Chestnut Hill Lodge Health And Rehab Ctr

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 updated in a timely manner for one of 10 records reviewed related to resident's behaviors (Resident R1). Findings include: Review of clinical documentation revealed that Resident R1 was admitted to the facility on [DATE], and had diagnoses including, bipolar disorder (condition in which a person has periods of depression and periods of being extremely happy), major depressive disorder (major loss of interest in pleasurable activities), anxiety disorder, post-traumatic stress disorder (a mental condition that's caused by an extremely stressful or terrifying event) and schizoaffective disorder (mental condition that combines schizophrenia and mood disorder). Reviewed of social worker note for Resident R1 revealed that on January 24, 2025, at 8:40 a.m. fire alarm went off shortly after and resident was in the vicinity. Further review revealed a clinical nurses note, dated January 27,…

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

Based on observation, staff and resident interviews, and review of clinical records, it was determined the facility failed to provide the necessary services to maintain adequate grooming and hygiene for one of 33 sampled residents (Resident R315). Findings include: Review of Resident R315's Admissions Minimum Data Set (MDS - federally mandated resident assessment and care screening) dated November 20. 2024, revealed the resident was alert and oriented, able to make needs know, and diagnosed with fractures and malnutrition, with impairments to both sides of her upper and lower body. The same MDS indicated the resident was dependent on staff for all activities of daily needs and when asked it was very important for the resident to choose between a tub bath, shower, bed bath or sponge bath. Interview with Resident R315 on December 4, 2024, at 11:00 a.m. stated that she was never offered a shower since she's been at the facility. I only get bed bath and I would really like a shower. Interview with Resident R351's Nursing Aide, Employee E3 on December 4, 2024, at 11:20 a.m. confirmed 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 observations of the food and nutrition services department, interviews with staff, reviews of policies and procedures and the pest control operator's reports, it was determined that the main kitchen was not maintained and operated to ensure an effective pest control program. Findings include: Review of the policy titled kitchen cleaning dated December, 2024 revealed that it was the responsibility of the dietary staff to ensure that the main kitchen was clean and sanitary by adhering to a comprehensive cleaning schedule throughout the food and nutrition department. Observations of the main kitchen in the presence of the director of dietary, Employee E5, at 9:30 a.m., on December 2, 2024 revealed the following: The plumbing in the dish room area was not draining properly. Soiled water and food waste was over flowing onto the floor in the this section of the main kitchen. A dietary staff member was using a hand held plunger to try to unclog the sink that was adjacent to the dish machine. The flooring throughout the dish room area contained a covering of a white substance…

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

Based on observations and interviews with residents, it was determined that the facility failed to maintain or enhance the dignity and respect for two of 33 residents reviewed (Resident R38 and R124). Findings include: During an interview with Resident R38 and R124 on December 4, 2024, at 3:40 p.m. the residents stated that when laundry labels their clothes with their names, they put it in places where it is visible when you are wearing them. Resident R38 stated they put my name on a collar of a shirt, in the front where you can see it when you are wearing it. Resident R124 revealed the jacket she was wearing had a 2-inch belt and on the back of the belt in large letters was the resident's name. 28 Pa. Code 201.18 (b)(1) Management 28 Pa. Code 201.29 (j )Resident rights

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, clinical record review and interview with staff, it was determined that the facility did not ensure that a comprehensive assessment was completed accurately related to language and communication for one of 33 records reviewed (R417). Findings include: Review of clinical documentation revealed that Resident R417 was admitted to the facility on [DATE], with diagnoses of traumatic subdural hemorrhage (brain bleed caused by injury, which can damage the brain and result in lack of normal functioning), cerebral infarction (death of an area of brain tissue), and dementia (a degenerative neurological condition which results in impaired memory and judgement). Progress notes for the resident revealed that she was on comfort care, a protocol intended to keep a resident comfortable during end of life, but which is not hospice care. Continued review of the documentation revealed that a Brief Interview for Mental Status (BIMS) assessment was completed for the resident on November 14, 2024. 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, clinical record review and interview with staff and residents and review of facility policy, it was determined that the facility did not develop a person-centered baseline care plan within 48 hours of a resident's admission related to language and communication for two residents, for a surgically wired jaw for one resident, and mental healthcare needs for one resident of 33 residents reviewed (Resident R158, R315, R417, R420). Findings include: Review of facility policy, Care Planning Process and Care Conference, revised July 3, 2023, revealed: Staff shall interact with the residents in a way that accomodates the physical or sensory limitations of the residents, promotes communication and maintains dignity. The facility's language access program will ensure that individuals with limited English proficiency (LEP) shall have meaningful access to information and services provided by the facility. When encountering LEP individuals, staff members will conduct the initial language assessment and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on 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 a diagnosis of anemia and psychotropic medications for one of 33 resident records reviewed (Resident R314). Findings include: Resident R314 was admitted to the facility on [DATE], diagnosed with anemia (not enough healthy red blood cells resulting in a reduced ability of the blood to carry oxygen to the body). Review of Resident R314's physician note, dated November 20, 2024, referenced the resident's critical hematology report dated November 15, 2024. The same note stated to monitor Resident R314's hematocrit (present of red blood cells in the blood) and hemoglobin (Hgb transports oxygen and carbon dioxide) relating to the resident's diagnosis of anemia and stated to consider Transfer for (blood) transfusion if Hg drops <7.0, and to monitor for…

