Saunders Nursing And Rehabilitation Center

Based on review of facility documentation, observations, and resident and staff interviews, it was determined that the facility failed to serve food at the proper temperature.Findings Include:A review of the facility's policy titled Food Temperatures Policy, revised February 2025, revealed that all hot food items must be cooked to appropriate internal temperatures and held and served at a temperature of at least 135 F. Temperatures must be taken frequently to monitor safe food-holding ranges of at or below 41 F for cold foods and at or above 135 F for hot foods.On December 18, 2025, at 10:39 a.m., an interview was conducted with Resident R1, who reported that the breakfast received that morning included sausages and pancakes that were served cold.On December 18, 2025, at 12:37 p.m., an interview was conducted with alert and oriented Resident R3, who reported a grievance regarding her dinner being served cold on December 13 and December 16, 2025.On December 18, 2025, at 12:27 p.m., a test tray was conducted with the Dietary Director, Employee E4. The following food temperatures were…

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 records, and staff interviews it was determined the facility failed to ensure that residents were free from neglect for one of five residents reviewed. (Resident R1)Findings include: Review of policy titled Abuse Policy -Prevention and Management, last revised August 2025, revealed The Facility prohibits the mistreatment, neglect, and abuse of residents/patients and misappropriation/exploitation of resident/patient property by anyone including staff, family, friends, visitors, etc. The Facility has designed and implemented processes, which strive to ensure the prevention and reporting of suspected or alleged resident/patient abuse, neglect, mistreatment, and/or misappropriation/exploitation of property. The facility must provide a safe resident environment and protect residents from abuse. This includes but is not limited to freedom from corporal punishment and involuntary seclusion. A review of Resident R1's clinical record revealed an admission date of March 11, 2020, with diagnosis of muscle weakness, contracture of 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 review of facility policies, clinical record reviews and interviews with staff, it was determined that the facility did not ensure that all allegations of neglect were reported immediately to the Pennsylvania Department of Health for one of 5 residents reviewed. (Resident R1).Findings Include:A review of the facility policy titled Incident Reporting and investigation of accident hazards, supervision, assistive device, last updated October 2025, revealed It is the policy of the Facility to monitor and evaluate any adverse occurrence which is not consistent with the routine operation of the Facility or care of a resident(s). All accidents/incidents where there is mistreatment, neglect, abuse or injuries of unknown origin will be reported to the Director of Nursing (DON) and Administrator (NHA) immediately for further review and reporting based on State and Federal regulations. A review of Resident R1's nursing notes revealed admission date of March 11, 2020, with diagnosis of muscle weakness, contracture…

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, review of facility provided documentation and interview with resident and staff, it was determined that facility did not ensure a resident received treatment and care in accordance with professional standards of practice related to heat therapy for one of five residents reviewed. (Resident R1)Findings include:Review of facility policy 'Hydrocollator - therapy,' revised November 7, 2022, indicates that hydrocollator temperature should be checked daily (therapeutic temperature range is 150-170 degrees Fahrenheit. This is the responsibility of therapy department.Further review of policy indicates the following: 10. Place hot pack in cover holder/envelope.11. wrap the hot pack in layers of toweling and place on the resident /patient's affected area.12. check the resident/patient's skin as indicated after application to ensure skin integrity.13. if skin presents with redness or is hot to the touch add another 2 layers of toweling for safety.14. 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, review of facility documentation, and staff and resident interviews, it was determined that the facility failed to ensure residents were kept free from abuse and neglect for two of three residents reviewed (Resident R1 and R3). Findings Include: Review of facility policy Abuse Policy - Prevention and Management reviewed August 2024, revealed the facility prohibits the mistreatment, neglect, and abuse of residents. The facility must provide a safe resident environment and protect residents from abuse. Review of Resident R1's clinical record revealed a quarterly Minimum Data Set (MDS - federally mandated resident assessment and care screening) dated May 3, 2025, which indicated the resident was cognitively intact, determined by a Brief Interview for Mental Status (BIMS) score of 15. Continued review of Resident R1's quarterly MDS dated [DATE], revealed the resident had diagnoses of anxiety (feeling of worry, fear, nervousness) and depression (persistent feeling of sadness and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of facility policy, resident clinical records, and staff interviews, it was determined that the facility failed to obtain a physician order and develop a comprehensive care plan for for hospice services for one of eight residents reviewed (Resident R8). Findings include : Facility policy titled Clinical Manual/Social Services Manual last reviewed April 2025 revealed It is the policy of this facility to participate in hospice care as an approach to caring for terminally ill residents that require palliative care as opposed to providing curative care. Based on Federal guidelines, the Facility has the following options as it relates to Hospice Care: i. Arrange for the provision of hospice services through an agreement with one or more Medicare-certified. It further revealed under iii D (f). Obtaining the following information from the hospice: The most recent hospice plan of care specific to each resident (f) Hospice physician and attending physician (if any) orders specific to each patient. v.…

