York North Skilled Nursing And Rehabilitation Ctr

Based on policy review, clinical record review, and staff interview, it was determined that the facility failed to ensure its residents receive treatment and care in accordance with professional standards of practice and the person-centered, comprehensive plan of care for one of four residents reviewed (Resident 3). Findings Include:Review of the facility's policy, titled Medication Administration, dated 2007, read, in part, Medications are administered in accordance with written orders of the prescriber.Review of Resident 3's physician orders revealed diagnoses that included Atrial Fibrillation (an irregular and very rapid heart rhythm that can lead to blood clots, stroke, and heart failure) and anxiety (characterized by intense worry, fear, or panic that interferes with daily life, often involving physical symptoms like a racing heart or sweating).Review of Resident 3's Medication Administration Record (MAR), dated December 1-31, 2025, revealed an order that read Amiodarone HCL Oral Tablet 200 MG .Give 1 tablet by mouth two times a day for A-Fib [Atrial Fibrillation] . start 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 in review of facility policy, documentation provided by the facility, clinical record review, and staff interviews, it was determined that the facility failed to protect the resident's right to be free from involuntary seclusion by a staff member (Resident 1).Findings include: Review of the facility policy and procedure, titled Abuse Prohibition, revised October 24, 2022, read, in part, the Center prohibits abuse, mistreatment, involuntary seclusion. Involuntary seclusion is definition included confinement of a resident to their room against the resident's will. Anyone who witnesses an incident of suspected abuse is to tell the abuser to stop immediately and report the incident to her/her supervisor immediately, regardless of shift worked. The notified supervisor will report the suspected abuse immediately to the Administrator. The employee alleged to have committed the act of abuse will be immediately removed from duty, pending investigation. Initiate an investigation within 24-hours of an allegation 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 review and staff interviews, it was determined that the facility failed to notify the resident/resident representative and the representative of the Office of the State Long-Term Care Ombudsman of resident transfers in writing to include the following: the reason for the transfer or discharge, date of transfer, location of transfer, statement of the resident's appeal rights, and name, address (mailing and email) and telephone number of the Office of the State Long-Term Care Ombudsman for three of four resident records reviewed regarding hospitalizations (Residents 37, 66, and 121). Findings include: Review of the clinical record for Resident 37 on February 11, 2025, revealed clinical diagnoses that included obstructive uropathy (a condition that causes a retention of urine), diabetes mellitus (the body has trouble controlling blood sugar). Further review of Resident 37's clinical record revealed transfers to the hospital on June 20, 2024, and October 24, 2024. The surveyor requested copies of the transfer, bed hold, and Ombudsman notification. The Ombudsman…

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, and staff interviews, it was determined that the facility failed to develop and implement a comprehensive person-centered care plan for three of 37 residents reviewed (Residents 10, 14, and 57). Findings Include: Review of the facility's policy, titled Person-Centered Care Plan, revised October 24, 2022, read, A comprehensive person-centered care plan must be developed for each patient. Review of the clinical record for Resident 10, revealed clinical diagnoses that included neurogenic bladder (a condition that occurs when the nervous system's connection to the bladder is disrupted), diabetes mellitus (the body has trouble controlling blood sugar), pneumonia (lung infection), and three Stage 4 chronic pressure ulcers (wounds that extend deep in the tissue, exposing muscle, tendon, or bone and a high risk of infection). Further review of Resident 10's clinical record revealed Resident 10 was required to have enhanced barrier precautions (EBP-infection control precaution measures) due to his internal devices supra pubic catheter (external…

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 resident 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 two of two residents reviewed for activities of daily living (Residents 112 and 117). Findings include: Review of Resident 112's clinical record revealed diagnoses that included chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe) and chronic heart failure (when the heart muscle does not pump blood as well as it should). During an interview with Resident 112 on February 10, 2025, at 9:51 AM, revealed the Resident does not always receive showers on their shower days. Resident 112 revealed her shower days are on Wednesdays and Saturdays, but due to short staff, Saturday showers often get missed. Resident 112 revealed she did not receive a shower as scheduled for this previous Saturday (February 8, 2025).…

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 the clinical record, and staff interviews, it was determined that the facility failed to ensure care and services are provided in accordance with professional standards of practice that will meet each resident's physical, mental, and psychosocial needs for three of 33 residents reviewed (Residents 14, 90, and 252). Findings include: Review of the clinical record for Resident 14 revealed diagnoses that included hospice status (end of life) and chronic diastolic congestive heart failure (a condition where the heart muscle becomes stiff, preventing it from properly filling during the resting phase [diastole]). Further review of the clinical record for Resident 14 revealed hospice status was initiated January 17, 2025, and the physician orders dated February 2025, failed to reveal a physician order for hospice status. During an interview with the Director of Nursing (DON) on February 12, 2025, 10:00 AM, the DON was informed there was no physician order for hospice status upon review…

