Midtown Oaks Health & Rehab Center

Based on clinical record reviews and staff interviews, it was determined that the facility failed to initiate nutritional interventions to assure that residents were offered sufficient food and fluid intake to maintain proper hydration and health for one of six residents reviewed (Resident 2). Findings include:A comprehensive Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 2, dated September 4, 2025, revealed that the resident was cognitively impaired and dependent on staff for daily care tasks, including feeding. The resident's care plan, most recently updated September 4, 2025, indicated that the resident had increased nutrition risk related to needing to be fed by staff and having swallowing difficulties. The resident's care plan indicated that the resident was to be offered an alternative meal if she consumed less than fifty percent of the meal. The resident was to be spoon fed nectar thick liquids by staff.According to Resident 2's meal intake record, dated November 2025, the resident ate less than fifty percent…

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 policies, as well as observations and staff interviews, it was determined that the facility failed to maintain confidentiality of residents' personal health information for one of seven residents reviewed (Resident 4).Findings include: The facility's policy regarding privacy of health information, dated April 29, 2025, indicated that the facility was to protect the confidentiality of resident health information. A Quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 4, dated November 17, 2025, revealed that the resident was cognitively intact, was understood and able to understand others. Observations during the lunch service on December 30, 2025, at 12:38 p.m. revealed that Resident 4's Heath Insurance Service Coordinator was standing next to her at the resident's dining table. There were two other residents at the same table, and two residents and a family member at another table that was approximately one foot behind Resident 4. There were multiple staff members present with the Health…

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 policies, observations and staff interviews, it was determined that the facility failed to ensure that food was stored, prepared, distributed and served in accordance with professional standards for food service safety in the kitchen, in one of two pantries (second floor) and one of two refrigerators (third floor pantry) observed.Findings include: The facility policy regarding food storage, dated April 29, 2025, revealed that any food that has been opened must be labeled, dated and secured in such a way that the food item is not open to air, and that the facility would ensure a clean and sanitary environment. The facility's policy regarding food production and safety, dated April 29, 2025, revealed that the purpose of the policy was to ensure food would be cooked and/or held at appropriate temperatures to maintain safety, and that temperatures would be taken prior to meal service. Observations in the main kitchen's walk in freezer on September 8, 2025, at 9:30 a.m. revealed that there were 25 egg omelets, 15 sausage patties, five chicken cutlets, six pork chops…

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 the Resident Assessment Instrument User's Manual and clinical records, as well as staff interviews, it was determined that the facility failed to complete accurate Minimum Data Set assessments for four of 50 residents reviewed (Residents 3, 8, 45, 82). Findings include:The Resident Assessment Instrument (RAI) User's Manual, which gives instructions for completing Minimum Data Set (MDS) assessments (required assessments of a resident's abilities and care needs), dated October 2024, indicated that Section O0110C1, oxygen therapy, was to be coded if oxygen was administered at any time within the last 14 days.Physician's orders for Resident 3, dated June 24, 2024, included orders for the resident to receive two liters/minute of oxygen as needed every shift to keep her oxygen saturation (percentage of oxygen in the blood) greater than 90%.Review of the Medication Administration Records for Resident 3, dated May and June 2025, revealed that the resident received oxygen within the last 14 days of the assessment period.A quarterly MDS assessment for Resident 3, dated…

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

Based on review of the facility's plans of correction for previous surveys, and the results of the current survey, it was determined that the facility's Quality Assurance Performance Improvement (QAPI) committee failed to maintain compliance with nursing home regulations and ensure that plans to improve the delivery of care and services effectively addressed recurring deficiencies.Findings include:The facility's deficiencies and plans of correction for a State Survey and Certification (Department of Health) survey ending August 22, 2024, December 23, 2024, and April 22, 2025 revealed that the facility developed plans of correction that included quality assurance systems to ensure that the facility maintained compliance with cited nursing home regulations. The results of the current survey, ending September 11, 2025, identified repeated deficiencies related to accuracy of Minimum Data Set (MDS) assessments (mandated assessment of a resident's abilities and care needs), care plan timing and revision, preventing issues with the accountability of controlled medications (drugs with the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the Resident Assessment Instrument User's Manual and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that comprehensive admission Minimum Data Set assessments were completed in the required time frame for four of 50 residents reviewed (Residents 35, 45, 89, 117). Findings include:The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which provides instructions and guidelines for completing required Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2023, indicated that an admission MDS assessment was to be completed no later than 14 days (admission date + 13 calendar days) following admission.A comprehensive admission MDS assessment for Resident 35, dated July 8, 2025, revealed that the resident was admitted to the facility on [DATE], and the resident's admission MDS assessment was dated as completed on July 15, 2025, which was 14 days after admission.A…

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

Based on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that a resident's care plan was updated/revised to reflect the resident's specific care needs for two of 50 residents reviewed (Residents 6 and 7).Findings include: The facility's policy regarding care plans, dated April 29, 2025, indicated that the facility will develop a comprehensive person-centered care plan for each resident that includes measurable goals, and timetables to meet the resident's medical, nursing, mental and psychosocial needs identified in the comprehensive assessment. The care plan is reviewed on an on-going basis and revised as indicated by the resident's needs, wishes or a change in condition. At a minimum, this will occur with each comprehensive, quarterly, assessment in accordance with Resident Assessment Instrument (RAI) requirements. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 6, dated June 10, 2025, revealed that the resident was…

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

Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to maintain a complete and accurate accounting of controlled medications (medications with the potential to be abused) for two of 50 residents reviewed (Residents 46, 53). Findings include:The facility's policy regarding medication administration, dated April 29, 2025, indicated that staff are to document the administration of controlled substances in accordance with applicable law.A quarterly Minimum Data Set (MDS) Assessment (a mandated assessment of a resident's abilities and care needs) for Resident 46 dated August 4, 2025 revealed that the resident is cognitively impaired, required assistance from staff for daily care needs and had medical diagnosis that include dementia and heart failure.Physician's orders for Resident 46, dated May 13, 2025, included an order for the resident to receive 10 milligrams (mg) of Oxycodone (a controlled narcotic pain medication) orally every 4 hours for pain.A review of Resident 46's-controlled drug record (used to keep count…

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 and clinical records, as well as staff interviews, it was determined that the facility failed to respond to a pharmacy recommendation for one of 50 residents reviewed (Resident 7). Findings include: A facility policy related to medication regimen review, dated April 29, 2025, indicated that the consultant pharmacist will conduct medication regimen reviews (MRRs) and will make recommendations based on the information made available in the resident's health record. The consultant pharmacist will provide the resident's MRRs to the facility identified personnel who will ensure that the attending physician, medical director, and other necessary facility staff receive the recommendations. The facility should maintain readily available copies of the consultant pharmacist's reports on file in the facility, and as a part of the resident's permanent health record. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 7, dated June 25, 2025, revealed that the resident was cognitively…

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

Based on observations, and staff interviews, it was determined that the facility failed to ensure that medications were properly stored for one of 50 residents reviewed (Resident 56). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 56, dated August 21, 2025, indicated that the resident was cognitively intact, required assistance from staff for daily care needs, received a antipsychotic medication, antidepressant medication, anticoagulant medication, diuretic medication and a hypoglycemic medication. Resident 56 had diagnoses that included diabetes, depression, high blood pressure, and deep vein thrombosis (blood clot). Observation of Resident 56 on September 8, 2025, at 9:13 a.m. revealed the resident was lying in bed and an unsupervised medicine cup containing 10 unlabeled clean and dry pills was sitting on her overbed table. An unlabeled medication was sitting on her bedside table, cut in half. Interview with Resident 56 at that time revealed that they were her morning medications that…

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

Based on review of the Pennsylvania Nurse Practice Act and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that physician's orders were clarified when needed for two of 12 residents reviewed (Residents 1, 2).Findings include:The Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.11 (a)(1)(2)(4) indicated that the registered nurse was to collect complete and ongoing data to determine nursing care needs, analyze the health status of individuals and compare the data with the norm when determining nursing care needs, and carry out nursing care actions that promote, maintain and restore the well-being of individuals.A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated May 23, 2025, revealed that the resident was understood, could understand others, had a diagnosis of included end-stage renal disease (ESRD - a permanent condition that occurs when the kidneys are no longer able to function properly), and received…