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

Based on observations, clinical record review, review of facility documents and staff interviews, it was determined that the facility failed to revise the care plan for tube feeding management, for one of 33 residents reviewed (Resident R63). Findings include: Review of Resident R63's clinical record revealed that the resident was admitted in the facility on February 12, 2024. Resident R32's diagnoses included Protein Calorie Malnutrition ( condition synonymous with starvation, resulting when the body's needs for protein, energy, or both cannot be met by diet), and Oropharyngeal Phase Dysphagia (swallowing problems occurring in the mouth and/or the throat. These swallowing problems most commonly result from impaired muscle function, sensory changes, or growths and obstructions in the mouth or throat). Review of physician order for Resident R63, dated April 1, 2024, indicated an order to cleanse area around feeding tube with soap and water and gently pat dry, daily and as needed; clean, dry drain sponge may be placed if needed; every day- shift and as needed. Review of physician…

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 of care and services, review of clinical record and review of facility policy and interviews with staff and residents, it was determined that the nursing staff failed to obtain and schedule examinations with a specialist as indicated by the physician and to ensure that a medication was administered during the time period prescribed by the physician for two of 47 residents reviewed. (Resident R16 and Resident R315) Findings include: A review of the facility policy titled verbal and telephone physician's orders dated May, 2024 revealed that it was the policy of the facility to secure physican's orders for the care and services for the residents. The physician's orders for care and services were required to be dated and signed accordingly and entered into the resident's medical record. The policy also indicated that an order for medical or therapeutic measures and medications or treatments were to be given to a registered or licensed nurse. The registered or licensed nurse were required to…

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

Based on observations, review of clinical records, and interviews with facility staff, it was determined that the facility failed to ensure that it was free of medication error rate of five percent or greater for two of four residents observed during medication administration (Residents R4, and R77). Findings include: On December 3, 2024, 9:39 a.m., observed that Employee E7, a Registered Nurse, administered to Resident R77, the medicine, Aspirin 81 mg, chewable tablet, one tablet by mouth; when asked the Licensed Nurse to double check the medicine, the nurse stated it was Aspirin 81 mg, chewable tablet. Review of physician order for Resident R77, revealed an order, dated September 28, 2020, to administer Aspirin Enteric-Coated (EC) Tablet Delayed Release 81 MG (Aspirin), give 1 tablet by mouth one time a day. Review of literature revealed that Aspirin comes in enteric-coated and non-enteric (regular) forms. Regular Aspirin is absorbed in the stomach, while Enteric-Coated aspirin is absorbed in the small intestine. At the time of the observation, interview with Registered Nurse,…

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, clinical record review, observations, and staff interviews, it was determined the facility failed to identify a bed against the wall and an abdominal binder as a possible restraint and failed to assess the functional status of the resident to determine the use of the restraint for one of eight residents reviewed. (Resident R5) Findings Include: Review of facility policy titled Restraints (Physical) with a revision date of May 5, 2023 states, Policy: The resident has a right to be treated with respect and dignity, including: The right to be free from any physical restraints imposed for purposes of discipline or convenience, and not required to treat the resident's medical symptoms. When the use of restraints is indicated, the facility must use the least restrictive alternative for the least amount of time and document ongoing re-evaluation of the need for restraints. Further review of the policy revealed, Procedure: 1. Complete a physical restraint assessment if resident is…

