid-19, last reviewed without changes March 1, 2026, revealed the facility will conduct education, surveillance, and infection control and prevention strategies to reduce the risk of transmission of COVID-19. Due to the constantly changing and fluid nature of the virus, the facilities will monitor, follow, and implement recommendations and guidelines in accordance with the Centers for Disease Control and Prevention (CDC), CMS, and the state Department of Health to include identification and isolation Of any suspected cases. The facility will encourage everyone to remain up to date with all recommended COVID-19 vaccine doses. Clinical record review for Resident 30 revealed that the facility admitted him…

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 policies and procedures, clinical record review, and staff interview, it was determined that the facility failed to thoroughly investigate and report to the appropriate agencies an injury of unknown origin and an allegation of potential misappropriation of resident property for one of two records reviewed (Resident CR2). Findings include: The current facility policy entitled Vulnerable Adult Abuse and Neglect Prevention, revealed the facility will follow the federal guidelines dedicated to the prevention of abuse and timely and thorough investigations of an allegation. Upon receiving a complaint of an alleged maltreatment, the Nursing Home Administrator and Director of Nursing must be notified immediately, and they will coordinate an investigation, which will include completion of witness statements. All parties involved including staff, residents, or visitors who were potentially involved, or observed the alleged incident, are to be interviewed. If it appears that the maltreatment may involve a crime, immediately notify the police. The facility…

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

Based on clinical record review, and staff interview, it was determined that the facility failed to provide a dependent resident with activities of daily living assistance for one of two residents reviewed (Resident CR2).Findings include: Clinical record review revealed the facility admitted Resident CR2 on October 8, 2025. Review of Resident CR2's most recent MDS (Minimum Data Set, an assessment completed at specific intervals to determine care needs) dated January 14, 2026, noted staff assessed Resident CR2 as dependent on staff for oral hygiene (the ability to use suitable items to clean teeth). Review of Resident CR2's Kardex (documentation system used by staff to organize and reference key resident information essential for resident care) revealed he is to have his teeth brushed twice daily. Review of Documentation Survey Report (electronic documentation completed by nurse aide staff for the completion of ADL care) from January 1 to February 11, 2026, revealed there was no documentation that staff assisted Resident CR2 with oral hygiene twice daily on 18 of 41 days reviewed.…

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 policies and procedures, clinical record review, and staff interview, it was determined that the facility failed to thoroughly investigate and report to the appropriate agencies an injury of unknown origin and potential neglect for one of seven records reviewed (Resident CR1).Findings include:The policy entitled Injury of Unknown Origin, last reviewed without changes on February 1, 2025, revealed it is the policy of the facility to immediately investigate all injuries of unknown origin to determine the cause, ensure resident safety, and comply with federal and state reporting requirements, including mandatory notifications to the Department of Health. The nurse discovering or notified of the injury must perform an assessment including pain, location, size, color, and pattern of injury. The attending physician or on-call provider will be notified promptly for evaluation and treatment orders. The facility will remove the resident from potential harm if indicated and ensure supervision until the resident's safety is assured. The Director of Nursing…

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 store food items in a safe and sanitary manner and maintain the environment in a safe and sanitary condition in the facility's main kitchen. Findings included: Observation of the facility's main kitchen with Employee 2, dietitian, on April 1, 2025, at 8:30 AM revealed the following: A mobile rack holding bowls had various debris on the base and felt greasy to touch. Two floor drains had an extensive amount of debris in them. The perimeter of the grease trap in the floor of the dishwasher area had an extensive build-up of debris, including food debris. A windowsill had a build-up of dust, a dead bug, and a discarded potato chip. A storage room adjacent to the main kitchen contained a refrigerator and freezer that held resident food items. The facility was unable to provide a history of temperature monitoring on these units. An interview with the Nursing Home Administrator on April 2, 2025, at 2:43 PM confirmed that facility staff are unable to find documented temperature monitoring for these…