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 clinical records, as well as staff interviews, it was determined that the facility failed to ensure that residents received care and treatment in accordance with professional standards of practice, by failing to ensure that physician's orders were followed for two of 12 residents reviewed (Residents 1, 2), and failed to follow recommendations from the orthopedist (a medical doctor specializing in the diagnosis, treatment, and prevention of musculoskeletal system disorders) for a therapy evaluation for one of 12 residents reviewed (Resident 2).Findings include: Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated May 23, 2025, revealed that the resident was understood, could understand others, had a diagnosis which included end-stage renal disease (ESRD - a permanent condition that occurs when the kidneys are no longer able to function properly), and received hemodialysis (a treatment that removes waste products and excess fluid from the blood when the kidneys are no…

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

Based on review of policies and clinical records, as well as observations and resident and staff interviews, it was determined that the facility failed to follow facility policy for the care and monitoring of residents receiving dialysis for one of 12 residents reviewed (Resident 2). Findings include: A facility policy for Hemodialysis Care, dated April 29, 2025, indicated that communication between the dialysis provider and the facility will occur before and after each hemodialysis treatment and as needed. Pre-dialysis, the staff are to document an assessment in the dialysis communication tool, print the tool and send it with the resident to dialysis. Post dialysis, staff are to receive report from the dialysis provider and/or review the dialysis communication tool documentation by the dialysis provider and contact dialysis promptly with any questions or concerns. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 2, dated June 2, 2025, revealed that the resident was cognitively intact, required assistance…

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 serve food items that were palatable.Findings include: The facility's policy regarding food temperatures, dated April 29, 2025, revealed that hot food should be palatable at point of delivery. Observations of the lunch meal tray line on August 6, 2025, at 11:41 a.m. revealed that dietary staff began to prepare the second floor low hall cart. At 12:04 p.m. the second floor low hall cart arrived on the unit and at 12:14 p.m. all but one of the trays from that cart were delivered to the residents. A test tray completed on August 6, 2025, at 12:16 p.m. revealed that the milk was 45.4 degrees Fahrenheit and tasted cold, the orange juice was 51.4 degrees Fahrenheit, the coffee was 142 degrees Fahrenheit, the beef stew was 117 degrees Fahrenheit and tasted cold and was not palatable, and the cauliflower was 129 degrees Fahrenheit, unseasoned, tasted cold and overcooked, and was not palatable. Interview with the Dietary Manager on August 6, 2025, at 12:18 p.m. confirmed…

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 clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that residents who required urinary catheterization (a flexible tube inserted into the bladder to drain urine) was completed as ordered for one of 12 residents reviewed (Resident 2).Findings include:An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 2 revealed that the resident was cognitively intact, required assistance for care needs, had a diagnosis of end stage kidney failure and received dialysis three times per week. A care plan for Resident 2, dated March 3, 2025, indicated that the resident had urinary incontinence, and was to be provided straight catheterization (a medical procedure used to drain urine from the bladder using a thin, flexible tube called a straight catheter) as ordered.Physician's orders for Resident 2, dated May 28, 2025, included an order for the resident to be straight catheterized three times a day (once every shift) for a neurogenic bladder.…

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 records, and shower schedules, as well as staff and resident interviews, it was determined that the facility failed to ensure that residents were provided with showers as scheduled for four of nine residents reviewed (Residents 4, 5, 6, 7). Findings include: The facility policy for bathing and showering, dated April 29, 2025, indicated that residents will be bathed or showered according to their preferences in order to maintain healthy hygiene and skin condition. Each resident will be asked about his/her bathing preferences upon admission (type of bath, preferred days and times). Each resident will be scheduled to receive bathing a minimum of two times per week. If the bath/shower cannot be given or the resident refuses, the nursing assistant will promptly report this to the charge nurse. The charge nurse will speak to the resident who refuses to ascertain why they are refusing and to determine if alternative arrangements that suit the resident can be made. If 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 a review of facility policies, observations, and staff interviews, it was determined that the facility failed to serve food items that were palatable. Findings include: The facility's policy regarding food temperatures, dated April 29, 2025, revealed that hot food should be palatable at point of delivery. Observations of the supper meal on June 16, 2025, at 4:55 p.m. revealed that dietary staff began to prepare the second floor low-hall cart. At 5:35 p.m. the second floor low-hall cart was complete and left the kitchen at 5:36 p.m. The cart arrived on second floor and staff began to pass the trays at 5:40 p.m. At 5:52 p.m. all supper trays were passed. A test tray was completed on June 16, 2025, at 5:52 p.m. revealing the milk was 41.4 degrees Fahrenheit and tasted cold, the salsa salad was 41.4 degrees Fahrenheit and tasted cold, the coffee was 133.3 degrees Fahrenheit and tasted hot, the taco beef was 109.3 degrees Fahrenheit and tasted cold and was not palatable, and the rice was 113.2 degrees Fahrenheit, tasted cold and was not palatable. Interview with the Dietary…

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, as well as observations and staff interviews, it was determined that the facility failed to store and prepare food in accordance with professional standards for food service safety by failing to have staff wear appropriate hair restraints during food preparation and tray line service. Findings include: The facility's policy regarding dress and personal hygiene, dated February 14, 2025, revealed that staff working in Food and Nutrition Services will wear a clean and appropriate hairnet and hair restraint. The hairnet/hair restraint will cover all hair. Beards and facial hair will be contained. Observations in the main kitchen on April 22, 2025, at 8:34 a.m. revealed three dietary staff on the tray line. Dietary Staff 2 was plating the breakfast meal cheesy eggs, cinnamon rolls, toast, and hot cereal without wearing a facial hair restraint. Interview with Dietary Staff 2, on April 22, 2025, at 8:43 a.m. confirmed that he should be wearing a facial hair restraint, but he took it off because it was hot and he had to answer the phone multiple times.…

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 clinical records, as well as staff interviews, it was determined that the facility failed to follow physician's orders for one of five residents reviewed (Resident 2). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) assessment for Resident 2, dated April 7, 2025, indicated that the resident was sometimes understood and able to sometimes understand others, was dependent on staff for personal hygiene care, and was always incontinent of urine and bowel. An incontinence care plan for Resident 2, dated July 4, 2023, revealed that the resident was to have barrier cream applied every shift and after every incontinent episode. Physician's orders for Resident 2, dated June 29, 2023, revealed that triad (barrier) cream was to be applied every shift and after each incontinent episode as needed. A wound care note for Resident 2, dated March 26, 2025, revealed that the resident was seen by wound care due to redness in the perineal region and denudement (missing the outer layer of skin). New orders…

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 clinical records, as well as staff interviews, it was determined that the facility failed to ensure that clinical records were complete and accurately documented for one of five residents reviewed (Resident 2). Findings included: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) assessment for Resident 2, dated April 7, 2025, indicated that the resident was sometimes understood and able to sometimes understand others, and was dependent on staff for personal hygiene care. A nursing note for Resident 2, dated April 24, 2025, at 10:00 a.m., revealed that the Registered Nurse Supervisor was made aware that the resident's daughter was requesting testing be completed to check for urinary tract infection (UTI). A nursing note for Resident 2, dated April 2, 2025, at 11:54 p.m., revealed that a straight catheterization (a tube used to drain urine from the bladder) was attempted three times without success. Interview with the Director of Nursing on April 22, 2025, at 1:56 p.m. revealed that a straight…

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

Based on clinical record reviews, as well as staff interviews, it was determined that the facility failed to ensure that dependent residents were provided with the necessary services to maintain personal hygiene by failing to provide showers as scheduled for one of six residents reviewed (Resident 2). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 2, dated January 16, 2025, revealed that the resident was cognitively impaired, required assistance from staff for daily care needs, required extensive assistance from staff for personal hygiene, was dependent on staff for bathing, and had diagnoses that included stroke. The resident's care plan, dated October 31, 2024, indicated that the resident preferred showers on Sunday and Wednesday during the second shift. However, the resident's bathing records for January, February, and March 2025 revealed that the resident did not receive a shower at all in those months. There was no documented evidence that the resident was offered a shower and refused…

