Quality Life Services - Sugar Creek

Based on review of facility policy, observation, and staff interview it was determined that the facility failed to maintain the confidentiality of residents' medical information on one of four nursing units (Willow Nursing Unit).Findings include: Review of facility policy HIPAA/HITECH Administrative Policy dated 2/16/26, indicated the facility is to protect residents' privacy rights and their individually identifiable health information as required by the Health Insurance Portability and Accountability Act (HIPAA), Standards for Privacy of Individually Identifiable Health Information, 45 CRF Parts 160 and 164, the Health Information Technology for Economic and Clinical Health Act (HITECH) and all Federal regulations and interpretive guidelines promulgated thereunder. During an observation on 3/4/26, at 2:01 p.m. the [NAME] Medication Cart at the nurses' station was left unattended with the computer screen open with identifiable information any passerby could see resident personal and confidential information. During an observation at 3/4/26, at 2:02 p.m. Nurse Aide (NA) Employee E1…

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 job descriptions, clinical records and staff interviews, it was determined that the Nursing Home Administrator (NHA) and the Director of Nursing (DON) failed to effectively manage the facility when the facility failed to provide an altered texture diet, as prescribed by the physician, for one of 40 residents (Resident R1). This failure resulted in Resident R1 choking on food that he was not ordered which caused him to cease to breathe. This failure placed an additional 40 residents that had similar diet needs at risk, and resulted in an Immediate Jeopardy situation for 40 of 107 residents. Findings include: The job description for the NHA specified the purpose of the position is to direct the day-to-day operations of the facility in accordance with current federal, state, and local standards governing long-term care facilities and to ensure that the highest degree of resident care and services are delivered and maintained. The job description for the DON specified the purpose of the position is to provide nursing management, set resident care standards for all…

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

Based on a review of facility policy, observation and staff interview, it was determined that the facility failed to properly maintain cleanliness and sanitation of the Main Kitchen. (Main Kitchen). Findings include: Review of facility policy Food Safety and Sanitation, dated 3/17/25, indicated that all local, state and federal standards and regulations are followed in order to assure a safe and sanitary food services department. During an observation of the main designated kitchen on 5/15/25, at 11:35 a.m. the following was observed: - Wall behind Cook's preparation area, build-up of food spillage/brown debris - Wall behind Robocoupe (food processor)/blender area, build-up of food spillage/brown debris - Wall behind garbage can located next to steamer, build-up of food spillage/brown debris During an interview conducted 5/15/25, at 11:36 a.m., Registered Dietitian (RD) Employee E13 confirmed that the facility failed to properly maintain cleanliness and sanitation of the Main Kitchen. (Main Kitchen). 28 Pa. Code: 201.14(a) Responsibility of licensee. 28 Pa. Code: 201.18(b)(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 resident and staff interviews, and review of facility documentation, it was determined that the facility failed to provide residents with their quarterly banking statements for three of five residents. Findings include: During a group interview on 5/14/25, at 10:45 a.m. residents indicated that they did not get quarterly statements from the facility for their monies that the facility receives. Residents indicated that they were not aware they were to receive quarterly statements for their monies. During a review of residents quarterly statements the following was noted: Resident R500: resident fund statement indicated that the responsible party of the resident received the resident fund quarterly statement for the period of 1/1/25, thru 3/31/25. Resident R501: resident fund statement indicated that the responsible party of the resident received the resident fund quarterly statement for the period of 1/1/25, thru 3/31/25. Resident R502: resident fund statement indicated that the responsible party of the resident received the resident fund quarterly statement for the period…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, facility provided documents, and staff interview, it was determined that the facility failed to ensure that residents medication regime was free from unnecessary psychotropic medication for three of five residents (Residents R4, R86 and, R106). Findings include: Review of facility Behavior Standard Index dated 3/17/25, indicated the facility will develop and implement behavior plans and medication regimes, in efforts to optimize the functional abilities of residents while monitoring for adverse side effects and improve behaviors. When control is needed to prevent harm and to allow evaluation and treatment, psychotropic medication may be required. Behavioral sheets will be utilized at the time of drug initiation or admission to home with drug order. Behaviors must be quantitatively and objectively documented by the nursing staff. Non-pharmacological interventions are implemented and assessed for effectiveness prior to considering initiation of medication. Review of the clinical…

