Acadia Nursing And Rehab Center

Based on observation and staff interview, it was determined that the facility failed to dispose of garbage into the dumpster properly for one dumpster observed outside of the building.Findings include: Review of the facility policy Food-Related Garbage and Refuse Disposal last reviewed 4/30/26, indicated garbage and refuse containing food waste will be stored in a manner that is inaccessible to pest. Outside dumpsters will be kept closed and free of surrounding litter. During an observation completed on 6/7/26, at 9:22 a.m. the outside dumpster lid was open with debris scattered on the ground. During an interview completed on 6/7/26, at 9:22 a.m. Dietary [NAME] Employee E13 confirmed the dumpster lid was open and there was debris scattered on the ground and stated, I haven't gotten to it yet, we usually clean it up in the morning and confirmed that the facility failed to dispose of garbage into the dumpster properly for one dumpster observed outside of the building. 28 Pa. Code 201.14(a) Responsibility of licensee28 Pa. Code 201.18(b)(1) Management

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical record review, observations, and staff interviews, it was determined that the facility failed to follow enhanced barrier precautions (EBP) for one of three residents (Resident R58) with enteral feeding tubes (G- Tube, a tube inserted in the stomach through the abdomen), and failed to implement an infection control program that included a system of surveillance to identify possible communicable diseases or infections for two of 12 months (July 2025, and April 2026).Findings include: Review of the facility policy Enhanced Barrier Precautions dated 4/30/26, indicated enhanced barrier precautions (EBP) are used as an infection prevention and control intervention to reduce the transmission of multi-drug resistant organisms (MDROs) to residents. EBP employ targeted gown and glove us in addition to standard precautions during high-contact resident care activity. An example of high-contact resident care activity includes device care or use (central line, urinary 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the facility's infection control policies and procedures and staff interview, it was determined that the facility failed to implement an antibiotic stewardship program for two of twelve months (July 2025, and April 2026) and failed to provide a complete antibiotic order for one of four residents (Resident R33). Findings include: Review of facility policy Antibiotic Stewardship dated 4/30/26, indicated as part of the facility antibiotic stewardship program, all clinical infections treated with antibiotics will undergo review by the infection preventionist or designee. If an antibiotic is indicated, prescribers will provide complete antibiotic orders including the following: drug name, dose, frequency of administration, duration of treatment, route of administration, and indications for use. Review of the facility's Infection Control surveillance for June 2025, through May 2026, failed to include documentation to indicate that antibiotic monitoring was completed for July 2025, and April 2026.…

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

Based on review of facility policy and staff interview, it was determined the facility failed to designate a qualified individual(s) onsite, who is responsible for implementing programs and activities to prevent and control infections for two periods during the time frame from June 2025, through May 2026 (11/12/25 - 11/24/25, and 4/26/26 - 5/20/26).Findings include: Review of the facility policy Infection Preventionist dated 4/30/26, indicated the infection preventionist (IP) coordinates the development and monitoring of the infection prevention and control program. The IP is employed on site and at least part time. Review of the facility provided document IP Timeline on 6/8/26, indicated the following IPs were responsible during the following time frames for the period of June 2025 - May 2026:-RN Employee E5 was responsible 5/1/24 - 11/12/25.-IP Employee E19 was responsible 11/13/25 - 3/5/26. -IP Employee E18 was responsible 3/5/26 - present. Review of IP Employee E19's certificate for qualifying education required was dated 11/24/25; therefore, there was not a qualified IP…

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, resident and staff interviews, it was determined that the facility failed to make certain resident funds were accessible on holidays and weekends for two of four residents reviewed (Residents R1 and R2).Findings include: Review of the facility Resident Trust Account Withdrawals when the Business Office is Closed indicated residents must be able to access their funds, even when the business office is closed. If a resident needs to withdraw money from their trust account outside of regular business hours, the following procedures must be followed that include but not inclusive to: A bank bag containing cash is kept locked in the Registered Nurse (RN) office. RNs may only issue the amount of cash available in the bag. If additional funds are requested, contact the Administrator immediately During an interview completed on 9/29/25, at 10:04 a.m. upon asking Resident R1 concerning access to her funds stated I asked one time during the weekend, and I could not get any it was on a Saturday a few weeks ago, they were going to set something…

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 menu, resident interviews, and staff interviews it was determined that the facility failed to follow the displayed menu for one of three observed meals on 5/27/25, (Dinner Meal). Findings include: The facility policy Menus reviewed 3/10/25, indicated menus are developed and prepared to meet resident choices including religious, cultural, and ethnic needs while following established national guidelines for nutritional adequacy. The dietician reviews and approves all menus. During a dining observation on 5/27/25, at 5:07 p.m. the resident's dinner meals failed to match the approved facility menu for dinner on this date. On 5/27/25, the facility menu was approved by the Registered Dietician (RD) as follow: - Minestrone Soup - Whole wheat crackers - Tuna salad plate - Carrot raisin salad - Mandarin oranges - Coffee, tea, milk On 5/27/25, the facility served residents the following: - Beef vegetable or chicken noodle soup - Whole wheat crackers - Tuna salad plate - 3 bean salad - Mandarin oranges - Coffee, tea, milk During an interview on 5/27/25, at 5:47…

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 a review of facility policies, observations, and staff interviews, it was determined that the facility failed to properly monitor food expiration dates in the Main Kitchen, failed to maintain food equipment in a clean, sanitary condition, failed to properly restrain beards, failed to maintain sanitary conditions during tray line which created the potential for cross contamination, and failed to verify the sanitizing temperature of the dish machine in the Main Kitchen (Main Kitchen), which created the potential for food borne illness. Findings include: Review of facility policy Date Marking for Food Safety, dated 3/10/25, indicated the facility adheres to a date marking system to ensure the safety of ready-to-eat, time/temperature control for safety food. The food shall be clearly marked to indicate the date or day by which the food shall be consumed or discarded. The individual opening or preparing a food shall be responsible for date marking the food the time the food is opened or prepared. The head cook or designee shall be responsible for checking the refrigerator daily…