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 policies and clinical records, as well as staff interviews, it was determined that the facility failed to provide timely treatment to a newly identified pressure ulcer for one of 10 residents reviewed (Resident 9). Findings include: The facility's policy regarding skin and wound care best practices, dated November 18, 2024, indicated that pressure injuries and wounds will be treated with evidence-based interventions as ordered by the provider. An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 9, dated November 19, 2024, revealed that the resident was cognitively intact, required substantial assistance with bed mobility, was incontinent of urine and frequently incontinent of bowel, was at risk for developing pressure ulcers (an injury to the skin and underlying tissue resulting from prolonged pressure), and had no unhealed pressure ulcers. A nursing note for Resident 9, dated December 28, 2024, at 3:25 p.m., revealed that the registered nurse was notified that the resident had a new pressure…

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 clinical records, as well staff interviews, it was determined that the facility failed to ensure that residents received oxygen as ordered by the physician for one of 10 residents reviewed (Resident 10). Findings include: A nursing note for Resident 10, dated January 17, 2025, at 6:03 p.m. revealed that an admission assessment indicated that his lung sounds were clear and diminished. A diagnoses list for Resident 10 revealed that he was admitted with acute respiratory failure (blood does not have enough oxygen and causes difficulty breathing) with hypoxia (low levels of oxygen in body tissues). A nursing note for Resident 10, dated January 19, 2025, at 10:46 a.m. revealed that the registered nurse was called to resident's bedside by his daughter who came in to visit. She was reporting that the resident's oxygen was at a flow rate of 3 liters per minute (LPM) and his oxygen was to be at a flow rate of 4 LPM. Upon assessment, the resident's oxygen saturation (blood oxygen level) was 68 percent (normal oxygen saturation ranges are 95-100 percent) on an oxygen flow…

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 clinical records, as well as staff interviews, it was determined that the facility failed to ensure that residents were free from significant medication errors for one of 10 residents reviewed (Resident 1). Findings include: An annual Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated January 9, 2025, revealed that the resident was cognitively intact, was independent to set up with care needs, used oxygen, and had diagnoses that included chronic obstructive pulmonary disease (COPD) (chronic lung disease making breathing difficult) and asthma (a lung disease making it difficult to breathe). Physician's orders for Resident 1, dated March 3, 2024, included orders for the resident to receive one puff/inhalation of fluticasone propionate inhaler 100 micrograms (mcg) twice daily for the morning medication pass between 7:00 a.m. and 11:00 a.m. and for the evening medication pass between 8:00 p.m. and 11:00 p.m. Review of Resident 1's Medication Administration Record (MAR) for January 2025 revealed that…

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

Based on review of facility polices and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that a resident's care plan was updated/revised to reflect the resident's specific care needs for two of eight residents reviewed (Residents 2, 5). Findings include: A facility policy for Comprehensive Care Plans, dated November 18, 2024, indicated that a comprehensive, person-centered care plan is developed and implemented for each resident that includes measurable objectives and timetables to meet the resident's medical, nursing and mental and psychosocial needs. The care planning coordinator will add minor changes in the resident's status to the existing care plans on a daily basis. A significant change Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 2, dated December 5, 2024, indicated that the resident was cognitively impaired, required substantial assistance with bed mobility and transfers, had a history of two or more falls since the prior assessment, and had a diagnosis of…

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

Based on review of facility investigation documents and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that safe transfer techniques were used in accordance with their care plans for one of eight residents reviewed (Resident 1) resulting in a fall. Findings include: An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated November 12, 2024, revealed that the resident was cognitively impaired, was understood and able to understand others, was dependent for transfers, had no history of falls, and had a diagnosis that included hemiparesis (weakness to one side of the body due to brain injury). A care plan for Resident 1, dated November 1, 2024, included an intervention with a start date of December 4, 2024, that indicated the resident's transfer status was moderate assistance (staff and the resident each put in half the effort) of two staff with use of the orbiturn (a transfer aid to facilitate standing and seat-to-seat transfers). A physical therapy…

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 and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that the resident and/or resident representative had an opportunity to develop an advance directive (instructions regarding the provision of health care when the resident is incapacitated) or assist in formulating an advance directive for 12 of 45 residents reviewed (Residents 56, 57, 64, 66, 69, 71, 76, 77, 78, 80, 86, 89). Findings include: The facility policy regarding advance care planning meeting protocol, dated July 1, 2024, indicated that upon each resident's admission to the facility, the resident will meet with the appropriate member of the healthcare team to ensure their preferences (Living Wills, Medical [NAME] of Attorney, etc.) are recorded in their medical record. Information regarding Advance Directives is provided to the resident and their family by the facility during the meeting. The resident and/or representative will be given the opportunity to discuss their goals for care including their preference for advance 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 policies, as well as observations and interviews with residents and staff, it was determined that hot foods were not served at proper and palatable temperatures. Findings include: The facility's policy regarding food temperatures, dated June 1, 2024, indicated that the temperatures of hot foods were to be served at 135 degrees Fahrenheit (F) or above. Observations of tray line for the lunch meal in the main kitchen on August 21, 2024, revealed that the Second Floor food cart left the kitchen at 12:28 p.m. and arrived on the Second Floor at 12:32 p.m. The last resident was served at 12:43 p.m. At 12:45 p.m. the temperature of the chicken breast was 124 degrees F. The chicken breast was lukewarm to taste and not appetizing. Interview with Dietary Director on August 21, 2024, at 1:11 p.m. confirmed that the temperatures of hot foods should have been at 135 degrees F when served to residents. 28 Pa. Code 211.6(b) Dietary Services.

Based on review of policies, as well as observations and staff interviews, it was determined that the facility failed to ensure that food was stored and served in accordance with professional standards for food service safety. The facility failed to ensure that the kitchen and its equipment was clean; that food stored in the kitchen and pantries was labeled, dated and secured; that an ice cream freezer had a thermometer; that food was thawing properly; and that staff should wear hairnets that covered all of their hair. Findings include: The facility's policy regarding storage of perishable food and food safety, dated July 1, 2024, revealed that staff are to cover, label, and date unused portions and opened packages, thawing meat should be placed below other food items and never on the counter to thaw, and freezers will be equipped with an internal thermometer. The facility's policy regarding proper hygiene, dated July 1, 2024, revealed that sanitary practices were to be used during food preparation in the kitchen, and hair restraints were to be worn in a manner to cover all hair.…

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, a review of clinical records, as well as staff interviews, it was determined that the facility failed to maintain an effective pest control program. Findings include: The facility's policy on pest control, dated July 1, 2024, indicated that the facility will maintain a pest control program and that treatment will be rendered as required to control insects. Observations of the cooks prep area/sink in the kitchen on August 19, 2024, at 9:10 a.m. revealed approximately six flies and several gnats in the sink around the food prep area. There were also several gnats in the general area of the kitchen. Interview with the Dietary Manager on August 19, 2024, at 9:20 a.m. revealed that she did realize that the flies and gnats were there and indicated that maintenance was aware and had a pest control company in several times; however, the problem remains. Interview with the Maintenance Director on August 20, 2024, at 3:05 p.m. revealed that the pest control company was coming every other month, and they were last there June 20, 2024. He indicated that the pest control…

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 policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that the resident and/or the resident's responsible party was given the opportunity to participate timely in the development and implementation of a person-centered care plan for two of 45 residents reviewed (Residents 12, 77). Findings include: The facility's policy regarding care planning, dated July 1, 2024, revealed that the resident and their representative will be given the opportunity to discuss their goals for care including their preference for advanced care planning. The results of the advanced care planning will be communicated to the resident's care providers and documented in the clinical record. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 12, dated June 19, 2024, revealed that the resident was cognitively impaired, was clearly understood and could usually understand others, and required assistance with care needs. There was no documented evidence that a 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of Pennsylvania's Nursing Practice Act, facility policies, and clinical records, as well as staff interviews, it was determined that the facility failed to obtain physician's orders for pacemaker checks for one of 45 resident reviewed (Resident 78). Findings include: The Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.11 (a)(1)(2)(4) indicated that the registered nurse was to collect complete and ongoing data to determine nursing care needs, analyze the health status of individuals and compare the data with the norm when determining nursing care needs, and carry out nursing care actions that promote, maintain, and restore the well-being of individuals. The facility's policy regarding pacemaker rate checks, dated July 1, 2024, indicated that upon the resident admission with, or insertion of, a cardiac pacemaker, the licensed nurse will gather pertinent information and complete the cardiac pacemaker data sheet, and it will be kept in the resident's…