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, policy review, and staff interviews, it was determined that the facility failed to monitor the resident's nutritional status for four of seven residents reviewed for nutrition (Residents 90, 117, 131, and 252). Findings include: Review of the facility policy, titled NSG244 Weights and Heights last reviewed December 2024, revealed that patients are weighed upon admission and/or re-admission, then weekly for four weeks and monthly thereafter. Review of Resident 90's clinical record revealed diagnoses that included hypertension (high blood pressure) and Alzheimer's disease (a progressive disease that destroys memory and other important mental functions). Review of Resident 90's weights summary task revealed the Resident was not weighed in September 2024, October 2024, November 2024, and January 2025. Review of Resident 90's September 2024 MAR (Medication Administration Record) revealed the monthly weights order was marked as completed, however, no weight was recorded. 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 observation, policy review, review of facility documentation, and resident and staff interviews, it was determined that the facility failed to provide sufficient dining services staff to ensure that resident meals and nourishments were served timely during two of three meals observed (February 11 and 12, 2025). Findings include: Review of facility policy Snacks, Nourishments, Supplements, and Pantry Stock, effective May 1, 2023, read, in part, Food and Nutrition Services delivers snacks to nursing stations at specified times. Resident interviews during the initial pool process revealed resident concerns with meals being served late. Review of Food Committee meeting minutes for October 2024 and November 2024, revealed concerns for meals being served late especially on the weekends, and that the food cart may sit in the hallway for 20 minutes before trays are being passed out. There were concerns with snacks not being offered at the November 2024 meeting. Documented meal service times are as follows: breakfast 7:10 AM - 8:20, lunch 11:35 AM - 12:45 PM, dinner 5:00 PM -…

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 for food safety in the kitchen. Findings include: Review of facility policy, Food and Nutrition Services Use By Dating Guidelines, dated May 1, 2023, read, in part, frozen shakes use by date of 14 days once thawed - use labels for individual items when removed from the carton. Bulk items in large quantities such as flour, sugar and food thickener - use by date six months when opened and transferred to a storage bin. Review of facility policy, Food and Nutritional Services Personal Hygiene, effective date May 1, 2023, read, in part, facial hair coverings are used to cover all facial hair. Observations at the three-compartment sink on February 10, 2025, at 9:30 AM, the test strips expired October 2022. Upon testing sanitizer solution in the third sink, which was in use, it registered 0. The temperature log at the three-compartment sink was documentation of dish machine temperatures for wash and…

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

Based on observation, policy review, and staff interviews, it was determined that the facility failed to maintain a safe environment that supports infection prevention and control for five of 33 residents reviewed (Residents 10, 37, 108, 113, and 119). Findings include: Review of the facility's infection control policy required residents colonized or infected with multi-resistant drug organisms (MDRO), have chronic wounds, or an internal device require enhanced barrier precautions (EBP). EBP is an infection control intervention designed to reduce the transmission of novel or multi-drug resistant organisms. The facility requires EBP signage be placed that directs staff to wear personal protective equipment (PPE) during high contact resident activities. Review of the clinical record for Resident 10 on February 11, 2025, revealed clinical diagnoses that included neurogenic bladder (a condition that occurs when the nervous system's connection to the bladder is disrupted), diabetes mellitus (the body has trouble controlling blood sugar), pneumonia (lung infection), and three Stage 4…

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 resident and staff interviews, policy review, clinical record record review, and facility document review, it was determined that the facility failed to ensure the resident right to receive mail, including packages, in a timely manner for one of one resident reviewed for personal property (Resident 19). Findings include: Review of the facility policy, titled OPS206 Resident Rights Under Federal Law, last reviewed December, 2024, revealed subsection 7.2.8 stated, The resident has the right to send and receive mail, and to receive letters, packages and other materials delivered to the facility for the resident through a means other than a postal service . Further, subsection 8.2 stated, The facility must respect the residents' right to personal privacy .including the right to send and promptly receive unopened mail and other letters, packages and other materials delivered to the facility for the resident . Review of Resident 19's clinical record revealed diagnoses that included anxiety disorder (mental health disorder characterized by excessive fear or worry) and congestive…