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, clinical record review, observation, and staff interview, it was determined the facility failed to implement an infection control program that included a system of surveillance to identify possible communicable diseases or infections for 12 of 12 months (April 2024, - April 2025). Findings include: Review of facility policy Infection Prevention and Control Plan dated 3/10/25, indicated an infection prevention and control program is established to maintain and provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Surveillance tools are used for identifying the occurrence of infections, recording their numbers and frequency, detecting outbreaks and epidemics, monitoring employee infection, monitoring adherence to infection prevention and control practices, and detecting unusual pathogens with infection control implications. Review of the facility's monthly tracking of surveillance on 5/28/25, failed to include floor mapping for twelve of twelve months April 2024, -…

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

Based on facility policy, pest control log, observations, and staff interviews it was determined the facility failed to maintain an effective pest control program related to gnats in the kitchen (Main Kitchen). Findings include: Review of the facility Pest Control policy dated 3/10/25, indicated that the facility shall maintain an effective pest control program. This facility maintains an on-going pest control program to ensure that the building is kept free of insects and rodents. During a kitchen tour on 5/27/25, at 1:00 p.m. an observation of the storage room where dry foods are stored had an abundance number of gnats on the boxes/cans of goods or were flying around in the area. During an observation on 5/27/25, at 1:10 p.m. gnats were observed flying around the main kitchen area above the prep table and around the dish machine. During an observation on 5/27/25, at 1:30 p.m. mounted bug lights were observed hanging on the wall by the door and in the back storage area where the ice machine is kept. During an interview on 5/27/25, at 1:33 p.m. Dietary Manager Employee E1 stated,…

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 resident records, admission documentation and staff interview, it was determined that the facility failed to maintain timely documentation of the admission agreement for four of four residents (Resident R2, Resident R12, R33, and R56) and failed to ensure residents had the capacity to understand the terms of the admission agreement for three of four residents (Residents R12, R33, and R56). Findings include: Review of the facility policy admission Agreement dated 3/10/25, indicated all residents have a signed and dated admission agreement on file. At the time of admission, the resident (or their representative) must sign an admission agreement (contract). Review of the Resident Assessment Instrument 3.0 User's Manual effective October 2024, indicated that a Brief Interview for Mental Status (BIMS) is a screening test that aides in detecting cognitive impairment. The BIMS total score suggests the following distributions: 13-15: cognitively intact 8-12: moderately impaired 0-7: severe impairment…

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, personnel records, and staff interview it was determined that the facility failed to complete annual performance evaluations for three out of three nurse aide personnel records (Nurse Aides (NA) Employee E10, NA Employee E11, and NA Employee E12). Findings include: Review of facility policy In-Service Training, Nurse Aide dated 3/10/25, indicated the facility completes a performance review of nurse aides at least every 12 months. Review of NA Employee E10's personnel record indicated a hire date of 4/11/18. Review of NA Employee E11's personnel record indicated a hire date of 8/27/89. Review of NA Employee E12's personnel record indicated a hire date of 9/17/17. Review of personnel records did not include annual performance evaluations based on the date of hire for NA Employee E10, NA Employee E11, and NA Employee E12. Interview on 5/28/25, at 3:00 p.m. the Nursing Home Administrator confirmed that the facility failed to complete annual performance evaluations based on date of hire for NA Employee E10, NA Employee E11, and NA Employee E12. 28 Pa…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, facility documents, resident clinical records and staff interviews it was determined that the facility failed to ensure residents had the capacity to understand the terms of a binding 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, whether contractual or not.) for three of five residents (Resident R12, R33, and R56). Findings include: Review of the facility policy Binding Arbitration Agreements dated 3/10/25, indicated the terms and conditions of a binding arbitration agreement are explained to the resident (or representative) in a way that ensures his or her understanding of the agreement, including that the resident may be giving up his or her right to have a dispute decided in a court proceeding (i.e. litigation). Review of Resident R12's admission record indicated and admission date of 9/16/24. Review of Resident R12's MDS dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, review of facility documentation, and staff interviews, it was determined that the facility failed to make certain that equipment was in safe operating condition for two of two crash carts (Front and Back hallways). Findings include: Review of facility policy Emergency Crash Cart and Automated External Defibrillators (AED's) dated [DATE], indicated it is the policy of the facility to ensure that the facility will maintain at least one emergency cart per nursing care floor in case of the need for basic life support. To ensure that all supplies critical to basic life support are readily available on the emergency cart. The emergency crash cart is checked every 24-hours and after every use. Missing or expired items are replaced, when applicable. During an observation of the Back hallway crash cart (a cart maintained with equipment used in cardiac emergencies) on [DATE], at 2:15 p.m. revealed a binder Crash Cart Checklist. Review of the binder failed to include a checklist for [DATE].…

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 documents and staff interview, it was determined that the facility failed to provide training on QAPI (Quality Assurance and Performance Improvement) for four of five employees (Nurse Aide (NA) Employees E10, E11, E12, and Licensed Practical Nurse (LPN) Employee E8). Findings include: Review of the Facility Assessment dated 3/10/25, indicated staff training/education and competencies will be completed during general orientation upon hire, annually, and as needed. Educations listed included: -Communication, resident rights and facility responsibilities, abuse, neglect and exploitation of residents, quality assurance and performance improvement (QAPI), infection control, compliance and ethics, and behavioral health. NA Employee E10 had a hire date of 4/11/18, failed to have QAPI in-service education between 3/15/24, and 3/15/25. NA Employee E11 had a hire date of 8/27/1989, failed to have QAPI in-service education between 2/8/24, and 2/8/25. NA Employee E12 had a hire date of 8/19/21, failed to have QAPI in-service education between 2/8/24, and 2/8/25. LPN…