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 and resident interview, it was determined that the facility failed to assist a resident to retain and use personal possessions on three of three nursing units (First, Second, and Third Floor Nursing Units; Residents 2, 19, 22, 64, 88, 92, 106, and 121). Findings include: Interview with Resident 22 on April 1, 2025, at 12:49 PM revealed that she could not locate a few pairs of pants and three shirts. Observation of the facility laundry on April 4, 2025, at 11:05 AM revealed that there was a large plastic laundry bin in the dirty laundry area that was stacked full of bagged dirty personal laundry and extended/overflowed 3.5 feet above the top of the plastic laundry bin. Further observation revealed that there were nine large bins identified for the first, second, and third floor nursing units in the clean laundry area that were stacked full of clean laundry that belonged to Residents 2, 19, 22, 64, 88, 92, 106, and 121. The clean bin of clothes was sitting for at least four days and the clothes were not distributed to the residents for their use. 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 observation, clinical record review, and resident and staff interview, it was determined that the facility failed to assist dependent residents with bathing and/or personal hygiene for 7 of 14 residents reviewed (Residents 2, 21, 88, 92, 96, 117, and 121). Findings include: Interview with Resident 2 on April 1, 2025, at 1:30 PM revealed that she did not receive her shower four times in February 2025, and two times in March 2025. She also indicated that she had missed showers in January but did not provide the number of showers she missed. Clinical record review for Resident 2 revealed that she did not receive her scheduled showers on January 19, 26, and 31, 2025. Review of Resident 2's clinical documentation for February 2025, revealed that she did not receive her scheduled showers on February 25, 2025. Review of Resident 2's clinical documentation for March 2025, revealed that she did not receive her scheduled showers on March 4 or 11, 2025. Review of Resident 2's current MDS (Minimum Data Set, 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.

Based on clinical record review and staff interview, it was determined that the facility failed to provide the highest practicable care regarding physician ordered pain medications for one of one resident reviewed (Resident 108) Findings include: Review of Physiopedia's and Wikipedia's definition of the numeric pain rating scale (parameters) from zero to 10 indicated that no pain was identified as zero, mild pain was identified as one to three, moderate pain was identified as four to six, and severe pain was identified as seven to 10. Clinical record review for Resident 108 revealed physician's orders for the following pain medications: Ordered on February 14, 2025, and discontinued on March 11, 2025, Oxycodone 5 mg (milligrams) 2 tablets PO (by mouth) every 4 hours PRN (as needed) for severe pain 7-10. Review of Resident 108's February and March 2025 MAR (medication administration record, a form to document medication administration) revealed that staff did not document a level of pain on the following dates and times: Oxycodone (for moderate to severe pain) 5 mg 2 tablets PO every…

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, and resident and staff interview, it was determined that the facility failed to implement appropriate enhanced barrier transmission-based precautions for three of 24 residents reviewed (Residents 2, 67, and 106) Findings include: Review of the memo entitled Enhanced Barrier Precautions (EBP, gown and glove use) in Nursing Homes to Prevent the Spread of Multi-drug Resistant Organisms (MDRO, bacteria that are resistant to some antibiotics) released by the Center for Medicaid and Medicare Services (CMS) on March 20, 2024, with an implementation date of April 1, 2024, revealed that nursing care facilities are to use EBP for residents with chronic wounds or indwelling medical devices during high-contact resident care activities regardless of their multidrug-resistant organism status. High-contact activity would include things like dressing, transferring, changing linens, providing hygiene, changing briefs, wound care, or device care. Review of the facility policy titled,…

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 provide adequate housekeeping and maintenance services to ensure a clean, safe, and orderly environment on one of three nursing units (200 Nursing Unit; Residents 19, 67, 84, 97, 108). Findings include: Observation of the 200 Nursing Unit on the following dates and times revealed: Observation on April 1, 2025, at 10:51 AM, revealed Resident 67's handrail on the left side of toilet was ripped off the wall with six open holes noted in the drywall where the handrail was located. Observation on April 1, 2025, at 10:57 AM revealed there was a strong urine odor on the 2 East hallway of the 200 Nursing Unit. Observation on April 1, 2025, at 11:06 AM revealed Resident 108's privacy curtain had a 3-foot by 2-foot yellow dried stain along the bottom of the curtain. Observation on April 1, 2025, at 11:14 AM revealed the drywall by Residents 97 and 84's closet and the drywall between Resident 84's bed and the bathroom was marred and gouged. Observation on April 3, 2025, at 3:15 PM revealed Resident 19's fan…

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 policies and procedures, clinical record review, and staff interview, it was determined that the facility failed to thoroughly investigate and report to the appropriate agencies an allegation of misappropriation of resident property for one of 24 records reviewed (Resident 38). Findings include: The policy entitled Vulnerable Adult Abuse and Neglect Prevention, last reviewed without changes on March 27, 2025, revealed upon receiving a complaint of alleged maltreatment, the Nursing Home Administrator must be notified immediately. The Director of Nursing or assigned designee and the Nursing Home Administrator will coordinate an investigation, which will include completion of witness statements. All parties involved including, staff, residents, or visitors who were potentially involved, or observed the alleged incident are to be interviewed by the Director of Nursing, Director of Social Services, or their designees. The facility must report to the State agency immediately, but no later than 2 hours after serious bodily injury, or not later than 24…

