Edenbrook Of Yeadon

Based on review of facility documentation, clinical record reviews and interviews with staff, it was determined that the facility failed to maintain accurate documentation of arbitration agreements for five of six arbitration agreements reviewed (Residents R37, R122, R48, R136 and R410). Findings include: Binding Arbitration Agreements are agreements by which the parties agree to submit to arbitration (private process where disputing parties agree that another individual can make a decision about the dispute after receiving evidence and hearing arguments) to resolve disputes between them within a defined legal relationship. The decision is final and can be enforced by court. Review of facility documentation dated March 20, 2025, revealed a list of Residents who are currently residing in the facility that have entered into a binding arbitration agreement on or after 9/16/2019: Residents R150, R37, R122, R48, R136 and R410 were selected for review from the list. On May 1, 2025, at 10:30 a.m. arbitration agreements for Residents R150, R37, R122 and R410 were provided for review. 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 policy, review of clinical records, and staff and family interviews, it was determined that the facility failed to ensure resident representatives had the opportunity to participate in the care planning process for one of 35 residents reviewed (Resident R31). Findings Include: Review of facility policy Care Conference revised June 20, 2023, revealed the purpose of the policy is to provide interdisciplinary communication with the resident and/or legal representative for purposes of the development of an individualized comprehensive plan of care. The resident and/or their representative will receive communication in advance of the scheduled care conference. Review of Resident R31's quarterly Minimum Data Set (MDS - federally mandated resident assessment and care screening) dated January 15, 2025, revealed the resident had diagnoses of dementia (decline in memory or other thinking skills severe enough to reduce a person's ability to perform everyday activities), anxiety (intense, excessive, persistent worry or fear), and depression (mood disorder…

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 interview, it was determined that the facility failed to maintain a clean and homelike environment in resident care areas and dining experience for one of four nursing units observed (Main Unit). Findings Include: Observations on April 28, 2025, at 11:08 a.m. revealed Resident R95's breakfast tray, with leftover food on the tray, was left on the windowsill in the dining room on the Main Unit. Continued observations in the dining room on the Main Unit revealed the railing on the wall was broken. Further observations on April 28, 2025, at 12:35 p.m. as resident's gathered in the dining room to have lunch on the Main Unit revealed Resident R95's breakfast tray was still left on the windowsill. Observations were confirmed by Registered Nurse, Employee E6. Observations on April 28, 2025, at 12:45 p.m. revealed broken floor tiles in the shower room on the Main Unit. Observations on April 28, 2025, at 12:49 p.m. in Resident R16's room revealed the wallpaper behind the bed was peeling, the privacy curtain was stained, and there was a brown 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policies, review of facility documentation, clinical record review and interviews with residents and staff, it was determined that the facility failed to ensure that residents were free from verbal abuse, for two of four residents reviewed for abuse (Residents R135 and R361). Findings include: Review of facility policy, Vulnerable Adult Abuse and Neglect Prevention dated revised February 25, 2025, revealed that abuse includes, Conduct which is not an accident or therapeutic conduct as defined in this section, which produces or could reasonably be expected to produce physical pain or injury or emotional distress including, but not limited to, the following . use of repeated or malicious oral, written, or gestured language toward a vulnerable adult or the treatment of a vulnerable adult which would be considered by a reasonable person to be disparaging, use of repeated or malicious oral, written, or derogatory, humiliating, harassing, or threatening language. Review of Resident R135's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, review of clinical records, observations, and staff interview, it was determined that the facility failed to ensure residents were free from physical restraint for one of 34 residents reviewed (Resident R310). Findings Include: Review of facility policy Physical Restraints revealed physical restraints are only used when they are used appropriately to treat the resident's medical symptoms and to promote an optimal level of function for the resident. A restraint may never be used for the purpose of discipline or staff convenience. Per the facility policy, a physical restraint includes all devices and practices that restrict freedom of movement or normal access to one's body. Review of Resident R310's quarterly Minimum Data Set (MDS - federally mandated resident assessment and care screening) dated March 2, 2025, revealed the resident had severe cognitive impairment, had impairment in functional limitation in range of motion to the upper and lower extremities, and required…

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 documentation, review of clinical records, and interviews with staff, it was determined that the facility failed to notify the Office of the State Long-Term Care Ombudsman of facility-initiated transfers to the hospital and that a resident's representative was made aware of a facility-initiated transfer in writing, for two of two clinical records reviewed. Resident R37 and Resident R119. Findings Include: Interview with Facility Administrator Employee E1 conducted on May 1, 2025 at 2:24pm revealed that the facility does not have a policy on discharge notification. Review of Resident R119's clinical record revealed that resident was admitted to the facility on [DATE], with diagnoses of but not limited to Cerebral Atherosclerosis, Poly-osteoarthritis. Further review of Resident R119's clinical record revealed that Resident R119 was transferred to a local hospital on February 9, 2025, and was readmitted to the facility on [DATE]. Review of Resident R37's clinical record revealed that…

