York South Skilled Nursing And Rehabilitation Ctr

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 31 residents reviewed (Residents 48, 86, and 101). Findings include: Review of the clinical record for Resident 48 on May 5, 2025, revealed diagnoses that include bilateral trochanter (hip bone) decubitus ulcers (pressure wounds over bony prominences) and End Stage Renal Disease (kidney function is severely impaired requiring dialysis or transplant). A review of Resident 48's care plan dated May 2025 revealed a focus for Documented Pressure Ulcer: bilateral hips. Date Initiated: 04/23/2025 Created on: 04/23/2025. A review of Resident 48's physician orders on May 6, 2025, revealed the following orders: Cleanse wounds on bilateral hips with Vashe (wound cleanser); soak 2-5 minutes; scrub 30 seconds; apply skin prep to peri wound; apply Medihoney (aids in removal of necrotic tissue and wound healing); cover with border foam. Every day shift every other day for decubitus ulcers. A 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 facility policy review, clinical record review, observation, and staff interviews, it was determined that the facility failed to ensure that the comprehensive care plan was reviewed and revised for three of 31 reviewed (Residents 39, 51, and 55). Findings include: Review of facility policy, titled Person-Centered Care Plan last revised October 24, 2022, read, in part, The care plan will be prepared by the interdisciplinary team. The care plan must be customized to each individual patient's preferences and needs. Care plans will be reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments, and as needed to reflect the response to care and changing needs and goals. Review of Resident 39's clinical record revealed diagnoses that included diabetes (a disease characterized by high blood glucose) and muscle weakness (when your full effort doesn't produce a normal muscle contraction or movement). Review of Resident 39's care plan revealed a care plan with a focus are of: Pressure Ulcer, Left great…

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, and staff interviews, it was determined that the facility failed to ensure that residents receive necessary treatment and services, consistent with professional standards of practice, to promote healing of a pressure ulcer for three of seven residents reviewed for pressure ulcers (Resident 4, 122, and 238). Findings include: Review of facility policy, titled Skin Integrity and Wound Management last revised May 1, 2025, read, in part, A comprehensive initial and ongoing nursing assessment of intrinsic and extrinsic factors that influence skin health, skin/wound impairment, and the ability of a wound to heal will be performed. Staff will continually observe and monitor patients for changes and implement revisions to the plan of care as needed. To provide safe and effective care to promote optimal skin health, prevent pressure injuries, and promote healing within the context of what matters most to all patients. The licensed nurse will: Complete wound evaluation upon admission/readmission, new in-house acquired, weekly, 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.

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 that a resident who needs respiratory care is provided such care, consistent with professional standards of practice, for three of four residents reviewed for respiratory care (Residents 17, 23, and 78). Findings include: Review of facility policy, titled Procedure: Nebulizer: Small Volume last revised November 1, 2023, read, in part, Upon completion of the treatment, check patient's heart rate, respiratory rate, pulse oximetry, and breath sounds. Rinse small volume nebulizer mouthpiece and 'T' piece with sterile water and dry. Place in treatment bag labeled with patient's name and date. Replace and date the set up daily, if used. Check compressor for air filters that require replacement and cleaning every 30 days. Follow manufacturer's instructions. Review of Resident 17's clinical record revealed diagnoses that included muscle weakness, need for assistance 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.

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 and for one of three nourishment pantries. Findings include: Review of facility policy, Food Handling, last revised January 26, 2024, read, in part, Hazard Analysis Critical Control Points (HACCP- a food safety management system that identifies, evaluates, and controls hazards that could contaminate food) flow charts are used when handling, preparing, cooling, storing, reheating, and reserving food. Foods are cooked to the internal temperature specified in the recipe directions. Foods that are prepared and not placed into service are considered unused portions. And are to be handled according to the HACCP Food Flow Chart. Roasted meats are cooled according to HACCP flow charts. Employees are to wear disposable gloves when handling food. Disposable gloves are considered a single-use item and are discarded when damaged, soiled, and after each use. Appropriate…