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 implement a comprehensive person-centered care plan regarding a pacemaker for one of 24 residents reviewed (Resident 78). Findings Include: Clinical record review for Resident 78 revealed a medical history that included the presence of a cardiac pacemaker (surgically implanted device used to control the electrical activity of the heart and regulate the heartbeat). A physician's order dated July 2, 2021, noted the presence of a cardiac pacemaker. Review of Resident 78's clinical record on April 1, 2025, at 2:05 PM revealed no care plan was developed related to the resident's pacemaker or associated resident monitoring/assessment. The above information for Resident 78 was reviewed in a meeting with the Nursing Home Administrator and Director of Nursing on April 2, 2025, at 2:30 PM. The Director of Nursing confirmed these findings on April 3, 2025, at 8:54 AM. 28 Pa. Code 211.10 (a)(c)(d) Resident care policies 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and resident and staff interview, it was determined that the facility failed to complete restorative range of motion programs to maintain a resident's range of motion for one of seven residents reviewed (Residents 64). Findings include: Interview with Resident 64 on April 1, 2025, at 11:35 AM revealed that her goal was to go home but the problem is her legs don't work right. She said that she can use her arms and do most things needed with them but that she can't use her legs, and she does not want them to get worse. She indicated that she has not had any therapy for about a week. Clinical record review for Resident 64 revealed an MDS (Minimum Data Set, an assessment completed at intervals by the facility to determine the care needs of the resident) assessment dated [DATE], that indicated she currently had no impairment of her upper or lower extremities. Further clinical record review for Resident 64 revealed that she was discontinued from both occupational and physical therapy on…

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

Based on review of select policy and procedures, clinical record review, and staff interview, it was determined that the facility failed to provide timely assessments and implement interventions to promote acceptable parameters of nutritional status for two of eight residents reviewed for nutritional concerns (Residents 88 and 112). Findings include: Review of the facility policy and procedure entitled, Resident height and weight, last reviewed without changes on March 27, 2025, revealed that all residents will be weighed upon admission and subsequently as the policy directs to provide a baseline and ongoing record for monitoring stability of weight as an indicator of nutritional status and medical condition over a period of time. The nursing department staff and dietary staff will cooperate to prevent, monitor, and provide intervention for undesirable weight variances for the residents. The purpose of the policy is to provide guidelines for physician notification and documentation of significant weight changes. Any weight change of five pounds or greater within 30 days 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.

Based on observation and staff interview, it was determined that the facility failed to provide appropriate respiratory care and services for one of one resident reviewed (Resident 19). Findings include: According to the American Association for Respiratory Care proper cleansing of respiratory (nebulizer) equipment reduces infection risk. The longer a dirty nebulizer sits and is allowed to dry, the harder it is to clean thoroughly. Parts of the aerosol drug delivery device should be rinsed and then washed with soap and hot water after each treatment. Once completely dry, store the nebulizer cup and mouthpiece in a zip lock bag. On April 1, 2025, at 10:46 AM and April 3, 2025, at 3:15 PM, Resident 19's oxygen NC (nasal canula, tubing to deliver oxygen to the nose) was lying on their bed unbagged and their oxygen concentrator was running. On April 1, 2025, at 10:46 AM and 2:48 PM, April 2, 2025, at 2:28 PM, and April 3, 2025, at 8:41 AM and 3:15 PM, Resident 19's nebulizer machine was sitting on the floor in front of their oxygen concentrator and their nebulizer tubing was lying on…

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

Based on clinical record review and staff interview, it was determined that the facility failed to develop and implement an individualized person-centered care plan to address dementia and cognitive loss displayed by one of three residents reviewed (Resident 63). Findings include: Clinical record review for Resident 63 revealed that the facility admitted her on April 1, 2024, with diagnosis of Dementia (loss of memory, language, problem-solving, and other thinking abilities that interfere with daily life). A review of Resident 63's significant change Minimum Data Set Assessment (MDS, a form completed at specific intervals to determine care needs) dated December 18, 2024, indicated that the facility assessed Resident 63 as having a diagnosis of dementia. The facility determined that a care plan for dementia and cognitive loss would be developed. A review of Resident 63's care plan entitled, impaired cognitive function/dementia and impaired thought processes related to dementia initiated on April 5, 2024, failed to identify individualized person-centered interventions to address…