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, interview with residents and staff, review of clinical records and facility policy, it was determined that the facility failed to maintain resident dignity and respect three of 34 residents reviewed. (Resident R57, Resident 107 and Resident 114) Findings Include: Review of facility's policy Statement of Resident Rights revealed a resident has a right to be treated with respect and dignity. Review of facility policy Hearing Impaired Residents revised on September 22, 2022, revealed that staff will assist hearing impaired residents to maintain effective communication with clinicians, caregivers, other residents and visitors. When interacting with the hearing impaired or deaf resident, staff will: directly face the resident when speaking so he/she can follow facial expressions and lip read, if possible. Review of Resident R57's clinical record revealed that Resident R57 was admitted to the facility on [DATE], with diagnoses of, but not limited to, muscle weakness, type 2 diabetes (failure of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, interviews with staff and residents and reviews of policies and procedures, it was determined that the facility failed to conduct complete and thorough investigations into allegations of abuse and neglect for six of 34 residents reviewed. (Residents R95, R55, R57, R104, R114 and R164) Findings include: A review of the facility policy titled abuse policy-prevention and management dated August, 2024 revealed that the facility's staff were responsible for prohibiting mistreatment, neglect, abuse, misappropriation of property and exploitation of the residents by anyone. The policy indicated that the facility was also responsible for implementing processes to ensure the prevention and reporting of suspected or alleged resident abuse. The policy indicated that the facility was responsible for providing a safe resident environment and protect residents from abuse, corporal punishment and involuntary seclusion. Continued review of the facility's policy revealed that neglect was failure…

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 reviews, and staff interviews, it was determined that the PASRR (Pre-admission screening and resident review) was not updated for one of 34 resident reviewed. (Resident R97) Findings include: The PASRR (Pennsylvania Preadmission Screening Resident Review) was created in 1987 through language in the OMNIBUS Budget Reconciliation ACT (OBRA) and it has three goals: to identify individuals with mental illness and or intellectual disability, to ensure that they are placed appropriately, weather in the community or in a nursing facility, and to ensure they are placed they receive the services they require of their mental illness or disability. The level I must be completed on all persons who are considering admission to a Medicaid certified nursing facility. A level II PASRR evaluation must be completed if the level I PASRR determined that the person is a targeted person with mental illness of an intellectual disability. The level II PASRR would determine if placement or continued stay in the requested or current nursing facility is appropriate. Review of 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 upon review of clinical records, interviews with staff and residents and reviews of policies and procedures, it was determined the facility did not ensure residents receive treatment and care in accordance with professional standards of practice, by failing to follow the physician's orders for medication administration for three of 34 residents reviewed (Resident R95, R24 and R172). Findings include: Review of the facility policy titled Self- Administration of Medications dated March 2025, states medications shall be administered in a safe and timely manner and as prescribed by the physician. Medications both prescription and non-prescription shall be administered under the orders of the attending physician, or the physician's designee. Medications must be administered in accordance with the written physician orders. Residents may self-administer their own medications if the attending physician, in conjunction with the interdisciplinary Care Plan Team, has determined they have the decision-making capacity…

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 up observation, interviews with staff, review of clinical records and facility policy, it was determined that the facility did not implement appropriate interventions to prevent pressure ulcers for one of 34 resident records reviewed (Resident R172). Findings include: Review of the facility's policy titles Risk Assessment and Prevention revised January 2025 states, Prevention of pressure ulcers require early identification of at-risk residents and the implementation of preventative strategies. Review of Resident R172's clinical record revealed that the resident was initially admitted to the facility on [DATE], and readmitted on [DATE], with the diagnoses of cerebral infarction due to embolism of left middle cerebral artery (stroke), hemiplegia and hemiplegia (one sided weakness) following the stroke that affected the resident's right dominant side, aphasia (loss of language, unable to speak), dysphagia (unable to swallow), and diabetes. Review of Resident R172's Significant change MDS (Minimal Data Set, an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record reviews and staff interviews, it was determined that the facility failed to ensure that weights were monitored for one of 34 residents reviewed (Resident R28). Findings include Review of facility's Statement of Resident Rights, revealed any weight change greater than or less than 5 pounds within 30 days will be retaken the next day for confirmation with licensed nurse confirming reweigh. Review of Resident R28 's clinical record revealed that Resident R28 was admitted to the facility on [DATE], with diagnoses of, but not limited to, Metabolic Encephalopathy (brain disorder that arises from disruption in body's metabolic processes), Type 2 Diabetes (failure of the body to produce insulin), and muscle wasting. Review of Resident R28 's care plan revised on May 6, 2025 revealed that resident was at risk for alteration in nutrition/ hydration related to obesity. Intervention implemented on July 15, 2025 was for weights as ordered. Review of Resident R28's physician orders revealed an order…