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, interviews with staff, and review of facility policy and procedures, it was determined that the facility failed to ensure that one out of eight residents reviewed were monitored for acceptable parameters of weight. (Resident R5) Findings Include: Review of facility policy titled, Weight and Height Assessment and Interventions with a revision date on March 18, 2024 states, Policy: Purposes of this procedure are to determine the resident's weight and height, to provide a baseline and ongoing record of the resident's body weight as an indicator of the nutritional status and medical condition of the resident, and to provide a height in order to determine the ideal weight of the resident. The Facility will ensure acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance are maintained, unless the resident's clinical condition demonstrates that is not possible or resident preferences indicate otherwise;…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of clinical records, facility documentation, and interviews with staff, it was determined that the facility failed to maintain ongoing communication between the facility and a dialysis provider for two residents reviewed. (Residents R2 and R5) Findings Include: Review of the facility policy titled, Dialysis Management (Hemodialysis) with a revision date of March 28, 2024 revealed, It is policy of the facility to ensure that residents who require outpatient hemodialysis treatment have appropriate arrangements made by the facility with an outpatient treatment center in order to provide such services as directed by the physician. Further review of the policy states, If Dialysis is provided at off-site Dialysis Center: 5. Develop a resident binder/folder to send to dialysis with the resident. Communication form is placed in the binder after completion of the pre dialysis assessment. 6. Facility to complete Pre-dialysis information on the communication form and send with resident to dialysis on…

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

Based on staff interview, observation, and review of facility documentation, it was determined that the facility failed to ensure a safe comfortable homelike environment relating to daily cleaning and pest control for two of 15 residents reviewed. (Resident R12 and R15) Findings: Review of policy titled pest control last revised November 11, 2019, revealed that it is the responsibility of the maintenance department to coordinate the control of pest with a company engaged in the business of providing Pest Control Services. The pest control company will provide the control of roaches, ants, rodents, spiders, and other insects that may be harmful to humans, equipment, supplies, or documents through direct contact or contamination. All service technicians shall strictly adhere to all applicable policies and any specific instructions given by environmental/ facility directors. Od particular importance are rules or restrictions regarding contamination of hospital supplies and access to restricted areas. Interview with Resident R12 on May 7, 2024, at 11:22 a.m. revealed disappointment and…

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

Based on observation, review of facility policies, and interview with resident and staff, it was determined that the facility failed to ensure one of 14 residents reviewed received assistance with toileting and personal hygiene in a timely manner. (Resident R2) Findings include: Review of facility policy titled ADL care Personal Care/ Grooming-Shaving reviewed March 12, 2024, revealed the facility will promote care for residents that maintain or enhance their dignity and respect. Report other information in accordance with facility policy and professional standards of practice. ADL documentation will be completed by the certified nursing assistant that provided the assistance by the end of each shift. The licensed nurse will be made aware of the refusal. Review of Resident R2's care plan-initiated December 13, 2022, revealed that resident was incontinent of bowel and bladder due to cognitive impairment with goals of having elimination and skin care met with dignity and respect. An intervention of this plan included for the resident to be check every two hours and provided…

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

Based on observations and staff interviews, it was determined that the facility failed to ensure that garbage and refuse was disposed of properly. Findings Include: An initial tour of the Food Service Department was conducted on February 25, 2024, at 9:15 a.m. with the Assistant Food Service Director, Employee E4, which revealed the following: Observations of the trash area revealed a large trash compactor. Continued observations revealed a significant build-up of trash, food, and debris surrounding and along the perimeter of the trash compactor. Interview with the Assistant Food Service Director, Employee E4, on February 24, 2024, at 9:20 a.m. confirmed the observations. 28 Pa. Code: 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(3) Management

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, resident and staff interview, it was determined that the facility failed accommodate the residents' needs by failing to provide proper bedding for sleeping for one of 34 residents reviewed (Resident R83). Findings include: Review of the clinical record revealed that Resident R83 revealed that the resident was admitted to the facility on [DATE] with the diagnoses of chronic obstructive pulmonary disease with respiratory infection (a lung infection), high blood pressure, and muscle weakness. It was observed on February 25, 2024, at 10:00 a.m. Resident R83 appeared cold as he laid in bed using his coat as a blanket. The resident explained last night his blanket got wet and the aides told him there were none left. The resident said he used his coat as a blanket all night through the morning and was cold. At the time of the observation and interview with Resident R83 nurse aide Employee E15 confirmed that the resident was without a blanket. 28 Pa. Code: 201.29(j) Resident rights