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 safe and sanitary storage and handling of personal food products brought in from outside sources for one of three nursing units (200 Nursing Unit, Resident 22). Findings Include: Observation of Resident 22's room on April 1, 2025, at 10:46 AM revealed that they had a personal refrigerator. There was no temperature monitoring log for Resident 22's refrigerator. Inside Resident 22's refrigerator there were the following items: A container of cottage cheese with a best by date of January 13, 2025 A gallon of sweet tea with a sell by date of January 24, 2025 Two undated Styrofoam containers Continued observation of Resident 22's refrigerator on April 2, 2025, at 2:16 PM revealed no temperature log. The above noted items continued to be in the refrigerator with the following items added: An undated Styrofoam container Two applesauce containers with a use by date of March 14, 2025. The above information was reviewed during an interview with the Nursing Home Administrator on April 4, 2025, 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 interview, it was determined that the facility failed to ensure a safe and sanitary environment at an outside designated employee break area located on the facility grounds. Findings include: Observation of an outside employee break area located near the facility's dumpsters at the front of the building on April 1, 2025, at 9:10 AM with Employee 2, dietitian, revealed the following: Various plastic and paper products, a hairnet, wet pieces of cardboard, and several balled up medical gloves discarded on the ground. Multiple discarded cigarette butts, especially around the perimeter of the area. A significant build-up of dead leaves. An overflowing garbage can that contained a brief. A metal bucket with brown-colored water and discarded cigarette butts in it. The above information was reviewed in a meeting with the Nursing Home Administrator and Director of Nursing on April 2, 2025, at 2:43 PM. 483.90(i) Other Environmental Conditions Previously cited deficiency 5/23/24 28 Pa. Code 201.18 (b)(1)(3) Management

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, clinical record review and resident and staff interview, it was determined that the facility failed to assist dependent residents with bathing, grooming, and dressing care for four of seven residents reviewed (Residents 1, 3, 5, and 7). Findings include: Observation of Resident 1 on September 19, 2024, at 8:50 AM revealed that his shirt was soiled with dried stains. Interview with Resident 1 at this time revealed staff only change his shirt on his shower days. Resident 1 stated he receives a bed bath on Tuesdays and Fridays. Further observation of Resident 1 revealed a lot of facial hair. Resident 1 stated that he prefers to be clean shaven but is unable to shave himself due to not getting out of bed, having no mirror, and his poor eyesight. Resident 1 stated that staff refuse to shave him and tell him he can do it himself. Clinical record review for Resident 1 revealed his most recent MDS (Minimum Data Set, an assessment completed at specific interval to determine care needs) dated August…

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 staff interview, it was determined that the facility failed to provide the highest practicable care regarding physician ordered weights, medications, and vital signs for four of 25 residents (Resident 3, 41, 67, and 88). Findings include: Review of Resident 3's clinical documentation revealed current physician orders for the following: On September 11, 2023, staff were to complete a daily weight every night shift and must be done before breakfast. Staff were to contact the physician if the weight dropped below 320 pounds. On March 19, 2024, call the physician if their weight changes two to three pounds in one day or five pounds in one week, every day and evening shift for monitoring. Review of Resident 3's clinical documentation revealed no documented weights on the following dates: February 23, 2024 February 24, 2024 May 21, 2024 Further review of Resident 3's clinical documentation revealed that there was no physician notification regarding their weight being below 320 pounds on the following dates: April 23, 24, 25, 26, 27, 28,…

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 resident and staff interview, it was determined that the facility failed to provide services to maintain a resident's range of motion (ROM) for two of nine residents reviewed (Residents 28 and 56). Findings include: Clinical record review for Resident 28 revealed a current care plan for staff to provide a restorative program related to immobility including the following: ROM (range of motion, movement of the body to maintain a resident's ability) supine and seated exercised to their BLLE (bilateral lower extremities) AROM (active range of motion, AAROM (active assisted range of motion) and/or PROM (passive and BLUE (bilateral upper extremities) to maintain SBA (stand by assistance) sideboard transfer bed to wheelchair and/or wheelchair to bed and maintain current BLLE strength Restorative transfer and OOB (out of bed) program to be OOB for at least one hour each day to build and/or maintain core strengthening. Restorative OOB daily. Refer to therapy if change in current level of function (CLOF). Review of task documentation for Resident 28 for…