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, and staff interview, it was determined that the facility failed to ensure each resident and/or representative the right to formulate an Advance Directive for one of two residents reviewed for Advance Directives (Resident 57). Findings Include: An Advance Directive is defined as a written statement of a person's wishes regarding medical treatment, often including a living will, made to ensure those wishes are carried out should the person be unable to communicate them to a doctor. A review of the facility's policy, titled Health Care Decision Making, revised January 8, 2024, read, It is the right of all patients/residents to participate in their own health care decision making .including the right to formulate or not formulate an advance directive. The policy continued, Approach a capable patient who does not have an advance directive upon admission; the patient will be approached by the Social Worker or another designated staff person on admission, quarterly, and with change in condition to discuss whether he/she wishes to consider…

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 and policy reivew, and staff interviews, it was determined that the facility failed to ensure residents were free from chemical restraints for one of five residents reviewed for unnecessary medication (Resident 143). Findings include: Review of facility policy, titled NSG233 Restraints: Use of, last reviewed December, 2024, revealed it stated it was the facility's policy that, Patients have the right to be free from any physical or chemical restraints imposed for the purposes of discipline or convenience, and not required to treat the patient's medical symptoms. Review of facility document, titled Un[n]ecessary Psychotropic Medications, not dated, revealed subsection titled, Chemical Restraints, stated, Facilities are responsible for knowing the effects medications have on their patients. If a medication has a sedating or subduing effect, and is not administered to treat a medical symptom, the medication acts as a chemical restraint. The sedating/subduing effects to the patient may have been caused intentionally or unintentionally…

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 the Resident Assessment Instrument (RAI- a standardized approach for applying a problem identification process in nursing homes, adopted to examine nursing home quality and to improve nursing home regulation), clinical record reviews, and staff interviews, it was determined that the facility failed to ensure that each resident received an accurate assessment, reflective of the resident's status at the time of the assessment, by staff who are qualified to assess relevant care areas for two of 37 residents reviewed (Residents 10 and 118). Findings include: Review of the RAI Version 3.0 v1.20.1 dated October 1, 2024, section O - special treatments, Coding Instructions for Column b. While a Resident Check all treatments, procedures, and programs that the resident received or performed after admission/entry or reentry to the facility and within the last 14 days. If no treatments, procedures or programs were received by, performed on, or participated in by the resident within the last 14 days or since admission/entry or reentry, check Z, None of the above. 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 clinical record review, facility policy review, and staff interview, it was determined that the facility failed to develop and implement a baseline care plan for one of one resident reviewed for baseline care plans (Resident 252). Findings include: Review of facility policy, titled OPS416 Person-Center Care Plan, last reviewed December 2024, revealed, it stated, The [Facility] must develop and implement a baseline person-centered care plan within 48 hours of admission/readmission for each patient/resident [sic] that includes the instructions needed to provide effective and person-centered care that meet professional standards of quality care . Further review of the aforementioned policy revealed subsection Practice Standards, stated, 1. A baseline care plan must be developed within 48 hours and include the minimum healthcare information necessary to properly care for a patient including, but not limited to: 1.1 Initial goals based on admission orders; 1.2 Physician orders; 1.3 Dietary orders; 1.4…

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 ensure the care plan was reviewed and revised for two of 37 residents reviewed (Residents 59 and 118). Findings Include: Review of Resident 59's clinical record revealed diagnoses that included malignant neoplasm of colon (a cancerous tumor in the colon) and congestive heart failure (a serious condition that occurs when the heart can't pump blood efficiently enough to meet the body's needs). Review of Resident 59's care plan revealed a focus area of, Resident 59 requires indwelling catheter due to terminal illness/comfort measures, with a revision date of December 15, 2024. Observation of Resident 59 on February 10, 2025, at 10:30 AM, revealed Resident 59 lying in bed and no catheter was present. Review of Resident 59's clinical admission assessment (readmission assessment completed at the facility after Resident 59's hospital stay), dated January 6, 2025, revealed that Resident 59's catheter was removed during Resident 59's hospital stay from January 2-6, 2025.…

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, record reviews, and resident and staff interviews, it was determined that the facility failed to provide respiratory care/oxygen services consistent with professional standards of practice for two of 37 residents reviewed (Residents 48 and 77). Findings include: Review of facility policy, Nebulizer: Small Volume, revised November 1, 2023, read, in part, rinse mouthpiece and T piece with sterile water and dry. Place in treatment bag, labeled with patient name and date. Review of Resident 48's clinical record contained diagnoses that included congestive heart failure (the heart doesn't pump blood as well as it should) and chronic obstructive pulmonary disease (COPD-a group of lung disease that block airflow and make it difficult to breathe) Resident 48's physician orders included: Ipratropium-Albuterol (medication used to control symptoms of lung disease) Solution 0.5-2.5 (3) MG/3ML 1 dose inhale orally three times a day for COPD, with a start date January 13, 2025; and Ipratropium-Albuterol Solution 0.5-2.5 (3) MG/3ML 1 dose inhale…