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

Based on review of facility policy and documents, and staff interview, it was determined that the facility failed to provide compliance and ethics training for four of five staff members (Nurse Aide (NA) Employees E10, E11, E12, and Licensed Practical Nurse (LPN) Employee E8). Findings include: Review of the Facility Assessment dated 3/10/25, indicated facility staff will complete annual mandatory training on compliance and ethics. Review of the policy In-service Training, Nurse Aide dated 3/10/25, indicated all personnel are required to participate in regular in-service education. Required training topics for all staff (including Nurse aides) include: Communication, resident rights and facility responsibilities, abuse, neglect and exploitation of residents, quality assurance and performance improvement (QAPI), infection control, compliance and ethics, and behavioral health. NA Employee E10 had a hire date of 4/11/18, failed to have compliance and ethics in-service education between 3/15/24, and 3/15/25. NA Employee E11 had a hire date of 8/27/1989, failed to have compliance and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the Code of Federal Regulations, facility provided documents, clinical records and staff interviews, it was determined that the facility failed to make certain residents were free from mental abuse, including abuse facilitated or enabled through the use of technology for two of four residents reviewed (Residents R13 and R21). Findings include: Review of the Code of Federal Regulations (CFR) §483.5 abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, facility policy, and staff interview, it was determined that the facility failed to ensure that residents medication regime was free from unnecessary psychotropic (substances that act on the brain to alter cognition, perception, and mood) medication for two of four residents (Resident R17, and R45). Findings include: Review of facility Psychotropic Medication Use dated 3/10/25, indicated that residents will not receive medications that are not clinically indicated to treat a specific condition. Drugs in the following categories are considered psychotropic medication and are subject to prescribing, monitoring, and review requirements: Anti-psychotics, Anti-depressants, Anti-anxiety, and Hypnotics. Psychotropic medications are not prescribed or given on a PRN (as needed) basis unless medication is necessary. PRN orders for psychotropic medications are limited to 14 days. Review of the clinical record indicated Resident R17 was admitted to the facility on [DATE]. 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 review of the Code of Federal Regulations, personnel records and staff interview, it was determined that the facility failed to conduct a criminal background check prior to working on the nursing unit for one out of five personnel records (Nurse Aide (NA) Employee E7). Findings include: Review of the Code of Federal Regulations §483.12(b) the facility must develop and implement policies and procedures that include the following component: Screening: The facility must have written procedures for screening potential employees for a history of abuse, neglect, exploitation, or misappropriation of resident property in order to prohibit abuse, neglect, and exploitation of resident property, and consistent with the applicable requirements at §483.12(a)(3). This includes attempting to obtain information from previous employers and/or current employers and checking with the appropriate licensing boards and registries. §483.12(b)(3) Include training as required. Review of NA Employee E7 personnel record on 5/29/25, indicated a start date of 3/17/25. The record indicated NA Employee…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, observations, staff interviews, and clinical record review, it was determined that the facility failed to provide appropriate respiratory care for two of three residents (Resident R3 and R42). Findings include: Review of facility policy Oxygen Administration last reviewed 3/10/25, indicated the purpose of this procedure is to provide guidelines for safe oxygen administration. Steps include but not inclusive to: Check the mask, tank, humidifying jar, etc., to be sure they are in good working order. Periodically re-check water in humidifying jar. Review of facility policy Departmental (Respiratory Therapy) Prevention of Infection last reviewed, 3/10/25, indicated the purpose of this procedure is to guide prevention of infection associated with respiratory therapy tasks and equipment. Infection control considerations related to oxygen administration include but not inclusive to: Check water level of any prefilled reservoir every forty-eight hours. Change pre-filled humidifier…

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 interviews, it was determined that the facility failed to ensure Medication Regimen Reviews (MRR) were completed and documented by the consultant pharmacist for one of four residents (Resident R44). Findings include: The facility policy Consultant Pharmacist Provider Requirements reviewed 3/10/25, indicated the consultant pharmacist will establish a system whereby observations and recommendations regarding resident drug therapy are communicated to those with authority to implement or respond to the recommendations in an appropriate and timely fashion. Reviewing the medication drug regimen of each resident at least monthly and documenting the review and findings in the resident ' s medical record. Review of Resident R44's admission record indicated resident was admitted to the facility on [DATE]. Review of Resident R44's MDS assessment (Minimum Data Set assessment: MDS -a periodic assessment of resident care needs) dated 4/9/25, indicated the…

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

Based on review of facility policies, observations, and staff interviews, it was determined that the facility failed to store all drugs and biologicals in a safe, secure, and orderly manner for one of two medication rooms (back hall medication room). Findings include: Review of the facility policy Medication Labeling and Storage last reviewed 3/10/25, indicated medications and biologicals dispensed by the pharmacy is consistent with applicable federal and state requirements and currently accepted pharmaceutical practices. The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. The medication label includes, at a minimum: the medication name, prescribed dose, strength, expiration date, residents name, route of administration and appropriate instructions and precautions. If medications containers have missing, incomplete, improper or incorrect labels, contact the dispensing pharmacy for instructions regarding returning or destroying these items. During an observation on 05/27/25, at 5:46 p.m. the back hall…