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

Based on review of facility policies, clinical record reviews and interviews with residents and staff, it was determined that the facility failed to ensure professional practice standards related to pain management for one of 34 residents reviewed (Resident R98). Findings include: Review of the facility's policy titled Pain Management revised March 2025 states, The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences. Review of Resident R98's nursing note dated April 3, 2025, indicated the resident was alert and oriented, able to make needs known. The resident admitted diagnosis was a fractured right tibia due to a fall with 14 staples to right knee, eight to shin, seven to ankle, four to front foot, and two in foot. Interview with Resident R98 on May 7, 2025, at 11:00 a.m. stated, When I first got here, they were giving me Tylenol for pain, the nurses would ask me what number my pain was, (1 out of 10, 10…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, clinical record review, and staff interview, it was determined that the facility failed to ensure that call bells were answered in a timely manner for two of 34 residents reviewed. (Resident R107 and Resident R114) Findings include: Review of Resident R107 's clinical record revealed that Resident R107 was admitted to the facility on [DATE] with diagnoses of, but not limited to, Hemiplegia and Hemiparesis following Cerebral Infarction (Muscle weakness and partial paralysis following a stroke). Review of Resident R107' s MDS (Minimum Data Set- assessment of resident's care needs) dated March 8, 2025, revealed that resident has a BIMS (Brief interview for mental status) of 15, indicating resident is cognitively intact. Interview with Resident R107 on May 6, 2025 at 12:30pm, resident stated call bell wait times can be 30 minutes sometimes. I waited an hour last week for someone to get me off the toilet. Review of Resident R114 's clinical record revealed that Resident R114 was admitted to 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 interviews with staff and residents, review of the facility tray audit form, and the completion of a lunch test tray, it was determined that the facility failed to provide food and drinks that were served at safe and appetizing temperatures on one of four nursing units (3rd floor nursing unit). Findings include: During an interview with Resident R7 on December 2, 2024, at 3:11 p.m. the resident reported that a group of residents had a meeting with the Nursing Home Administrator (NHA) a few weeks ago about cold food and other issues concerning the Dietary Department. Another resident (Resident R8) organized the meeting due to these issues being ongoing issues for months and not resolved by the NHA and the Dietary Director when it was discussed at various resident council meetings. Regarding the concerns with cold food, Resident R7 reported during the group meeting the NHA reported to the residents in attendance that the burner that heats up the food was broke. During interview with Resident R4 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 staff interviews, and review of facility documentation, it was determined that the facility failed to ensure that resident grievances were investigated and resolved for 3 of 3 residents reviewed. (Resident R12 R15 and R14) Findings include: Review of the facility policy, Grievances, with a revision date of November 2022 indicated that upon receipt of a written grievance/concern form, the grievance official or designee will forward the concern form to the appropriate department for investigation, and the investigating department will submit a written report of findings and resolutions to grievance officials. Continued review of the policy indicated that grievence official or designee will forward the concern form to the appropriate department for review, and that the grievance official at the facility will ensure that all written grievance decisions include the date the grievance/concern was received, a summary of the resident's grievance/concern, the steps taken to investigate the grievance, a summary…