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 interview, it was determined that the facility failed to maintain complete and accurate records related to dialysis communication for one of two residents reviewed for dialysis (Resident 88). Findings include: Review of the facility policy, titled Dialysis Guidelines with a last review date of December 2024, revealed, in part, that collaborative communication forms must be used and include the following information regarding: nutritional/fluid management including documentation of weights, patient compliance with food/fluid restrictions or the provision of meals before, during, and after dialysis, and monitoring intake and output measurements as ordered. Review of Resident 88's clinical record revealed diagnoses that included discitis (an inflammation of the intervertebral discs) and chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe). Review of Resident 88's comprehensive care plan revealed a focus area that Resident 88 is at risk for impaired renal…

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, pharmacy statement review, and staff interviews, it was determined that the facility failed to ensure pharmaceutical services that assured the accurate acquiring and administration of medications were provided that met the needs of each resident for one of 33 resident records reviewed (Resident 252). Findings include: Review of Resident 252's clinical record revealed diagnoses that included type two diabetes mellitus (decreased ability of the body to utilize insulin for the transport of glucose from the blood into the cells for nourishment) and chronic pain syndrome (condition that is characterized by persistent pain that last more than three to six months). Review of Resident 252's admission medication orders revealed an order for benazepril (medication used to treat high/elevated blood pressure) 20 mg (milligrams - metric unit of measure), once a day, which was dated January 30, 2025, with a start date of January 31, 2025. Review of the facility pharmacy medication delivery manifest revealed that on January 31, 2025 (no…

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 resident and staff interviews, the facility failed provide therapy services to ensure residents receive specialized rehabilitative services to assist them to attain, maintain, or restore their highest practical level of physical, mental, functional, and psycho-social well-being for one of 37 residents reviewed (Resident 23). Findings include: Review of Resident 23's clinical record documented diagnoses that included artificial right shoulder joint. Interview with Resident 23 on February 10, 2025, at 10:48 AM, revealed she had right shoulder surgery and was in a sling, but was released from using the sling last Monday (February 3rd, 2025) and was to start therapy to increase range of motion to her right arm and shoulder, and that she is restricted to 1 pound weight limit. She stated that she would like to receive therapy services because she was unsure what stretching exercises were appropriate, however, she wasn't on therapy case load. She also noted that she has had muscle atrophy and wanted to prevent it from getting worse. 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 policy review, clinical record review, and staff interviews, it was determined that the facility failed to ensure all residents receive treatment and care in accordance with professional standards of practice for one of three residents reviewed (Resident 2). Findings Include: A review of the facility's policy, titled Medication Regimen Review, recently reviewed June 1, 2024, read, in part, The consultant pharmacist will conduct MRR's [Medication Regimen Reviews] .and will make recommendations based on the information made available in the resident's health record. The policy continued, Facility should independently review each resident's medication regimen directly from the resident's medical chart and with interdisciplinary care team member, resident, or responsible party, as needed. A review of Resident 2's clinical record revealed diagnoses that included Diabetes Mellitus Type II (A long-term condition in which the body has trouble controlling blood sugar and using it for energy) and hypercholesterolemia (High amounts of cholesterol in the blood). A review of Resident…