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, record review, policy review, and staff interview, it was determined that the facility failed to ensure the environment meets the individual needs of each resident by ensuring the call bell was in reach for three of 31 residents reviewed (Residents 31, 59, and 67). Findings include: Review of facility policy, Call lights, with a revision date of June 1, 2021, revealed, All Genesis HealthCare patients will have a call light or alternative communication device within their reach at all times. Review of Resident 31's clinical record revealed diagnoses that included diabetes (a disease characterized by high blood glucose) and muscle weakness (when your full effort doesn't produce a normal muscle contraction or movement). Review of Resident 31's current care plan revealead a focus area of, at risk for falls due to history of cardiovascular accident, and an intervention of, Reinforce need to call for assistance. Observation of Resident 31 on May 5, 2025, at 9:42 AM, revealed Resident 31 lying in bed and his call bell was lying on the floor under the center 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 facility policy review, clinical record review, and staff interview, it was determined that the facility failed to ensure that the resident and/or their representative received written notice of the facility bed-hold policy at the time of transfer for one of six residents reviewed for hospitalization (Resident 86). Findings Include: Review of facility policy, titled Bed Holds last revised January 16, 2023, read, in part, Bed hold notification is required per Federal Regulation. The resident/resident representative may choose to pay to hold the bed privately if the bed hold is not covered by Medicaid, Medicare, insurance, etc. If the resident representative is not present to receive the written notice upon transfer, the notice is delivered via e-mail, fax, or hard copy via mail. Purpose: To properly secure a private payer source, if applicable, to ensure a bed is reserved and available upon the resident's return. Review of Resident 86's clinical record revealed diagnoses that included protein calorie…

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 develop and implement a baseline care plan within 48 hours for one of six residents reviewed that were admitted during the prior 30 days (Resident 238). Findings include: Review of Resident 238's clinical record revealed diagnoses that included pressure ulcers to the left and right heel (wound that can extend into the deep tissue and bone that is caused by pressure over a bony prominence) and atrial fibrillation (irregular heartbeat). Review of Resident 238's clinical record revealed that Resident 238 was discharged from the hospital to the facility on May 1, 2025. Review of Resident 238's clinical record revealed that at the time of admission to the facility Resident 238 had pressure ulcers to the left and right heel and an unhealed surgical wound as a result of a partial amputation of the right toe. Review of Resident 238's baseline care plan revealed that Resident 238 did not have a care plan that addressed Resident 238's wound/skin concerns. Further review of Resident 238'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 policy review, clinical record review, and staff interviews, it was determined that the facility failed to ensure that each resident with limited range of motion receives appropriate treatment and services to increase range of motion and/or prevent further decrease in range of motion for one of 31 residents reviewed (Resident 95). Findings Include: Review of the facility's policy, titled Restorative Nursing, recently revised August 7, 2023, defined its purpose To promote the patient's ability to adapt and adjust to living as independently and safely as possible. Also, To help the patient attain and maintain optimal physical, mental, and psychosocial functioning. Restorative programs are coordinated by nursing or in collaboration with rehabilitation and are patient-specific based on individual patient needs. Review of Resident 95's physician's orders revealed diagnoses that included muscle weakness (a decrease in muscle strength, where the muscles may not contract or move as easily as usual) and reduced mobility (a partial or total loss of the ability to move around freely,…

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 reviews, clinical record review, observations, and staff interviews, it was determined that the facility failed to precisely and effectively monitor hydration for one of one resident reviewed for hydration status (Resident 78), and failed to ensure proper monitoring to maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range, for one of four residents reviewed for nutritional status (Resident 131). Findings include: Review of the facility's policy, titled Weights and Heights, recently revised June 15, 2022, read Patients are weighed upon admission and/or readmission, then weekly for four weeks and monthly thereafter. Review of facility policy, titled Hydration Plan with an effective date of May 1, 2023, read, in part, A hydration plan is developed for residents who are at risk of dehydration and for those requiring fluid restrictions. Nursing and Food and Nutrition Services work together to calculate the amount of fluid provided with meals and the amount of fluid provided by nursing in conjunction 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.