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

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 develop a person-centered comprehensive care plan related to behaviors for one of 35 residents reviewed (Resident R135). Findings include: Review of facility policy, Care Plan - Baseline and Comprehensive dated revised June 20, 203, revealed that care plans will be developed to ensure that each resident receives care individualized to him or herself and that goals and approaches for care are communicated to all parties including caregivers, the resident, and the resident's representative. Review of Resident R135's Quarterly MDS (Minimum Data Set - a mandatory periodic resident assessment tool) dated October 21, 2024, revealed that the resident was admitted to the facility on [DATE], and had diagnoses including epilepsy (a disorder in which nerve cell activity in the brain is disturbed, causing seizures) and encephalopathy (damage or disease that affects the brain). Review of…

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

Based on review of facility policy, review of clinical records, observations, and staff interview, it was determined that the facility failed to timely provide feeding assistance for a dependent resident for one of 34 residents reviewed (Resident R78). Findings Include: Review of facility policy Activities of Daily Living (ADLs) revealed the facility will provide care and services for eating, assistance with feeding or preparation of meals. Based on the assessments, a personalized care plan is created and outlines the level of assistance needed for activities of daily living. Review of Resident R78's quarterly Minimum Data Set (MDS - federally mandated resident assessment and care screening) dated March 7, 2025, revealed the resident had severe cognitive impairment and required substantial/maximal (helper does more than half the effort) assistance with eating (the ability to bring food to mouth). Review of Resident R78's comprehensive care plan revised May 1, 2025, revealed the resident had an activities of daily living self-care performance deficit related to contractures 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 review of facility documents, review of clinical records, observations, and staff interviews, it was determined that the facility failed to implement both group and individual activities to meet the needs of each resident for 15 of 39 residents on the Main Nursing Unit (Resident R31, R78, R51, R71, R21, R142, R88, R4, R111, R133, R125, R131, R117, R64, and R150). Findings Include: Review of the April 2025 Activities Calendar revealed on April 29, 2025, Coffee & Chat was scheduled for 10:00 a.m. and Fun & Fit Exercise was scheduled for 11:15 a.m. on the Main Nursing Unit. Observations on April 29, 2025, at 9:45 a.m. revealed Resident R21, R88, R125, R64, and R131 were sitting in the dining room with no music and no television. These residents were observed to be sitting quietly with no stimulation. Follow up observations on April 29, 2025, at 11:45 a.m. revealed Residents R51, R71, R21, R142, R88, R4, R111, R133, R125, R131, R117, R64, and R150 were sitting in the dining room with only the television 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, review of clinical records, review of facility policy and staff interview, it was determined that the facility failed to ensure residents with limited range of motion received treatment and services to maintain or improve range of motion/mobility for one of one resident reviewed with limited range of motion (Resident R101). Findings include: Review of the facility policy, Specialized Rehabilitative and Restorative Services, dated April 1, 2022 indicated that the facility will provide restorative services, such as, but no limited to walking, transfer training, bowel and/or bladder training, bed mobility, range of motion, splint and brace, eating and/or swallowing, amputation/prostheses care and communication, when necessary, as indicted by the assessment of the interdisciplinary team. Review of Resident R101's clinical record revealed that Resident R101 was most recently admitted to the facility on [DATE]. Resident R101's current diagnoses were but not limited to Rheumatoid arthritis, COPD,…

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 interviews with staff, it was determined that the facility failed to obtain orders for oxygen for one of three residents reviewed who was receiving oxygen therary (Resident R410). Findings include: Review of Resident R410 clinical record revealed that Resident R410 was admitted to the facility on [DATE], with diagnoses of but not limited to Chronic Respiratory Failure with Hypoxia, Pleural Effusion Further review of Resident R410's clinical record revealed that Resident R410 was transferred to a local hospital on April 14, 2025, and was readmitted to the facility on [DATE]. Review of Resident R410's physician order revealed an order for Oxygen humidification: O2 (oxygen) liters via trach collar at 4LPM (liters per minute) every shift related to Trachesotomy status. Order Date-03/18/2025 . Further, there was no order for O2(Oxygen) upon return on April 23, 2025. Review of Resident R410's April 2025 Treatment Administration Record (TAR) revealed that resident was on Oxygen…