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

Based on review of facility policies, clinical record review, and staff interview, it was determined that the facility failed to provide the highest practicable care regarding physician ordered pain medications for four of four residents reviewed (Residents 3, 56, 96, and 123). Findings include: Review of Physiopedia's and Wikipedia's definition of the numeric pain rating scale (parameters) from zero to 10 indicated that no pain was identified as zero, mild pain was identified as one to three, moderate pain was identified as four to six, and severe pain was identified as seven to 10. Clinical record review for Resident 3 revealed physician orders for the following pain medications: Ordered on April 19, 2024, Acetaminophen (Tylenol, for mild pain) 325 milligrams (mg) 2 tablets by mouth (PO) every 4 hours as needed (PRN) for pain 1-10, not to exceed 3 grams per 24 hours. Ordered on May 2, 2024, Oxycodone (for moderate to severe pain) 5 mg PO every 8 hours PRN for pancreatic pain. There was no documentation that the facility identified which pain medication that staff were 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 clinical record review and staff interview, it was determined that the facility failed to identify triggers related to a resident's diagnosis of Post-Traumatic Stress Disorder, to provide culturally, competent, trauma-informed care, and to eliminate or mitigate re-traumatization for two of four residents reviewed for mood/behavior (Residents 93 and 112). Findings include: Clinical record review revealed the facility admitted Resident 93 on May 19, 2022, and added a diagnosis of Chronic Post Traumatic Stress Disorder (PTSD, a mental and behavioral disorder that develops related to a terrifying event) on October 9, 2022. Review of a psychiatry note dated August 23, 2022, revealed Resident 93 had a history of premorbid PTSD (a vulnerability that can increase the severity of PTSD symptoms associated with previous trauma exposure when someone is exposed to new stressors). Further review of Resident 93's clinical record there was no evidence that the facility identified Resident 93's history of trauma. A review of Resident 93's care plan revealed there were no identified triggers…

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 develop and implement individualized person-centered care plans to address dementia and cognitive loss displayed by two of three residents reviewed (Residents 34 and 87). Findings include: Clinical record review for Resident 34 revealed that the facility admitted her on January 4, 2024, with diagnoses including dementia (loss of memory, language, problem-solving, and other thinking abilities that interfere with daily life) with agitation. A review of her admission Minimum Data Set Assessment (MDS, a form completed at specific intervals to determine care needs) dated January 10, 2024, indicated that the facility assessed Resident 34 as having a diagnosis of dementia. The facility determined that a care plan for dementia and cognitive loss would be developed. A review of Resident 34's care plan revealed that there was no indication that the facility had developed and implemented a person-centered care plan to address…

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 ensure a resident's medication regime was free from potentially unnecessary medications for one of five residents reviewed (Resident 41). Findings include: Clinical record review for Resident 41 revealed the following physician orders: Ordered on February 4, 2024, and discontinued on February 11, 2024, for Ativan 0.5 milligram (mg) by mouth PO every 8 hours as needed for increased anxiety. Ordered on February 11, 2024, Ativan Oral Tablet 0.5 mg PO every 8 hours as needed for increased anxiety discontinue after 14 days nonuse. Review of Resident 41's pharmacy recommendation dated February 8, 2024, revealed the pharmacist identified the concerns with the PRN Ativan and indicated for the physician to evaluate if the medication could be discontinued or if a 14 day stop date could be added. The physician's assistant responded on February 11, 2024, agreed with the pharmacist's recommendation, and indicated to discontinue Ativan after 14 days non-use (to be discontinued on February 25, 2024).…

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 the facility failed to store food in a safe and sanitary manner in the facility's main kitchen. Findings include: An observation of the facility's main kitchen on May 20, 2024, at 8:00 AM revealed the following: The floor in the dry storage room was dirty with black marks and sticky. There were pieces of cardboard, plastic spoons and forks, and a coffee mate packet noted on the floor. On two food storage units there were black dirt particles on the top shelf of each. Employee 4, Dietary cook, indicated that the black particles were from the air-conditioning unit when they turn it on. The unit was not on at the time of the observation. The refrigerator in the main kitchen, located to the left of the door to the dry storage area (as you are looking at it), had a bag of lettuce, waffles in plastic packaging, and sausage patties wrapped in foil with no date to indicate when they were placed in the refrigerator or an expiration date. The bottom shelf of the freezer located next to the coffee pot had spillage noted on it 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of select facility policy and procedures, observations, and resident and staff interviews, it was determined that the facility failed to ensure that residents could make choices about aspects of their lives that were significant to them, such as smoking, for one of 25 residents reviewed (Resident 1). Findings include: An interview with the Nursing Home Administrator (NHA) on May 20, 2024, at 8:22 AM revealed the facility was non-smoking. Smoking for residents was eliminated for new admissions beginning April 2023. However, there were three grandfathered residents that were still permitted to smoke. The NHA also reported that facility staff are permitted to smoke in a designated area, which is located on the facility property. The NHA indicated that the skilled nursing facility has a designated smoking area located outside of the main lobby for the grandfathered residents to smoke. Staff are permitted to smoke during break times in their designated area. Interview with Resident 1 on May 23, 2024,…