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 resident clinical records, facility policy, and staff interviews, it was determined the facility failed to obtain a physician order for hospice services and failed to ensure the coordination of hospice services (supportive services for end stage terminal illness) with facility services to meet the needs of each resident for end-of-life care for two of four residents (Resident R22, and R31). Findings include: Review of the facility policy Hospice Program dated 3/10/25, indicated that hospice services are available to residents at the end of life. Upon admission and periodically during their stay, residents are informed of hospice services. The facility collaborates with hospice in care planning process for residents receiving services. Ensures the facility communicates with the resident ' s attending physician. Review of the clinical record revealed that Resident R22 was admitted to the facility on [DATE]. Review of Resident R22's MDS (Minimum Data Set- periodic assessment of resident care…

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

Based on review of facility policy and documents, and staff interview, it was determined that the facility failed to provide training on effective communication for two of five staff members (Nurse Aide (NA) Employees NA E11, and NA E12). Findings include: Review of the policy In-service Training, Nurse Aide dated 3/10/25, indicated all personnel are required to participate in regular in-service education. Required training topics for all staff (including Nurse aides) include communication, resident rights and facility responsibilities, abuse, neglect and exploitation of residents, quality assurance and performance improvement (QAPI), infection control, compliance and ethics, and behavioral health. Review of facility provided documents and training records for NA Employees E11 and NA Employee E12, revealed the following staff members did not have documented training on effective communication. NA Employee E11 had a hire date of 8/27/1989, failed to have effective communication in-service education between 2/8/24, and 2/8/25. NA Employee E12 had a hire date of 8/19/21, failed to have…

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

Based on review of facility policy and documents, and staff interview, it was determined that the facility failed to provide behavioral health training as determined by the Facility Assessment for two of five staff members (Employees E8, and E10). Findings include: Review of the Facility Assessment dated 3/10/25, indicated facility staff will complete annual mandatory training on behavioral health. Licensed Practical Nurse (LPN) Employee E8 had a hire date of 6/7/06, failed to have behavioral health in-service education between 2/6/24, and 2/6/25. Nurse Aide (NA) Employee E10 had a hire date of 4/11/18, failed to have behavioral health in-service education between 3/15/24, and 3/15/25. Interview on 5/30/25, at approximately 11:30 a.m. the Director of Nursing confirmed that the facility failed to provide training on behavioral health for two of five employees (Employees E8, and E10). 28 Pa Code: 201.14 (a) Responsibility of licensee. 28 Pa Code: 201.18 (b)(1) Management. 28 Pa Code: 201.20 (a)(6)(d) Staff development.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, resident, and staff interviews, it was determined that the facility failed to obtain physician orders and failed to care plan interventions for medication self-administration for one of three residents (Residents R1). Findings include: Review of the facility policy Administering Medications last reviewed 8/19/24, indicates residents may self-administer their own medications only if the attending physician, in conjunction with the interdisciplinary care planning team, has determined that they have the decision-making capacity to do so safely. Review of the clinical record indicated Resident R1 was admitted to the facility on [DATE], with the diagnosis of diabetes (high sugar in the blood), atrial fibrillation (heart does not pump as it should) and high blood pressure. During an observation completed on 3/26/25, at 10:35 a.m. Resident R1 was sitting in her chair she was holding a medication cup that contained one pink pill, one yellow pill, one white pill, and one salmon colored pill. 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 review of facility policy, resident clinical records, observation, and staff interviews, it was determined that the facility failed to implement infection prevention and control monitoring policies for COVID-19 for ten out of ten residents (Resident R1, R2, R3, R4, R5, R6, R7, R8, R9 and Resident R10), and failed to use Personal Protective Equipment (PPE) appropriately, which created the potential for the cross-contamination and the spread of diseases and infections on 3 out of 10 COVID-19 positive rooms. Finding include: Review of facility policy Covid-19 Testing and Exposure Management dated 4/15/24, indicated the facility is dedicated to detecting and preventing the transmission of COVID-19. Review of facility policy Coronavirus Disease (COVID-19) - Using Personal Protective Equipment dated 4/15/24, indicated all staff will follow standard precautions and transmission-based precautions if required based on resident ' s condition. When caring for a resident with suspected or confirmed SARS-CoV-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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy, clinical record review and staff interview, it was determined that the facility failed to complete influenza vaccination consent for one of five residents (Resident R4), failed to make certain that influenza vaccination was administered in a timely fashion for one of five residents (Resident R5), and failed to complete pneumococcal vaccine consent for two of five residents (Resident R4 and R5). Findings include: Review of the facility policy Pneumococcal Vaccine dated 4/15/24, indicated all residents are offered pneumococcal vaccines to aid in preventing pneumonia-pneumococcal infections. Prior to or upon admission, residents are assessed for eligibility to receive the pneumococcal vaccine series. The resident receives information and education regarding the benefits and potential side effects of the vaccine. Residents have the right to refuse vaccination. If refused, appropriate information is documented in the resident ' s medical record. Review of facility policy Influenza Vaccine…

