Hopkins Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, observations, interviews with resident and staff and review of facility documentation, revealed the facility failed to provide a safe, functional, and comfortable environment for residents for two of eleven resident rooms reviewed (Resident R4 and R7) Findings Include: Review of facility policy titled, Center Operations Policies and Procedures with a revision date of February 1, 2023. The policy states, The resident/patient has the right to a safe, clean, comfortable, and homelike environment including, but not limited to, receiving treatment and support for daily living safely. Patients have the right to reside and receive services in the center with reasonable accommodation of individual needs and preferences, expect when the health or safety of the individual or other patients would be endangered. Further review of the policy under process states, 1.6 Comfortable and safe temperature levels. Facilities initially certified before October 1, 1990 must maintain a temperature…

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 interview with staff, it was determined that the facility did not ensure that care plans were revised in a timely manner related to discharge planning for one of six records reviewed (Resident R2). Findings include: Review of clinical documentation revealed that Resident R2 was admitted to the facility on [DATE] and had diagnoses including, but not limited to, bipolar disorder, alcohol dependence, and chronic pain. Further review revealed that the resident had been issued a discharge notice, dated March 4, 2025, which stated we are hereby notifying you that effective April 4, 2025, which is thirty (30) days from the date of this letter, you will be discharged from [the facility]. The documented reason was the resident has failed .to pay for .a stay at the facility. Review of the resident's care plan revealed that she had a care plan developed on January 14, 2025, which stated [Resident R2] plans to remain at [the facility] for LTC (Long Term Care) placement. Interview with the…

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

Based on review of personnel records and interviews with staff, it was determined that the facility failed to complete annual performance reviews for nurse aide staff as required for five of five nurse aide personnel files reviewed (Employees E5, E6, E21, E22 and E23). Findings include: Review of Employee E5's personnel filed revealed that the employee was hired by the facility on June 13, 2023, as a nurse aide. Continued review revealed than an annual performance review had not been completed for the employee. Review of Employee E6's personnel filed revealed that the employee was hired by the facility on July 16, 2004, as a nurse aide. Continued review revealed than an annual performance review had not been completed for the employee. Review of Employee E21's personnel filed revealed that the employee was hired by the facility on October 2, 2006, as a nurse aide. Continued review revealed than an annual performance review had not been completed for the employee. Review of Employee E22's personnel filed revealed that the employee was hired by the facility on April 1, 2020, as a…

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

Based on review of clinical records, observations, review of facility policy and interview with staff, it was determined that the facility failed to implement special contact precautions, enhanced barrier precautions and practice infection control practices related to residents reported to be under precautions for care for four of eight residents reviewed. (Resident R15, Resident R7, Resident 69 amd Resident 75) Findings include: Review a facility policy titled Special Contact and Droplet Precautions Revised dated February 24, 2025, revealed special contact and droplet precautions will be used to prevent transmission of infectious organisms that can be spread via pathogens that spread through the air or by direct person to person respiratory transmission. An example of a disease requiring special droplet and contact precaution is SARS / COVID. Further review of this policy revealed anyone entering the room must wear proper personal protective equipment (PPE)including respiratory protection N95 respirator, gowns, and gloves prior to entering the room of those who require special…