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

Based on clinical record reviews and staff interviews, it was determined that the facility failed to follow physician's orders and residents' requests for ophthalmology appointments for two of 45 residents reviewed (Residents 69, 87). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 69, dated July 10, 2024, revealed that the resident was cognitively intact, clearly understood, able to clearly understand others, and required supervision with care needs. An interview with Resident 69 on August 19, 2024, at 11:44 a.m. revealed that she wanted to go to the eye doctor and that Senior Life was not scheduling it. She indicated that it had been scheduled, but she did not go due to a screw up with Senior Life and transportation. She voiced that she was nearly blind, could not see, and wanted to be seen by the eye doctor. The Social Service Director received an email from the local Senior Services office on July 18, 2024, regarding Resident 69's vision exam. They had left messages with Senior Life…

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 policy and clinical records, as well as staff interviews, it was determined that the facility failed to respond timely to a pharmacy recommendation for two of 45 residents reviewed (Residents 30, 89). Findings include: A facility policy for medication regimen review, dated July 1, 2024, revealed that the attending physician should document in the resident's health record that the identified irregularity has been reviewed and what, if any, action has been taken to address it. An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 30, dated July 3, 2024, revealed that the resident was cognitively impaired, required total care from staff, and was medicated with a hypotensive (a medication to treat low blood pressure). A pharmacy consultant note for Resident 30, dated June 27, 2024, revealed that the pharmacist recommended that the physician reassess the prescription for midodrine scheduled medication times. It was not to be given after 6:00 p.m., and it was scheduled to be given at 8:00 p.m. As of…

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

Based on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that residents were free from unnecessary psychotropic medications for one of 45 residents reviewed (Resident 87). Findings include: The facility's policy regarding psychotropic medications (any medication that affects brain activities associated with mental processes and behavior), dated July 1, 2024, indicated that all residents receiving psychoactive medications will have their behaviors and effectiveness of interventions (pharmacological and non-pharmacological) monitored and documented. Nurses will document on the following each shift: number of behavioral episodes, specific non-medication interventions used, and outcomes of interventions including individualized non-pharmacological approaches. An annual Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 87, dated July 2, 2024, revealed that the resident was cognitively impaired, usually understood, able to sometimes understand…

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 policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment to prevent the transmission of infections. Findings include: The facility's policy for linen management, dated July 1, 2024, revealed that soiled linens will be bagged at the point of use and placed in a soiled linen bin in the designated area. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 11, dated August 6, 2024, revealed that the resident was sometimes understood, could sometimes understand others, was cognitively impaired, and was dependent on staff for all care needs. Observations of Resident 11's room on August 19, 2024, at 12:00 p.m. and 12:25 p.m. revealed a sign for contact precautions and to see the nurse for instructions. Interview with Licensed Practical Nurse 8 on August 19, 2024, at 12:10 p.m. regarding the sign revealed that Resident 11…

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 and clinical records, as well as observations and staff interviews, it was determined that facility failed to determine if residents were safe to self-administer medications for one of 45 residents reviewed (Resident 100). Findings include: The facility's medication brought in from home/self administration education policy, dated July 2024, indicated that residents were not permitted to bring in medications from outside the facility. If self administration was deemed safe then medications must be stored properly and should not be sitting out in open view on the night stand or over-bed table. An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 100, dated July 31, 2024, indicated that the resident was cognitively intact, required supervision for care needs, had a diagnosis of cellulitis (infection of skin and tissue), and was taking an antibiotic. Physician's orders, dated July 24, 2024 included orders for the resident to receive two tablets of 800-160 milligrams of Bactrim DS…

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 and clinical records, as well as observations and resident and staff interviews, it was determined that the facility failed to ensure that a resident's call bell was within reach for one of 45 residents reviewed (Resident 19). Findings include: The facility's policy regarding answering call bells, dated July 1, 2024, indicated that the facility provides residents with a means of communicating with staff. A call system was installed in each residents' room and toilet/bath area. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 19, dated July 29, 2024, revealed that the resident was understood, could understand, was cognitively impaired, and was totally dependent on two staff for assistance with bed mobility and transfers. A care plan for Resident 19, revised on July 30, 2023, revealed that she was at risk for falls related to being non-ambulatory. Interventions included having the call bell in reach at all times. Observations on August 19, 2024, at 1:00 a.m. revealed that…

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

Based on review of policies, as well as observations and staff interviews, it was determined that the facility failed to provide confidentiality of residents' personal health information during medication administration for one of 45 residents reviewed (Resident 5). Findings include: The facility's policy regarding privacy of health information, dated July 1, 2024, indicated that the facility was to protect the confidentiality of a resident's health information. Observations during medication administration on August 21, 2024, at 7:50 a.m. revealed that Licensed Practical Nurse 1 walked away from the medication cart to take the blood sugar of another resident without securing the computer screen. Resident 5's personal health information was visible on the computer screen, which was facing the hallway and elevator door. Interview with Licensed Practical Nurse 1 on August 21, 2024, at 7:57 a.m. confirmed that she should have covered Resident 5's personal information on the computer screen when leaving the medication cart. Interview with the Assistant Director of Nursing on August 21,…

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 and clinical records, as well as staff interviews, it was determined that the facility failed to develop and implement comprehensive care plans that included specific and individualized interventions to address specific care needs for two of 45 residents reviewed (Residents 12, 30). Findings include: The facility's policy regarding care plans, dated July 1, 2024, indicated that a comprehensive person-centered care plan for each resident will be developed that includes measurable objective and timetables to meet the resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessments. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 12, dated June 19, 2024, revealed that the resident was cognitively intact, understood, could usually understand others, and was receiving physical therapy and occupational therapy. Observations of Resident 12 on August 22, 2024, at 1:00 p.m. revealed that the resident was unable to move her left…

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 and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that care plans were updated/revised to reflect changes in care needs for three of 45 residents reviewed (Residents 5, 12, 77). Findings include: The facility's policy regarding care plans, dated July 1, 2024 revealed that the care planning coordinator will add minor changes in the resident's status to the existing care plans on a daily basis, and care plans are to be maintained with the current medical record. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 5, dated July 8, 2024, revealed that the resident was cognitively impaired, understood, usually able to understand others, required maximum assistance with care needs, and had a mechanically altered diet. A nurse's note for Resident 5, dated July 25, 2024, at 6:40 a.m., revealed that hospital radiology recommended a level 7, easy-to-chew diet, with thin liquids. Interview with the Director of Rehabilitation 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 clinical record reviews and staff interviews, it was determined that the facility failed to ensure that upon discharge from the facility, a discharge summary, including a recapitulation of the resident's stay, was completed for one of three discharged residents reviewed (Resident 104). Findings include: admission diagnoses for Resident 104, dated June 25, 2024, revealed that the resident was admitted to the facility with diagnoses that included diabetes mellitus, hypertension (high blood pressure), atrial fibrillation (irregular heartbeat), and cellulitis (bacterial infection of the skin). A nurse's note for Resident 104, dated June 29, 2024, revealed that the resident left the facility against medical advice (AMA). As of August 22, 2024, there was no documented evidence that a discharge summary that included a recapitulation of the resident's stay was completed for Resident 104. Interview with Registered Nurse Assessment Coordinator (RNAC) on August 22, 2024, at 6:35 p.m. confirmed that a discharge summary with a recapitulation of the resident's stay was not completed for…

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 clinical records, as well as resident and staff interviews, it was determined that the facility failed to ensure that restorative nursing programs to maintain or improve physical abilities were provided as ordered and/or care planned for one of 45 residents reviewed (Resident 56). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 56, dated July 10, 2024, revealed that the resident was cognitively intact, clearly understood, able to clearly understand others, required supervision with care needs, had a fall without injury since prior assessment, and had a diagnosis of Cerebral Palsy. A care plan for Resident 56, initiated July 5, 2023, indicated that he had an activities of daily living deficit related to impaired balance. A care plan intervention for Resident 56, initiated on July 12, 2023, indicated that the resident was on a restorative ambulation program with a goal to walk 100 feet with a front-wheeled walker and non-skid footwear with supervision twice a day (between…