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

Based on observation, facility-provided documentation, and resident and staff interviews, it was determined that the facility failed to provide meals at regular times and in accordance with resident needs, preferences, and requests for five of 10 resident areas reviewed for mealtimes and one of three residents reviewed (Resident 1). Findings Include: A review of the facility's document, titled Time Sheet for Cart Services to Stations, dated June 4, 2024, revealed the posted arrival time for the dinner meal on Medbridge #2 at 5:20 PM. A review of the document also revealed the cart left the kitchen at 6:05 PM. The document also revealed the posted arrival time on the C-1 Station at 5:30 PM, and the cart arrival at 6:15 PM; the posted arrival time on the C-2 Station at 5:40 PM, and the cart arrival time at 6:22 PM; and the posted arrival time on the A Station-1 at 5:55 PM, and the cart arrival time at 6:34 PM. An interview and observation with Resident 1 on June 18, 2024, at 1:20 PM, revealed the arrival of the lunch meal cart on the Heritage -1 hall. According to the facility'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, policy review, and resident and staff interviews, it was determined that the facility failed to have sufficient nursing staff to provide nursing and related services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident for one out of five nursing units (Medbridge). Findings Include: Review of the facility's policy, titled NSG101 Call Lights, last review date February 1, 2023, revealed the following: Staff will respond to call lights and communication devices promptly. During an observation on April 23, 2024, at 10:47 AM, Resident 1's call light was noted to be on. The call light remained on until a staff member entered the room at 11:33 AM. During an interview with Resident 1, she stated that her call light was on because she needed to be toileted and expressed concern regarding the wait time for staff response. During an observation on April 23, 2024, at 10:47 AM, Resident 3's call light was noted to be on. On April 23, 2024, at 11:17 AM, a Nurse Aide entered Resident 3's room and proceeded to answer 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 clinical record review, observations, and resident and staff interviews, it was determined that the facility failed to ensure that the resident assessment accurately reflected the resident's status for six of 33 residents reviewed (Resident 3, 10, 67, 111, 118, and 127). Findings Include: Review of the Resident Assessment Instrument, Version 3.0, dated October 2023, Chapter 3, Section L, read, in part, if resident has dentures examine for loose fit. Ask resident to remove denture to examine and complete exam of lips and oral cavity. Review of Resident 3's clinical record revealed diagnoses that included low back pain, depression, and dementia (a chronic disorder of the mental processes caused by brain disease, and marked by memory disorders, personality changes, and impaired reasoning). Review of Resident 3's Quarterly MDS (Minimum Data Set - an assessment tool to review all care areas specific to the resident such as a resident's physical, mental or psychosocial needs) with the assessment reference…

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, facility policy reivew, and staff interviews, it was determined that the facility failed to revise and/or update the resident comprehensive plan of care for six of 30 residents reviewed (Residents 10, 11, 73, 93, 118, and 129). The facility also failed to ensure that care plan meetings included representation from the interdisciplinary team for four of 33 residents reviewed (Residents 10, 11, 93, and 129). Findings include: Review of facility policy, titled Person Centered Care Plan, with a last review date of December 29, 2023, revealed the following: 1) in the section titled Policy, in part, The interdisciplinary team, in conjunction with the patient and/or representative, as appropriate, will establish the expected goals and outcomes of care, the type, amount, frequency, and duration of care, and any other factors related to the effectiveness of the plan of care; 2) in the section titled Purpose that to promote positive communication between patient, patient representative, and team to obtain the patients and resident representative…

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 and resident interviews, facility policy review, and review of facility documents, it was determined that the facility failed to provide an ongoing program of activities designed to meet the needs, interests, and functional abilities for seven of seven months reviewed (September 2023-March 2024) and for five of five residents interviewed (Residents 39, 54, 77, 109, and 132). Findings include: Review of facility policy, Recreation Services Policies and Procedures, Rec202 Program Design, revised August 7, 2023, revealed in step 6, Opportunities for evening entertainment and leisure opportunities are provided. Structured programs are offered a minimum of two times weekly during waking hours, following the dinner meal unless specified as more frequent due to designation as a special care unit. Interviews with five residents (Residents 39, 54, 77, 109, and 132) present at the resident council meeting on March 26, 2024, at 10:20 AM, revealed that the facility didn't provide any activities for the residents in the evening hours, and they were wondering if it was a…

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

Based on clinical record review, policy review, and staff interview, it was determined that the facility failed to ensure physician orders were followed for catheter care for one of four residents reviewed for catheters (Resident 127). Findings include: Review of facility policy, titled Catheter: Indwelling urinary - care of, with a review date of December 29, 2023, revealed 1. Perform catheter care twice a day and PRN (as needed). Section 10. Provide routine hygiene for meatal care, 22. Document, and 22.1 catheter care provided. Review of Resident 127's clinical record on March 27, 2024, at 11:26 AM, revealed diagnoses that included end stage renal disease (condition in which kidneys cease functioning) and obstructive and reflux uropathy (blockage of the urinary tract that causes urine to back up into one or both kidneys). Review of Resident 127's comprehensive plan of care revealed a focus area for use of indwelling urinary catheter needed due to obstructive uropathy/benign prostatic hyperplasia (noncancerous enlargement of the prostate gland), with an intervention for catheter…