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

Based on review of facility policy, and resident and staff interview , it was determined that the facility failed to inform residents on the grievance policy and procedures for seven of seven residents. Findings include: Review of facility policy Communication of Resident, Family, and Staff Concerns and Grievances, stated 3/17/25, indicated: The facility offers several communication avenues for residents, family members, and staff to questions and to report any concerns related to quality of care, customer service, regulatory issue or employee matter. Resident group interview on 5/14/25, at 10:40 a.m. indicated that residents did not know who the grievance officer was, how to file a grievance, where the grievance forms were or what the process was. Residents were asked how the facility responds to grievances and the residents said that they did not know how they respond to concerns. Review of resident council minutes for six months (November, December, January, Febraury, March, and April) failed to include discussion of resident rights, how residents file grievance, where the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policies, facility provided documents, clinical records and staff interviews, it was determined that the facility failed to make certain a resident was free from neglect for two of five residents reviewed (Resident R48 and R260) which resulted in actual harm of a skin tear (Resident R48) and a dislocation of right elbow, fracture of the right distal radius (bone near wrist) and a fractured of the right coronoid process of the ulna (bone of forearm) (Resident R260). Findings include: The facility's policy Resident Protection from Abuse, Neglect, Mistreatment or exploitation last reviewed 3/17/25, indicated it is the facility's policy to treat residents with kindness, respect and in a manner that is at all times free from abuse, neglect, misappropriation of property, exploitation or mistreatment. To protect our residents, procedures will be implemented in the areas of screening, training, prevention, identification, investigation, protection, reporting/response and corrective action. -…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility documents, facility policy, clinical records, and staff interviews, it was determined that the facility failed to implement written policies and procedures to prohibit and prevent abuse, neglect, and exploitation with a complete and thorough investigation of an incident involving the potential for neglect for one of four residents (Resident R260). Findings include: The facility's policy Resident Protection from Abuse, Neglect, Mistreatment or exploitation last reviewed 3/17/25, indicated it is the facility's policy to treat residents with kindness, respect and in a manner that is at all times free from abuse, neglect, misappropriation of property, exploitation or mistreatment. To protect our residents, procedures will be implemented in the areas of screening, training, prevention, identification, investigation, protection, reporting/response and corrective action. - Neglect is defined of the failure of the facility, its employees or service providers to provide goods and services to 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 review of facility policy, resident clinical record, incident reports, reports submitted to the State, and staff interview it was determined that the facility failed to report an allegation of neglect for one of three residents (Resident R260). Findings include: The facility's policy Resident Protection from Abuse, Neglect, Mistreatment or exploitation last reviewed 3/17/25, indicated it is the facility's policy to treat residents with kindness, respect and in a manner that is at all times free from abuse, neglect, misappropriation of property, exploitation or mistreatment. To protect our residents, procedures will be implemented in the areas of screening, training, prevention, identification, investigation, protection, reporting/response and corrective action. - Neglect is defined of the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. - Neglect occurs when the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical record review and staff interview, it was determined that the facility failed to fully investigate an incident to eliminate possible abuse neglect for one of four residents (Resident R260). Findings include: The facility's policy Resident Protection from Abuse, Neglect, Mistreatment or exploitation last reviewed 3/17/25, indicated it is the facility's policy to treat residents with kindness, respect and in a manner that is at all times free from abuse, neglect, misappropriation of property, exploitation or mistreatment. To protect our residents, procedures will be implemented in the areas of screening, training, prevention, identification, investigation, protection, reporting/response and corrective action. - Neglect is defined of the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. - Neglect occurs when the facility is aware…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to make certain that the necessary resident information was communicated to the receiving health care provider for one of three residents sampled with facility-initiated transfers (Resident R57) and failed to provide a discharge summary completed by a physician for one of two residents (Resident R108). Findings include: Review of facility policy Transfer of Resident to Another Care Community dated 3/17/25, indicated transfer of resident to another care community is carried out based on physician order. Copy and prepare documents needed for transfer, including, but not limited to: - Medical Records Face sheet - Advanced Directives/POLST - Current physician orders - Medication Administration Record - Problem List - History and Physical - Appointments - Lab Work Review of the clinical record indicated Resident R57 was admitted to the facility on [DATE]. Review of Resident R57's MDS (Minimum…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of facility policy, clinical record, and staff interview, it was determined that the facility failed to provide an ongoing neurological assessment post unwitnessed fall for one of four residents (Resident R100). Findings include: Review of the facility policy Falls: Care During and After last reviewed 3/17/25, indicates all residents experiencing a fall will receive appropriate care and investigation of the cause. Assess residents ' condition immediately to determine extent of injury for both witnesses and unwitnessed falls by following Guideline for Fall Aftercare. Guidelines for Fall Aftercare: - If head injury, assess neurological status. - Monitor resident, including vital signs and neurological checks as indicated and ordered. Review of the clinical record indicated that Resident R100 was admitted to the facility on [DATE]. Review of Resident R100's Minimum Data Set (MDS - a periodic assessment of care needs) dated 3/11/25, indicated diagnoses of unsteadiness on feet, abnormalities of gait…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical record review, and staff interview it