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, clinical record review and staff interview, it was determined that the facility failed to provide accurate and timely documentation related to offering the COVID-19 vaccine and providing education for two of five residents reviewed for immunizations (Resident R1 and R5), and failed to offer staff COVID-19 vaccines for 7 of 7 employees interviewed. (E4, E5, E6, E7, E8, E9, and E10) Findings include: Review of the Centers for Disease Control (CDC) Staying Up to Date with COVID-19 Vaccines dated 7/3/24, indicated the CDC recommends the 2023-2024 updated COVID-19 vaccines-Pfizer-BioNTech, Moderna, or Novavax-to protect against serious illness from COVID-19. People aged 65 years and older who received 1 dose of any updated 2023-2024 COVID-19 vaccine (Pfizer-BioNTech, Moderna or Novavax) should receive 1 additional dose of an updated COVID-19 vaccine at least 4 months after the previous updated dose. Review of facility policy Coronavirus Disease (COVID-19)- Vaccination of Residents dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policies, closed resident records and staff interview, it was determined that the facility failed to acquire and document a physician's discharge order and acquire and document physician orders for medications for one out of two closed resident records (Closed Resident Record CR1). Finding include: The facility Discharge Medications policy dated 5/28/24, indicated that a physician must be contacted for an order to discharge a resident with medications before they will be dispensed, the charge nurse shall verify that the medications are labeled consistent with current physician orders. Review of Closed Resident Record CR1's admission record indicated she was admitted on [DATE], with diagnoses that included nondisplaced fracture of ankle left leg, hypertension (high blood pressure) and diabetes (high sugar in the blood). Review of Closed Resident Record CR1's clinical nurse note dated 7/22/24, indicated that resident and daughter requested discharge to home today. Review of Closed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policies, clinical record reviews and staff interviews it was determined that the facility failed to provide written notice, including reason for the change, prior to moving a resident to another room, for two of four residents reviewed (Residents R1, and R2). Findings include: Review of facility policy, Transfer, Room to Room , last reviewed 5/28/24, indicated that the following information should be recorded in the resident's medical record: · The date and time the room transfer was made. · The name and title of the individual(s) who assisted with the move. · All assessment data obtained during the move. · How the resident tolerated the move. · If the resident refused the move, the reason(s) why and the intervention taken. · The signature and title of the person recording the data. Review of the clinical record revealed that Resident R1 was admitted to the facility on [DATE]. Review of Resident 1's MDS (Minimum Data Set, periodic assessment of resident care needs) dated 3/12/24,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, resident records, admissions documentation and staff interview it was determined that the facility failed to provide a comprehensive review of resident admission rights and maintain admission documentation for one of four sampled records (Resident R3). Finding include: The facility policy Admissions Orientation last reviewed 5/28/24, indicated that the facility shall provide each resident with a facility tour and an orientation of the facility's policies, programs, and services which includes but is not limited to residents rights and responsibilities. Review of Resident R3 admission record indicated she was admitted on [DATE]. Review of Resident R3's MDS assessment (Minimum Data Set assessment: MDS -a periodic assessment of resident care needs) dated 5/12/24, indicated diagnoses of anorexia nervosa (an eating disorder causing patients to obsess about weight and what they eat), low potassium, and muscle weakness. Review of Resident R3's admission packet (no date) did not…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident observations, resident interviews, staff interviews, clinical record review, and grievance review, 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 three of ten residents (Resident R35, R46, and R104). Findings Include: Review of a resident grievance dated 10/25/23, Resident R 35 stated concern over response time to call bells being answered. During an interview on 2/28/24, at 12:01 p.m. MDS (minimum data set- periodic assessment of resident care needs) Coordinator Employee E13 stated Lately we've had no agency (nursing staff). I think it ' s because they weren't being paid. We were pretty good there for a while until we didn ' t get paid the second time. During a group interview on 2/28/24 at 1:31 p.m. the following was stated: 11 out of 11 residents stated that there is not enough staff 2 out of 11 residents clarified that evening…

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 a review of clinical records and facility documentation, and staff interviews, it was determined the facility failed to implement a complete drug regimen review process for five months for five out of five sampled residents (Resident R3, R8, R11, R17, and R49). Findings include: The facility Medication utilization and prescribing-clinical protocol policy dated 9/28/23, indicated that the consultant pharmacist should us the monthly and interim drug regimen review to help identify potentially problematic medications, including medication regimens that are not supported based on clinical signs or symptoms. The staff and practitioners in collaboration with the consultant pharmacist will take into account medication related issues and drug interactions. Review of the clinical record indicated Resident R3 was admitted to the facility on [DATE]. Review of Resident R3's Minimum Data Set (MDS - a periodic assessment of care needs) dated 1/3/24, indicated diagnoses of coronary artery disease (damage or disease in…

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

Based on observation and staff interview it was determined that the facility failed to maintain sanitary conditions in the main kitchen and dining room creating the potential for unsafe condition and cross contamination. Findings include: During an observation of the main designated kitchen on 2/27/24 at 9:15 a.m., the following was observed: -ice machine in the main kitchen contained a brown like substance. Cleaning chart hanging beside the ice machine noted that last cleaning was November 2023 -chemicals were directly on the floor: grease cutter, pot sheen, kex-plus, booster and eco-rinse -bases and lids for the resident trays were being stores right side up inside of upside down -6 packages of hot dog buns not dated -1 bag of sugar was open and not dated -chemicals in a spray bottle on the prep table in the main kitchen while food was being prepared During an observation of tray line in the designated main dining room on 2/27/24 at 11:59 a.m., it was revealed [NAME] Employee E28's coat was covering the clean plates and serving utensils for lunch service. During an interview 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.