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 files, review of facility documentation and interviews with staff, it was determined that the facility failed to ensure that nurse aides were able to demonstrate competency in skills and techniques necessary to care for residents' needs for two of five newly hired personnel files reviewed (Employees E16 and E17). Findings include: Review of the facility's job description for nurse aides, dated May 5, 2015, revealed that nurse aides provide care to residents including: bathing, dressing, grooming, toileting, feeding, incontinence care, transferring, ambulation, range of motion, turning, repositioning, obtaining vital signs, weights, applying creams and collecting specimens. Review of facility documentation revealed that Employees E16 and E17 were hired by the facility as nurse aides on March 25, 2025. Personnel files, including documentation of skills competencies evaluations, for Employees E16 and E17, nurse aides, were requested on April 29 and 30, 2025. Personnel files were provided for review on May 1, 2025. There was no evidence of any skills…

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 staff, it was determined that the facility did not ensure that that trash was properly disposed of in the receiving and dumpster area. Findings Include: A tour of the main kitchen was conducted on April 28, 2025, at 9:32 a.m. with the Food Service Director, Employee E13. The tour included observations of the outside area where food deliveries are accepted and where the dumpsters are stored. Observations in the receiving area outside revealed trash, food, and debris on the ground surrounding the dumpsters. On one dumpster, the door on the back was open, and trash was exposed. 28 PA Code: 201.14(a) Responsibility of licensee.

Based on review of personnel files, observations, and staff interview it was determined that the facility failed to ensure staff were qualified to provide feeding assistance for one of one employee reviewed (Employee E27). Findings Include: Review of Resident R124's comprehensive care plan revised December 30, 2024, revealed the resident exhibited dysphagia (swallowing difficulties) when consuming foods by mouth putting the resident at risk for aspiration (inhaling food or saliva into the airway or lungs) and weight loss. Continued review of Resident R124's comprehensive care plan revised June 30, 2023, revealed the resident had an activities of daily living self-care performance deficit and required supervision assistance with eating. Review of Resident R125's comprehensive care plan revised April 10, 2025, revealed the resident had an activities of daily living self-care performance deficit and required set-up/assistance with eating. Review of Resident R125's physician order summary revealed a diet order dated April 24, 2025, that the resident required a mechanically altered diet…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, observations, and staff interviews, it was determined that the facility failed to implement enhanced barrier precautions for one of five residents on enhance barrier precaution observed (Residents R410). Findings Include: Review of facility Policy on Enhanced Barrier Precaution with an issue date of March 26, 2024 revealed that under section Policy, It is the Policy of this facility that Enhanced barrier Precautions, in addition to Standard and Contact Precautions will be implemented during high0contact resident activities when caring for residents that have an increased risk for acquiring a multidrug-resistant organism (MDRO) such as residents with Chronic wounds requiring a dressing, indwelling medical device or residents with infection or colonization with an MDRO. Under section Definition, Enhanced Barrier Precaution (EBP) refer to an infect ion control intervention designed to reduce transmission of multidrug-resistant organism that employs targeted gown and glove use…

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 the physical environment, interviews with staff and residents, it was determined that the facility failed to maintain an effective pest control program. Findings include: Review of Resident R37's clinical record revealed that resident was admitted to the facility on [DATE], with diagnoses of but not limited to cardiovascular disease, and gastrostomy status. Observation conducted on April 28, 2025, at 11:13 a.m. during the tour of the first-floor unit revealed that Resident R37 was in bed asleep. Further observation revealed that Resident R37 was on tube feeding with feeding bag of Jevity 100 cc hanging on a pole, the tubing was primed (feeding formula was in the tubing) but not connected to the pump. Further observation revealed a fly on Resident R'37's sheet. Further, three other flies were observed flying about Resident R37. Further observation of Resident R37's bedroom revealed that the screen on one of the windows in her room had a hole. Interview with unit manager Employee E5…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, facility policy, resident and staff interview, it was determined that the facility failed to ensure complete and accurate treatment administration for one of 10 residents reviewed (Resident CL1). Findings include: Review of CL1's clinical record revealed that the resident was admitted to the facility on [DATE], with diagnoses including cognitive communication deficit, and a chest surgical incision related to severe aortic valve stenosis; Resident CL1 underwent arctic valve replacement and CABG (Coronary Artery Bipass Surgery). Review of Resident CL1's physician orders revealed an order dates January 22, 2025, which indicated, Wash all incisions with mild soap as Dove or Ivory. No lotions, ointments, creams, gel, colognes or powder at the sites. DO NOT emerge incision into water; every day and evening shift for 4 Weeks. Review of the Treatment administration record revealed that incision care was completed on January 23, 2025, through January 31, 2025. Further review 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.

