Pleasant Acres Rehabilitation And Nursing Center

Based on policy review, clinical record review, and staff interview, it was determined that the facility failed to provide a rationale and duration for expending a PRN (as needed) psychotropic dedication beyond 14 days for one of 41 residents reviewed (Resident 92). Findings include: Review of facility policy, titled Psychotropic medication use, including use in dementia residents, reviewed November 1, 2024, revealed, PRN orders for psychotropic drugs, other than antipsychotics, may not exceed 14 days. Rationale for use extending beyond the 14 days must be documented in the medical record and indicate duration of the PRN order. Review of Resident 92's clinical record revealed diagnoses that included anxiety disorder (group of mental health conditions characterized by excessive and persistent fear or worry, significantly impacting daily life and functioning) and depression (major loss of interest in pleasurable activities, characterized by change in sleep patterns, appetite, and or daily routine). Review of Resident 92's physician's orders revealed an order for Lorazepam (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 review of facility policy, observations, and staff interviews, it was determined that the facility failed to store and serve food/beverages in accordance with professional standards regarding the operation of the dish machine in the kitchen. Findings include: Review of facility policy, Dish Machine Temperatures, revised April 5, 2024, read, in part, dish machine final rinse temperatures should be maintained at temperature not less than those established by the Food and Drug Administration, high temperature dish machine will be no less than 180 degrees Fahrenheit (F). Observation of the dish machine on March 17, 2025, at 9:32 AM, the final rinse temperature registered 176 degrees F. Observation of the dish machine temperature log for March 1st through 17th, 2025, breakfast read, in part, the final rinse temperature was documented below 180 degrees F for all meals. During an interview with the Employee 8 (Food Service Director) on March 17, 2025, at 9:34 AM, it was revealed the final rinse temperature should be 180 degrees F . It was also revealed that the documented final…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff interviews, it was determined that the facility failed to ensure that the resident assessment accurately reflected the resident's status for three of 41 residents reviewed (Residents 21, 259, and 351). Findings Include: Review of Resident 21's clinical record revealed diagnoses that include anoxic brain damage (occurs when the brain is completely deprived of oxygen, leading to brain cell death and potential long-term impairments) and gastro-esophageal reflux disease (a chronic condition where stomach contents flow back up into the esophagus, causing irritation and various symptoms). Review of Resident 21's Significant change MDS (Minimum Data Set is part of federally mandated process for clinical assessment of all Medicare and Medicaid certified nursing homes) dated December 19, 2024, revealed in Section O0110. Special Treatments, Procedures, and Programs, that Resident 21 has not been treated for in the previous 14 days while a resident. Review of Resident 21's…

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

Based on observations, clinical record review, and staff interviews, it was determined that the facility failed to review and revise the resident's care plan to reflect the resident's current status for two of 41 residents reviewed (Residents 161 and 327). Findings include: Review of Resident 161's clinical record revealed diagnoses that included cerebral vascular accident and peripheral vascular disease (a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs). Review of Resident 161's POLST (Pennsylvania orders for Life-Sustaining Treatment) and advance directive (a form to make health care decisions for the individual if the individual loses the capacity to make health care decision) on March 19, 2025, revealed the Resident desired his code status be do not resuscitate (DNR). Review of Resident 161's March 2025 physician orders revealed the Resident desired his code status DNR. A review of Resident 161's care plan dated March 2025 stated, wants to be full code. With a created date of September 30, 2024. A review of the progress notes 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.

Based on staff interviews, record review, and the facility's licensed staff scope of practice, it was determined that the facility failed to follow professional standards of practice when transcribing orders and administering medications to one of 41 residents reviewed (Resident 144). Findings include: Review of the Pennsylvania Nursing Practice Act for Licensed Practical Nurses (LPN), Chapter 21.145. revealed Functions of the LPN. (a) The LPN is prepared to function as a member of the health-care team by exercising sound nursing judgement based on preparation, knowledge, experience in nursing and competency. The LPN participates in the planning, implementation and evaluation of nursing care using focused assessment in settings where nursing takes place. (1) An LPN shall communicate with a licensed professional nurse and patient's healthcare team members to seek guidance when the patient's care needs exceed the licensed practical nursing scope of practice. Review of the clinical record for Resident 144 revealed diagnoses that included dysphagia following nontraumatic subarachnoid…

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, clinical record review, and staff interviews, it was determined that the facility failed to maintain adequate personal hygiene and grooming of residents dependent on staff for assistance with these activities of daily living for one of 41 residents reviewed (Resident 120). Findings include: Review of Resident 120's clinical record revealed diagnoses that included dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life) and muscle weakness. Review of Resident 120's care plan revealed that she was a self care deficit and required assistance with most activities of daily living. Further review revealed that she removes her footwear and walks barefoot. Observation of Resident 120 on March 18, 2025, at 9:42 AM, revealed her asleep in bed. Her feet were exposed, and she was barefoot. A significant accumulation of dark black soiling was present on the soles of her feet. Observation of the floor in Resident 120's room revealed it felt dusty/gritty and had a dark buildup around the edges 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.