Based on staff and resident interviews, observation, and completion of one meal test tray, it was determined that the facility failed to provide foods that are palatable, attractive, and at appetizing temperatures at one of one meal observed (May 6, 2025, lunch meal). Findings include: During an interview with Resident 23 on May 5, 2025, at 12:11 PM, revealed meals are often served cold. Review of Resident Council Minutes for February 17th, 2025; March 17th, 2025; and April 21st, 2025, concerns were expressed regarding hot food being served cold. Review of facility form, Test Tray Evaluation, dated May 1, 2023, read, in part, test tray standard for hot entree and vegetable is greater than 140 degrees Fahrenheit (F). Test tray is also evaluated for taste, portion, and appearance of the food. A test tray completed on May 6, 2025, at 12:35 PM, revealed inadequate portions of coffee. The peas and coffee weren't palatable for temperature. The roast pork and mashed potatoes did not meet the standard. The test tray was placed on a meal cart to be delivered with room trays; 22 minutes had…

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, facility policy review, clinical record review, and staff interviews, it was determined that the facility failed to ensure staff implemented infection control policies to prevent the spread of infection for two of 31 residents on transmission-based precautions reviewed (Residents 67 and 238) Findings Include: Review of facility policy, Transmission Based Precautions, revised May 1, 2025, revealed in a section: Initiating Transmission Based Precautions, Signage that includes instructions for use of specific PPE will be placed in a conspicuous location outside the patient's room. Additionally, either the CDC category of Transmission Based Precautions (e.g., Contact, Droplet, or Airborne) or instructions to see the nurse before entering the room will be included in the signage. Review of Resident 67's clinical record revealed diagnoses of sepsis (a serious condition in which the body responds improperly to an infection) and urinary tract infection (an infection of any part of the urinary system). Review of Resident 67's clinical record revealed a urine culture…

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, and staff interview, it was determined that the facility failed to ensure a resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections consistent with physician orders and the resident's person-centered care plan for one of three residents reviewed (Resident 1). Findings include: Review of facility policy, titled Catheter: Indwelling Urinary last revised February 1, 2023, read, in part, Provide catheter care twice a day and as needed. Explain the procedure and provide privacy. Inspect the periurethral area for signs of inflammation and infection. Document: Catheter care provided; amount of urine output if ordered; and abnormal findings to the physician, if indicated. Review of Resident 1's clinical record revealed diagnoses that included obstructive uropathy (when urine can't flow normally through your urinary tract due to a blockage), congestive heart failure (a chronic condition in which the heart doesn't pump blood as well as it should), and dementia (a chronic…

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, document 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 comprehensive person-centered plan of care for two of eight residents reviewed (Residents 1 and 3). Findings Include: A review of Resident 1's clinical record revealed diagnoses that included Alzheimer's disease (a brain disorder that gradually destroys memory and thinking skills, and eventually the ability to perform daily tasks) and acute pancreatitis (a sudden inflammation of the pancreas). A review of Resident 1's physician's orders revealed an order dated September 28, 2024, that read Daily Weight: Notify cardiology or PCP [primary care physician] if increased by 3 lbs.[pounds] in one day or greater than 5 lbs. in one week. A review of Resident 1's weight information revealed no documented weights on September 30, 2024, and October 1, 2024. A review of Resident 3's clinical record revealed diagnoses that included end-stage renal disease…

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 interview, it was determined that the facility failed to provide routine drugs for its residents and provide pharmaceutical services, including procedures that assure the accurate acquiring and administration of drugs to meet the needs of each resident, for one of eight residents reviewed (Resident 2). Findings Include: A review of the facility's policy, titled Provider Pharmacy Requirements, dated 2007, read, Regular and reliable pharmaceutical service is available to provide residents with prescription and non-prescription medications . The policy continued, The provider pharmacy agrees to perform the following pharmaceutical services, including but not limited to accurately dispensing prescriptions based on authorized prescriber orders. Also, Providing routine and timely pharmacy service per contractual agreement and emergency pharmacy service 24 hours per day, seven days per week. A review of Resident 2's clinical record revealed diagnoses that included diabetes mellitus Type II (a common condition that occurs when 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 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 four of five residents reviewed with wound care orders (Residents 15, 17, 18, and 19). Findings Include: Review of Resident 15's clinical record revealed diagnoses that included severe protein-calorie malnutrition (insufficient protein intake or protein deficiency) and congestive heart failure (CHF-weakness of the heart that leads to buildup of fluid in the lungs and surrounding body tissues). Review of Resident 15's July 2024 TAR (Treatment Administration Record - form used to document physician orders as well as when and how treatments are administered to a resident) revealed the following orders: Cleanse open area on buttocks with wound cleanser. Apply therahoney (promotes wound closure) and cover with 4x4 foam border (type of dressing) for protection every day shift, starting July 6, 2024, and ending July 19, 2024; Cleanse…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility investigation documentation and job descriptions, review of online nurse aide registry information, as well as staff interview, it was determined that the facility failed to ensure that services provided to residents were provided by staff with the appropriate skills, experience, and qualifications to provide such services for two of two residents reviewed (Residents 20 and 21). Findings include: Review of facility Certified Nursing Assistant job description, revised November 23, 2020, revealed, He/she will function within the standards of practice as accorded by his/her Certification. Review of online Nurse Aide Registry information revealed that Employee 3 (Nurse Aide [NA]) was currently actively registered as a certified NA in Pennsylvania, with an effective date of January 31, 2023, and an expiration date of February 7, 2025. Review of facility electronic event report submission and related investigation documentation revealed that on July 10, 2024, nursing administration was made…