Based on observations, review of facility policies, clinical record reviews and interviews with staff, it was determined that the facility failed to maintain an effective infection control program related to Enhanced Barrier Precautions for three of three residents with sacral wounds observed (Residents R1, R2 and R3). Findings include: Review of facility policy, Enhanced Barrier Precautions dated March 6, 2024, revealed, It is the policy of this facility that Enhanced Barrier Precautions, in addition to Standard and Contact Precautions will be implemented during high-contact resident care activities when caring for residents that have an increased risk for acquiring a multidrug-resistant organisms (MDRO) such as a resident with chronic wounds requiring a dressing, indwelling medical devices or residents with 'infection or colonization with an MDRO'. Enhanced Barrier Precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities.…

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 policies and interviews with residents and staff, it was determined that the facility failed to provide a comfortable environment related to water temperatures for two of four nursing units observed (First and Second Floor Nursing Units). Findings include: Review of facility policy, Water Temps - Bathing dated February 1, 2025, revealed, It is the policy of this facility to provide a safe and comfortable temperature for residents during bathing and procedures to protect them from avoidable injury whenever possible. The facility will monitor domestic hot water temperatures prior to bathing/showering residents and testing will be conducted on a routine basis by the Maintenance Department. Domestic hot water ideally will be maintained at 105 degrees to 110 degrees Fahrenheit. Acceptable range is 100-110 degrees. Interview on March 5, 2025, at 10:22 a.m. Resident R13 stated that there was no hot water in her bathroom sink. Observation on March 5, 2025, at 10:24 a.m. in room…

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 records, job description, and staff interviews, it was determined that the Nursing Home Administrator (NHA) did not effectively manage the facility to ensure that water temperatures in the central shower room and resident bathroom sinks were maintained at a safe temperature for one of four nursing units observed (TCU Nursing Unit). This failure placed residents on the TCU Nursing Unit at risk for serious injury from a burn and resulted in an Immediate Jeopardy situation. Findings include: Review of the job description of the nursing home administrator indicated that the Nursing Home Administrator manages all business-related activity to achieve the faciltiy's vision and supporting strategies and assures that the company image as an ethical and high quality provider of health services is maintained. Safety and Sanitation included to follow established safety policies and procedures. Ensures potential safety/health hazards are eliminated. Under Administrator Provision of Services…

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 obtaining medical records in a timely manner for 1 out of 2 residents reviewed (Resident R1). Findings include: Review of the resident's August 2024 indicated that the resident was admitted into the facility on April 23 2023, with the diagnose of viral hepatitis; psychoactive substance dependence, depression and dysphasia (difficulty swallowing). Review of the resident's clinical notes indicated that in March 2023, the resident fell six stories from a window and sustained multiple injuries and fractures as a result and was transferred to the facility for rehabilitation services. Review of an orthopedic consultation visit dated June 3, 2024 where the resident was seen for follow up for ankle and foot treatment/care related to his fall from March 2023. Review of the consultation from the resident's current orthopedic physician who treated the resident's on June 3, 2024, documented that the medical records were needed from a 1st named local hospital/physician prior 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.

Based on clinical record reviews, interviews with staff, reviews of hospital records and facility policies and procedures, it was determined that the facility failed to permit one of three residents reviewed to return to the facility after they were hospitalized . (Resident R1) Findings include: Review of the undated policy titled Bed Hold and readmission Policy revealed that for those residents that are transferred with an expectation of returning to the facility, the facility must comply with the requirements related to discharge. Clinical record review for Resident R1 revealed that this resident was admitted from the hospital on July 12, 2024, with diagnoses to include adjustment disorder with mixed anxiety and depressed mood (a stressor-induced disorder that creates personal distress through symptoms of both anxiety and depression). The nursing note dated July 14, 2024, written by the nursing supervisor, Employee E11, indicated, Myself, nurse and CNA went into resident's room to give care. During incontinent care, resident hit CNA in her stomach. Md made aware, new order to send…

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 interview and review of facility policy, it was determined that the facility failed to ensure that personal privacy was maintained related to patient care and tracheostomy care for one of 35 residents observed. (Resident R130) Findings include: Review of facility policy on Dignity dated April 1, 2022, reveal that under section Policy: each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect, and individuality. Under section Policy Interpretation and Implementation #11. Staff shall promote, maintain, and protect residents' privacy, including bodily privacy, during assistance with personal care and during treatment procedures. Observation of tracheostomy care conducted on June 25, 2024, at 12:36 p.m. with Licensed nurse, Employee E14 and Unit Manager, Employee E15 and in the presence of Resident R130's husband revealed that Resident R130's bed was located close to the door and her roommate's bed was located closest to the window. Further observation revealed that Resident R130's privacy curtain on the side of…