Based on facility policy, review of the clinical records, and staff interviews, it was determined that the facility failed to ensure care and services are provided in accordance with physician orders for three of 41 residents reviewed (Residents 121, 221, and 338). Findings include: Review of facility policy, Medication Administration/Disposition, last revised September 6, 2023, read, in part, medications shall be administered in a safe and timely manner, and as prescribed by the physician. Medications must be administered within one hour of their prescribed time. The individual administering the medication must check the label three times to verify the right resident, right medication, right dosage, right time and right method or rout of administration before giving the medication. 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 Medication Administration Record (MAR - an electronic record of medication administration) to indicate the medication was not…

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, clinical record review, and staff interviews, it was determined that the facility failed to maintain complete and accurate records related to dialysis communication for one of two residents reviewed who received dialysis services (Resident 96). Findings Include: Review of facility policy, Dialysis Management, last revised March 28, 2024, read, in part, interchange of information necessary for the care of the resident, communication form is placed in the binder after completion of the pre dialysis assessment and sent to dialysis with the resident; dialysis center personnel to complete Dialysis communication form and return to facility; upon return the facility is to review information provided on the communication form and address as priorate; facility is to complete post-dialysis information/data and place in resident's medical record; and obtain resident's dry weigh from dialysis center, post treatment documentation. Review of Resident 96's clinical record documented diagnoses that included congestive heart failure (the heart doesn't pump blood…

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

Based on clinical record review, facility policy review, and staff interviews, it was determined that the facility failed to ensure Medication Regimen Reviews were completed by a consultant pharmacist and responded to in a timely manner by the attending physician or prescriber for two of 41 residents reviewed (Residents 90 and 144). Findings include: Review of facility policy, titled Medication Regimen Reviews, reviewed May 2024, revealed, 4. If the Attending Physician declines or otherwise rejects the Consultant Pharmacist's non-urgent Recommendation, an explanation as to the rationale for the rejection shall be documented in the Resident's medical record. Review of Resident 90's clinical record revealed diagnoses that included schizoaffective disorder (a chronic mental health condition characterized primarily by symptoms such as hallucinations or delusions, and symptoms of a mood disorder, such as mania and depression) and anxiety disorder (group of mental health conditions characterized by excessive and persistent fear or worry, significantly impacting daily life and…

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

Based on observations and staff interview, it was determined that the facility failed to maintain a clean, comfortable, homelike interior on one of five units observed (5th floor). Findings include: Observations on August 27, 2024, at the noted times revealed the following: 11:28 AM and 1:30 PM - debris and soiled areas on the floor were noted under and around the head of Resident 1's bed. 11:33 AM and 1:30 PM - a dried liquid spill was present on the door of Resident 3's room. A vitals monitor located in the hallway outside of Resident 3's room was observed to have spots of debris on the machine, and the base of the stand had multiple spots of debris and dried soiled areas. Additionally, a dried liquid spill was present on the wall and baseboard in the hallway outside of Resident 3's room. 11:37 AM and 1:30 PM - multiple ants were gathered around a dropped piece of food next to Resident 4's bed, dried spills were present on the legs of Resident 4's bed, and multiple spots/smears of debris were present on the fall mat next to Resident 4's bed. Debris was present around and under…

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 policy review, clinical record review, and resident and staff interviews, it was determined that the facility failed to develop and implement a comprehensive person-centered plan of care for three of 35 residents reviewed (Residents 220, 291, and 317). Findings Include: Review of the facility's policy, titled Care Planning Process and Care Conference, revised July 2023, read, in part, the facility will develop a comprehensive, resident centered care plan for each resident/patient. Care plan development, renewal and revision will be based upon the results of the resident assessment. The care plan is a working tool that provides a profile of the needs of the individual resident/patient; the resident/patient care plan will be available for use by staff caring for the resident. Review of Resident 220's clinical record revealed diagnoses that included muscle weakness and portal vein thrombosis (a narrowing or blockage of the portal vein by a blood clot). Review of Resident 220's physcian's orders revealed the medication Eliquis prescribed two times per day for thrombosis, dated…