Based on review of facility policy, resident council documents, resident council group interview, resident interview, and staff interview it was determined that the facility failed to respond to concerns from resident council and failed to respond to concerns in a timely manner for three out of nine months (December 2023, January 2024, and February 2024). Findings include: The facility Resident council policy dated 9/28/23, indicated that the facility supports resident rights' to organize and participate in a resident council. The purpose of the resident council is for residents to have input in the operation of the facility, discussion of concerns for improvement, and communication between residents and facility staff. Review of Resident council minutes dated December 2023 and February 2024 identified a request from council to obtain a new beautician. The documentation did not indicate follow-up actions or communication from nursing home administration to obtain a new professional beautician. During an interview on 2/27/24, at 11:27 a.m. Resident R46 stated: I need a haircut!…

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, tour of the facility, and staff interview it was determined that the facility failed to make certain that a posted grievance policy and procedure was met federal guidelines for two out of two nursing units (Front hall nursing unit and back hall nursing unit). Findings include: The facility Grievance procedure policy dated 9/28/23, indicated that the facility encourages residents and their family members to make known to the facility any concerns. The facility has developed grievance procedure that will address all such concerns. The grievance official will be responsible for overseeing the grievance process. During a tour on 2/27/24, at 9:25 a.m. observations of the facility did not find a posted grievance policy, grievance official e-mail and business address. During a tour on 2/28/24, at 9:13 a.m. observations of the facility did not find a posted grievance policy, grievance official e-mail and business address. During a tour on 2/28/24, at 11:45 a.m. observations with Assistant Nursing Home Administrator/Director of Social Services Employee E1…

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

Based on review of personnel records, and staff interview it was determined that the facility failed to complete annual performance evaluations for four out of five nurse aides (NA Employee E4, E19, E20, and E21). Findings include: Review of personnel files revealed that Nurse Aide Employee E4 start date was 9/4/18, last performance evaluation was completed 8/14/19. Review of personnel files revealed that Nurse Aide Employee E19 start date was 8/8/13, last performance evaluation was completed 10/30/19. Review of personnel files revealed that Nurse Aide Employee E20 start date was 6/2/11, last performance evaluation was completed 5/15/20. Review of personnel files reviewed that Nurse Aide Employee E21 start date was 10/21/20, last performance evaluation was completed 10/21/21. During an interview on 2/28/24, at 12:30 p.m. the Human Resource Employee E18 confirmed that the facility does not have up to date performance reviews completed on NA Employee E4, E19, E10 and E21. 28 Pa Code: 201.20 (a)(b)(c)(d) Staff development. 28 Pa Code: 201.14 (a) Responsibility of licensee.

Based on staff interviews it was determined that the facility failed to employ a qualified Dietary Manager and Registered Dietitian since October 2023. Findings include: During a kitchen tour on 2/27/24 at 9:30 a.m. Dietary Manager Employee E5 stated that he started his position October 2023 and he is not a CDM (Certified Dietary Manager) and he has catering experience. Review of personnel file revealed Employee E5 hire date 10/23. Personnel file confirmed no certification. Interview on 2/29/24 at 1:30 p.m. Director of Nursing confirmed Dietary Manager was not qualified as required. During an interview 3/2/24, 11:30 a.m. Registered Dietitian Employee E17 confirmed there hasn't been an Registered Dietitian at the facility since October 2023. She has been PRN (per resident needs) and she has since resigned from the company effective 3/11/24. 28 Pa. Code 201.18(e)(1)(6)Management. 28 Pa. Code 211.6(c) Dietary services.

Based on menu, resident council group interview and staff interviews, it was determined that the facility failed to follow the menu for two of two meals (Breakfast and Lunch meal Saturday 2/24/24). Findings include: A review of the menu indicated that the menu for breakfast was as follows: Cereal of Choice Pancakes Banana Coffee Milk of Choice, 8 oz Syrup/Margarine A review of the menu indicated that the menu for lunch was as follows: Chicken Sweet & Sour Fluffy Steamed Rice Broccoli Cuts Pears Beverage of Choice Pepper During a resident council group interview on 2/28/24, at 1:31 p.m. three out of 11 residents stated they were not served the correct breakfast and lunch on 2/24/24. During an interview on 2/28/24, at 2:30 p.m. Dietary Manager Employee E5 confirmed that on 2/24/24 the posted menu was not served because of dietary staff call off's. During an interview on 3/1/24, at 11:40 a.m. the Director of Nursing confirmed that the facility served donuts and oatmeal for breakfast, pizza and salad for lunch on 2/24/24. 28 Pa. Code: 211.6(a)(b) Dietary services.

Based on review of facility documents, and staff interview, it was determined that the facility failed to ensure that all required staff persons were in attendance at quarterly Quality Assurance Process Improvement (QAPI) Committee meetings for two of three quarters reviewed (second quarter April-June 2023, and third quarter July-September 2023). Findings include: Review of the CFR (Code of Federal Regulations) §483.75(g) Quality assessment and assurance. §483.75(g)(1) A facility must maintain a quality assessment and assurance committee consisting at a minimum of: (i) The director of nursing services; (ii) The Medical Director or his/her designee; (iii) At least three other members of the facility's staff, at least one of who must be the administrator, owner, a board member or other individual in a leadership role; and (iv) The infection Preventionist. (i) Meet at least quarterly and as needed to coordinate and evaluate activities under the QAPI program, such as identifying issues with respect to which quality assessment and assurance activities, including performance improvement…

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, clinical record review, observation, and staff interview, it was determined the facility failed to implement measures to prevent the potential for cross contamination during a dressing change for one of three residents (Resident R10) and the facility failed to implement an infection control program that included a system of surveillance to identify possible communicable diseases or infections for three of nine months (October 2023, November 2023, and December 2023). Findings include: Review of facility policy Infection Prevention and Control Program dated 9/28/23, indicated an infection prevention and control program is established to maintain and provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Surveillance tools are used for recognizing the occurrence of infections, recording their numbers and frequency, detecting outbreaks and epidemics, monitoring employee infection, monitoring…