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 clinical records, facility policy review, and resident and staff interviews, it was determined that the facility failed to ensure that residents were provided with showers as scheduled for one of 45 residents reviewed (Resident 12). Findings include: A facility policy for resident personal care, dated July 1, 2024, indicated that residents will be provided showers and oral care as per request or as per facility schedule protocols. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 12, dated June 19, 2024, indicated that the resident was understood, could usually understand others, cognitively intact, and dependent on staff for personal care needs. A care plan for Resident 12, dated March 27, 2024, indicated that the resident preferred to have showers every Tuesday and Saturday during the second shift and to have oral care completed twice a day. Review of bathing documentation for Resident 12 from August 13, 2024, through August 22, 2024, indicated that the resident did not receive a shower…

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 clinical records and facility investigation reports, as well as staff interviews, it was determined that the facility failed to complete safety assessments for two of 45 residents reviewed (Residents 13, 51) who used an air mattress. Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 13, dated June 29, 2024, revealed that the resident was understood, could understand others, was cognitively intact, required assistance from staff for care needs, and had a Stage IV pressure ulcer (a wound with full-thickness skin loss that extends through into the muscle, exposing the bone, tendon, or joint) upon admission. A care plan for Resident 13, dated December 22, 2024, revealed that the resident had a Stage IV pressure ulcer. A wound healing consult completed outside of the facility for Resident 13, dated July 5, 2024, revealed that the resident had a Stage 4 pressure injury with bone exposed on the sacral area. The wound consult recommended a low air loss mattress and frequent…

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 and clinical records, as well as observations and staff interviews, it was determined that the facility failed to address a change in urine status for one of 45 residents (Resident 12), and failed to provide proper care for indwelling urinary catheters for one of 45 residents reviewed (Resident 67). Findings include: A diagnosis list for Resident 12, dated March 19, 2024, revealed that the resident had a history of chronic urinary tract infections (UTI's). A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs), dated June 19, 2024, revealed that the resident was cognitively intact, required extensive assistance from staff for daily care tasks, and had an indwelling urinary catheter (a flexible tube inserted and held in the bladder to drain urine). A review of the clinical record for Resident 12 revealed that on August 15, 2024, the resident had 300 milliliters (ml) of blood-tinged urine in her foley catheter collection bag. A nursing note for Resident 12, dated August 18, 2024, at 7:40 p.m.,…

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 clinical records, as well as staff interviews, it was determined that the facility failed to provide aggressive hydration of 4 liters a day recommended by urology for one of 45 residents reviewed (Resident 12). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 12, dated June 19, 2024, indicated that the resident was cognitively intact, required assistance from staff for her daily care needs, and had a medical diagnosis of chronic urinary tract infections (UTI). A urology consult for Resident 12, dated July 17, 2024, included a recommendation for the resident to have aggressive hydration of 4 liters (4000 milliliters) a day. Physician's orders for Resident 12, dated July 17, 2024, included an order for the resident to have 4 liters of water a day and to have the total water intake documented every 6 hours (at 9:00 a.m., 3:00 p.m., 9:00 p.m., and 3:00 a.m.). A review of the clinical records for Resident 12 revealed a total fluid intake of 1162 milliliters (mL) on August 20,…

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 policies and clinical records, as well as staff interviews, it was determined that the facility failed to have sufficient nursing staff to provide and document care as scheduled for two of 45 residents reviewed (Residents 12, 19). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 12, dated June 19, 2024, indicated that the resident was understood and could usually understand others, was cognitively intact, and was dependent on staff for personal care needs. A care plan for Resident 12, dated March 27, 2024, indicated that the resident preferred to have showers every Tuesday and Saturday during the second shift, and to have oral care completed twice a day. Review of bathing documentation for Resident 12 from August 13, 2024, through August 22, 2024, indicated that the resident did not receive a shower during that time. There was no documented evidence that the resident was offered and refused showers twice weekly as per her care plan. A review of oral care documentation for…

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 clinical records and staff interviews, it was determined that the facility failed to ensure the accountability of controlled medications for one of 45 residents reviewed (Resident 86). Findings include: An annual Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 86, dated July 22, 2024, indicated that the resident was cognitively intact, required assistance from staff for all daily care needs, and had pain rated as a 6 on a scale of 1 to 10 (with 1 being mild and 10 being the worst) during the assessment period. Physician's orders for Resident 86, dated December 26, 2023, included an order for the resident to receive one 10-325 milligram (mg) tablet of oxycodone/Tylenol (a combination controlled narcotic pain medication) between the hours of 12:00 a.m. and 4:00 a.m. as needed. Review of Resident 86's controlled drug record (used to keep count of narcotic medication) for April and May 2024 revealed that staff signed out one table of hydrocodone/Tylenol on the controlled drug log on April 7, 2024, at 3:34…

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 manufacturer's instructions, facility policies, and clinical records, as well as observations and staff interviews, it was determined that the facility failed to maintain a medication error rate of less than five percent. Findings include: The facility's policy regarding medication administration procedures, dated July 1, 2024, indicated that medications were to be administered in a safe and timely manner, and medications listed as should not crush should not be crushed unless the physician writes otherwise, and manufacturer's instructions were to be followed unless otherwise directed. Observations during medication administration on August 21, 2024, revealed that two medication administration errors were made during 30 opportunities for error, resulting in a medication administration error rate of 6.67 percent. The manufacturer's instructions for Trelegy Ellipta (a combination medicine that is inhaled to treat chronic obstructive pulmonary disease (COPD) and asthma), dated May 2024, indicated that after inhalation, the resident was to rinse their mouth with water…

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

Based on observations and staff interviews, it was determined that the facility failed to ensure that controlled medications were stored in a separately locked, permanently affixed compartment in one of two medication rooms reviewed (second floor), and failed to date an insulin pen with the date it was opened (third floor long hall medication cart). Findings include: A facility policy titled Storage and Expiration Dating of Medications and Biologicals, dated July 1, 2024, revealed that the facility will maintain narcotics stored in the medication room locked refrigerator in a separately locked permanently affixed compartment, and that upon using an insulin pen for the first time, it must be dated with the opened date. Observations in the second floor medication room on August 21, 2024, at 9:50 am. revealed that there was a narcotic storage box containing two bottles of 2 mg/ml liquid Ativan (a controlled medication used to treat anxiety). The storage box was attached to the glass shelf; however, the shelf was not permanently affixed to the inside of the refrigerator. An interview…

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 policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that staff provided assistive devices to eat in accordance with the resident's care plan for two of 45 residents reviewed (Residents 12, 28). Findings include: The facility's policy regarding adaptive equipment, dated July 1, 2024, indicated that adaptive equipment to meet residents' needs would be provided per order. An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 12, dated June 19, 2024, indicated that the resident was cognitively intact and required set-up assistance with eating. A speech therapy note, dated June 20, 2024, at 9:54 a.m. indicated that Resident 12 was to use a two-handled cup with all liquids. A nursing note for Resident 12, dated June 20, 2024, at 2:12 p.m., indicated that the resident was on a straw restriction. Observations of Resident 12 during the lunch meal on August 22, 2024, at 1:09 p.m. revealed that the resident was in the dining…

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 plans of correction and the results of the current survey, it was determined that the facility's Quality Assurance Performance Improvement (QAPI) committee failed to correct quality deficiencies and ensure that plans to improve the delivery of care and services effectively addressed recurring deficiencies. Findings include: The facility's deficiencies and plans of corrections for State Survey and Certification (Department of Health) survey ending September 8, 2023, revealed that the facility developed plans of correction that included quality assurance systems to ensure that the facility maintained compliance with cited nursing home regulations. The results of the current survey, ending August 22, 2024, identified repeated deficiencies related to failure to correct deficient practices related to accommodation of resident needs, accuracy of Minimum Data Set (MDS) assessments, professional standards of practice, quality care, safe environment free from accident hazards, nutrition and hydration maintenance, accounting of controlled medications, storage…

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 attendance records for the facility's Quality Assurance Committee, as well as staff interviews, it was determined that the facility failed to ensure that Quality Assurance meetings were held at least quarterly. Findings include: Review of the attendance records for the facility's Quality Assurance Committee meetings revealed that there were no records of a meeting held during the facility's second quarter of 2024 (April, May and June of 2024). Interview with the Nursing Home Administrator on August 22, 2024, at 3:09 p.m. confirmed that there were no records of any Quality Assurance meetings held during the second quarter in 2024. She stated that they were to have a meeting in July 2024 but it was pushed back. She indicated that it had still not been scheduled as of this date. 28 Pa. Code 201.18(e)(1)(2)(3) Management.