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 residents requiring urostomy services receive care consistent with professional standards of practice and based on the comprehensive person-centered plan of care for one of one resident reviewed needing nephrostomy care (Resident 53). Findings Include: A urostomy is defined as an opening in the belly (abdominal wall) that's made during surgery. It re-directs urine away from a bladder that's diseased, has been injured, or isn't working as it should. Review of Resident 53's clinical record revealed diagnoses that included obstructive and reflux uropathy (a disorder of the urinary tract that occurs due to obstructed urinary flow) and a history of urinary tract infection (UTI-An illness in any part of the urinary tract, the system of organs that makes urine and often start when bacteria get into the tube through which urine leaves the body, the urethra). Review of Resident 53's March 2024 physician orders revealed documentation that read Nephrostomy Right-maintain monitor for s/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 review of facility policy, clinical record review, and interviews with staff, it was determined that the facility failed to ensure that residents who require dialysis receive such services consistent with professional standards of practice for one of one residents reviewed for dialysis (Resident 127). Findings include: Review of facility policy, titled Dialysis: Hemodialysis (HD) - External Catheter Evaluation and Maintenance, with a review date of December 29, 2023, revealed section 11. Document, 11.1 Catheter/Site observation q shift. Review of facility policy, titled NSG253 Dialysis: Hemodialysis (HD) - Communication and Documentation, with a review date of December 29, 2023, revealed center staff will communicate with the certified dialysis facility regarding the ongoing assessment of the patient's condition by monitoring for complications before and after hemodialysis (HD) treatments received at a certified dialysis facility. Section titled Practice Standards revealed 1. Prior to a patient leaving the Center for HD, a licensed nurse will complete the top portions 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 observation, review of facility policy, and resident and staff interviews, it was determined that the facility failed to provide food and beverage that were at a safe and appetizing temperature for one of one meals observed on the Heritage Nursing Unit. Findings include: Review of the Food And Nutrition Services Test Tray Evaluation form, not dated, read, in part, hot entrée, starch, and vegetable should be greater than 140 degrees Fahrenheit; and the cold food and beverage should be less than 55 degrees Fahrenheit (F) Interviews with several residents (Residents 3, 36, and 65) during the initial pool process on March 25, 2024, revealed concerns with the temperature and the quality of the food. A test tray was completed on March 26, 2024, on the Heritage Nursing Unit. Test tray temperatures were taken by Employee 2 (Food Service Director 1) on March 26, 2024, at 1:07 PM, and revealed the following: Roast Pork 127 degrees F, not palatable temperature; Green Peas 136 degrees F, not palatable temperature and texture; Mashed Potatoes 146 degrees F, palatable; Vanilla Ice Cream…

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

Based on observations, review of facility policy, and staff interviews, it was determined that the facility failed to store and serve food/beverages in accordance with professional standards for food safety in the kitchen area. Findings include: Review of facility policy, Food And Nutrition Services Use By Dating Guidelines, dated May 1, 2023, read, in part, use manufacture's expiration date, when available, is the use by for unopened items. Ready-to-eat foods, including thickened liquids, are to be used by seven days after opening; frozen foods stored in the freezer use by date within 45 days. Observation in the reach-in refrigerator in the receiving area revealed there were two 46 ounce containers of nectar thickened apple juice, dated received on March 9th; one 46 ounce container of nectar thickened cranberry juice, dated received on March 9th; and one 32 ounce container of nectar thick milk, dated received on March 9th. All aforementioned items were open with contents partially removed and were not date marked with an open or use by date. During an interview with Employee 2…

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 document review and staff interview, it was determined that the facility failed to ensure nurse-aides are sufficient with in-service training, continuing education competencies to include dementia and resident abuse prevention training, and the training be no less than 12 hours per year for five of five nurse aide training documents reviewed (Employees 16-20). Findings Include: Review of Employee 16's employment documentation revealed a hire date of December 10, 2022. Continued review of the documentation revealed Employee 16 to have no annual dementia or abuse prevention training and annual training hours to total 4.5 hours. Review of Employee 17's employment documentation revealed a hire date of December 10, 2022. Continued review of the documentation revealed Employee 16's annual training hours to total 10:44. Review of Employee 18's employment documentation revealed a hire date of December 10, 2022. Continued review of the documentation revealed Employee 16 to have no annual dementia or abuse prevention training and annual training hours to total 1:26 hours. 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, clinical record review, and staff interviews, it was determined that the facility failed to maintain adequate personal hygiene and grooming, transfers, and meal assistance for residents dependent on staff for assistance with these activities of daily living (ADL) for two of 33 residents reviewed (Residents 33 and 241). Findings include: Review of Resident 33's clinical record documented diagnoses that included polyneuropathy (multiple peripheral nerve become damaged; symptoms include problems with sensation and coordination), congestive heart failure (CHF - the heart doesn't pump blood as it should), cognitive loss, and chronic obstructive pulmonary disease (COPD - lung diseases that block airflow and make it difficult to breathe). Review of Resident 33's care plan included a focus area for activities of daily living self-care deficit, as evidenced by ambulatory dysfunction related to COPD and shortness of breath, initiation date November 9, 2021. Interventions included one-person physical…