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

Based on facility policy review, clinical record review, facility document review, and staff interviews, it was determined that the facility failed to ensure resident medication regimens were free from unnecessary psychotropic medication for one of five residents reviewed for unnecessary medications (Resident 224). Findings include: Review of facility policy, titled Psychotropic Medication Use, Including Use in Dementia Residents, last reviewed March, 2024, revealed the policy stated, Based on a comprehensive assessment of a resident the Facility will ensure that residents who have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the medical record .Psychotropic medications will be prescribed at the lowest possible dosage for the shortest duration of time to effectively treat the target mood/behavior; they are subject to gradual dose reduction, unless clinically contraindicated, and re-reviewed .Antipsychotic medications may be prescribed for residents with dementia but only after…

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 select facility document review, clinical record review, observations, and staff interviews, it was determined the facility failed to ensure the menu was followed at one of one meal observed, and failed to ensure residents on therapeutic diets needs were met for two of 52 residents observed (Residents 121 and 338). Findings include: Review of the menu extension sheet for the lunch meal on April 24, 2024, revealed residents that ordered the main meal on the regular diet should be served Italian sausage with peppers and onions as their entrée. Observation in the main kitchen during tray line meal service on April 24, 2024, between 11:59 AM and 1:15 PM, failed to reveal onions and peppers being served with the Italian sausage for the main meal. Interview with Employee 2 (Dietary Manager) on April 24, 2024, at 1:25 PM, revealed she was working in the back of the kitchen during meal service, and she will follow-up about the onions and peppers not being served. During an interview with the Nursing Home Administrator (NHA) on April 24, 2024, at 2:18 PM, the surveyor revealed 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 menu extension sheet review, observations, and staff interviews, it was determined the facility failed to ensure residents were served food prepared in a form designed to meet their individual needs for 13 of 52 residents observed at one of one meals observed (Residents 17, 43, 81, 90, 97, 111, 165, 170, 188, 193, 220, 311, and 338). Findings include: Review of the menu extension sheet for the lunch meal on April 24, 2024, revealed residents who are on the chopped texture diet should be served four ounces of pastina pasta instead of bowtie pasta. Observation in the main kitchen during tray line meal service on April 24, 2024, between 11:59 AM and 1:15 PM, revealed the tray tickets for Residents 17, 43, 81, 90, 97, 111, 165, 170, 188, 193, 195, 220, 311, and 338 notated they were ordered a chopped diet texture and should be served the pastina pasta instead of bowtie pasta. Further observation in the main kitchen during tray line meal service on April 24, 2024, between 11:59 AM and 1:15 PM, revealed Residents 17, 43, 81, 90, 97, 111, 165, 170, 188, 193, 195, 220, 311, and 338…

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 policy review, observation, and staff interviews, it was determined that the facility failed to ensure that care and services were provided in a manner that enhanced or maintained resident dignity for one of 35 residents observed (Resident 146). Findings include: Review of facility policy, titled Dignity and Respect, revised May 2023, revealed, Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect .Residents shall be treated with dignity and respect at all times. 'Treated with dignity' means the resident shall be assisted in maintaining and enhancing his or her self-esteem and self-worth. Review of Resident 146's clinical record revealed diagnoses that included Alzheimer's disease (gradually progressive brain disorder that causes problems with memory, thinking, and behavior) and major depressive disorder (mental disorder characterized by at least two weeks of low mood that is present across most situations). Observation on April 22, 2024, at 1:45 PM, revealed Resident 146 ambulating in the hallway. Resident 146 was wearing…

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

Based on clinical record review, observations, and staff interview, it was determined that the facility failed to ensure that resident needs were accommodated regarding call bell accessibility for two of 35 residents reviewed (Residents 39 and 271). Findings include: Review of Resident 39's clinical record revealed diagnoses that included morbid obesity (a complex disease involving having too much body fat, which increases the risk of many other health problems), difficulty in walking, and muscle weakness. Observation in Resident 39's room on April 22, 2024, at 12:46 PM, revealed she was in bed during lunchtime and her call bell was on the floor. Observation in Resident 39's room on April 22, 2024, at 1:49 PM, revealed she was finished with lunch, her lunch tray was gone, and her call bell remained in the same place on the floor. Review of Resident 39's care plan on April 22, 2024, revealed a focus area of: [Resident 39] is at risk for falls related to new and unfamiliar environment, deconditioning (changes in the body that occur during a period of inactivity), and weakness, last…