was determined that the facility failed to provide adequate supervision to prevent elopement for one of three residents (Resident R106). Findings include: Review of the facility policy Accidents and Incidents dated 3/17/25, indicated: An accident/incident is any happening, which is not consistent with routine operations or the routine care of the particular resident. Resident R106 was admitted to the facility on [DATE]. Resident R106's MDS (minimum data set an assessment of resident needs) dated 3/10/25, indicated the following diagnosis Unspecified Nondisplaced Fracture Of Second Cervical Vertebra Subsequent Encounter For Fracture With Routine Healing ( a cervical fracture often called a broken neck) , wandering (person becomes lost or confused), and unspecified dementia ( a condition where people lose the ability to think, remember, learn, make decisions and solve problems). Review of facility documentation progress notes dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, observations, and staff interviews, it was determined that the facility failed to provide adequate treatment and care for a peripheral inserted central catheter (PICC - a thin tube that's inserted through a vein in your arm and passed through to the larger veins near your heart) in accordance with professional standards of practice for one of two residents (Resident R70). Findings include: Review of the facility provided quick reference guide last reviewed 3/17/25, indicates dressing changes to central lines: PICC should be performed every seven days and if needed as soiled using aseptic (practices to prevent infection) technique. Review of the clinical record indicated Resident R70 was admitted to the facility on [DATE]. Review of Resident R70's Minimum Data Set (MDS - a periodic assessment of care needs) dated 4/15/25, indicated diagnoses of heart failure (a progressive heart disease that affects pumping action of the heart muscles), diabetes (a metabolic disorder in which…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of resident record review, and staff interviews, it was determined that the facility failed to provide a trauma survivor with trauma informed care to eliminate or mitigate triggers that may cause re-traumatization of the resident for two of two residents (Resident R4, and R9). Findings include: Review of the clinical record indicated Resident R4 was admitted to the facility on [DATE]. Review of Resident R4's MDS (Minimum Data Set - a periodic mandatory Federal assessment used to determine a resident's care needs) dated 2/20/25, indicated diagnoses of post-traumatic stress disorder (PTSD-a mental health condition in people who have experienced or witnessed a traumatic event), anemia (low iron in the blood) and high blood pressure. Review of Resident R4's care plan indicated that resident had PTSD but failed to identify what the triggers were and how to avoid them. Review of the clinical record indicated Resident R9 was admitted to the facility on [DATE]. Review of Resident R9's MDS dated [DATE],…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical records, and staff interview, it was determined that the facility failed to make certain medications were administered as ordered by the physician for one of three residents (Resident R88). Findings include: Review of the facility policy Specific Medication Administration Procedures last reviewed 3/17/25, indicates to administer medications in a safe and effective manner. After administration, return to cart, replace medication container (if multi-dose and doses remain). Review of the facility policy Physician Orders last reviewed 3/17/25, last reviewed 3/17/25. indicated physician orders are followed in accordance with good nursing principles and practices and are transcribed and carried out by persons legally authorized to do so. Review of Resident R88's clinical record indicated she was admitted to the facility on [DATE]. Review of Resident R88's Minimum Data Set (MDS - periodic assessment of resident care needs) dated 4/2/25, indicated diagnosis of anemia (low…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policies, observations, and staff interviews, it was determined that the facility failed to store all drugs and biologicals in a safe, secure, and orderly manner for one of two medication rooms (Hemlock Medication Room), and failed to store medications and biologicals properly and securely in three of five medications carts (Hickory hall, Hemlock hall, and [NAME] hall medication carts). Findings include: Review of the facility policy Storage of Medications last reviewed [DATE], indicates medications and biologicals are stored safely, securely, and properly, following manufacture's recommendations or those of the supplier. Orally administered medications are kept separate from externally used medications and treatments. Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled or without secure closures are immediately removed from inventory. The nurse will check the expiration date of each medication before administering it. Review of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy, clinical record review, observation, and staff interview, it was determined that the facility failed to prevent cross contamination during a dressing change for one of three residents (Resident R107). Findings include: Review of the facility policy Skin Integrity and Wound Management last reviewed 3/17/25, indicates to provide safe and effective care to prevent the occurrence of pressure ulcers, manage treatment and promote healing of all wounds. Review of the facility policy Wound Dressing Change last reviewed 3/17/25, indicates all wound care will be performed using medical aseptic technique, unless otherwise ordered by the physician, to prevent contamination of the wound bed. Procedure includes but not inclusive to: If a break in the aseptic technique occurs at any point, stop the procedure, remove your gloves, cleanse your hands, re-glove and/or re-gown and continue the procedure. Individual resident supplies may be placed on the over-bed table after it has been disinfected and 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 observations, review of facility documentation, and staff interview, it was determined that the facility failed to make certain that equipment was in safe operating condition for one of three crash carts (Exam Room). Findings include: Review of the facility Emergency Cart policy dated [DATE], indicated the emergency cart will be appropriately stocked and ready for use when attempting to resuscitate a resident. The cart will be readily available for use and its inventory maintained. During an observation of the Exam Room crash cart (a cart maintained with equipment used in cardiac emergencies) on [DATE], at 10:49 a.m. revealed the following expired supplies: - Foley Insertion Kit (a thin flexible tube inserted into the bladder to drain urine), expired [DATE]. - IV Start Kit expired [DATE]. - Syringe Piston not sealed closed. - Dressing Kit expired [DATE]. - Yanker Suction device (used to clear drainage out of a person ' s mouth) expired [DATE]. - Tracheostomy (an opening in the front of the neck that…