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

Based on closed clinical record review, review of facility policy and interviews with staff, it was determined that the facility failed to ensure that resident assessments were completed in a timely manner for one of three discharged records reviewed (Residents R77). Findings include: Review of the undated facility policy titled MDS 3.0 Completion revealed that, According to federal regulations, the facility conducts initially and periodically a comprehensive, accurate and standardized assessment of each resident's functional capacity, using the RAI (Resident Assessment Instrument) specified by the State. Clinical record review for Resident R77 revealed a nursing note written on April 2, 2024, indicating that the resident was discharged in stable condition ambulating independently with daughter, with all belongings, scripts, paperwork and medications. Further review of the clinical record for Resident R77 revealed an April 2, 2024, MDS (Minimum Data Set, comprehensive assessment of resident) that indicated the discharge status as 04 - Short-Term General Hospital. Interview on June…

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 revealed that the facility failed to revise a resident's PASARR (Pre-admission Screening and Resident Review) with mental health diagnosis for one of 35 resident's records reviewed (Resident R77). Findings include: Review of the facility policy titled, PASARR date on April 1, 2022, stated the facility will coordinate assessment with the pre-admission screening and resident (PASARR) program. Referring all level II residents and all residents with newly evident or possible serious mental disorder, intellectual disability, or a related condition for level II residents review upon a significant change in status assessment. Review of the clinical record on June 25, 2024 for Resident R77 revealed diagnoses that included schizoaffective disorder (schizoaffective -a mental disorder condition mix schizophrenia symptoms by delusions, hallucinations and mood disorder); major depressive disorder (depression-a mood disorder that causes a persistent feeling of sadness and loss of interest); anxiety…

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, record review and interview with staff, it was determined that the facility failed to develop a resident's care plan related to oxygen therapy for one of 35 clinical records reviewed. (Resident R112). Findings include: Observation on June 24, 2024 at 11:00 a.m. revealed Resident R112 in bed receiving oxygen therapy via nasal cannula. Observation of the oxygen concentrator revealed that it was set at 2 liters per minute. Review of Resident R112's current care plan revealed that there was no care developed for oxygen therapy. Interview on June 25, 2024 at 2:20 p.m. with Licensed nurse, Employee E19 confirmed that Resident R112's care plan was not updated to include oxygen administration. 28 Pa. Code 211.12(d)(1) Nursing services

Based on observation, record review and interviews with staff and resident, it was determined that the facility failed to ensure a physician order was obtained realated to oxygen therapy for one of 35 clinical records reviewed. (Resident R112). Findings include: Observation on June 24, 2024 at 11:00 a.m. revealed Resident R112 was in bed and receiving oxygen therapy via nasal cannula. Review of Resident R112's clinical record did not reveal oxygen therapy was included with physician orders. Interview on June 25, 2024 at 2:20 p.m. with Employee E19 confirmed that Resident R112 was receiving oxygen therapy without a physician order. 28 Pa Code 211.3(b) Oral and telephone orders 28 Pa Code 211.5(f)(i) Clinical records

Based on observations, review of clinical records and interview with staff, it was determined that facility did not ensure to provide sufficient services to restore bladder function for one of 35 residents reviewed. (Resident R61) Findings include: Review of Residents R61's clinical record revealed a medical history of calculus of ureter (kidney stones), benign prostatic hyperplasia with lower urinary tract symptoms, neuromuscular dysfunction of bladder, presence of urogenital implants, urinary tract infections, colostomy status. During observations of wound care treatment on June 25, 2024, at 10:45 a.m., Resident R61 had bloody urine in the suprapubic catheter. Interview conducted with Licensed nurse, Employee 12 was assigned to care for Resident R61 stated that it's always been like that . Review of R61's nursing notes, dated June 6, 2024, at 3:17 p.m. and June 3, 2024 at 8:33 a.m. indicate that some sm (small) blood strands noted in urine; unit mgr (manager) aware-will obtain C&S (culture and sensitivity). Already on abt. (antibiotic). Review of R61's care plan included…

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, review of professional literature, review of facility policies and interviews with staff, it was determined that the facility failed to assess a PICC line in accordance with professional practice standards for two of four residents with peripheral central cathether lines (Resident R179). Findings include: Review of the undated facility policy, Documentation Guidelines for Infusion Therapy revealed that Midline Catheters and PICCs (Peripherally Inserted Central Catheter Line) documentation at established intervals, including the external length of the catheter and the original length of the catheter inserted, and arm circumference to check for edema and rule out deep vein thrombosis. According to the standards of nursing practice guidelines in the Journal of the American Nurse's Association, dated November 2013, complications of a PICC line (Peripherally Inserted Central Catheter Line, type of IV used for long term use) includes, but is not limited to catheter-tip migration…