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

Based on observations and staff interviews, it was determined that the facility failed to maintain a safe, clean, comfortable, and home-like interior in three of four resident shower rooms (first and second floor nursing units). Findings include: Observations in the second floor men's shower room on June 26, 2024, at 12:48 PM and at 1:50 PM, with Employee 3 (Director of Housekeeping), revealed in two of the three showers there was a black substance on the floor at the base of the wall. Observations in the second floor women's shower room on June 26, 2024, at 12:49 PM and at 1:55 PM, with Employee 3, revealed there was a pink and black substance on the floor at the base of the wall on all 3 sides of the shower, the blue mat on the shower gurney was cracked in seven areas with the foam exposed, and the ceiling vent in front of shower on the right wasn't functioning. Observations in the first floor shower room on June 26, 2024, at 12:54 PM and at 2:00 PM, with Employee 3, revealed there was a black substance on the floor at the base of the wall on two sides, the sink was separated from…

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, document review, clinical record review, and resident and staff interviews, it was determined that the facility failed to ensure that all allegations of abuse, neglect, or mistreatment are reported no later than 24 hours to other officials, including Adult Protective Services, for two of three resident abuse investigations reviewed (Residents 40 and 61). Findings Include: A review of the facility's policy, titled Abuse Prohibition, revised October 24, 2022, defined abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, injury or mental anguish. Verbal abuse is defined as any use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to patients . A continued review of the policy revealed, regarding reporting allegations of abuse, read The Administrator and/or DON [Director of Nursing] will verify that the state reporting occurs within required time frames and via appropriate method of reporting. The policy continued under the section titled When 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 observation, clinical record review, and staff interviews, it was determined that the facility failed to ensure that a comprehensive, person-centered care plan was developed for four of 31 residents reviewed (Residents 38, 67, 68, and 82). Findings include: Review of a facility policy, titled Person-Centered Care Plan, with a review date of May 28, 2024, revealed that: Care plans will be reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments, and as needed to reflect the response to care and changing needs and goals. Review of Resident 38's clinical record revealed diagnoses that included dementia (A group of thinking and social symptoms that interferes with daily functioning) and hypertension (elevated blood pressure). Review of Resident 38's clinical record revealed an admission to hospice care and services on June 17, 2024. Review of Resident 38's interdisciplinary plan of care revealed none developed to address Resident 38's need for hospice care and services. Continued review of…