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 documentation and staff interview, it was determined the facility failed to ensure residents were provided a Notification of Medicare Non-coverage (NOMNC) and an Advanced Beneficiary Notice of Non-coverage (ABN) for three of three residents reviewed (Resident 91, Resident 151, Resident 152). Findings include: Review of facility documentation for three residents revealed a Notification of Medicare Non-Coverage (NOMNC) was not provided to Resident 91, Resident 151 or Resident 152. Review of facility documentation for three residents revealed Advanced Beneficiary Notice of Non-Coverage (ABN) was not provided to Resident 91, Resident 151 or Resident 152. Interview with the Administrator in Training, Employee E8, on March 13, 2025 at 1:42 p.m. revealed that the facility could not locate a NOMNC or an ABN notification for Resident 91, Resident 151 or Resident 152. Interview with the Nursing Home Administrator on March 13, 2025, at 2:00 p.m. confirmed that the facility could not provide evidence that Resident 91, Resident 151 or Resident 152 received a NOMNC or an ABN…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, review of the facility policy and staff and resident interview, it was determined that the facility failed to ensure that call bells were available and operable for resident use for two of 38 residents observed residents. (Residents R63 and R39) Findings include: Review of facility policy, Call Lights, revised June 6, 2021, revealed that all Genesis Healthcare patients will have a call light or alternative communication device within their reach at all times when unattended. Interview with Resident R63 in room [ROOM NUMBER], on March 10, 2025, at 11:25 a.m. revealed that he does not use the call bell much and he pointed to the call bell which was wound around the bedrails. It was noted that the other end of the cord was cut off and laying on the floor, and the severed cord attached to the plug was in the wall jack. When the button was pushed it did not activate. Further observation of the light on the ceiling outside her door revealed that it did not light after pressing the button multiple…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and review of facility provided documentation, it was determined facility did not ensure to provide a sanitary, comfortable environment for residents for four out of 11 rooms observed on third floor unit (Room# 300, 302, 304, 305) Findings include: Review of facility provided policy 'Accommodation of Needs,' revised on February 1, 2023, indicates that residents have a right to a safe, clean, comfortable, and homelike environment, and housekeeping and maintenance services necessary to maintain a sanitary , orderly and comfortable interior. Observations on March 10, 2025 at 9:39 a.m., room [ROOM NUMBER], revealed food crumbs on floor, and a strong urine odor. Further observations on March 10, 2025 at 11:56 a.m., revealed dry yellow substance under chair on floor, urinal on floor. Further observations on March 10, 2025 of room [ROOM NUMBER], at 9:45 a.m., revealed mustard packets on floor under bedside table, empty soda can on floor, sweetener packets, lotion cap on floor, papers and a brief…

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 staff and resident's responsible party interview and review of clinical records, it was determined that the facility failed to ensure that advanced notice was provided to the resident and his emergency contact of care plan meetings and failed to ensure that care plan meetings were held in a timely manner for 3 out of 3 residents reviewed (Resident R1, R2 and R3). Findings include: Review of Resident R1's person-centered plan of care indicated that the resident had impaired thought processes related to diagnosis of dementia. Review of a nursing note dated November 22, 2024 at 7:27 a.m. documented that the resident was disoriented and required cues. Review of a nursing note dated November 22, 2024, at 11:33 p.m. documented that the resident was confused and required cues. The note also documented that the resident had a wander guard (a device that is placed on an individual's wrist or ankle, who has been identified as an elopement risk, and alerts staff when the resident is an area that is not safe) on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff interviews and review of facility documentation, it was determined that the facility failed to ensure that an effective pest control program and a pest free environment. Findings include: Review of the facility's contract with a local pest control company which began May 13, 2024 indicated that the pest control company services will cover mice, ants, all species of roaches, and stinging insects up to 15 ft high. The pest control company indicated that the services in the contract do not include bed bugs, termites and wildlife. Continued review of the pest control contract indicated that the company will provide services to the facility twice monthly, and that the company will inspect, monitor and treat as needed for the above primary targeted pests, in addition to servicing resident rooms by request, check and date the pest log book in kitchen, and all nursing stations, in addition to other listed tasks during their visit. During an interview with the emergency contact for 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 staff and resident's emergency contact interviews, review of faciltiy policy and review of clinical records, it was determined that the facility failed to ensure that documented room change notifications to the resident and emergency contact were provided for 1 out of 7 residents reviewed (Resident R1). Findings include: Review of the facility policy, Room Changes, with a revision date of January 25, 2024, indicated that Notification of room change of new roommate will be provided within reasonable/required time when necessary. Continued review of the policy also indicated that social services or designee will process and coordinate all request for room changes in accordance with state and federal guidelines. Continued review of the policy indicated that if the room change is patient initiatived, the facility will discuss the move request with the patient and/or patient representative and appropriate staff. Review of the December 2024 physician orders for Resident R1 indicated that the resident was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interviews, review of facility policy and review of the clinical record, it was determined that the facility failed to develop and implement an effective discharge planning process for 1 out of 2 residents reviewed for this care area (Resident R1). Findings include: Review of the facility policy Discharge Planning Process, with a revision date of November 15, 2022 indicated that the facility must implement an effective discharge planning process that focuses on the patient's/resident's/ discharge goals, the preparation of patients to be active partners and effectively discharge them to post-discharge care, and the reduction of factors leading to the reduction of factors leading to preventable readmissions. Continued review of the policy indicated that the facility's discharge planning process will include, involving the patient and resident representative in order to establish goals of care and treatment preferences; recommending options for the continuing care of the patient; referring 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, review of clinical records, facility documentation, and interviews with staff, it was determined that the facility failed to conduct a thorough investigation related to an allegation of mental abuse for one of six residents reviewed (Resident R1) Findings include: Review of facility policy Abuse Prohibition revised October 24, 2022, revealed mental abuse includes, but is not limited to humiliation, harassment, and threats of punishment or deprivation. Mental abuse may occur through verbal or nonverbal conduct which causes or has the potential to cause the patient to experience humiliation, intimidation, fear, shame, agitation, or degradation. Further review revealed the facility is to report allegation to the appropriate state and local authority involving neglect, exploitation, or mistreatment, suspected criminal activity, and misappropriation of patient property within 24 hours if the event does not result in serious bodily injury. Review of Resident R1's clinical record…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interview with staff and residents and review of facility documentation, it was determined that the facility failed to provide a functional heating unit for one of eight rooms observed. (room [ROOM NUMBER]) Findings include: Observation completed on November 6, 2024 at 10:15 a.m., on 2nd floor unit, revealed a non-working unit in room [ROOM NUMBER]. Further observations revealed non-working unit was used to hold resident's hygiene supplies, linens and personal belongings. Interview with Resident R1 who resides in room [ROOM NUMBER], on November 6, 2024 at 10:15a.m., revealed that he was told that a portable heating unit was installed temporarily during last week of October 2024 in the unit in room [ROOM NUMBER] but cold air comes out only. Observations and interview with facility's Director of Maintenance, Employee E3, on November 6, 2024 at 10:45 a.m., revealed that broken unit in room [ROOM NUMBER] had temporary air conditioner installed in unit, not a portable heating unit, which was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff interviews and review of facility documentation, it was determined that the facility failed to ensure that an effective pest control program and a pest free envioronment. Findings include: Review of the facility's contract with a local pest control company which began May 13, 2024 indicated that the pest control company services will cover mice, ants, all species of roaches, and stinging insects up to 15 ft high. The pest control company indicated that the services in the contract do not include bed bugs, termites and wildlife. Continued review of the pest control contract indicated that the company will provide services to the facility twice monthly, and that the company will inspect, monitor and treat as needed for the above primary targeted pests, in addition to servicing resident rooms by request, check and date the pest log book in kitchen, and all nursing stations, in addition to other listed tasks during their visit. Review of the pest control logs on both 2nd and 3rd floor…

