Joyce Eisenberg Keefer Medical Center D/P SNF

Inspectors wroteBased on observation, interview, and record review, the facility failed to notify residents of the existence and the location of the results of the most recent standard survey (means the Statement of Deficiencies Form CMS-2567) for ten (Resident 189, Resident 30, Resident 51, Resident 59, Resident 62, Resident 65, Resident 83, Resident 203, Resident 219, and Resident 236) of 11 sampled residents in the resident council. This deficient practice had the potential for residents and their representative to not know how the facility is performing regarding resident care.

Inspectors wroteBased on interview and record review, the facility failed to ensure adequate monitoring of resident's orthostatic blood pressure (taking blood pressure measurements when lying, sitting, and standing to detect for significant drop in blood pressure during each position change) when taking a prescribed antipsychotic medication for one out of five residents (Resident 81) reviewed under unnecessary medications. This failure had the potential to result in Resident 81 receiving inappropriate dosage of an antipsychotic medication and experiencing symptoms of orthostatic hypotension (a significant drop in blood pressure with position change), which could lead to serious complications such as fainting and falls.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan (a document outlining a detailed approach to care customized to an individual resident's need) for: 1. One of two sampled residents (Resident 1) with a moisture associated damage (MASD) investigated during review of pressure ulcer/pressure injury (PU/PI - injury to the skin and underlying tissue resulting from prolonged pressure on the skin). 2. One of two sampled residents (Resident 180) whose care plan did not include all interventions agreed upon by the interdisciplinary team (IDT - a collaborative group of health care team members from different specialties who work together to address all aspects of resident's well-being) investigated for falls. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement the facility's infection control policy when: 1. An incorrect sign was placed on the door of one of one resident (Resident 72) on transmission-based precautions (TBP - extra infection control measures used in healthcare settings, beyond standard precautions, for patients known or suspected to be infected with highly infectious pathogens [virus, bacteria, fungus] investigated under the infection control task. This deficient practice had the potential to increase the risk of spreading infection to other residents. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to: a. Ensure to provide the name of the medication and its indication (reason for the use of the medication) prior to administration of the medication for one of four (Resident 59) residents observed for medication administration. This deficient practice violated Resident 59's rights to make decisions regarding her medication regimen. b. Obtain informed consent for the use of bed siderails for one of two (Resident 101) residents reviewed for restraints. This deficient practice violated Resident 101's right to be informed of and participate in the resident's treatment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that a call light (a device used by a patient to signal his or her need for assistance from a professional staff) was within reach for one of one sampled resident (Resident 72) investigated during a random observation. This deficient practice had the potential to result in Resident 72 not being able to call for facility staff assistance and delay in the provision of necessary care and services which could negatively affect the residents' comfort and well-being.

Inspectors wroteBased on interview and record review, the facility failed to ensure the physician was notified when one of two sampled residents (Resident 94) repeatedly refused insulin (medication to lower blood sugar) injection. This deficient practice placed Resident 94 at risk for delayed care and poor blood glucose management, placing the resident at risk for health complications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to safeguard resident confidentiality and privacy when a medication cart computer screen was left open and unattended on one of five medication carts (Medication Cart 3). This deficient practice had the potential to result in unauthorized disclosure of residents' personal information.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe, clean, comfortable, and homelike environment for two of five sampled residents (Residents 95 and 111) when the carpet in the residents' shared room was in disrepair. This deficient practice denied Residents 95 and 111 the right to a safe and homelike environment and had the potential to negatively impact their quality of life.

Inspectors wroteBased on interview and record review, the facility failed to implement its grievance policy and procedure for one out of two residents (Resident 222) when the facility failed to assist Resident 222's family member in filing a grievance related to the care provided to Resident 222 by Certified Nursing Assistant (CNA) 5 and failed to conduct an investigation into the concerns. This deficient practice violated Resident 222's right to have a grievance addressed, had the potential to negatively affect Resident 222's care, and had the potential to cause Resident 222 to feel invalidated and disrespected.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident's Minimum Data Set (MDS) annual assessment was transmitted to Centers for Medicare and Medicaid Services (CMS, a federal government agency that manages the Medicare and Medicaid programs, which provide health coverage to people) within the required 14 day timeframe for one of one sampled residents (Resident 87) reviewed under the resident assessment facility task. This deficiency prevents the CMS from having the most accurate information of Resident 87 and had the potential to result in delayed services for the resident.