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 and resident and staff interview, it was determined that the facility failed to provide adequate housekeeping and maintenance services to ensure a clean, safe, and orderly environment on two of three nursing units (2nd and 3rd Floor Nursing Unit, Residents 56 and 60) and ensure properly functioning of resident equipment for one of 25 residents (Resident 1). Findings include: Interview with Resident 56 on May 20, 2024, at 10:27 AM revealed that she indicated concerns with her bathroom environment, noting the toilet was dirty and the floor was black. Resident 60 stated that she was independent with her care and wears a brief due to incontinence. She indicated concerns with the hem/bottom of her pants becoming soiled from the condition of the bathroom. Observation of Resident 56's bathroom on May 20, 2024, at 10:37 AM confirmed her statement. The floor around the base of the toilet was stained that extended four inches out on the floor from the toilet. Inside the toilet bowel, there were brown…

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, review of facility documents, and resident and staff interview, it was determined that the facility failed to protect a resident to be free from neglect by not providing the services necessary to avoid physical harm resulting in injury for one of two residents reviewed (Resident 60). Findings include: Clinical record review for Resident 60 revealed a progress note dated April 19, 2024, at 11:00 AM that indicated she had a fall in her room. Staff members heard her yelling, entered her room, and observed her on the floor between the beds in the room. She was in a prone position, facing the wall. Blood was noted on the floor near her head. Her walker was in an upright position near her. A laceration was noted to the right side of her head just above her ear and measured 5.0 centimeters x 3.0 centimeters x 1.0 centimeters. Pressure was applied to the laceration. The Physician Assistant was notified and ordered staff to send the resident to the emergency room. Further clinical record review for Resident 60 revealed a progress note dated April 19, 2024, at…

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

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 ensure that the resident or resident representative received written notice of the facility's bed hold policy at the time of transfer for two of 11 residents reviewed for hospitalizations (Residents 19 and 126 ). Findings include: Clinical record review for Resident 19 revealed he was transferred to the hospital from [DATE]-17, 2024. There was no evidence to indicate that Resident 19 or his responsible party were provided written notification of the facilities bed hold policy at the time of his transfer out of the facility. A closed clinical record review revealed that Resident 126 went out to the hospital on March 3, 2024, related to a change in mental status. There was no evidence to indicate that Resident 126 or her responsible party were provided with written notification of the facilities bed hold policy at the time of her transfer. The facility failed to provide written notice of their bed hold policy at 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, clinical record review, and resident and staff interview, it was determined that the facility failed to obtain proper treatment and assistive devices to maintain vision for one of one resident reviewed (Resident 46). Findings include: An interview with Resident 46 on May 20, 2024, at 11:00 AM revealed the resident was at the eye doctor last year and was told she needed eyeglasses but has not received the eyeglasses. The resident further reported she utilizes readers, which help her see up close, but has trouble viewing the television because it is blurred. An optometry evaluation dated June 1, 2023, revealed that Resident 46 was seen by optometry for a new facility ordered vision consultation. The evaluation further indicated on the form to Circle all that applies if dispensed or ordered any glasses or frames. SPH (sphere) BF (bifocal) was circled under the Frames section. The form also noted for the resident to follow-up in six months. A Care Plan Note dated August 28, 2023, at 5:38 PM revealed Resident 46 asked about the delivery of her glasses ordered on…

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

Based on clinical record review, review of select facility policies and procedures, and staff interview, it was determined that the facility failed to assess and implement treatment and services to prevent the development and promote the healing of a pressure ulcers for one of three residents reviewed for pressure ulcer concerns (Resident 64). Findings include: The facility policy entitled Skin Integrity, last reviewed without changes on May 4, 2024, revealed residents will be assessed/observed for risk of skin breakdown, utilizing the Braden scale within 24 hours of admission, quarterly, and as necessitated by a residents change in condition. Wound status is monitored on a weekly basis. The interdisciplinary plan of care will address problems, goals, and interventions directed toward the prevention of pressure injuries and/or skin integrity concerns identified. If identified risk is present the interventions will be documented in the baseline plan of care and/or comprehensive care plan. If there is a decline in skin integrity pressure redistribution surfaces will be reviewed and…