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, review of clinical records, observations, and staff interviews, it was determined that the facility did not complete a comprehensive care plan for one of 35 residents reviewed (Resident R128). Findings include: Review of Resident R128's clinical record revealed that the resident was admitted to the facility on [DATE] with the diagnoses of Colostomy Status (an operation that creates an opening for the large intestine, through the abdomen, to treat disease or to relieve an obstruction or to prevent the remaining bowel from contamination by fecal matter), and Dysphagia (difficulty swallowing) . Review of physician order dated March 31, 2023, for Residnet R128, indicated an order stating, Resident has a colostomy on the Right Upper Quadrant. On February 27, 2024, at 12:23 p.m. Resident R128 was observed having his colostomy bag attached to his colostomy site. Review of the care plan for Resident R128, on February 27, 2024, at 2:12 p.m., revealed that there were no focus,…

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, review of clinical record, observations, and staff and resident interviews, it was determined that the facility failed to ensure a dependent resident received assistance with activities of daily living for one of 34 residents reviewed (Resident R40). Findings Include: Review of facility policy ADL (Activities of Daily Living) Care - Supporting Resident revised 01/31/2023 revealed residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene. Review of Resident R40's comprehensive Minimum Data Set (MDS - federally mandated resident assessment and care screening) dated January 25, 2024, revealed the resident was cognitively intact and had diagnoses of muscle weakness and abnormalities of gait and mobility. Continued review of the MDS revealed Resident R40 had impairment in functional range of motion to the lower extremities and was dependent on staff for transfers to and from bed, rolling left and right, toileting hygiene, and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policies, clinical record reviews and interviews with staff, it was determined that the facility failed to clarify physician orders related to insulin, for one of two residents reviewed related to insulin (Resident R14). Findings include: Review of facility policy, Guidelines for Diabetes Mellitus dated reviewed June 2023, revealed that glucose monitoring guidelines include to check blood sugar level and frequency as ordered and for facility protocol in place for physician notification with specific parameters for notification. Review of Resident R14's Quarterly MDS (Minimum Data Set - a mandatory periodic resident assessment tool), dated January 19, 2024, revealed that the resident was admitted to the facility on [DATE], and had diagnoses including diabetes (ability to produce or respond to the hormone insulin is impaired, resulting in abnormal metabolism of carbohydrates and elevated levels of glucose) and schizophrenia (mental illness associated with loss of reality contact,…

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 upon interview with resident and staff, review of clinical records and facility policy and procedures, it was revealed the facility failed to ensure that residents who were continent of bladder and bowel on admission received services and assistance to maintain continence for one of 34 resident records reviewed (Resident R122). Findings include: Review of the facility's policy titled, Bladder Incontinence Management Program, last revised October 2023 states the facility policy is to identify residents with urinary incontinence and provide an appropriate incontinence program based on incontinence status, 3-day elimination tracking and competition of a Comprehensive Bowel and Bladder assessment. The same policy instructs to consult therapy if applicable for evaluation of functional needs, develop and implement individualized interventions, discuss goals and interventions with resident and educate staff on toileting plan. Review of Resident R122's clinical record revealed that the resident was was admitted to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, review of clinical record, observations, and staff and resident interviews, it was determined that the facility failed to provide residents with respiratory therapy per physician orders for two of two residents reviewed (Residents R40 and R2). Findings Include: Review of facility policy BIPAP (bilevel positive airway pressure - a type of ventilator that helps with breathing by delivering different levels of air pressure to the lungs) and CPAP (continuous positive airway pressure) Policy and Procedure revised May 2021, revealed BIPAP and CPAP is administered by licensed nurses with a physician's order. BIPAP and CPAP may be prescribed for some residents to augment resident breathing when they have difficulty maintaining adequate ventilation. Review of Resident R40's comprehensive Minimum Data Set (MDS - federally mandated resident assessment and care screening) dated January 25, 2024, revealed the resident was cognitively intact and had a diagnosis of obstructive sleep apnea (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 observation, interviews with resident and staff and review of clinical records and facility policy, it was determined that the facility failed to ensure pain management was provided to a resident consistent with professional standards of practice, the comprehensive care plan and the resident's preferences for one of 34 resident records reviewed (Resident R230). Findings include: Review of facility policy titled Pain revised September 2022, stated the facility is committed to reducing physical and psychosocial symptoms associated with pain to assist the resident in achieving their highest practicable level of functioning. Review of Resident R230 clinical record revealed he was admitted to the facility on [DATE], post discharge from the hospital where he was being treated after experiencing a seizure episode. Resident was noted as awake alert and oriented able to voice his needs and concerns. Review of Resident R230's current care plan revealed that the resident was care plan for pain related to subdural…