Inspectors wroteBased on interview and record review, the facility failed to ensure the interdisciplinary team (IDT- a collaborative approach where healthcare professionals from various disciplines work together to provide comprehensive patient care) reviewed and revised a resident's care plan to include appropriate interventions addressing the resident's refusal of prescribed insulin injections for one of two (Resident 94) sampled residents. This deficient practice had the potential to result in failure to deliver the necessary care and services to Resident 94.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Clarify with the physician the basis for determining the appropriate setting for a resident's low air loss mattress (LALM - designed to distribute a patient's body weight over a broad surface area and help prevent skin breakdown) in accordance with the facility policy for one (Resident 4) out of two sampled resident investigated for pressure ulcer/injury (a skin and soft tissue injury that occurs when skin is under pressure). This deficient practice placed the resident at risk of discomfort and development of new pressure ulcers (areas of damaged skin and tissue caused by sustained pressure that reduces blood flow to vulnerable areas of the body). 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Ensure one of five sampled residents (Resident 40) reviewed for accidents, was safely transferred from bed to wheelchair using the sit-to-stand lift (Sara lift, a mechanical device that helps lift a resident to rise from a seated position. This requires a resident to be able to support at least partial body weight while standing) with a two-person assist in accordance with the facility policy. This deficient practice had the potential to place Resident 40 at risk for fall. 2. Ensure prepared medication was not left unattended on one of five medication carts (Medication Cart 2). This deficient practice had the potential to result in accidental ingestion of medication and can lead to adverse reactions (any unexpected or dangerous reaction to a drug).

Inspectors wroteBased on interview and record review the facility failed to complete a resident's Hemodialysis (HD, the removing of waste and excess fluid to prevent build up in the body for residents who have loss of kidney [organs that remove waste products from the blood and produce urine] function) Record with information including assessment of the arteriovenous fistula (AVF- a surgically created connection, typically between an artery and a vein in the forearm or upper arm, with the non-dominant arm preferred) for bruit and thrill (you can feel for a thrill at the fistula incision site. A thrill feels like buzzing under your skin. The bruit and thrill tell you that your fistula is working) for one of one (Resident 16) resident investigated under the Dialysis care area. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that staffing information, including the actual hours worked by licensed and unlicensed nursing staff directly responsible for resident care per shift, was posted daily for two of two days (3/9/2026 and 3/10/2026), in accordance with the facility's policy and procedure (P&P) on Administrative Manual. This deficient practice resulted in the total number of staff and the actual hours worked by the staff in the facility were not readily accessible to residents, staff and visitors.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of four residents received the correct form of medication in accordance with the physician's order when one of four sampled residents (Resident 216), who had an order for lactobacillus acidophilus (probiotic/supplement medication) in capsule form was administered the tablet form during the medication pass observation. This deficient practice had the potential to alter the medication absorption and effectiveness, resulting in suboptimal treatment or increased risk of adverse effects (unwanted or harmful reaction to a medication or treatment).

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Remove Resident 72's discontinued medication from the medication cart after the physician discontinued the order in one (1) of five (5) inspected medication carts (Medication Cart 2). 2. Label an over the counter (OTC-medications available to consumers without a prescription) medication in one of three sampled medication storage rooms (Medication Storage Room C) These deficient practices had the potential to result in a medication error by allowing discontinued medication to remain in the cart and creating the risk of administering medication to the wrong resident, lost medication, or delayed treatment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to prepare food by methods that conserved appearance and flavor for lunch when chicken was served with some of the quills (the hollow central part of a feather) still in the skin for one of three residents (Resident 172) during dining observation. This failure had the potential to result in the resident not consuming meals or having poor food intake, which could lead to unintended weight loss.

Inspectors wroteBased on observation, interview, and record review, the facility failed to prepare food in a form designed to meet individual needs for one out of ten residents (Resident 3) observed while dining when Resident 3 was served a sandwich made with softened bread with the crusts left on while on a soft and bite-sized diet (foods that are soft, tender, moist, and easy to chew and swallow). This deficient practice had the potential to result in Resident 3 having difficulty with chewing and swallowing leading to a potential decrease in food intake and choking (when food gets stuck in your airway, blocking the flow of air to your lungs).

Inspectors wroteBased on interview and record review, the facility failed to accurately document the blood glucose (BG-the main sugar found in the bloodstream) level, amount of the insulin (medication that lowers the blood sugar) units, and injection site in Medication Administration Record (MAR) for one of two sampled residents (Resident 94). This deficient practice had the potential to negatively impact on the delivery of treatment and services to Resident 94.

Inspectors wroteBased on interview and record review, the facility failed to ensure the binding arbitration agreement (arbitration agreement, a binding agreement by the parties to submit to arbitration all or certain disputes which have arisen or may arise between them in respect of a defined legal relationship. The decision is final, can be enforced by a court, and can only be appealed on very narrow grounds) was explained to residents' representatives in a form and manner that he or she understands for 1 (Resident 34) of 4 sampled residents. This had the potential for residents' rights to not be honored.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure patient care equipment was maintained in safe, comfortable operating condition for one of five sampled residents (Resident 78) by failing to ensure Resident 78's wheelchair was repaired in a timely manner when Resident 78's wheelchair push rim (also called hand rim-metal or plastic ring attached to the outside of a manual wheelchair's large wheels that allow users to self-propel [push/move]) was damaged. This deficient practice resulted in Resident 78's inability to comfortably propel her wheelchair and had the potential to negatively affect the provision of care and service provided to Resident 78.