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, observations, clinical record review, and staff interviews, it was determined that the facility failed to ensure care and services are provided in accordance with professional standards of practice that will meet each resident's physical, mental, and psychosocial needs for two of 33 residents reviewed (Residents 11 and 241). Findings include: Review of facility policy, titled NSG236 Skin Integrity and Wound Management, with a last revision date of February 1, 2023, and a last review date of December 29, 2023, revealed, in part: 4. Identify patient's skin integrity status and need for prevention or treatment interventions through review of all appropriate assessment information. 5. The nursing assistant will observe skin daily and report any changes or concerns to the nurse. 6. The licensed nurse will: 6.1 Evaluate any reported or suspected skin changes or wounds;6.2 Document newly identified skin/wound impairments as a change in condition; 6.3 Document skin/wound findings on 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, clinical record review, facility incident report review, and staff interviews, it was determined that the facility failed to ensure that a thorough investigation was conducted following resident falls, and failed to ensure that residents received adequate assistance to prevent accidents for one of four residents reviewed for falls (Resident 3). Findings include: Review of facility policy, titled OPS100 Accidents/Incidents, with a last review date of December 29, 2023, revealed, in part, in section titled Policy, that Center staff will report, review, and investigate all accidents/incidents which occurred. The policy further indicated in section titled Follow-up/Investigation, the following: 4.2 that the Administrator, DON [Director of Nursing], or designee will review all accidents/incidents to determine if: [in part] 4.2.2. Required documentation has been completed; 4.2.3 Accident/Incident has been investigated; 4.4 When conducting an investigation, the Administrator, DON, or designee will 4.4.1 Make every effort to ascertain the cause 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 clinical record review, facility policy review, and staff interview, it was determined that the facility failed to monitor the resident's clinical condition after a significant weight loss was identified for two of five residents reviewed for nutrition (Residents 93 and 129). Findings include: Review of facility policy, titled NSG244 Weights and Heights, last revised June 15, 2022, revealed it stated, Patients are weighed upon admission and/or re-admission, then weekly for four weeks and monthly thereafter. Additional weights may be obtained at the discretion of the interdisciplinary care team . During an interview with Resident 93 on March 25, 2024, at 10:54 AM it was revealed that she has had weight loss. Clinical record review of Resident 93 documented diagnoses that included: diabetes mellitus (the body's ability to produce or respond to the hormone insulin is impaired, resulting in abnormal metabolism of carbohydrates and elevated levels of glucose in the blood and urine), edema (swelling in extremities), and pressure ulcer (an open area of the skin caused by…

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, record review, and staff interviews, it was determined that the facility failed to provide respiratory care/oxygen services consistent with professional standards of practice of one of 33 residents reviewed (Resident 73). Findings include: Review of facility policy, Bi-level Positive Airway Pressure/Continuous Positive Airway Pressure (CPAP- a method of respiratory therapy in which air is pumped into the lungs through the nose or nose and mouth during spontaneous breathing), revised April 1, 2022, read, in part, orders for C-PAP must include pressure and hours of use. Review of Resident 73's clinical record revealed diagnoses that included diabetes mellitus (the body's ability to produce or respond to the hormone insulin is impaired, resulting in abnormal metabolism of carbohydrates and elevated levels of glucose in the blood and urine), sleep apnea (a potentially serious sleep disorder in which breathing repeatedly stops and starts), and Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular…

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 resident and staff interviews, it was determined that the facility failed to ensure that the physician addressed a significant weight loss in a timely manner for two of four residents reviewed for nutritional concerns related to weight loss (Residents 93 and 129). Findings include: Review of Resident 93's clinical record revealed diagnoses that included diabetes mellitus (the body's ability to produce or respond to the hormone insulin is impaired, resulting in abnormal metabolism of carbohydrates and elevated levels of glucose in the blood and urine), edema (swelling in extremities), and pressure ulcer (an open area of the skin caused by pressure). During an interview with Resident 93 on March 25, 2024, at 10:54 AM, it was revealed that she had weight loss. Review of Resident 93's weight history revealed an 11 pound (lb) weight loss between August 2023 and March 2024, equating to greater than 10% in six months. Review of nutrition progress notes dated November 2, 2023, revealed a significant weight loss of 5% from the previous month, and a…