Based on review of facility policies, infection control documentation, and staff interviews, it was determined that the facility failed to implement an antibiotic stewardship program that contained a system of reports and forms, and collaboration with an interdisciplinary team approach to monitor, track and trend antibiotic use and resistance for seven consecutive months (January 2024 through July 2024). Findings include: A facility policy regarding Antimicrobial Stewardship Program, dated July 1, 2024, indicated that the antimicrobial stewardship will focus on improving antibiotic/antimicrobial use by avoiding unnecessary or inappropriate antibiotics. The process will be overseen and managed by the Infection Preventionist (IP) who works collaboratively with the medical director, consulting pharmacist, nursing and administrative leadership to also implement the Antimicrobial Stewardship Program (ASP). As a component of the monthly Infection and Prevention and Control Committee (IPCC) meeting, the facility's use of antibiotics will be reviewed to include monitoring and tracking of…

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

Based on review of facility policy and clinical records, as well as observations and resident and staff interviews, it was determined that the facility failed to ensure that the call bell system was adequately equipped to allow residents to call for staff assistance, by failing to ensure that the call bell system was working for one of 45 resident reviewed (Resident 34). Findings include: The facility's policy regarding resident communication system and call lights, dated April 30, 2024, revealed that it was the policy of the facility to provide residents with a means of communicating with staff. A call system is installed in each resident room and toilet/bath area. The facility will respond to resident needs and requests. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 34, dated August 6, 2024, revealed that the resident was understood, could understand others, was cognitively impaired, and required staff assistance for all care needs. Observations on August 19, 2024, at 1:00 a.m. revealed that Resident 34…

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

Based on review of facility policy, clinical records, and Resident Council meeting minutes, as well as observations and resident and staff interviews, it was determined that the facility failed to make ongoing efforts to resolve resident grievances presented during the resident council meetings and for one of 22 residents reviewed (Resident 17). Findings include: The facility's grievance policy, dated April 30, 2024, indicated that the grievance official, or designee, would investigate the concern/grievance immediately, and that upon conclusion of the investigation, residents would be notified of the results. Resident Council meeting minutes, dated April 2024, May 2024, and June 2024, revealed that the residents were upset regarding long call bell wait times, and that they were not getting the food items they were supposed to get for their meals. Observations on July 2, 2024, from 10:01 a.m. to 10:22 a.m. revealed that Resident 17's call bell light was lit and ringing. No staff responded to the resident's call bell, although nurses were in the hallway passing medications until 10:22…

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 clinical records, facility policy review, and resident and staff interviews, it was determined that the facility failed to ensure that residents were provided with showers as scheduled for one of 22 residents reviewed (Resident 16). Findings include: A facility policy for resident showers indicated that residents will be provided showers as per request or as per facility schedule protocols. An annual MDS assessment for Resident 16, dated April 11, 2024, indicated that the resident was understood and could understand others, was dependent on staff for personal care needs, and had diagnoses that included diabetes. A care plan for Resident 16, dated July 26, 2023, indicated that the resident preferred to have showers every Wednesday and Saturday during the second shift. Review of bathing documentation for Resident 16, dated May 3, 2024, through July 3, 2024, indicated that the resident only received six showers during that time. There was no documented evidence that the resident was offered or refused showers twice weekly as per her care plan. Interview with…

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

Based on clinical record reviews and staff interviews, it was determined that the facility failed to ensure that there was timely physician notification and intervention for a significant weight loss for two of 22 residents reviewed (Residents 1, 16). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated May 9, 2024, indicated that the resident was severly cognitively impaired, was dependent on staff for daily care, and that he had diagnoses that included dementia. The resident's weight records revealed that he experienced a 17.5-pound weight loss from January 13, 2024, to March 25, 2024; and another 4.5 pound weight loss from April 2, 2024, to May 2, 2024. The resident's care plan, dated August 18, 2023, indicated that staff were to monitor the resident for malnutrition and significant weight loss of greater than 5 percent in one month, 7.5 percent in three months, or 10 percent in six months and notify the physician of the weight loss. There was no documented evidence that the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the facility's written menus, observations, and staff interviews, it was determined that the facility failed to follow their planned menu for three of 22 residents reviewed (Residents 17, 18, 20). Findings include: The facility's written and posted menu for the lunch meal on July 2, 2024, revealed that the residents were to receive homemade meatloaf, mashed potatoes, green beans, cinnamon applesauce, milk, coffee, roll/bread, and margarine. The alternate was a ham and cheese sandwich, tomato soup, and hot tea. An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 17, dated April 17, 2024, indicated that the resident was moderately cognitively impaired, had limited range of motion of her upper extremities, and required partial assistance with eating after set up. The resident's care plan, dated April 11, 2024, indicated that staff were to provide her diet per order, encourage intake, and to honor her dietary choices.…

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 clinical records, observations, and resident and staff interviews, it was determined that the facility failed to ensure that a therapeutic diet was provided as ordered by the physician for one of 22 residents reviewed (Resident 19). Findings include: Review of quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 19, dated June 1, 2024, indicated that the resident was cognitively intact and that she had diagnoses that included diabetes. A care plan, dated April 12, 2024, revealed that Resident 19 was to receive a low-sugar meal and that she prefers diet iced tea to drink. Physician's orders for Resident 19, dated May 29, 2024, included an order for the resident to receive a low concentrated sweets, high protein, low carbohydrate diet. Observations of Resident 19's meal tray on July 2, 2024, at 12:11 p.m. revealed that her tray ticket indicated that she was to have tomato soup, ham and cheese sandwich, cinnamon applesauce, coffee, milk, a mighty shake (special milk shake with added protein), and…

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

Based on review of clinical records, as well as staff interviews, it was determined that the facility failed to maintain clinical records that were complete and accurately documented for one of 22 residents reviewed (Resident 2). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 2, dated April 18, 2024, indicated that the resident was cognitively impaired, exhibited physical behavior symptoms, wandered daily, required assistance with personal care needs, and had diagnoses that included dementia. The resident had an MDS assessment, dated May 5, 2024, indicating that the resident was discharged with return anticipated. A review of the census record for Resident 2 revealed that he was discharged on May 20, 2024. A nursing note for Resident 2, dated May 5, 2024, at 10:00 p.m. revealed that the resident's physical and verbal aggression had increased, the physician was notified, and Resident 2 was transferred to the hospital. A nursing note for Resident 2, dated May 14, 2024, at 3:33 p.m. revealed…

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

Based on clinical record reviews, observations, and resident and staff interviews, it was determined that the facility failed to treat residents with dignity by failing to answer call bells timely for one of 22 residents reviewed (Resident 17). Findings included: An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 17, dated April 17, 2024, indicated that the resident was moderately cognitively impaired, usually could make herself understood, had limited range of motion of her upper and lower extremities, and required assistance from staff for daily care tasks. The resident's care plan, dated April 11, 2024, indicated that the call bell was to be in reach at all times. Observations on July 2, 2024, from 10:01 a.m. to 10:22 a.m. revealed that Resident 17's call bell light was lit but there was no sound. No staff responded to the resident's call light, although nurses were in the hallway passing medications until 10:22 a.m., at which time Nurse Aide 1 arrived and Resident 17 told her that she needed her lotion,…

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 and staff interviews, it was determined that the facility failed to provide a clean and homelike environment in residents' rooms on one of two halls toured (200 hall). Findings include: Observations of resident rooms 211, 220, 223, and 230 on July 2, 2024, at 10:13 a.m., 12:10 p.m., and 12:38 p.m. revealed that there was food debris, food wrappers, used gloves, medication cups, and used tissues on the floor. Interview with the Director of Housekeeping on July 2, 2024, at 10:15 a.m. revealed that the housekeeping department is short staffed and that the little staff she has are trying to keep up with the work. She stated that there are some residents that are [NAME] than others and need their rooms cleaned more often; however, she does not have the staff to get that done. She stated she works with one full time staff on the second floor, and she has them alternate the long side one day and the short side the next. She said it is not ideal, but it is all she can do. She stated that the…