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 record, observations, and staff and resident interviews it was determined that the facility failed provide food items consistent with the prescribed diet order for one of five residents observed during dining (Resident R40). Findings Include: Review of facility diet guide sheet revealed Sunday lunch offerings on February 25, 2024, was breaded chicken, beef chopped steak, baked fish, mashed potatoes, steamed rice, yellow squash, carrots, and tropical fruit. Per the diet guide sheet, a resident on a Renal (a specialized diet for people with kidney problems)/CCD (carbohydrate controlled) diet should receive steamed rice instead of mashed potatoes. Review of Resident R40's physician orders revealed the resident was ordered a Carbohydrate Controlled/Renal diet dated January 23, 2024. Review of Resident R40's nutrition assessment dated [DATE], confirmed to continue CCD/Renal diet as ordered by the physician. Observations on February 25, 2024, at 12:46 p.m.…

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

Based on clinical record review, observation, interview with staff and residents and review of facility policy, it was determined that the facility failed to shower residents on a regular basis for seven out of seven residents reviewed (Residents R1, R2, R3, R4, R5, R6 and R7) Findings include: Review of facility policy on activities of daily living (ADL) documentation revealed that under policy Statement, all activities of daily living services provided to residents will be documented and will become part of the residents permanent record. Under section procedure. #1. The Certified Nursing Assistant and other licensed nursing personnel will assist residents in achieving maximum function and care by providing assistance with ADL's as needed. #2. ADL is a task related to personal care. ADL's include bed mobility, transfers, walking in room, walking in corridor, locomotion on unit, locomotion off unit, dressing, eating, toilet use, personal hygiene, and bathing. #4. All ADL assistance provided will be documented by the employee providing the care into the resident's Medical 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.

Based on observation, review of facility documentation and interviews with residents and staff, it was determined that the facility failed to prepare and serve items as planned on the menu and failed to provide residents with their requested foods of preference for four of seven residents interviewed (Residents R7, R8, R9 and R11). Findings include: Observation of the menu posted on C Wing and E Wing on Monday, November 20, 2023, revealed that the menu included Monday lunch as Chicken Cacciatore with tomatoes, peppers and mushrooms, Bowtie Pasta, French [NAME] Beans and Chilled pears. Observation of a test tray revealed a meal ticket which listed Chicken Cacciatore with tomatoes, peppers and mushrooms, Bowtie Pasta, French [NAME] Beans, Chilled pears, Cranberry Juice and milk. Further observation of the actual contents of the test tray revealed cut green beans which were dark and very soft and tasted mushy and overcooked (and were not French cut) and a cup of tropical mixed fruit which included papaya, mango and bananas (and no pears.) Observation of Resident R7's lunch tray 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 review of clinical records and a staff interviews, it was determined that the facility failed to ensure that the resident's representative was notified timely about a change in condition requiring antibiotic therapy for one of four records reviewed (Residents R1). Findings include: A review of Resident R1's clinical records revealed that Resident R1 was admitted to the facility on [DATE], with diagnosis to include acute respiratory failure (a life-threatening condition where the lungs cannot provide enough oxygen to the body or remove enough carbon dioxide). A review of Resident R1's nursing note dated July 21, 2023, by Licensed nurse, Employee E10, revealed that Resident R1 had medium amount of lose stools during morning care with a slight smell and brown in color. Stool sample collected to test for C-Diff (Clostridioides difficile, is a bacterium that causes an infection of the large intestine) and stool softeners discontinued per doctor's orders. Further review revealed another progress note written…

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 the review of facility policy, interviews with staff, and review of facility documentation, it was determined that the facility failed to release requested clinical records to resident representative in a timely manner for one of Five residents reviewed. (Resident R1) Findings Include: Review of facility policy, Medical Record Release dated May 1, 2023, revealed that It is imperative that all medical record request for release of information be addressed in a timely manner as they are time sensitive. All information contained in the resident's medical record is confidential and may only be released by the written consent of the resident or his legal representative(sponsor), consistent with state laws and regulations. A resident may obtain photocopies of his or her records by providing the facility with at least a forty-eight (48) hours (excluding weekends and holidays) advance notice of such request. A fee may be charged for copying services at the prevailing rate. Interview with medical record director, Employee E3, on August 2, 2023, at 12:30 p.m. stated facility should…

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.