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

Based on review of clinical records, interview with staff and review of facility policy, it was determined that the facility failed to revise a resident's PASARR (Pre-admission Screening and Resident Review) with mental health diagnosis for 3 of 21 resident records reviewed (Resident R37, R63 and R15). Findings include: Review of facility policy titled Pre-admission Screening for Mental Disorder and or Intellectual Disability Patients, revised February 16, 2024, revealed the center social worker or designated staff will assure that all patients with mental disorders and or intellectual disability receive appropriate pre-admission screening according to federal and state regulation. The social service will coordinate updates as needed and notify the state mental health authority after any significant change in the mental or physical changes in a resident who has a mental disorder. Review of resident R15's Quarterly Minimum Data Set (MDS- a federal mandated process for clinical assessment of all residents) dated August 2, 2024, revealed that Resident R15 was admitted into 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical record review and interviews with staff, it was determined that the facility failed to ensure a Level 2 PASARR was conducted for residents with mental disorders as required for two of four residents reviewed. (Resident R86 and R13) Findings include: Review of facility policy 'pre-admission screening for mental disorder and/or intellectual disability patients,' revised on February 16, 2024, states the following: To ensure that all individuals are screened for a mental disorder (MD) and/or intellectual disability (ID) prior to admission, and To ensure that individuals identified with MD or ID are evaluated and receive care and services in the most integrated setting appropriate to their needs. Further review of facility policy revealed that social services will review PASRR to determine appropriate care needs and refer to the appropriate state designated authority when a patient is identified as having an evident or possible MD, ID or related condition. The…