Inspectors wroteBased on interview and record review, the facility failed to ensure for one of two sampled patients (Resident 1), Resident 1's physician was notified of Resident 1's low blood pressure (BP, amount of force blood uses to move through the body), when Resident 1's blood pressure values were above and below their baseline (average). This deficient practice had the potential for Resident 1 to suffer from complications such as dizziness, stroke, hospitalization, and even death.

Inspectors wroteBased on interview and record review, the facility failed to ensure there was documented evidence that non-pharmacological interventions (healthcare treatments that do not primarily involve medication) were attempted prior to administering as needed (PRN) opioid (medications prescribed by doctors to treat persistent or severe pain) pain medications on multiple dates for two (Residents 126 and 65) out of three sampled residents investigated under the care area of pain management. This deficient practice had the potential to place the residents at increased risk of experiencing adverse side effects such as drowsiness, constipation, and decrease in respiration (breathing).

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure safe provision of pharmaceutical services to six (6) out of eight (8) sampled residents investigated under the storage of drugs and biologicals (Resident 219, Resident 36, Resident 4, Resident 51, Resident 214 and Resident 111) by failing to: 1. Label Resident 219's opened Lantus-100 (type of insulin [a hormone that works by lowering levels of sugar in the blood]) pen), with an open date to readily identify its beyond use date. This deficient practice had the potential for the for unintentional administration of possibly expired medications for Resident 219. 2. Ensure the opened (in-use) Olopatadine HCl solution (type of eye drops used to treat eye itching) 0.1% (measurement of concentration) vial was discarded after its beyond use date of 11/26/24 from medication cart team B on the second floor. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to meet the nutritional needs for four of 49 sampled residents (Resident 35, Resident 68, Resident 163, and Resident 8) by failing to provide a mechanical soft diet as ordered by the physician by failing to: 1. Ensure kitchen staff placed chopped squash on the tray table for residents on mechanical soft (diet that is ground or chopped for those that have difficulty swallowing or have missing teeth) and dysphagia diets (diet that is chopped or pureed [prepared in a way similar to a pudding] for those with difficulty swallowing) for Resident 35, Resident 68, and Resident 163. 2. Ensure staff did not accidentally serve Resident 8 the incorrect diet when being served lunch. These deficient practices had the potential to place the residents at risk for choking which could then lead to hospitalization and death.

Inspectors wroteBased on observation, interview, and record review, the facility failed to adhere to professional standards of practice when Licensed Vocational Nurse 4 (LVN 4) did not record a resident's blood sugar after taking it for one (Resident 185) out of six residents observed during the dining observation task. This failure placed the resident at risk for complications such as hypoglycemia (low blood sugar) or hyperglycemia (high blood sugar)

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a resident was provided a communication device (a device that can help patients communicate with care providers and family using symbols, photos, or illustrations) with the language that the resident was able to understand for one of one sampled resident (Resident 10). This deficient practice had the potential to prevent the resident from communicating with the staff and had the potential to delay receiving appropriate care/treatment the resident needed.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident's low air loss mattress (LALM - designed to distribute the patient's body weight over a broad surface area and help prevent skin breakdown) was set to the correct setting for one (Resident 480) out of five sample residents investigated under the care area of pressure ulcer/injury (localized damage to the skin and/or underlying tissue usually over a bony prominence). This deficient practice had the potential to increase the resident's risk of skin breakdown.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a licensed nurse did not leave a cup of medications unattended at a resident's bedside for one (Resident 223) out of five sampled residents investigated under the care area of accidents. This deficient practice had the potential for Resident 223 to miss a dose of medications and residents obtaining medication without staff knowledge resulting in accidental ingestion causing harm to residents.

Inspectors wrote2. During a review of Resident 114's admission Record, the admission Record indicated that the facility initially admitted Resident 114 on 4/6/2022 and readmitted the resident on 8/16/2023 with diagnoses including hypertensive chronic kidney disease (a condition in which the kidneys are damaged and cannot filter blood well), Alzheimer's disease (a brain disorders that slowly destroys memory and thinking skills and eventually, the ability to carry out the simplest tasks), and 2019-nCov acute respiratory disease (Covid-respiratory illness that causes fever, coughing, and shortness of breath). [...]

Inspectors wroteBased on interviews and record review, the facility failed to report an incident of alleged abuse involving one of one sampled resident (Resident 1) to the Department in accordance with State law within five working days of the incident. Resident 1 made sexual allegations against one CNA 1 who worked at the facility. This deficient practice had the potential for the underreporting of abuse incidents and a delay in an investigation of abuse allegations, placing the affected Resident 1 and/or other residents at risk for potential further abuse.