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, facility policy review, clinical record review, and staff interview, it was determined that the facility failed to provide the resident personal privacy during medical treatment for one of 38 residents reviewed (Resident 93). Findings Include: Review of facility policy, titled Dignity and Respect, last reviewed May 2023, revealed, Staff shall maintain an environment in which confidential clinical information is protected. Review of Resident 93's clinical record revealed diagnoses that included peripheral artery disease (a vascular disorder that causes arteries to narrow abnormally, reducing blood flow to the limbs) and cerebrovascular disease (a group of conditions that affect blood flow and the blood vessels in the brain). Observation of Resident 93 on April 22, 2024, at 1:34 PM, revealed Resident 93 sitting in her wheelchair in the middle of the hallway with five other residents in the hallway. Employee 5 approached Resident 93 in the hallway and notified her that, as a result of a recent consultation, they were recommending that Resident 93 have an above the…

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

Based on observations and resident and staff interviews, it was determined that the facility failed to maintain a safe, clean, comfortable, and home-like environment for two of 35 residents observed (Residents 220 and 258). Findings include: Observation on April 22, 2024, at 12:11 PM, revealed that Resident 220's bilateral wheelchair armrests had vinyl covering that was cracked and torn away on the sides. Further observation revealed the foam stuffing was protruding from both armrests. An immediate interview with Resident 220 revealed that she utilizes the wheelchair every day for mobility, and that the wheelchair belonged to the facility. During an interview with the Nursing Home Administrator (NHA) on April 25, 2024, at 10:53 AM, the NHA stated that maintenance and therapy personnel are assessing the wheelchair at that time to determine replacement and repair. During an interview with the NHA on April 25, 2024, at 11:51 AM, the NHA stated that the facility performs periodic inspections, but this wheelchair was not observed, and acknowledged the wheelchair armrests will be replaced…

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

Based on clinical record review, facility document review, and staff interview, it was determined that facility failed to provide an appropriate rationale to a pharmacy recommendation, resulting in the continuance of an antipsychotic medication for indications that were not present, for one of five residents reviewed for unnecessary medications (Resident 224). Findings include: Review of Resident 224's clinical record, revealed diagnoses that included unspecified dementia (irreversible, progressive degenerative disease of the brain that results in decreased reality awareness and decreased ability to perform activities of daily living) unspecified severity without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, and major depressive disorder (condition of persistently low mood, that may include symptoms of decrease interest in pleasurable activities, lack of energy, and/or sleep disturbance). Review of Resident 224's clinical record revealed that on November 14, 2023, Hospice services ordered the addition of Seroquel (antipsychotic medication used to…

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

Based on observations, policy review, and staff interview, it was determined that the facility failed to follow infection control standards for two of five residents observed for medication administration (Residents 93 and 281). Findings include: Review of facility policy, titled Medication Administration/Disposition, last reviewed June, 2023, revealed that subsection 21 of Procedures, stated, Staff shall follow established facility infection control procedures (e.g., hand hygiene, gloves, [i]solation precautions, etc) for the administration of medications prior to and after medication [a]dministration. During medication administration observations on April 25, 2024, at approximately 8:52 AM, Employee 7 was observed preparing medications for administration to Resident 281. During preparation of the medications, Employee 7 was observed dispensing one tablet of vitamin D 25 micrograms (mcg - metric unit of measure) from a multidose container into her bare hand. Employee 7 then placed the tablet from her hand into a medicine cup. Employee 7 then completed preparation of medications 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 facility policy review, clinical record reviews, and staff interviews, it was determined that the facility failed to timely notify a resident's physician of a change in condition for two of four residents reviewed (Residents 1 and 4); and failed to notify a resident's responsible party of a change in condition and/or treatment changes for four of four residents reviewed (Residents 1, 2, 3, and 4). Findings include: Review of facility policy, titled Change in Condition, with a last revised date of June 28, 2023, revealed the following: The Clinical Nurse will recognize and appropriately intervene in the event of a change in resident condition. The Facility will notify the resident, attending physician and resident representative of changes in the resident' s condition and/or status; 1. If the CNA [Certified Nurse Assistant] identifies a change in resident's condition he/she will immediately notify the nurse of the situation. 2. The nurse will communicate to the nurse manager/supervisor any change in…