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

Based on Review of facility documentation, clinical record review and interviews with staff, it was determined that the facility failed to maintain an effective antibiotic stewardship program that included a system to effectively monitor antibiotic usage for seven of seven months reviewed. Finding include: A review of the CDC (Center for Disease Control and Prevention) guideline, The core element of Antibiotic Stewardship for Nursing Homes, revealed that improving the use of antibiotic resistance is a national priority. 1. Antibiotic Stewardship refers to a set of commitments and actions designed to optimize the treatment of infections while reducing the adverse events associated with antibiotic use. 2 the Center for Disease Control and Prevention (CDC) recommends that all acute care hospitals implement an antibiotic stewardship program (ASP) and outlined the seven core elements which are necessary for implementing successful ASP's. 2.CDC also recommends that all nursing home take steps to improve antibiotic prescribing practices and reduce inappropriate use. Nursing Homes monitor…

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 policies and procedures, employee personnel records, and staff interviews, it was determined that the facility failed to develop and implement an abuse prohibition policy that required a thorough investigation of prospective employees' employment history for one of five newly hired employees reviewed. (Employees 8) Findings include: The policy titled OPS300 Abuse Prohibition revision date October 24, 2022, states centers prohibit abuse, mistreatment, neglect, misappropriation of resident/ patient (hereinafter patient) property, and exploitation for all patients. The center will implement an abuse prohibition program through the following: screening of potential hires. A review of the Licensed Practical Nurse (LPN), Employee E8's personnel file revealed that Employee E8 was hired on May 22, 2024, out of state. A continued review of the personnel file revealed no documented evidence that an FBI or fingerprint was completed. Interview conducted on August 15, 2024, at 10:07 a.m. with Administrator, Employee E1 confirmed that Licensed Practical Nurse (LPN),…

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 documentation, review of clinical records, and interview with staff, it was determined that the facility did not complete a thorough investigation of the alleged violation for one of 21 residents reviewed (Resident R252) Findings include: Review of R252's clinical record revealed he was admitted on [DATE] with medical diagnosis of dementia, visual loss in both eyes, difficulty walking, anxiety, tremors, muscle weakness, and type two diabetes. Further review of clinical record revealed on July 23, 2024 at 4:24 PM, resident was seen sitting back in chair after attempting to elope down fire steps. Staff called to resident location and observed a small laceration above left eye and noted swelling to peri orbital area. Nurse practitioner, employee E10 , called and gave instructions to send resident out to emergency room for evaluation of unwitnessed fall and agitation. Progress note completed by licensed nurse, employee E12. Progress note dated July 23, 2024 at 11:13 PM, indicated R252 was admitted…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, review of facility policy, review of clinical records, and interview with resident and staff it was determined that the facility failed to develop and implement comprehensive, person-centered care plans to address resident care needs related to restorative nursing program, antipsychotic use, and refusal of care for three of 21 residents reviewed (Resident R92, R89, and R70). Findings Include: Review of facility policy 'Person Centered Care Plan,' revised October 24, 2022, indicates that A comprehensive person-centered care plan must be developed for each patient and must describe the following: any services that would otherwise be required but are not provided due to the patient's exercise of rights, including the right to refuse treatment . Review of Resident R92's admission Minimum Data Set (MDS - federally mandated resident assessment and care screening) dated June 3, 2024, revealed the resident had moderate cognitive impairment and diagnoses of dementia (symptoms affecting memory,…

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

Based on observations, review of facility policy, review of clinical records, and staff and resident interviews it was determined that the facility failed to implement resident-directed care and treatment consistent with the resident's comprehensive assessment and care plan, physician orders, and professional standards of practice for two of 21 residents reviewed (Resident R22 and R29). Findings Include: Review of facility policy 'Enhanced Patient Supervision: Continuous 1:1,' revised on September 1, 2022, indicates that the designated staff will only be involved with the delivery of care to this patient and no other ; the designated staff must be with the patient at all times; must obtain coverage for breaks; and will provide positive interaction in conjunction with therapeutic interventions. Review of Resident R22's comprehensive Minimum Data Set (MDS - federally mandated resident assessment and care screening) dated May 23, 2024, revealed the resident was cognitively intact and had a diagnosis of dysphagia (difficulty swallowing). Review of Resident R22's clinical record revealed…

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 policy, review of clinical records, and staff and resident interviews it was determined that the facility failed to ensure a resident with limited range of motion received treatment and services to maintain or improve range of motion/mobility for one of one resident reviewed for limited range of motion (Resident R89). Findings Include: Review of facility policy Restorative Nursing revised August 7, 2023, revealed restorative programs are coordinated by nursing or in collaboration with rehabilitative and are patient specific based on individual patient needs. A licensed nurse must supervise the activities in a restorative nursing program. Review of Resident R89's quarterly Minimum Data Set (MDS - federally mandated resident assessment and care screening) dated May 8, 2024, revealed the resident had moderate cognitive impairment and had diagnoses of stroke (when part of the brain does not have enough blood flow), and hemiplegia (paralysis of one side of the body) 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.