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

Based on staff interviews, and employee file review, it was determined that the facility failed to employ a full-time qualified Food Service Director for ten of ten months (August 2023 through December 2023, and January 2024 through June 2024). Finding include: During an interview conducted at initial tour on 6/10/24, at 10:29 a.m. Food Service Director (FSD) Employee E3, stated that he was not a Certified Dietary Manager (CDM) and did not have any formal education or certificates in food service management. FSD Employee E3 stated that the facility employs a Registered Dietitian, but that he comes in building only two days per week. During an interview on 6/10/24, at 2:29 p.m. Nursing Home Administrator (NHA) confirmed that FSD Employee E3 did not possess the appropriate qualifications as required. Review of FSD Employee E2's employee file, revealed that he did not possess qualifications for Food Service Director, and had been employed at the facility since 8/9/23. During an interview on 6/11/24, at 11:05 a.m. Registered Dietitian (RD) Employee E4 stated that he works in the…

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

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 make certain that the necessary resident information was communicated to the receiving health care provider for four out of four residents sampled with facility-initiated transfers (Residents R5, R37, R94, and R108). Findings include: Review of Title 42 code of Federal Regulations (CFR) §483.15(c)(2) Documentation indicated: When the facility transfers or discharges a resident under any of the circumstances specified in paragraphs (c)(1)(i)(A) through (F) of this section, the facility must ensure that the transfer or discharge is documented in the resident's medical record and appropriate information is communicated to the receiving health care institution or provider. (i) Documentation in the resident's medical record must include: (A) The basis for the transfer per paragraph (c)(1)(i) of this section. (B) In the case of paragraph (c)(1)(i)(A) of this section, the specific resident need(s) that cannot be met,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy review, clinical record review, resident, and staff interviews, it was determined that the facility failed to provide colostomy care and services consistent with professional standards of practice for two of two residents reviewed (Resident R58 and R262). Findings include: Review of facility policy Ostomy Care dated 4/8/24, indicated ostomy care will be provided for residents who have a urostomy, colostomy, or ileostomy. Ostomy appliances are changed and ostomy pouches are emptied as needed. The purpose of this policy is to maintain integrity of peristomal (around the stoma) skin, monitor condition of stoma (any opening in the body), manage odor, and promote resident's self-esteem. Review of facility policy Care Plan and Interdisciplinary Care Conferences- NU 6.1 dated 4/8/24, indicated an individualized care plan is initiated within 24 hours for each resident as part of the care delivery process. The care plan is a working tool that is reviewed and revised at specific intervals and 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of Resident Assessment Instrument (RAI) User's Manual, clinical records, and staff interviews, it was determined that the facility failed to ensure that MDS assessments accurately reflected the resident's status for two of three residents (Resident R9 and Resident R58). Findings include: Review of facility policy Resident Assessment: RAI/MDS/CAA Process dated 4/8/24, indicated a minimum data set (MDS) will be completed for every resident within 14 days of admission and according to the Medicare and OBRA Guidelines. Refer to the MDS 3.0 manual for the requirements. The Resident Assessment Instrument (RAI) User's Manual, which gives instructions for completing Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2023, indicated the following instructions: -Section J - Health Conditions: Current Tobacco Use, Ask the resident if they used tobacco in any form during the 7-day look-back period. If the resident states