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

Based on facility policy review, clinical record review, facility incident report review, and staff interviews, it was determined that the facility failed to ensure that residents received adequate assistance to prevent accidents for one of three residents reviewed (Resident 3); and failed to ensure that a thorough investigation was conducted following falls for two of three residents reviewed (Residents 3 and 4). Findings include: Review of facility policy, titled Incident Reporting and Investigation of Accident Hazards, Supervision, Assistive Devices, with a last revised date of January 17, 2023, revealed the following, in part: The Facility will thoroughly investigate any adverse occurrence which is not consistent with the routine operation of the Facility or care of a resident(s); 3. Complete the incident report: a. Collect information that is related to the facts and circumstances of the incident being investigated; e. Interview all potential witnesses; obtain information about what was actually observed; Data Analysis: a. Summarize analysis of facts gathered that: Establish…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy review, clinical record review, and staff interviews, it was determined that the facility failed to ensure care and services were provided in accordance with professional standards for one of four residents reviewed (Resident 4). Findings Include: Review of facility policy, titled Change in Condition, with a last revised date of June 28, 2023, revealed the following, in part: The Clinical Nurse will recognize and appropriately intervene in the event of a change in resident condition. The Facility will notify the resident, attending physician and resident representative of changes in the resident's condition and/or status; 1. If the CNA [Certified Nurse Assistant] identifies a change in resident's condition he/she will immediately notify the nurse of the situation; 2. The nurse will communicate to the nurse manager/supervisor any change in resident condition as it occurs. This will also be communicated in the 24 hour/and or shift report as well; and 4. If a significant change in condition…

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 and resident and staff interview, it was determined that the facility failed to maintain a safe, clean, home-like interior on three of five nursing units observed (100, 200, and 300 units). Findings include: Observations on February 7, 2024, revealed the following: - 9:40 AM and at 1:48 PM in the 100 unit visiting lounge: an accumulation of dust and debris on the side frame and rungs of the double seat chair. Additionally, a wheelchair leg and bunched up blanket were present on top of the cabinet. - 9:42 AM and at 1:48 PM in the 100 unit hallway bathroom: the curtain in the 100 unit hallway bathroom had multiple holes present in the top mesh portion of the curtain. - 9:44 AM and 1:48 PM in the 100 unit main dining room: a pile of soiled linens including a hospital gown, blankets, towels, and sheet, as well as a clean incontinence brief were present on the countertop near the sink. The sink was noted to be discolored, and dried streaks of liquid were present on the wall behind the sink and on the cabinet below the sink. The grout to the left side of the sink was…

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

Based on clinical record review and staff interview, it was determined that the facility failed to ensure care and services were provided in accordance with professional standards of practice to meet each resident's physical, mental, and psychosocial needs for one of 13 residents reviewed (Resident 9). Findings Include: Review of Resident 9's clinical record revealed diagnoses that included dementia with agitation (loss of memory, language, problem-solving, and other thinking abilities that are severe enough to interfere with daily life) and major depressive disorder (mental disorder characterized by at least two weeks of low mood that is present across most situations). Review of Resident 9's December 2023 and January 2024 MARs (Medication Administration Records - form used to document physician orders as well as when and how medications are administered to a resident) revealed that the following medications were not documented as being administered per physician orders on the noted dates: Lexapro (antidepressant) on December 16 and 22, 2023, and on January 6 and 24, 2024;…

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

Based on clinical record review, policy review, observations, and staff interviews, it was determined that the facility failed to provide respiratory care consistent with professional standards of practice for one of six residents reviewed for respiratory care (Resident 5). Findings include: Review of facility policy, titled Hand Held Nebulizer/ Small Volume Nebulizer, revised March 2020, revealed Drain any excess medication form nebulizer at end of treatment, rinse if needed. Store nebulizer equipment in a storage bag. Review of Resident 5's clinical record revealed diagnoses that included Parkinson's Disease (long-term movement disorder where the brain cells that control movement start to die and cause changes in how one moves, feels, and acts) and heart disease (refers to problems affecting the heart). Review of Resident 5's orders revealed an order for Albuterol Sulfate Inhalation Nebulization Solution (relaxes muscles in airways of the lungs for easier breathing) via nebulizer (turns liquid medicine into a fine mist that can be inhaled through a face mask or mouthpiece) four…

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.