Based on review of clinical records it was determined that the facility failed to provide pharmaceutical services to assure the acquiring and administering of medications to meet the needs of each resident for one of 21 residents reviewed (Resident R95). Findings Include: Review of Resident R95's admission Minimum Data Set (MDS - federally mandated resident assessment and care screening) dated July 23, 2024, revealed the resident had severe cognitive impairment and a diagnosis of benign prostatic hyperplasia (a condition in which the flow of urine is blocked due to the enlargement of the prostate gland). Review of Resident R95's August 2024 medication administration record revealed a physician order with a start date of August 9, 2024, for Cephalexin (antibiotic that fights bacteria in your body) 500 milligrams (mg) four times a day (scheduled at 6:00 a.m., 11:00 a.m., 4:00 p.m., and 9:00 p.m.) for urinary tract infection. Per a review of the medication administration record, the Cephalexin was not signed out as administered for the 4:00 p.m. and 9:00 p.m. doses on August 9, 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, review of facility documentation and interviews with staff, it was determined that the Nursing Home Administrator and Director of Nursing failed to effectively manage the facility resulting in an immediate jeopardy situation regarding the safety of a resident who was on a leave of absence relating to the failure to located resident after not returning and not properly educating the resident on medication administration prior to leave of absence For one resident (Resident R 81 ) . Findings include: Review of the job description of the Nursing Home Administrator (NHA) revealed that, the primary responsibility is accountable for all activities and departments of the Center subject to rules and regulations promulgated by government agencies to ensure proper health care services to residents. The Administrator administers, directs, and coordinates all activities of the Center to assure that the highest degree of quality of care is consistently provided to residents. The job description 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 observations, clinical record review and interviews with staff, it was determined that the facility failed to develop a comprehensive person-centered care plan related to intravenous (IV) therapy for one of three residents reviewed (Resident R1). Findings include: Observation on July 9, 2024, at 9:25 a.m. revealed that Resident R1 had a PICC (peripherally inserted central catheter - a thin soft tube inserted in a vein in the arm with the tip of the tube positioned in a large vein that carries blood to the heart) line in his left upper arm. Review of Resident R1's admission MDS (Minimum Data Set - a mandatory periodic resident assessment tool), dated June 27, 2024, revealed that the resident was admitted to the facility on [DATE], and had diagnoses including pneumonia (lung inflammation caused by bacterial or viral infection) and septicemia (a life-threatening infection that occurs when bacteria enter the bloodstream). Continued review revealed that the resident received IV medications (intravenous…

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, clinical record review, review of facility policies and interviews with staff, it was determined that the facility failed to administer intravenous (IV) medications in accordance with professional standards of practice for one of three residents reviewed related to IV therapy (Resident R1). Findings include: Review of facility policy, Central Venous Access Device (CVAD) Dressing Change dated June 1, 2021, revealed, Central vascular access devices (CVADs) include: Peripherally inserted central catheter [PICC - a thin soft tube inserted in a vein in the arm with the tip of the tube positioned in a large vein that carries blood to the heart]. Continued review revealed that the length of the external catheter should be measured during dressing changes by measuring from the insertion site to where the catheter meets the hub to assess for line migration and to measure the arm circumference ten centimeters above the antecubital (inside of the elbow) and compare to baseline measurements to assess…

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 review of personnel files, clinical record reviews and interviews with staff, it was determined that the facility failed to ensure that nursing staff had the specific competencies and skills sets necessary to care for residents' needs related to medication administration and infusion therapy, which resulted in a significant medication error for Resident R1, for two of two personnel files reviewed (Employees E3 and E4). Findings include: Review of the Pennsylvania Nurse Practice Act, 49 Pa Code 21.145(f)(g) Functions of the LPN (licensed practical nurse), revealed, An LPN may perform only the IV therapy functions for which the LPN posses the knowledge, skill and ability to perform in a safe manner. Continued review revealed, Prior to the initiation of IV therapy, an LPN shall: Verify the order and identity of the patient. Further review revealed, An LPN who had met the education and training requirements . may perform the following IV functions . Administration of IV fluids and medications;…