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

Based on clinical record reviews and staff interviews, it was determined that the facility failed to notify the resident and legal guardian, in writing, regarding the reason for hospitalization for one of 22 residents reviewed (Resident 2). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 2, dated April 18, 2024, indicated that the resident was cognitively impaired, required supervision from staff for her personal care needs, and had diagnoses that included dementia. A nursing note for Resident 2, dated May 5, 2024, at 10:00 p.m., revealed that the resident's physical and verbal aggression had increased. The physician was notified, and the resident was transferred to the hospital. There was no documented evidence that a written notice of Resident 2's transfer to the hospital was provided to the resident's responsible party regarding the reason for transfer. Interview with the Nursing Home Administrator on July 2, 2024, at 2:30 p.m. confirmed that the facility did not provide a written notice…

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 clinical records and staff interviews, it was determined that the facility failed issue a bed hold notice at the time of an anticipated leave of absence from the facility for one of 22 residents reviewed (Resident 2). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 2, dated April 18, 2024, indicated that the resident was cognitively impaired, required supervision from staff for her personal care needs, and had diagnoses that included dementia. A nursing note for Resident 2, dated May 5, 2024, at 10:00 p.m. revealed that the resident's physical and verbal aggression had increased. The physician was notified, and the resident was transferred to the hospital. There was no documented evidence that a bed-hold notice was issued to Resident 2 or his responsible party at the time of the transfer to the hospital. Interview with the Nursing Home Administrator on July 3, 2024, at 4:30 p.m. confirmed that the facility did not provide a bed-hold notice to the Resident 2 or 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 Pennsylvania's Nursing Practice Act, clinical record review, and staff interviews, it was determined that the facility failed to ensure that a professional (registered) nurse assessed a resident after a change in condition for one of 22 residents reviewed (Resident 8), and failed to clarify physician's orders for one of 22 residents reviewed (Resident 12). Findings include: The Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.11 (a)(1)(2)(4) indicated that the registered nurse was to collect complete and ongoing data to determine nursing care needs, analyze the health status of individuals and compare the data with the norm when determining nursing care needs, and carry out nursing care actions that promote, maintain, and restore the well-being of individuals. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 8, dated April 13, 2024, indicated that the resident was cognitively impaired, required supervision with personal hygiene care, and had…

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

Based on review of clinical records and staff interviews, it was determined that the facility failed to follow physician's orders for three of 22 residents reviewed (Residents 2, 3, 12). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 2, dated April 18, 2024, indicated that the resident was cognitively impaired, exhibited physical behavior symptoms, wandered daily, required assistance with personal care needs, and had diagnoses that included dementia. Physician's orders for Resident 2, dated May 2, 2024, included an order for the resident to have one-on-one supervision to monitor behaviors for 24 hours. Review of the Medication Administration Record (MAR) for Resident 2, dated May 2024, revealed that one-on-one supervision was not done on the night shift of May 2, 2024. Interview with the Director of Nursing (DON) on July 2, 2024, at 10:49 a.m. confirmed that there was no documented evidence that one-on-one supervision of Resident 2 was completed on May 2, 2024, as ordered. A quarterly MDS…

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 and resident and staff interviews, it was determined that the facility failed to ensure oxygen concentrators were functioning properly for four of 22 residents reviewed (Residents 13, 14, 15, 16). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 13, dated May 9, 2024, indicated that she was cognitively impaired, was dependent on staff for personal care needs, and had diagnoses that included chronic obstructive pulmonary disease (COPD - lung disease causing restricted airflow and breathing problems) and received supplemental oxygen therapy. Observations on July 2, 2024, at 10:15 a.m. revealed that the oxygen concentrator (device used to provide supplemental oxygen to someone with difficulty breathing) being used by Resident 13 in her room was providing oxygen; however, it was producing a loud beeping sound approximately every fifteen seconds that could be heard from the hallway. A clinical record…

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 policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that staff provided assistive devices to eat in accordance with the resident's care plan for one of 22 residents reviewed (Resident 17). Findings include: The facility's policy regarding adaptive equipment, dated April 30, 2024, indicated that adaptive equipment to meet residents' needs would be determined by therapy. An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 17, dated April 17, 2024, indicated that the resident was moderately cognitively impaired, had limited range of motion of her upper extremities, and required partial assistance with eating after set up. An occupational therapy note, dated April 26, 2024, indicated that Resident 17 was to use foam built-up utensils for self-feeding. Observations of Resident 17 during the lunch meal on July 2, 2024, at 12:31 p.m. revealed that the resident was in her room eating her meal using regular utensil, and did…

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 job descriptions and the deficiencies cited during the current survey, it was determined that the Nursing Home Administrator (NHA) and the Director of Nursing (DON) failed to assume responsibility for effective management of the facility to ensure that the facility was adequately equipped to allow residents to call for staff assistance through a communication system, which relays the call directly to a staff member or to a centralized staff work area from their rooms or bathrooms. Findings include: The job description for the NHA, dated May 15, 2023, indicated that the NHA would lead and direct the overall operations of the nursing facility in accordance with the community policies and procedures, customer and resident needs, and both state and federal guidelines. The job description for the DON, dated June 17, 2024, indicated that the DON would organize, develop, manage, and direct the overall operations of the Nursing Service Department in accordance with the current federal, state and local standards, guidelines and regulations that govern the community. The…

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

Based on clinical record reviews and staff interviews, it was determined that the facility failed to conduct a thorough investigation to rule out abuse or neglect for one of seven residents reviewed (Resident 7). Findings include: The facility's policy regarding abuse, dated January 1, 2024, indicated that the facility will investigate all allegations, suspicions and incidents of abuse, neglect, involuntary seclusion, intimidation, exploitation of residents, misappropriation property and injuries of unknown source. A quarterly Minimum Data Set (MDS) assessment (a federally-mandated assessment of a resident's abilities and care needs) for Resident 7, dated April 1, 2024, revealed that the resident was cognitively impaired, required assistance from staff for daily care needs, and had a diagnosis of dementia. A nursing note, dated April 14, 2024, at 5:35 a.m. revealed that Resident 7 entered another resident's room and was involved in an altercation that involved physical contact. The residents were separated and there were no injuries. Witness statements, dated April 14, 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of clinical records and facility reports, as well as staff interviews, it was determined that the facility failed to ensure that the residents' environment remained safe for two of nine residents reviewed (Residents 2, 4) and failed to conduct a thorough investigation of resident-to-resident altercations to determine if care-planned interventions were followed for one of nine residents reviewed (Resident 6). Findings include: An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 2, dated January 26, 2024, revealed that the resident was cognitively impaired, had physical behaviors, wandered, had behavioral symptoms not directed toward others, was receiving antipsychotic and antidepressant medications, and had diagnoses that included dementia. A behavior care plan for Resident 2, revised March 18, 2024, revealed that staff were to recognize/anticipate when the resident was becoming agitated so they could redirect and provide…

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

Based on clinical record reviews and staff interviews, it was determined that the facility failed to accommodate residents' preferences regarding showers for two of nine residents reviewed (Residents 5, 8). Findings include: An annual Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 5, dated February 20, 2024, revealed that the resident was sometimes understood, sometimes understands, and had a diagnosis which included dementia and Alzheimer's disease. A care plan for the resident, dated November 29, 2023, revealed that she required assistance with care tasks and preferred to shower. Nurse aide shower assignments for Resident 5, undated, revealed that the resident was to receive a shower every Tuesday and Saturday. Shower records for Resident 5, dated February, March, and April 2024, revealed that on February 10, 17, 20, 24, and 27, 2024; March 16, 19, and 26, 2024; and April 2, 6, and 9, 2024, the resident received a bed bath and did not receive a shower as she preferred. A quarterly MDS assessment for Resident 8, dated…

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

Based on review of facility polices and clinical record reviews, as well as staff interviews, it was determined that the facility failed to develop a plan of care to address a resident's psychosocial well-being related to her fear and not feeling safe after a resident-to-resident incident for one of nine residents reviewed (Resident 7). Findings include: The facility's policy regarding care plan development, dated January 1, 2024, indicated that an interdisciplinary plan of care will be established for every resident and updated in accordance with state and federal regulatory requirements and on an as needed basis to meet the resident's medical, nursing, and mental and psychosocial needs. An annual Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) assessment for Resident 7, dated March 19, 2024, revealed that the resident was cognitively intact, was understood and could understand, had no behaviors, and required assistance with care needs. A nursing note for Resident 7, dated April 14, 2024, at 5:30 a.m., revealed that she reported…