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 facility's infection control policies and procedures and staff interview, it was determined that the facility failed to implement an antibiotic stewardship program for three of nine months (October 2023, November 2023, and December 2023). Findings include: Review of facility policy Antibiotic Stewardship - Review and Surveillance of Antibiotic Use and Outcomes dated 9/28/23, indicated as part of the facility antibiotic stewardship program, all clinical infections treated with antibiotics will undergo review by the infection preventionist or designee. All resident antibiotic regimens will be documented on the facility-approved antibiotic surveillance tracking form. Review of the facility's Infection Control surveillance for June 2023 through February 2024, failed to include documentation to indicate that antibiotic monitoring was completed for October 2023, November 2023, and December 2023. During an interview on 2/29/24, at 10:42 a.m. the Director of Nursing (DON) confirmed that the facility was unable to locate and provide documentation to indicate that…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, resident clinical record, resident interview and staff interview it was determined that the facility failed to provide goods and services resulting in neglect for one of two residents (Resident R104). Findings include: The facility Identifying types of abuse policy last reviewed 9/28/23, indicated neglect is defined as the failure of the facility, its employees or service providers to provide goods and services that a resident requires, but the facility fails to provide them. And this results in physical harm, pain, mental anguish or emotional distress. Review of Resident R104's admission record indicated she was admitted on [DATE], with diagnoses that included Polycythemia vera (an increase in blood cells creating the potential of blood clotting and blood that is thicker than normal), hypothyroidism (decrease in production of thyroid hormone), and major depressive disorder (a constant feeling of sadness and loss of interest). Review of Resident R104's MDS assessment (Minimum…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, resident clinical record, reports submitted to the State, resident interview and staff interview it was determined that the facility failed to report an allegation of neglect within 24 hours to the local state field office for one of two residents (Resident R104). Findings include: The facility Identifying types of abuse policy last reviewed 9/28/23, indicated neglect is defined as the failure of the facility, its employees or service providers to provide goods and services that a resident requires, but the facility fails to provide them. And this results in physical harm, pain, mental anguish or emotional distress. The facility Abuse, neglect, exploitation, or misappropriation--reporting and investigating policy last reviewed 9/28/23, indicated that all reports of resident abuse, neglect, exploitation, or misappropriation of resident property are reported to local, state and federal agencies. The administrator immediately reports his or her suspicion to the state licensing…

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 a review of clinical records, and staff interviews, it was determined that the facility failed to ensure that a comprehensive resident care plan was implemented to meet resident care needs for one of six residents reviewed (Resident R37) to address care needs related to a Life Vest (a wearable defibrillator designed to protect residents from sudden cardiac death). Findings include: Review of the clinical record revealed that Resident R37 was admitted to the facility on [DATE]. Review of Resident 37's MDS (Minimum Data Set, periodic assessment of resident care needs) dated 1/31/24, indicated diagnoses of dilated cardiomyopathy (a condition in which the heart's main pumping chamber is enlarged. And becomes weaker as it grows larger), Multiple Sclerosis (a disease that affects the central nervous system), and acute respiratory failure (occurs suddenly and interferes with the ability of the lungs to deliver oxygen). Review of Resident R37's Nursing admission evaluation dated 1/24/24, stated Life Vest noted.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policies and clinical records, and staff interviews, it was determined that the facility failed to adhere to acceptable standards of practice related to participation in interdisciplinary meetings and monitoring of Food Service operations Findings include: The Pennsylvania Code, Title 49, Chapter 21, Professional and Vocational Standards: Responsibilities of the Licensed Dietitian/ Nutritionist Section 21.711 Professional Conduct indicated that the Licensed Dietitian/ Nutritionist shall provide information which will enable patients to make their own informed decisions regarding nutrition and dietetic therapy, including the reasonable expectations of the professional relationship. Review of Facility assessment dated [DATE] states that the facility will have a full time Dietitian on staff. During an interview on 2/27/24 at 12:33 p.m. Dietary Manager Employee E5 stated he does not talk to resident's regarding their food preferences. During an interview on 3/2/24 at 11:30 a.m. Registered…

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 policy and clinical record review and resident, family, and staff interviews, it was determined that the facility failed to make certain that showers and assistance for activities of daily living were consistently provided for one of five residents (Resident R46). Findings include: Review of the facility policy Activities of Daily Living, Supporting last reviewed 9/28/23, indicated that residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. Supervision is defined as oversight, encouragement or cueing provided three or more times during the last seven days. Review of the clinical record revealed that Resident R46 was admitted to the facility on [DATE]. Review of Resident R46's MDS (Minimum Data Set, periodic assessment of resident care needs) dated 11/29/23, indicated diagnoses of stroke, hemiplegia (paralysis of one side of the body), and unsteadiness on feet. Section GG0130…