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

Based on clinical record review, review of select facility policies and procedures, and staff interview, it was determined that the facility failed to implement interventions to promote acceptable parameters of nutrition for one of nine residents reviewed (Resident 64). Findings include: The facility Weight Policy, last reviewed without changes on May 4, 2024, revealed any resident with weight changes of five or more pounds will be re-weighed within 24 hours post the original weight. The dietitian will review the medical record of any resident with significant weight changes (greater than/equal to five percent in one month, greater than/equal to seven and a half percent in three months, and greater than/equal to 10 percent in six months). Interventions will be recommended, as needed. The nurse will confirm with the physician any order recommendations made by the dietician. Interventions that are initiated in response to a weight change will be reflected in the residents care plan. Residents with significant weight loss/ gain will be further reviewed by the interdisciplinary 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.

Based on clinical record review and resident and staff interview, it was determined that the facility failed to ensure that medically related social services were provided to one of two residents reviewed (Resident 6). Findings include: Observation of the First Floor Nursing Unit on May 20, 2024, at 12:16 PM revealed Resident 6 was visibly upset and pacing in the hallway. Resident 6 approached the surveyor and asked if she worked for the Office of the Aging. Resident 6 opened a piece of paper with the local ombudsman's name and contact information on it and stated that the staff would not allow him to call her. Resident 6 stated that he is being kept prisoner and locked on the unit. Resident 6 proceeded to discuss how he fell at home and hit his head along with possible carbon monoxide poisoning. The resident then drove himself to the hospital. Resident 6 stated that he may have been confused in the hospital due to hitting his head, the hospital transferred him to the facility, and now the facility will not allow him to leave. Resident 6 asked the surveyor to review 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.

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 properly account for, secure, dispose of, or return physician ordered medications for two or 25 residents reviewed (Residents 125 and 126). Findings include: Closed clinical record review for Resident 125 revealed physician orders dated [DATE], for the following: Lorazepam (schedule 4, controlled medication) Tablet 0.5 milligram (mg) one tablet by mouth (PO) every 4 hours as needed (PRN) for restlessness or Anxiety. Morphine Sulfate (narcotic, controlled medication) 20 mg/ml (milligrams/milliliter) give 0.25 ml PO every 2 hours PRN for pain or Dyspnea (difficulty breathing). Hyoscyamine Sulfate 0.125 mg PO every 4 hours PRN for tracheal (throat) secretions. Review of Resident 125's clinical documentation dated [DATE], revealed that he expired at 3:50 AM. There was documentation that the facility counted Resident 125's Lorazepam and Morphine medications. There was no documentation of the disposition or security 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 clinical record review and staff interview, it was determined that the facility failed to ensure that pharmacy recommendations were responded to for one of five residents reviewed (Resident 87). Findings include: Review of Resident 87's clinical record revealed that the pharmacist completed monthly medication reviews and noted that a recommendation was made on the following dates: October 10, 2023, November 13, 2023, January 9, 2024, and February 8, 2024. Review of the recommendation provided on October 10, 2023, November 13, 2023, January 9, 2024, and February 8, 2024, revealed a request for nursing to correct the diagnosis for Seroquel (a medication used to treat certain mental/mood disorders) on the medication administration record to bipolar disorder (a disorder associated with mood swings ranging from depressive lows to manic highs). Review of Resident 87's clinical record revealed that the diagnosis associated with his Seroquel is behaviors. Interview with the Director of Nursing on May 23, 2024, at 1:30 PM confirmed the above noted findings related to Resident 87'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.

Based on observation and staff interview, it was determined that the facility failed to ensure a safe and clean environment in the facility laundry area. Findings include: Observation of the facility's main laundry area with Employee 1, laundry aide, and the Nursing Home Administrator on May 23, 2024, at 9:28 AM revealed an extensive build-up of wet lint, debris including three discarded medical gloves, a plunger head, and a dirty blanket behind the area of the main washing machines. Excessive lint buildup not only affects dryer performance but can also be a fire hazard. Regular maintenance and cleaning are essential to keep the dryer functioning properly and safely. 28 Pa. Code 201.18 (b)(1)(3) Management