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 a review of facility policies and documentation, it was determined that the facility did not ensure that food was stored, prepared, distributed, and served in accordance with professional standards for food service safety. Findings include: The Policy: Food Storage, which was dated January 17, 2019, states, All foods should be covered, labeled and dated and Frozen food must be maintained at a temperature to keep the food frozen solid. An initial tour of the Food Service Department was conducted on June 24, 2024, at 9:45 a.m. with Employee E3, Food Service Director (FSD), which revealed the following: Observation in the walk-in refrigerator revealed an open box of hot dogs with the inner plastic lining open to the air and no date when product was open. Observation in the walk-in freezer revealed an internal thermometer reading 17 degrees above zero and there were several food items not frozen solid including donut holes, sausage links and tater tots. Interview with the FSD on June 24, 2024, at 9:55 a.m. confirmed that these food items…

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, interview with staff and review of facility policy, it was determined that the facility failed to ensure proper infection control procedures during tracheostomy care for one of one resident observed with a tracheostomy. The facility failed to ensure the proper processing of lines and accessibility to hand washing station in the laundry. (Resident R130) Findings include: Review of Facility Policy on Infection Control Program Overview dated October 24, 2022, revealed that under section Purpose: The facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Under section Goals: The goal of the infection control program are to provide a safe, sanitary and comfortable environment, prevent the development and transmission of communicable diseases and infections, ensure compliance with state and federal regulations relating to infection control. Under sections Scope of the infection…

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 interviews with resident and staff, it was determined that the facility failed to ensure a safe sanitary and functional environment for 6 residents and 15 residents rooms of two floors (Resident R1, R2, R3, R10, R14, R15; First, A, B, C and Second floor nursing units). Finding Include: Interview with Resident R1 on March 15, 2024, at 10:41 a.m. observations were made a dirty left over breakfast and of a take out order of scrambled eggs, steak and pasta . Resident R1 reported that it has been on her bedside dresser for two days and it's still here. Observations of Resident R1's restroom revealed a takeout container with dirty water being soaked on the top the toilet lid. Resident R1 reported that that container belonged to her roommate, Resident R2 who was interviewed at this time and reported that she does not desire to keep that container and is unsure why it's on the toilet. The restroom also had two basins on the floor. Interview and observations were completed on March 15, 2024, at…

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

Based on review of facility policy, and interviews with residents and staff, it was determined that the facility failed to establish grievance policies and procedures that include the right to file a grievance for 2 of 13 residents reviewed. Findings include: Review of facility policy titled Grievance Policy revealed each resident has the right to voice grievances to the facility or other agency or entity that hears grievances without discrimination or reprisal and without fear of discrimination or reprisal . Interview with Resident R2 on March 15, 2024, at 10:41 a.m. revealed that call bell response being a problem, last weekend it took two hours to get a response. Resident R2 did notify administration and he reported that I'll take care of it. Interview with Resident R1 on March 15, 2024, at 10:43 a.m. revealed that call bell response being a problem and last weekend it took couple of hours for her call bell to be answered. The call bell response is the worse during the shift form 3PM-11PM, 11PM-7AM and weekends. Resident R1 also complained about food taste being horrible and that…

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

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 provide written notice, including reason for the change, prior to moving a resident to another room, for one of 38 residents reviewed (Resident R40). Findings include: Review of facility policy, Room change/Roommate Assignment dated April 1, 2022, revealed, Prior to changing a room or roommate assignment all parties involved in the change/assignment will be given advance notice of such change. Continued review revealed, The notice of a change in room or roommate assignment may be oral or in writing, or both, and will include the reason(s) for such change. Further review revealed, Information regarding transfers will be documented in the resident's medical record. Review of Resident R40's care plan revealed that he was admitted to the facility on [DATE], and that he had impaired visual function, hearing deficits and ambulation deficits. Continued review of Resident R40's care…

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 employee record reviews of newly hired employees, interviews with staff and reviews of facility policies and procedures, it was determined that for one of five employee records reviewed that the facility failed to initiate and complete a federal criminal back ground check. Finding include: A review of the policy titled abuse revealed that it was the facility's responsibility to ensure that each resident was free from abuse. The policy also indicated that the residents will be protected from abuse, neglect and harm by the facility's implementation of abuse and neglect detection and prevention by prescreening of newly hired employees. The procedure for employee screening included a criminal background check for prospective employee in accordance with State and Federal Regulations. A review of the employee E7's personnel file revealed that this employee was hired on August 16, 2023, as a licensed practical nurse. The file indicated that Employee E7 had lived out of Pennsylvania during the prior two years before employement at the facility. There was no documented federal…