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 clinical records and staff interview, it was determined that the facility failed to make certain that residents were provided appropriate treatment and services for one of three residents (Resident R37) to address care needs related to Life Vest (wearable defibrillator designed to protect residents from sudden cardiac death). Findings include: Review of the clinical record revealed that Resident R37 was admitted to the facility on [DATE]. Review of Resident 37's MDS (Minimum Data Set, periodic assessment of resident care needs) dated 1/31/24, indicated diagnoses of dilated cardiomyopathy (condition in which the heart's main pumping chamber is enlarged. And becomes weaker as it grows larger), Multiple Sclerosis (a disease that affects the central nervous system), and acute respiratory failure (occurs suddenly and interferes with the ability of the lungs to deliver oxygen). Review of Resident R37's Nursing admission Evaluation dated 1/24/24, stated Life Vest noted. Review of Resident R37's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical records, and staff interviews, it was determined that the facility failed to make certain that residents were monitored, assessed, and received the necessary services to prevent pressure ulcers from developing or worsening for one of three residents (Resident R10). Findings include: Review of facility policy Pressure Ulcers/Skin Breakdown - Clinical Protocol dated 9/28/23, indicated the staff and practitioner will examine the skin of newly admitted residents for evidence of existing pressure ulcers or other skin conditions. Review of the clinical record indicated Resident R10 was admitted to the facility on [DATE]. Review of resident R10's Minimum Data Set (MDS - a periodic assessment of care needs) dated 2/27/24, indicated diagnoses of high blood pressure, peripheral vascular disease (circulatory condition in which narrowed blood vessels reduce blood flow to the limbs), and malnutrition (lack of sufficient nutrients in the body). Review of a physician's order dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical record review, and staff interview it was determined that the facility failed to provide a resident with necessary behavioral non-pharmacological interventions to maintain the highest practicable mental and psychosocial well-being for one out of four sampled resident records (Resident R3). Findings include: Review of facility policy Psychotropic Medication Use dated 9/28/23, indicated that a psychotropic medication is any medication that affects brain activity associated with mental processes and behavior. Psychotropic medication management includes indications for use, dose, duration, adequate monitoring for efficacy and adverse consequences and preventing, identifying, and responding to adverse consequences. Review of Resident R3's admission record indicated Resident R3 was admitted on [DATE]. Review of Resident R3's MDS assessment (Minimum Data Set Assessment: A periodic assessment of resident care needs) dated 1/3/24, indicated she was admitted with the following…

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 policies, clinical record review, and staff interview, it was determined that the facility failed to make certain resident medication regimens were free from potentially unnecessary medications for two of four residents (Resident R3 and R8). Findings include: Review of facility policy Antipsychotic Medication Use dated 9/28/23, indicated antipsychotic medications will be prescribed at the lowest possible dosage for the shortest period of time and are subject to gradual dose reduction and re-review. Residents who are admitted from the community or transferred from a hospital who are already receiving antipsychotic medications will be evaluated for the appropriateness and indications for use. The interdisciplinary team will re-evaluate the use of the antipsychotic medication at the time of admissions and/or within two weeks (at the initial MDS assessment) to consider whether or not the medication can be reduced, tapered, or discontinued. PRN (as needed) orders for antipsychotic medications will…

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 policies, observations, and staff interviews, it was determined that the facility failed to properly and safely store medications under appropriate temperatures in one of two medication rooms (Front medication room). Finding include: The facility Medication: labeling and storage policy last reviewed on 9/28/23, indicated that the facility stores all medications and biologicals under proper temperature, humidity, and light controls. During observations on 2/27/24, at 10:24 a.m. observations of medication room/ front medication room with MDS coordinator RN Employee E13 found the following: medication room refrigerator observed with a temperature reading 50°F The Refrigerator temperature log indicated that refrigerator temperatures must fall between 36°F and 46°F. During an interview, on 2/27/24, at 10:27 a.m. MDS coordinator RN Employee E13 confirmed that the facility failed to properly and safely store medications under appropriate temperatures 28 Pa. Code: 211.9(a)(1)(h)(k)(l)(1) Pharmacy services. 28 Pa. Code:211.12(d)(1)(2)(3)(5) Nursing services.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interviews and a review of the facility's assessment it was determined that the facility failed to implement and document a complete facility wide assessment, which identified the specific resources necessary to care for its specific resident population. Findings include: Review of the clinical record revealed that Resident R37 was admitted to the facility on [DATE]. Review of Resident 37's MDS (Minimum Data Set, periodic assessment of resident care needs) dated 1/31/24, indicated diagnoses of dilated cardiomyopathy (a condition in which the heart's main pumping chamber is enlarged. And becomes weaker as it grows larger), Multiple Sclerosis (a disease that affects the central nervous system), and acute respiratory failure (occurs suddenly and interferes with the ability of the lungs to deliver oxygen). Review of Resident R37's Nursing admission evaluation dated 1/24/24, stated Life Vest noted. Review of Resident R37's physician orders revealed an order written on 1/29/24,…

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 a review of facility policy, observations, and staff interview, it was determined the facility failed to store food items in accordance with professional standards for food service safety in one of two food service areas (Main Kitchen.) Findings include: Review of facility policy titled Food Storage last reviewed on 9/28/23, informed food is stored, prepared, and transported at an appropriate temperature and by methods designed to prevent cross contamination. Procedures include to re-wrap packages of frozen food which have been opened. This prevents freezer burns and spoilage. During an observation on 1/24/24 at 1:45 p.m. the freezer in the main kitchen contained the following: - 14 pre-made omelets were not sealed after opening. - 35 pre-made egg patties were not sealed when open, and were not dated when opened. During an interview on 1/24/24, at 1:50 p.m. the Dietary Manager Employee E3 confirmed the facility failed to store food items in accordance with professional standards for food service safety. 28 Pa. Code: 211.6(c) Dietary services.

Based on a review of facility policies, observations and staff interviews it was determined that the facility failed to properly label, date and store medications in two of three medication carts. (Med Cart 1-9, and Med Cart Long Hall) Findings include: A review of facility policy Labeling of Medication Containers dated 9/28/23, indicated that all medication maintained in the facility are properly labeled in accordance with state and federal guidelines and regulations. A review of facility policy Storage of Medications dated 9/28/23, indicated that drugs and biologicals are stored in a safe, secure and orderly manner. During an observation on 10/17/23, at 10:30 am it was revealed that in medication cart 1-9 the top drawer contained an unlabeled and undated plastic cup of orange pills and in medication cart long hall the top drawer contained three unlabeled and undated cups of a white pills. During an interview on 10/17/23, at 10:55 am Licensed Practical Nurse (LPN) Employee E1 confirmed that Medication Cart long hall contained improperly stored containers of medication or…

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.