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 interviews from staff and residents, and review of facility documentation, it was determined that the facility failed to act promptly upon resident grievances and recommendations, which included concerns related to the dietary department for 3 out of 3 months reviewed (September 2024, October 2024 and November 2024). Findings include: Review of the policy, Resident Council Meeting, with a revision date of March 2023, indicated that the role of the resident council is to improve residents quality of life, increase resident life satisfaction, and residents input into their daily life in a facility. The policy stated that the resident council governing body works closely with the administration of the facility and other staff to possible [sic] affect changes and resolve problems within the facility where they reside. Continued review of the policy also indicated that the meeting may be coordinated by the Activity or Social Services Directors, in conjunction with the resident council officers. Procedures of the resident council meetings include, but are not limited 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 staff interviews, review of facility policy, and the review of clinical records, it was determined that the facility failed to ensure that a person-centered plan of care was developed for a resident related to irritants (e.g. aerosol sprays, perfumes, bleach, dust mites) and the adverse reactions that they can have on the resident's health for 1 out of 1 residents reviewed (Resident R1). Findings include: Review of the facility policy, Care Planning Process and Care Conference, with a revision date of July 2023, indicated that each care need/problem of the resident must have a goal and interventions to address the need of the resident/patient. Review of the December 2024 physician orders for Resident R1 included the following diagnosis: pulmonary hypertension (increased blood pressure in the arteries of the lungs); heart failure (a condition in which the heart muscle doesn't pump blood as well as it should), chronic kidney disease (a condition in which the kidneys become damaged over time and have difficulty their essential functions), and chronic obstructive pulmonary…

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, interviews with staff and residents, review of clinical records and facility documentation, it was determined that the facility failed to ensure adequate supervision during medication administration for 1 out of 15 residents observed (Resident R2). Fimdings include: Review of the facility policy, Medication Administration/Disposition with a review date of June 2023, indicated that medications, both prescription and non-prescription, shall be administered under the orders of the attending physician, or the physician's designees. Review of Resident R2's December 2024 physician orders included diagnosisof kidney failure (a condition where the kidney reaches advanced state of loss of function); hypertension (high blood pressure); diabetes (a condition that affects an individual's blood sugar levels and can cause serious complications); cerebral infarction (a stroke); senile degeneration of the brain (a type of dementia characterized by a decline in cognitive function, memory and behavior abilities, typically occurring in older adults). Review of a Decisional…

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 residents' records and facility policy and interviews with staff, it was determined that the facility failed to ensure residents received treatment and care in accordance with professional standards of practice when the facility failed to inform the physician of blood sugars outside the acceptable parameters and when insulin medication was not administered for three of 35 resident records reviewed (Resident R57, R135 and R149). Findings include: Review of the facility policy for Medication Management for unavailable medication dated April 2024 states, When medication are not received or are unavailable, the licensed nurse should initiate action in cooperation with the attending physician and the pharmacy provider. Review of Resident R57 order summary revealed an admission date of June 23, 2023 diagnosed with diabetes (a disease in which the body's ability to produce or respond to the hormone insulin is impaired, resulting in abnormal metabolism of carbohydrates and elevated levels of glucose…

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, review of facility policy, review of clinical records, and staff interviews, it was determined that the facility failed to conduct a thorough investigation of an allegation of abuse, neglect and injury of unknown origin for four of 35 resident records reviewed (Residents R120, Resident R51,R102, R33 and R371) Findings include: Review of the policy titiled Abuse policy-Prevention and Management dated September, 2023 indicated that the facility was responsible for prohibiting mistreatment, neglect and abuse of residents, misappropriation of residents by staff, family friends and visitors. The policy also indicated that the facility was responsible for implementation of policies and procedures to prevent abuse, neglect and injuries of unknown origin. The policy indicated that neglect was the failure of the facility to provide goods and services necessary to avoid physical harm, pain, mental anguish or emotional distress. Neglect occurs when the facility was aware of or 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.

Based on review of clinical records and facility policy and staff interviews, it was determined that the facility failed to develop and implement a comprehensive person-centered care plan regarding one resident's chronic condition of constipation for one of 35 resident records reviewed (Resident R57). Findings include: Review of the facility's policy titled Care Planning Process and Care Conference revised on July 2023 stated it will develop the comprehensive resident centered plan of care for each resident. Each care plan need/problem must have a goal and interventions to address the need of the resident. Review of Resident R57's progress note, from the Certified Registered Nurse Practioner (CRNP) dated April 15, 2024, revealed the CRNP was alerted that the resident had no bowel movement (BM) in 96 hours. The resident was assessed and ordered Milk of Magnesia (MOM) given for constipation, and further instructed if MOM was not effective to offer a suppository. On May 6, 2024, CRNP seen Resident R57 for no BM for 48 hours and ordered nursing to initiate the bowel protocol and to give…