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

Based on observation, staff and resident interviews, and record review, it was determined that the facility failed to provide routine and/or emergency dental services for one of 33 residents reviewed (Resident 67). Findings: Review of Resident 67's clinical record revealed diagnoses that included anxiety (a feeling of worry, nervousness, or unease), chronic obstructive pulmonary disease (COPD - a group of lung disease that block airflow and make it difficult to breathe), and epilepsy (a disorder in which nerve cell activity in the brain is disturbed, causing seizures). During an interview with Resident 67 on March 25, 2024, at 11:04 AM, it was revealed that she saw the dentist several months ago, and it was recommended that her full upper denture be replaced and that she be fitted for a partial lower denture; however, the dentist never came back and the Resident hasn't heard anything. It was also revealed that her upper denture is loose, but that it didn't hinder her ability to eat. Observation on March 25, 2024, at 11:04 AM, revealed Resident 67's upper denture was noted to be…

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 provide sufficient maintenance services necessary to maintain a safe, sanitary, comfortable, and home-like interior on three of five nursing units (Heritage, A, and Mebridge units). Findings include: Interview with Resident 1 on January 18, 2024, at 9:24 AM, revealed that the grab bars on both sides of the toilet were loose. The Resident stated he is unable to use them due to fear they will break and/or not steady him. Observation in Resident 1's room on January 18, 2024, at 9:24 AM, revealed the a portion of the drywall to the right of the toilet had been replaced. There was a hole in the aforementioned drywall where the drywall touches the floor, and the drywall wasn't patched or painted. Additionally, the grab bars on both sides of the toilet were loose, the foot on each bar was able to fluctuate 2 inches. Interview with the Nursing Home Administrator (NHA) January 18, 2024, at 10:45 AM, revealed there was a clog in the sewer line January 8, 2024, causing several toilets 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 clinical record review, staff interview, and policy review, it was determined that the facility failed to ensure accurate clinical record documentation for one of eight residents reviewed (Resident 1). Findings include: A review of the facility policy, titled Neurological Evaluation, last reviewed February 1, 2023, revealed neurological evaluation (assessment of level of consciousness, orientation, follow simple commands, sensation/response to pain, pupil check for equal, round and reactive to light, motor function, vital signs, and any change in baseline) will be performed as indicated or ordered. When a patient sustains an injury to the head or face and/or has an unwitnessed fall, neurological evaluation will be performed; every 30 minutes x two hours; every 60 minutes x four hours; every 8 hours until at least 72 hours has elapsed. A review of the clinical record for Resident 1 on December 19, 2023, revealed clinical diagnoses that included osteomyelitis of the right foot (inflammation of the bone caused by infection) and insomnia (difficulty falling asleep). 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 observation, document review, and resident and staff interviews, it was determined that the facility failed to provide food at a safe temperature for one of one lunch meal observed on the 600 hallway. Findings include: Review of Resident Council meeting minutes dated August 2, 2023, revealed that sometimes the food isn't served at the proper temperatures. During an interview with Resident 7 on August 29, 2023, at 11:15 AM, it was revealed a concern that hot food and beverages are being served cold. A test tray was completed during the lunch meal, on the 600 unit. Test tray temperatures were taken by Employee 2 (Registered Dietitian) in the 600 unit dining room, on August 29, 2023, at 12:43 PM, and revealed the following: Turkey 129 degrees Fahrenheit, not an adequate temperature Mashed Potatoes 140 degrees Fahrenheit, acceptable Broccoli 132 degrees Fahrenheit, acceptable Peach cobbler 65 degrees Fahrenheit, acceptable Coffee 142 degrees Fahrenheit, acceptable Milk 48 degrees Fahrenheit, acceptable. During an interview with Employee 2 on August 29, 2023, at 1:00 PM, it was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff and resident interviews, clinical record review, and policy review, it was determined that the facility failed to provide standards of practice to ensure the provision of meals when receiving dialysis for one of three residents reviewed (Resident 1). Findings include: A review of the facility policy, titled Dialysis: Hemodialysis (HD) Communication and Documentation, does not address the provision of meals before, during, and/or after dialysis. A review of Resident 1's care plan revealed diagnoses of end stage renal disease (ESRD - failure of kidney function to remove toxins from blood) and atrial fibrillation (irregular and rapid heartbeat), with interventions that included sending the Resident for dialysis every Monday, Wednesday, and Friday. Further review revealed an admission to the facility on August 4, 2023, with clinical diagnoses that included ESRD. Review of the [NAME] (brief overview of each resident for quick access) states that Resident 1 is to have a bag meal sent with…

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.