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 and the review of clinical record, it was determined that the facility failed to ensure a complete and through investigation for an injury of unknown origin for 1 out of 39 residents reviewed (Resident R17). Findings include: Review of the facility's abuse policy with a revision date of October 24, 2022, indicated that reports of abuse are promptly and thoroughly investigated. Review of the September 2023 physician orders for Resident R17 included the following diagnosis: chronic kidney disease (a gradual loss of kidney function occurs over a period); diabetes (a chronic health condition that is characterized by sustained high blood sugar levels); dementia (the loss of cognitive functioning such as thinking, remembering, and reasoning); osteoarthritis and osteopenia (an individual's bones are weaker than normal, but not so far gone that they break easily). Review of the resident's Significant Change Minimum Data Set (MDS- a periodic assessment of a resident's needs) dated, April 26, 2023 indicated that the resident was severely cognitively impaired. Review of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policies and documentation, clinical record reviews and interviews with staff, it was determined that the facility failed to develop and implement comprehensive person-centered care plans related to caregiver preferences, and substance use disorder for two of 38 residents reviewed (Residents R9 and R183). Findings include: Review of facility policy, Baseline Care Plan, Comprehensive Care Plan and Ongoing Care Plan Updates dated April 1, 2022, revealed, The facility will develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, an mental and psychosocial needs that are identified in the comprehensive assessment. Review of Resident R9's care plan, dated last revised May 3, 2023, revealed that the resident had an activities of daily living self-care performance deficit related to a right leg amputation (surgical removal or part 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 reviews and interviews with staff, it was determined that the facility failed to obtain physician orders related to blood sugar monitoring (Resident R9) and failed to follow physician orders related to weights (Resident R22) for two of 38 residents reviewed. Findings include: Observation of morning medication pass, on September 12, 2023, at 10:04 a.m. revealed Employee E13, licensed nurse, obtained Resident R9's blood sugar. Review of Resident R9's active physician orders on September 12, 2023, at 12:22 p.m. revealed that the resident was not prescribed any blood sugar checks. Review of progress notes for Resident R9 revealed a nurse practitioner note, dated September 11, 2023, at 2:29 p.m. which indicated that the resident had a diagnoses of diabetes (ability to produce or respond to the hormone insulin is impaired, resulting in abnormal metabolism of carbohydrates and elevated levels of glucose), was prescribed diabetes medications including Januvia, metformin 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.

Basedoninterviewswithresidentsandstaffandreviewofclinicalrecords itwasdeterminedthatthefacilityfailedtoensurethatoneresidentparticipatedintherestorativecarenursingprogramtomaintain improve orpreventavoidabledeclineinrangeofmotionandmobilityfor2 outof38 reviewed(ResidentR6 andR61). Findingsinclude Reviewofthefacilitypolicy SpecializedRehabilitativeandRestorativeServices datedApril1, 2022 indicatedthatthefacilitywillproviderestorativeservices suchas butnolimitedtowalking transfertraining bowelandorbladdertraining bedmobility rangeofmotion splintandbrace eatingandorswallowing amputationprosthesescareandcommunication whennecessary asindictedbytheassessmentoftheinterdisciplinaryteam ReviewoftheSeptember2023 physicianordersforResidentR61 includedthefollowingdiagnosis hypertension(highbloodpressure; seizures(asudden uncontrolledburstofelectricalactivityinthebrainthatcancausechangesinbehavior movements feelingsandlevelsofconsciousness; schizophrenia(amentaldisordercharacterizedbyfalsebeliefs sensingsomethingthatisnotreallypresent disorganizedthoughts speechandbehavior;…

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 staff and residents, and review of clinical record, it was determined that the facility did not provide a safe environment related to possession of disposable razors for one of 38 residents (Resident R133). Findings include: An observation on September 13, 2023 at 2:30 p.m. revealed a disposable razor on top of a dresser in Resident R133's room. Interview on September 13, 2023 at 2:30 p.m. with Resident R133 revealed, That is my razor. I shaved myself today. Nobody is going to put a razor to my face except me. Review of Resident R133's clinical health record revealed Resident R133 was admitted to the facility on [DATE] with the following diagnoses: arthritis due to bacteria right knee; chronic pain syndrome; type 2 diabetes mellitus; major depressive disorder, recurrent; post-traumatic stress disorder; other psychoactive substance dependence; gastro-esophageal reflux disease; nicotine dependence, cigarettes; unspecified abnormalities of gait and mobility; nontraumatic…

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, interviews with staff and residents and reviews of policies and procedures, it was determined that the facility failed to ensure that each resident maintained acceptable parameters of nutritional status for body weight and laboratory values for two of eight residents reviewed. (Residents R96 and R97) Findings include: A review of the undated policy titled nutritional assessment revealed that the registered dietitian was responsible for documentation of the assessment of each resident's nutritional status upon admission and during the resident's stay. The registered dietitian was also responsible for the implementation of nutrition interventions, monitoring and evaluations to ensure that the optimal, resident centered care was provided for each resident. Clinical record review for Resident R96 revealed a quarterly comprehensive assessment dated [DATE] that indicated this resident was cognitively impaired This assessment also indicated that Resident R96 was not on a 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.