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 the review of clinical records, it was determined that the facility failed to ensure that restorative nursing services was provided for one of 35 clinical records reviewed (Resident R47). Findings include: Resident R47 was admitted to the facility status post aftercare for right-sided neurosurgery for a brain tumor, diagnosed with seizures, and hemiplegia (one-sided weakness). Review of Resident R47 quarterly MDS (minimum data set, an assessment of resident's needs) dated May 29, 2024, indicated the resident was alert, oriented able to make her own personal decisions. Interview with Resident R47 on July 16, 2024, at 11:00 a.m. stated, I really want to walk again. When I went to PT (Physical Therapy), they would hold on to me and I would walk. I was doing really good but since therapy ended no one has helped me try to walk again. Review of Resident R47's plan of care indicated that the resident had an activity of daily living (ADL) performance deficit due to her one-sided weakness, having impaired balance, limited mobility, and limited range of motion.…

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 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 a resident assessment, monitoring and supervision, and inappropriately providing a hot beverage to a resident whom was determined to need assistance (Resident R371). Findings include: Review of the job description of the Nursing Home Administrator (NHA) revealed that, the primary responsibility is to establish and maintain systems that are efficient and effective to operate the nursing home in a manner to safely meet residents needs in accordance with the current federal, state, and local guidelines and regulations that govern long term care facilities. The job description of the Director of Nursing (DON) revealed that, the employee is responsible for effective overall management of the nursing department personnel, policies and procedures and coordination with other discipline to ensure the efficacy of nursing services. The DON…

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 documents, observations, interviews with residents and staff, it was determined that the facility failed to ensure that medications were administered in accordance with professional standards for two of 12 residents' records reviewed. (Resident R1 and Resident R2) Finding include: Review of facility policy titled Medication Administration/ Disposition last revised September 6, 2023, revealed If a drug is withheld, refused, or given at a time other than the scheduled time, the individual administering the medication shall initial and use the corresponding code on the EMAR to indicate the medication was not given and the reason for not administering. Further review of the policy revealed that if the individual administering the medication must initial the resident's MAR on the appropriate line after giving each medication and before administering the next ones. Review of Resident R1's clinical record reveals a diagnosis of hyperthyroidism (a common condition where the thyroid doesn't create and release enough thyroid hormone into your bloodstream. This…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record reviews and interviews with staff, it was determined that the facility failed to ensure that a resident's representative was informed of and allowed to participate in decisions regarding the resident's care and treatment for one of three residents reviewed (Resident R1). Findings include: Review of Resident R1's Quarterly MDS (Minimum Data Set - a mandatory periodic resident assessment tool), dated August 23, 2023, revealed that the resident was admitted to the facility on [DATE], and had diagnoses including dementia (decline in memory or other thinking skills severe enough to reduce a person's ability to perform everyday activities). Continued review revealed that the resident had a BIMS (Brief Interview of Mental Status) of eight, which indicates that the resident was moderately cognitively impaired. Review of Resident R1's care plan, dated initiated March 16, 2023, revealed that the resident has problems with his memory and confusion related to dementia. The care plan states that his…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record reviews and interviews with staff, it was determined that the facility failed to ensure that a resident's representative was informed in advance of changes to the resident's plan of care for one of three residents reviewed (Resident R1). Findings include: Review of Resident R1's Quarterly MDS (Minimum Data Set - a mandatory periodic resident assessment tool), dated August 23, 2023, revealed that the resident was admitted to the facility on [DATE], and had diagnoses including dementia (decline in memory or other thinking skills severe enough to reduce a person's ability to perform everyday activities). Continued review revealed that the resident had a BIMS (Brief Interview of Mental Status) of eight, which indicates that the resident was moderately cognitively impaired. Review of Resident R1's care plan, dated initiated March 16, 2023, revealed that the resident has problems with his memory and confusion related to dementia. The care plan states that his family member is very involved 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 policies and documentation, clinical record reviews and interviews with staff, it was determined that the facility failed to ensure that one resident remained free from abuse, of three residents reviewed (Resident R2). Findings include: Review of facility policy, Abuse Policy dated revised November 2021, revealed, The facility prohibits the mistreatment, neglect, and abuse of residents/patients and misappropriation of resident/patient property by anyone including staff, family, friends, etc. Continued review revealed, Sexual abuse includes, but is not limited to, humiliation, harassment, coercion, or assault. Review of Resident R2's Annual MDS (Minimum Data Set - a mandatory periodic resident assessment tool), dated August 18, 2023, revealed that the resident was admitted to the facility on [DATE], and had diagnoses including dementia (decline in memory or other thinking skills severe enough to reduce a person's ability to perform everyday activities), aphasia (loss of ability 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.