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 assist a dependent resident with bathing assistance for two of six residents reviewed for bathing concerns (Residents 3 and CR1). Findings include: Clinical record review for Resident 3 revealed the resident resided on the facility's dementia unit. Further review revealed the resident was to receive a shower on Monday and Thursday evenings. An observation of Resident 3 on February 2, 2024, revealed the resident lying in bed with covers over her and only her head and arms exposed, talking to herself in confused conversation. A review of Resident 3's bathing record from January 3 to February 2, 2024, revealed the resident was documented as receiving showers on January 4, 22, 28 (scheduled for January 29), and February 1, 2024. The resident was marked as not applicable for bathing on January 15, 18, 25, and 29, 2024. There was no documentation of the resident refusing her scheduled showers on January 8, 11, 15, 18, 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 interview, it was determined that the facility failed to provide necessary treatment and services to promote healing of a pressure ulcer for one of two residents reviewed (Resident CR1). Findings include: Closed clinical record review for Resident CR1 revealed the resident was admitted to the facility from the hospital on December 15, 2023, after a fall and having right hip surgery. Resident CR1 had a change in condition and was admitted to the hospital on [DATE]. Resident CR1 was not in the facility at the time of the survey. Review of a nursing admission assessment dated [DATE], for Resident CR1 revealed that a Stage I (non-blanchable redness of a localized area over a bony prominence) pressure ulcer measuring 0.3 cm (centimeters) length x 0.2 cm width x 0.0 cm depth was observed on the resident's buttocks. Review of a wound care consultant assessment dated [DATE], revealed the consultant identified this pressure ulcer as a Stage I over the sacrum (the large flat bone…

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, and staff interview, it was determined that the facility failed to ensure safety interventions were in place and that a fall was investigated for one of three residents with falls (Resident CR1). Findings include: Closed clinical record review for Resident CR1 revealed the resident was admitted to the facility from the hospital on December 15, 2023, after a fall and right hip surgery was performed. Resident CR1 had a change in condition and was admitted to the hospital on [DATE]. Resident CR1 was not in the facility at the time of the survey. Documentation indicated that the resident planned to return to the facility after hospitalization. Review of facility documentation for Resident CR1 revealed the staff heard the resident yelling and heard a fall. The staff immediately responded and found the resident laying on the left side with the head against the wall. The RN (registered nurse) assessed Resident CR1 and observed the surgical site bleeding (from right hip…

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 resident and staff interview, it was determined that the facility failed to secure transportation for outside services for one of two residents reviewed for transportation needs (Resident 6). Findings include: In an interview with Resident 6 on February 2, 2023, at 11:55 AM revealed the resident was visibly upset. Resident 6 indicated he was scheduled to receive an infusion outside the facility on January 25, 2024, and that date came, and he was told transportation wasn't available and the appointment had to be rescheduled for Monday, January 29, 2024. On Monday, the resident stated he was again told the facility could not get him transportation, and the appointment was changed to February 2, 2024, the day of the interview. Staff got him up at 6:30 in the morning and he was all ready to go and found out at 8:30 AM that he again did not have transportation and the appointment was rescheduled for February 7, 2024. The resident stated he went to talk to administration and was given the response that because he was in an electric wheelchair it wasn't…

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 an employee personnel file, clinical record review, and staff interview, it was determined that the facility failed to ensure a nurse demonstrated competency in skills necessary for resident care for one of one staff reviewed for medication administration competencies (Employee 1, Resident CR1). Findings include: Closed clinical record review for Resident CR1 revealed that he was admitted to the facility on [DATE], due to acute osteomyelitis (bone infection) of the foot and ankle. Resident CR1 was discharged to home on July 27, 2023. A physician's order for Resident CR1 dated June 26, 2023, revealed the nurse was to administer Oxycodone (a narcotic medication to treat severe pain) 5 mg (milligrams) every four hours as needed for pain for 14 days (last dose to be given July 12, 2023). Review of the Individual Patient Controlled Substance Administration Record for Resident CR1 revealed that Employee 1, RN (registered nurse) signed the form as administering the Oxycodone 5 mg on July 15, 2023, 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, observation, and staff interview, it was determined that the facility failed to ensure that physician's orders for medications were followed, resulting in a significant medication error for one of 15 residents reviewed (Resident CR1). Findings include: Closed clinical record review for Resident CR1 revealed that he was admitted to the facility on [DATE], due to acute osteomyelitis (bone infection) of the foot and ankle. Resident CR1 was discharged to home on [DATE]. A 5-day Medicare MDS (MDS, Minimum Data Set, an assessment tool completed at specific intervals to determine resident care needs) dated [DATE], for Resident CR1 revealed the resident had a BIMS (BIMS, Brief Interview for Mental Status, assessment that scores a resident's response to memory questions; a score of 13-15 indicates intact cognitive response) of 15. A physician's order for Resident CR1 dated [DATE], revealed the nurse was to administer Oxycodone (a narcotic medication to treat severe pain) 5 mg (milligrams)…

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.