Based on observation of medication administration, review of clinical records, facility policies and procedures, and interviews with staff, it was determined that the facility failed to ensure the medication error rate was less than five percent. Findings include: The facility's medication error rate was 6.45 percent based on observation of 31 medication administration opportunities with two medication errors observed. Review of facility policy, Administering Medications dated April 1, 2022, revealed, The individual administering the medication must check the label to verify the right medication, right dosage, right time and right method of administration before giving the medication. Observation of the morning medication pass on September 12, 2023, at 9:26 a.m. revealed Employee E12, licensed nurse, prepared one tablet of enteric coated aspirin (a medication to prevent and to treat heart attacks, to prevent strokes, and to treat inflammation) 81 mg (milligrams) and one tablet of omeprazole (medication used to treat acid reflux) delayed release 20 mg for Resident R18. Employee E12,…

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 interviews with staff, it was determined that the facility failed to ensure that medications were properly stored and labeled in two of five medication carts reviewed (Second floor B and C Wing medication carts). Findings include: Review of facility policy, Medication Storage dated September 6, 2019, revealed, All medications will be stored in a locked cabinet, cart or medication room that is accessible only to authorized personnel. Review of facility policy, Administering Medications dated April 1, 2022, revealed, When opening a multi-dose container, place the date on the container. Review of facility policy, Insulin (injectable medication used to lower blood sugar levels) vials - Expiration Dates After Opening dated July 6, 2023, revealed: Vials of Lantus insulin expire 28 days after opened; Vials of Novolog insulin expire 28 days after opened; Vials of Humalog insulin expire 28 days after opened; Vials of Humulin 70/30 insulin expire 31 days after opened; Vials of Lispro insulin expire 28 days after opened. Review of…

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

Based on clinical record reviews, observations of the food and nutrition department, reviews of food committee meeting minutes and interviews with residents and staff, it was determined that the facility failed to provide residents with nourishing, palatable, well-balanced diets that met their daily nutritional and special dietary needs for 2 of four nursing units observed (first floor nursing and second floor nursing unit ). Findings include: Interview on September 11, 2023, at 11:13 a.m. Resident R164 stated that the food was not good, juice and condiments were not served at meals and that milk products served were not consistent. Interview on September 11, 2023, at 12:24 p.m. Resident R61 stated that the food was terrible, that meals were often served late, that milk and other meal items were often missing and that foods served do not match the menus. Observation of the second floor unit B wing hallway revealed that the food truck of lunch trays arrived at 12:11 p.m. Staff began distributing the trays to residents at 12:18 p.m., seven minutes after the trays had arrived.…

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, interview with staff and review of facility policy and procedures revealed that the facility failed to maintain infection control practices related to hand hygiene for one of 38 residents (Resident R285). Findings include: Review of Hand Hygiene Policy dated April 1, 2022 revealed, It is the policy of the facility that handwashing/hand hygiene be regarded as the single most important means of preventing the spread of infections. All employees will wash their hands and any other skin with antimicrobial soap and, or flush mucous membranes immediately or as soon as feasible following contact of such body areas with blood or other potentially infectious materials. Purpose: To prevent and to control the spread of infectious disease. To provide guidelines to staff for proper and appropriate handwashing and hygiene techniques that will aid in the prevention of the transmission of infections. When: 1. Employees must perform at least appropriate twenty second hand washing procedures using antimicrobial or non-antimicrobial soap and water under the following conditions:…

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 files, review of facility polices and interviews with staff, it was determined that the facility failed to provide annual abuse training for two of four employees reviewed for abuse training (Employee E11 and E16). Findings include: Review of facility policy, Abuse dated October 24, 2022, revealed, A yearly in-service on the Abuse Policy and on Resident Rights is mandatory for all employees. Review of Employee E11, registered nurse, personnel file revealed that the employee received abuse training on May 13, 2021. Review of Employee E16, nurse aide, personnel file revealed that the employee received abuse training on May 13, 2021. Continued review of Employee E11 and E16 personnel files revealed that there were no additional training records related to abuse training available for review at the time of the survey. Interview, on September 13, 2023, at 3:41 p.m. the Nursing Home Administrator confirmed that Employees E11 and E16 had not received abuse training since 2021. The Nursing Home Administrator stated that he in-serviced those two employees 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.