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

Based on review of facility policy, observations, and staff interviews, it was determined that the facility failed to appropriately monitor the pH of the sanitizer sink for manual ware-washing, and failed to store and serve food/beverages in accordance with professional standards for food safety in the kitchen area and two of three nourishment pantries (second floor and Arcadia units). Findings include: Review of Facility policy, titled Manual Ware-washing and Sanitizing, effective May 1, 2023, read, in part, sanitizing is accomplished in the third sink by use of chemical sanitizer. Measure the concentration of the sanitizer utilizing a quaternary test strip; the strip should darken to the range of 200-400 parts per million. If the test strip doesn't turn the appropriate darkness, corrections are made before the sanitizing process can take place. The result of the test is recorded on the Manual Ware-washing Sanitation Long at each wash period. Review of facility policy, titled Pantry/Nourishment Room Sanitation, effective date May 1, 2023, read, in part, food and beverages are 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 clinical record review, policy review, observations, and staff interviews, it was determined that the facility failed to maintain infection control practices to prevent the spread of infection for two of 31 residents reviewed (Resident 78 and 82). Findings include: Review of facility policy, titled Procedure: Enhanced Barrier Precautions, last revised May 1, 2024, revealed enhanced barrier precautions should be used when a resident has, Chronic wounds .regardless of [multi-drug resistant organism] colonization status. Further review of the document revealed that implementation of enhanced barrier precautions included posting a sign on the resident's door, indicating the resident is on enhanced barrier precautions and the use of a gown and gloves during wound care. Review of Resident 78's clinical record revealed diagnoses that included congestive heart failure (CHF - decreased ability of the heart to pump blood throughout the body) and peripheral vascular disease (decreased blood circulation to extremities due to a narrowing of the arteries). Further review of Resident 78'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 document review and staff interview, it was determined that the facility failed to ensure each resident is periodically informed of charges for services not covered under Medicare or Medicaid for one of three residents reviewed at the termination of Medicare A services (Resident 239). Findings Include: A review of Resident 239's clinical record revealed an admission date of November 29, 2023, with diagnoses that included hypertension (elevated blood pressure) and heart failure (A lifelong condition in which the heart muscle can't pump enough blood to meet the body's needs for blood and oxygen). According to the clinical record, Resident 239 was admitted for short-term rehabilitation with a planned discharge to return to the community. A review of Resident 239's Notice of Medicare Non-Coverage (NOMNC) form revealed the last covered day of Medicare A services ending on January 30, 2024. As of January 31, 2024, Resident 239 would be responsible for privately paying, or out of pocket, for the facility's daily rate for the non-covered services provided at the facility. Continued…

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 resident and staff interviews, it was determined that the facility failed to ensure the care plan was reviewed and revised for three of 31 residents reviewed (residents 32, 62, and 70). Findings include: Review of Resident 32's clinical record revealed diagnoses that included hemi-paresis (partial paralysis) right dominate side, stroke (damage to the brain from interruption of blood supply), and aphagia (language disorder that affects a person's ability to communicate). Review of Resident 32's care plan documented a focus area for neurological deficiencies and dysfunction of activities of daily living related to stroke, initiated August 13, 2014, revised September 18, 2023. Interventions included for Resident to wear a palm protector as ordered, initiated September 28, 2022, revised on May 16, 2024. Further review of the care plan included a focus area for activities of daily living self-care deficit secondary to stroke, initiated August 13, 2014, revised September 18, 2023. Interventions included cam boot to right lower extremity,…