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 documentation, clinical record reviews and interviews with staff, it was determined that the facility failed to ensure that residents remained free from significant medication errors for one of five residents reviewed (Resident R1). Findings include: Review of facility policy, General Dose Preparation and Medication Administration dated April 30, 2024, revealed, Prior to administration of medication, facility staff should take all measures required by facility policy and applicable law, including, but not limited to the following: Verify each time a medication is administered that it is the correct medication, at the correct dose, at the correct route, at the correct rate, at the correct time, for the correct resident. Continued review revealed, During medication administration, facility staff should take all measures required by facility policy and applicable law, including, but not limited to the following: Verify resident identification per facility policy (e.g.…

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, observation, and interview with staff, it was determined that the facility failed to maintain proper infection control practices related to hand hygiene and wound care for one of 8 residents reviewed (Resident R8). Findings include: Review of facility policy titled Wound Dressings: Aseptic, revised on December 1, 2021, revealed that if gloves become contaminated, remove gloves, cleans hands, and apply clean gloves. Review of the Pennsylvania Department of Health document titled Wound Care Observation Checklist for Infection Control, dated April 2018, revealed that gloves should be changed and hand hygiene performed when moving from dirty to clean wound care activities. Review of clinical documentation revealed that Resident R8 was admitted on [DATE], and had diagnoses including unstageable pressure ulcer (injury to skin and underlying tissue resulting from prolonged pressure on the skin) of left heel, pressure ulcer of sacral region (end of the spine 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.

Based on review of facility policies and documentation, clinical record review and interviews with staff, it was determined that the facility failed to ensure that a licensed nurse and a nurse aide maintained professional standards of quality of care for one of five residents reviewed (Resident R1). This failure resulted in Resident R1 eloping from the building through a second floor window due to lack of supervision and sustaining serious injuries. Findings include: Review of facility policy, Elopement of Patient dated revised October 24, 2022, revealed, For patients identified as at risk, an interdisciplinary elopement prevention patient-centered care plan will be developed with patient participation and patient representative when applicable. Review of facility policy, Nursing Documentation dated revised June 1, 2021, revealed, Nursing staff will not falsify or improperly correct nursing documentation. Continued review revealed, Nurses will not: Document services that were not performed; Document services before they are performed; Alter the nursing documentation of a coworker.…

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

Based on a review of clinical records, facility documentation and interviews with staff, it was determined that the Nursing Home Administrator and the Director of Nursing failed to effectively mange the facility related to the elopement of one resident (Resident R1) who sustained serious injuries and resulted in a Immediate Jeopardy situation. Findings include: Review of the job description for the Nursing Home Administrator revealed, Responsible for assuring that the center operates in full compliance with Federal and State regulations. Review of the job description for the Director of Nursing revealed, Overall accountability for providing leadership, direction, and administration of day-to-day operations associated with direct patient care activities, nursing practice, and clinical education and development, including continuous improvement of nursing services and staff to meet patients/residents and their families' needs and expectations. Review of Resident R1's care plan, dated initiated August 8, 2022, revealed that the resident was at risk for elopement related to the resident…

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

Based on review of facility's documentation, interview with staff, and interview with residents, it was determined facility failed to ensure that smoking paraphernalia was not in resident possession and that resident were supervised during the smoking period in the designated smoking area for two out of two residents reviewed. (Resident R1 and R2) Findings include: Review of facility' 'Smoking' policy, revised on March 1st, 2022, 2.6.1 if the patient is cognitively and physically able to secure all smoking materials, the Center may allow him/her to maintain his/her own tobacco products in a locked compartment. 2.6.2 Patients will not be allowed to maintain their own lighter fluid or matches. Review of facility's 'smoke break schedule,' smoking is allowed on weekdays and weekends at 10AM and 4:00PM; smoking takes place on 3rd Fl (floor) patio. Review of R1's 'Smoking Evaluation', completed on August 24, 2023, revealed that resident was to be supervised during smoking times. Under section D1. Considerations: resident has a history of sharing/selling cigarettes or smoking material;…

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.