Inspectors wroteBased on interview and record review, the facility failed to prevent further potential abuse when CNA 1 was allowed to finish his (CNA 1) shift after an allegation of abuse was made by one of one sampled resident (Resident 1) in accordance with the facility's policy and procedure regarding abuse investigation. This deficient practice had the potential for exposing Resident 1 and other residents to potential abuse by the alleged perpetrator by not removing him (CNA 1) from the facility pending investigation of the abuse allegation and allowing him (CNA 1) to work for the remainder of his (CNA 1) shift.

Inspectors wroteBased on observation, interview and record review, the facility failed to: 1. Ensure Licensed Vocational Nurse 1 (LVN 1) administered medications via the physician ordered oral (PO, by mouth) route (location at which a drug is administered) for one of 14 sampled residents (Resident 61) investigated during the Medication Administration task. This deficient practice had the potential to reduce medication effectiveness, increase the risk of toxicity (the degree to which a substance is poisonous), and increased the likelihood of obstruction of the gastrostomy tube (G-tube- a tube placed directly into the stomach to give direct access for supplemental feeding, hydration, or medicine). 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the refrigerator temperature was maintained per the facility's policy and procedure for refrigerated stored medications for one of three medication rooms (Medication Room A) and two of two sampled residents (Resident 90 and 209) investigated during the Medication Storage and Labeling task. This deficient practice had the potential to result in residents receiving medications that have decreased in efficacy resulting in mismanagement of resident illness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain infection control practices by failing to: 1. Ensure the licensed nursing staff disinfected the silver metal trays used to hold and transport resident medications before and after preparing resident medications for seven of 14 sampled residents (Resident 61, 115, 171, 184, 207, 224, and 4) investigated during the Medication Administration task. These deficient practices had the potential to spread communicable diseases and infections among staff and residents. 2. Ensure a gallon of distilled water is not placed on the floor beside an oxygen concentrator in the resident`s room for one of one resident (Resident 210) investigated under Infection Control. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident was not wearing a hospital gown for multiple days despite the resident's request to wear her own personal clothes for one of one sampled resident (Resident 63) investigated under resident rights. This deficient practice resulted in the resident not being treated with dignity and respect which had the potential to affect the resident's sense of self-worth and self-esteem.

Inspectors wroteBased on observation, interview, and record review, the facility failed to accommodate a resident's preference of keeping his urinal (a container used to collect urine) by his bedside for one of one sampled resident (Resident 21) investigated for accommodation of needs. This deficient practice violated the resident's right to make choices.

Inspectors wroteBased on interview and record review, the facility failed to ensure a copy of the resident's advance directive (a written statement of a person's wishes regarding medical treatment) is kept in the resident's chart and easily retrievable for one of eight sampled residents (Resident 215) investigated for advance directive. This deficient practice had the potential to create confusion which could lead to conflict with the resident's wishes regarding their health care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Ensure Certified Nursing Assistant 1 (CNA 1) provided bodily privacy to a resident while the resident was in the bathroom for one of two sampled residents (Resident 38) investigated for dignity. 2. Ensure a resident's rights to personal privacy and confidentiality of their personal and medical records by failing to ensure Licensed Vocational Nurse 2 (LVN 2) did not leave an unattended computer screen in a public area displaying a resident's Medication Administration Record (MAR, a record of all medications taken by a resident on a day-to-day basis) for one of two sampled residents (Resident 19). This deficient practice violated the residents' right to privacy.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a comprehensive, person-centered care plan (a centralized document of a resident's condition, diagnosis, the nursing team's goals for the resident, and measure of the resident's progress) for a resident's use of an antibiotic (medicine that fights bacterial infections) for one of six sampled residents (Resident 224) investigated for antibiotic use. This deficient practice had the potential to result in failure to deliver necessary care and services.

Inspectors wroteBased on interview and record review, the facility failed to update and revise a resident's care plan (a document that summarizes a resident's health conditions, care needs, and treatments) to reflect an actual choking incident for one of four sampled residents (Resident 142) investigated for care plans. This deficient practice had the potential to result in the resident not receiving appropriate care and treatment specific to the resident's needs.

Inspectors wroteBased on interview and record review, the facility failed to ensure a physician's order for hydrocodone-acetaminophen (medication used to relieve moderate to severe pain) 10-325 milligrams (mg- unit of measurement) every six hours as needed (PRN) for back pain was clarified to prevent overmedicating one of one sampled resident (Resident 101) investigated under pain management. Resident 101's physician order for hydrocodone-acetaminophen 10-325mg every six hours PRN did not include a pain scale (numeric rating scale: Zero is considered no pain; one to three is mild pain; four to six is moderate pain, and seven to 10 is severe pain). [...]