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, observations, and resident and staff interviews, it was determined that the facility failed to provide care and services regarding shaving facial hair for one of 31 residents reviewed (Resident 72). Findings include: Review of facility policy, titled Activities of Daily Living (ADLs), revised May 1, 2023, revealed, A patient who is unable to carry out ADLs will receive the necessary level of ADL assistance to maintain good nutrition, grooming, and personal and oral hygiene. Review of Resident 72's clinical record revealed diagnoses that included Alzheimer's disease (loss of cognitive functioning) and pleural effusion (a condition that occurs when fluid builds up in the pleural space, the thin cavity between the layers of tissue that line the lungs and chest cavity). Observation of Resident 72 on June 25, 2024, at 8:45 AM, revealed the Resident lying in bed. At that time, Resident 47 was observed to have significant facial hair above her upper lip and on her chin. An interview with Resident 72 revealed that she would like 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 observation, clinical record review, and staff interview, it was determined that the facility failed to ensure treatment and services were provided to promote healing and prevent infection for one of four resident's reviewed for pressure injury (Resident 78). Findings include: Review of Resident 78's clinical record revealed diagnoses that included congestive heart failure (CHF - decreased ability of the heart to pump blood throughout the body) and peripheral vascular disease (decreased blood circulation to extremities due to a narrowing of the arteries). Review of Resident 78's clinical record revealed Resident 78 had a stage 4 pressure ulcer (wound of the skin over a bony prominence that extends to the bone or other connective tissue) to the sacrum, stage 4 pressure ulcer to the right heel, and non-pressure full thickness ulcer (wound of the skin that extends below the layers of the skin to the muscle, bone, or other connective tissue) of the lower right leg. During wound treatment change observation conducted on June 26, 2024, at approximately 10:00 AM, Employee 1 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 record review and staff interview, it was determined the facility failed to ensure that a resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for one of 31 residents reviewed (Resident 56). Findings include: Review of Resident 56's clinical record revealed diagnoses that included peripheral vascular disease (a slow and progressive disorder of the blood vessels) and hypertension (high blood pressure). Review of Resident 56's clinical record revealed a diagnosis of a urinary tract infection (UTI), with an active date of April 30, 2024. Review of Resident 56's May 2024 Medication Administration Record revealed the Resident was prescribed Keflex Oral Capsule 500 milligrams, one capsule by mouth three times a day for UTI for seven days. The last day Resident 56 received a dose of Keflex was on May 8, 2024, at 2:00 PM. Review of Resident 56's clinical record revealed a progress note on May 8, 2024, at 2:58 PM, with the following text: Continues Keflex/UTI, 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 observations, facility policy review, clinical record review, 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 one of three residents reviewed for respiratory care (Resident 62). Findings Include: Review of facility policy, titled Bi-level Positive Airway Pressure (Bi-PAP- non-invasive ventilation is the use of breathing support administered through a face mask) /Continuous Positive Airway Pressure (CPAP- a machine that uses mild air pressure to keep breathing airways open while you sleep) including Trilogy (an all-in-one ventilation device capable of delivering both invasive and non-invasive ventilation modes) , revised April 1, 2022, failed to include information pertaining to cleaning and storage of equipment. Review of Resident 62's clinical record revealed diagnoses that included amyotrophic lateral sclerosis (ALS - a nervous system disease that affect nerve cells in the brain and spinal cord, causes loss of muscle control), abnormal posture,…

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, facility document review, and staff interview, it was determined that the facility failed to complete a performance review for one of five nurse aides reviewed at least once every 12 months (Employee 2). Findings include: Review of facility policy, titled HR616 Performance Appraisal, last reviewed June 20, 2024, revealed the facility policy stated, Managers will meet with their regular full-time, regular part-time and regular casual employees at least annually to conduct a performance appraisal or have a performance based conversation. In-service education will be provided based on the outcome of these reviews. Review of facility documentation revealed Employee 2's hire date was December 10, 2022. On June 26, 2024, a request was made for Employee 2's yearly performance evaluation. During a staff interview on June 27, 2024, at approximately 11:15 AM, Nursing Home Administrator (NHA) revealed that Employee 2 did not have a performance evaluation conducted. During the interview, the NHA revealed employees should have performance reviews conducted yearly…

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 interview, it was determined that the facility failed to ensure residents were educated on influenza vaccination for one of five residents reviewed (Resident 82). Findings include: Review of Resident 82's clinical record revealed diagnoses that included type 2 diabetes mellitus (decreased ability of the body to utilize insulin for the transport of glucose from the blood stream into the cells for nourishment) and hypertension (elevated/high blood pressure). Review of Resident 82's clinical record revealed that Resident 82 was admitted to the facility on [DATE]. Further review the clinical record revealed that staff documented that Resident 82 refused the influenza vaccination for the 2023-2024 influenza season (period of time between October to May). During a staff interview on June 27, 2024, Director of Nursing revealed the facility did not have documentation of Resident 82's declination of the 2023-2024 influenza vaccination nor evidence that Resident 82 was provided…

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

Based on 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 five of seven newly admitted residents reviewed (Residents 1, 4, 5, 7, 8). Findings Include: Review of Resident 1's clinical record revealed diagnoses that included cellulitis of left lower limb (bacterial infection involving the inner layers of the skin) and diabetes mellitus (impairment in the way the body regulates and uses sugar [glucose] as a fuel resulting in too much sugar circulating in the bloodstream). Review of Resident 1's January and February 2024 MARs (Medication Administration Records - forms used to document physician orders as well as when and how medications are administered to a resident) revealed orders for insulin glargine twice daily for diabetes mellitus, and hydralazine three times a day for hypertension (high blood pressure) and metoprolol every 12 hours for hypertension. Further review of the MAR…

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.