that they used tobacco…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to notify the physician of increased Capillary Blood Glucose (CBG) levels as ordered for one of three residents (Resident R82) and obtain physician orders for a resident's wound for one of three residents (Resident R260). Findings include: Review of facility policy Physician Orders- NU 2.18 dated 4/8/24, indicated physician orders are followed in accordance with good nursing principles and practices and are transcribed and carried out by persons legally authorized to do so. It was indicated treatments may not be administered to the resident without the written approval from the attending physician. Review of facility policy Nursing Services - NU 2.15 dated 4/8/24, indicated nursing care includes the provision of all prescribed medications and treatments, and nursing care will be provided within the scope of practice and in accordance with nursing standards of care. Review of facility policy…

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 record, and staff interview, it was determined that the facility failed to ensure a resident was offered sufficient fluid intake to maintain proper hydration and health for one of two residents (Resident R54). Findings include: Review of the Nutrition/Hydration Management- NU 9.9 policy last reviewed 4/8/24, stated residents will receive care and support to enhance potential for attaining the highest level of nutrition and hydration status and the pleasure of eating. It is the facility's policy to provide safe and effective care to manage residents' nutrition and hydration needs. Review of the clinical record revealed that Resident R54 was admitted to the facility on [DATE]. Review of Resident 54's MDS (Minimum Data Set, periodic assessment of resident care needs) dated 5/2/24, indicated diagnoses of dementia (the loss of cognitive functioning - thinking, remembering, and reasoning - to such an extent that it interferes with a person's daily life and activities), anxiety, and muscle…

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, interviews, and clinical record review, it was determined that the facility failed to provide appropriate respiratory care for one of three residents (Residents R75). Findings include: Review of the clinical record indicated that Resident R75 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnosis of obstructive sleep apnea, (occurs when your breathing is interrupted during sleep, for longer than 10 seconds at least 5 times per hour (on average) throughout your sleep period), high blood pressure, and heart failure (a progressive heart disease that affects pumping action of the heart muscles. This causes fatigue, shortness of breath.) Review of Resident R75's care plan dated 5/4/22, indicated the resident receives oxygen therapy for ineffective gas exchange. Review of Resident 75's MDS (Minimum Data Set, periodic assessment of resident care needs) dated 5/8/24, indicated the resident receives oxygen therapy while a resident. Review of Resident R75's physician'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 review of facility policy, observation, and staff interviews, it was determined that the facility failed to date opened medications in one of three medication carts (Willow Medication Cart). Findings include: Review of facility policy Storage of Medications dated 4/8/24, indicated when the original seal of a manufacturer's container or vial is initially broken, the container or vial will be dated. Drugs dispensed in the manufacture's original container will carry the manufacturer's expiration date. Once opened, these will be good to use until the manufacturer's expiration date is reached unless the medication is in a multi-dose injectable vial, an ophthalmic medication, or an item for which the manufacturer has specified a usual life after opening. During an observation on 6/12/24, at 8:42 a.m. of the [NAME] Medication Cart indicated the following medications not dated upon opening: - Resident R41's TobraDex eye drops, no date opened. - Resident R41's Muro 128 eye drops, no date opened. - Resident R58's Lantus (prefilled pen to inject long acting insulin under the skin)…

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

Based on facility policy, observation, and staff interview it was determined that the facility failed to properly contain and dispose of garbage in one of one outside dumpsters to prevent the potential for rodent and insect infestation. Findings include: Review of facility policy Waste Disposal, dated 4/8/24, indicated that trash will be deposited into a sealed container outside the premises. During an observation of the facility's outdoor trash receptacle on 6/10/24, at 11:00 a.m. revealed approximately five empty boxes piled up outside of the dumpster. During an interview on 6/10/24, at 11:00 a.m. Food Service Director Employee E93 confirmed that the facility failed to properly contain and dispose of garbage in the outside trash receptacles to prevent the potential for rodent and insect infestation. 28 Pa. Code 201.18(b)(3) Management. 28 Pa. Code 207.2(a) Administrator's responsibility.

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 clinical records were complete and accurate for one of six residents reviewed (Resident R260). Findings include: Review of the facility policy Medical Records-The Medical Record date 12/12/23, indicated that the medical record will contain complete and accurate documentation, which clearly identifies the resident, justifies the diagnoses, condition, treatment, care approaches, and responses to the care provided. Review of Resident R260's admission record indicated the resident was admitted to the facility on [DATE], with the diagnoses of dementia (a general term for loss of memory, language, problem solving and other thinking abilities that are severe enough to interfere with daily life), fracture of one rib on right side, and high blood pressure. Review of Resident R260's progress note dated 6/5/24, indicated the resident was admitted from the hospital after a fall. It was documented that 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 observation, staff interviews, resident interviews, it was determined the facility failed to maintain patient care equipment in a safe operating condition for one of three residents (Resident R11). Findings include: Review of the clinical record revealed that Resident R11 was admitted to the facility on [DATE]. Review of Resident 11's MDS (Minimum Data Set, periodic assessment of resident care needs) dated 5/10/24, indicated diagnoses of dementia (the loss of cognitive functioning - thinking, remembering, and reasoning - to such an extent that it interferes with a person's daily life and activities), morbid obesity, hemiplegia following cerebral infarction affecting left nondominant side (paralysis of left side of body following a stroke), and muscle weakness. Review of facility provided documentation, it was indicated the facility initially reached out to the resident's wheelchair manufacturer to repair Resident R11's wheelchair on 3/14/24. Resident R11's order for her wheelchair part was not confirmed…

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

Based on review of job descriptions, clinical records and staff interviews, it was determined that the Nursing Home Administrator (NHA) and the Director of Nursing (DON) failed effectively manage the facility to prevent the development and transmission of communicable infections. Findings include: The signed job description for Nursing Home Administrator dated 4/8/24, indicated the purpose of this position is to direct the day-to-day operations of the facility in accordance with current federal, state, and local standards governing long-term facilities and to ensure that the highest degree of resident care and services are delivered and maintained. ' The signed job description for Director of Nursing dated 7/13/23, indicated the purpose of this position is to provide nursing management, set resident care standards for all direct care providers, and provide complete supervision and management for the nursing department. Based on the findings in this report that identified that the facility failed to prevent the transmission of Norovirus for 46 residents, which placed residents in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical records, and staff interviews it was determined that the facility failed to notify the physician and a family representative of a change in condition for two of three residents (Resident R14 and CR8). Findings include: Review of the facility Resident Change in Conditionv or Status policy last reviewed 4/8/24, indicated when a resident exhibits a change in condition from their baseline, the license nurse assigned to the resident will ensure timely notification to charge nurse, physician, and family. Review of the clinical record indicated that Resident R14 was admitted to the facility on [DATE], and readmitted [DATE], with diagnoses of anxiety, depression, and dementia (loss of cognitive functioning, thinking, remembering, and reasoning to such an extent that it interferes with a person's daily life and activities). Review of Resident R14's Minimum Data Set (MDS - a periodic assessment of care needs) dated 2/21/24, indicated the diagnoses were current. Review of…

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