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 and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that a resident's care plan was updated/revised to reflect the resident's specific behavioral intervention for one of nine residents reviewed (Resident 4). Findings include: The facility's policy regarding care plan development, dated January 1, 2024, indicated that an interdisciplinary plan of care will be established for every resident and updated in accordance with state and federal regulatory requirements and on an as needed basis to meet the resident's medical, nursing, and mental and psychosocial needs. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) assessment for Resident 4, dated April 1, 2024, revealed that the resident was cognitively impaired, walked independently without an assistive device, had wandering behaviors, and had a wander/elopement alarm used daily. A nursing note on April 15, 2024, at 9:47 a.m. revealed that the interdisciplinary team reviewed the incident…

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 policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that a resident who displayed mental or psychosocial adjustment difficulties received appropriate treatment and services to correct the problem for one of nine residents reviewed (Resident 2). Findings include: The facility's behavior policy, dated January 1, 2024, revealed that the goal of the facility was to improve management of behaviors and move closer to the goal of ending any inappropriate or unnecessary use of antipsychotic medications. The facility would assess and track a behavior(s) that negatively impacted each resident in regards to their quality of life. An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 2, dated January 26, 2024, revealed that the resident was cognitively impaired, had physical behaviors, other behavioral symptoms not directed toward others, wandered, was receiving and antipsychotic and antidepressant medications, and had diagnoses that included…

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

Based on clinical record reviews and facility reports, as well as staff interviews, it was determined that the facility failed to ensure that a resident did not display increased angry and aggressive behaviors by not following care-planned interventions for one of nine residents reviewed (Resident 6), resulting in the resident hitting another resident, and failed to evaluate appropriate treatment and services to maintain the resident's highest practicable physical and mental well-being by failing to address a resident's fear and not feeling safe after a resident-to-resident incident for one of nine residents reviewed (Resident 7). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated March 29, 2024, revealed that the resident was sometimes understood, sometimes understands, exhibited wandering daily, and had a diagnosis which included Alzheimer's disease and dementia. A care plan for the resident, dated March 20, 2024, revealed that the resident exhibited wandering behaviors. Staff were…

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 policies, investigative reports, and residents' clinical records, as well as staff and family interviews, it was determined that the facility failed to ensure that residents were free from neglect caused by a failure to follow a resident's care plan and transfer status for one of 10 residents reviewed (Resident 1). Findings include: The facility's current policy regarding abuse, neglect and exploitation indicated that neglect was the failure of the facility, its employees or service providers to provide goods and services to a resident that were necessary to avoid physical harm, pain, mental anguish, or emotional distress. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated February 9, 2024, revealed that the resident was severely cognitively impaired, required assistance from staff for transfers, and had diagnoses that included dementia. The resident's fall care plan, revised on February 15, 2024, indicated that she was a physical assist of two for transfers. A physical therapy…

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 policies, clinical records, and investigation documents, as well as staff interviews, it was determined that the facility failed to ensure that staff reported allegations of sexual abuse by one resident (Resident 7) towards two residents (Residents 8, 9) in a timely manner. Findings include: The facility's abuse policy, dated September 6, 2023, indicated that staff would report any incidents of suspected abuse immediately to the administrator/abuse coordinator. The administrator/abuse coordinator would immediately begin an investigation and notify the applicable local and state agencies in accordance with the procedures in the policy. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 7, dated October 23, 2023, indicated that the resident was sometimes understood and could sometimes understand others, required partial or moderate assist for personal hygiene needs, and had diagnoses that included heart failure and dementia with agitation. A nurse's note for Resident 7, dated November 29, 2023,…

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 policies and clinical records, as well as staff interviews, it was determined that the facility failed to conduct a thorough investigation into incidents involving inappropriate sexual behavior of one resident (Resident 7) towards two other residents (Residents 8, 9). Findings include: The facility's abuse policy, dated September 6, 2023, indicated that staff would report any incidents of suspected abuse immediately to administrator/abuse coordinator. The administrator/abuse coordinator will immediately begin an investigation and notify the applicable local and state agencies in accordance with the procedures in the policy. Once the administrator and Department of Health are notified, an investigation of the allegation or suspicion will be conducted. The investigation must be completed within five working days from the alleged occurrence. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 7, dated October 23, 2023, indicated that the resident was sometimes understood and could sometimes…

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 and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that residents were provided with showers as scheduled for one of seven residents reviewed (Resident 6). Findings include: A facility policy for resident bathing and showering schedules indicated that residents will be bathed or showered according to their preference in order to maintain healthy hygiene. Each resident will be scheduled to receive bathing a minimum of two times per week unless they prefer less frequent. When the bath or shower is complete, the nursing assistant will document the activity. An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 6, dated November 25, 2023, indicated that the resident was understood and was able to understand others, required set-up assistance with showers or baths, and had diagnoses that included Down's Syndrome (genetic disorder causing developmental and intellectual delays). A care plan for Resident 6, dated December 7, 2023,…

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 clinical records, as well as staff interviews, it was determined that the facility failed to ensure that physician's orders for medications were followed for one of seven residents reviewed (Resident 3). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 3, dated September 5, 2023, revealed that the resident was cognitively impaired, required extensive assistance with daily care needs, and had diagnoses that included Huntingdon's Chorea (a neurological disease that causes uncontrollable movements, emotions and behaviors). Physician's orders for Resident 3, dated August 21, 2023, included an order for the resident to receive 12 mg of Austedo (a drug used to treat uncontrollable movements caused by Huntingdon's Chorea) by mouth twice a day. A neurology consultation for Resident 3, dated October 12, 2023, revealed that the neurologist increased the resident's Austedo to 24 mg by mouth twice daily. There was no documented evidence in Resident 3's clinical record 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.

Based on review of clinical records and staff interviews, it was determined that the facility failed to obtain blood work as ordered by the physician for one of seven residents reviewed (Resident 4). Findings include: An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 4, dated November 29, 2023, indicated that the resident was sometimes understood, could sometimes understand others, was dependent on staff for personal hygiene needs, and had diagnoses that included atherosclerotic heart disease (plaque buildup in the arteries). Physician's orders for Resident 4, dated November 25, 2023, included an order for the resident receive 5 mg of warfarin (a blood thinning medication) at bedtime, and to obtain a PT/INR (protime and international normalized ratio - a blood test that measures the time it takes for blood to clot) on November 27, 2023, and to call the physician with the results for an order for the next warfarin dose. There was no documented evidence that the PT/INR was obtained or that the physician was…

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

Based on observations and staff interviews, it was determined that the facility failed to provide a clean and homelike environment in residents' rooms for two of 13 residents reviewed (Residents 2, 7). Findings include: Observations of Resident 2 and 7's room on November 15, 2023 at 8:20 a.m. revealed that the resident's ceiling was stained, cracked and had visible paint peeling and damage along the seem of the wall and ceiling. Interview with the Director of Maintenance on November 15, 2023 at 8:40 a.m. confirmed that Resident 2 and 7's ceiling was leaking water and damaged. He stated that when it rains heavily, as it had recently, the water pools up in a certain area of the roof and it needs to be swept off, or it will cause damage. He stated that he is one person and trying to get to everything that needs done in the large building. He stated that the ceiling repair has been on his list of things that needs done. 28 Pa. Code 201.29(j) Resident rights. 28 Pa. Code 207.2(a) Administrator's responsibility.

Based on clinical record reviews, as well as staff and resident interviews, it was determined that the facility failed to ensure that residents were provided with showers/baths as scheduled for one of 13 residents reviewed (Resident 8). Findings include: An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 8, dated October 21, 2023, indicated that the resident was moderately cognitively impaired, was able to make herself understood, that it was very important to her to choose the type of bathing she wanted, and she required supervision with bath/shower. A care preference sheet, dated October 16, 2023, revealed that Resident 8 preferred a bath in the morning three or more times a week. Review of the resident's bathing records for October and November 2023 revealed that the resident received an other bath on October 16, 17, 18, 23 and 30, and November 2, 2023. There was no documented evidence that Resident 8 received a complete bed bath in October or November. Interview with Registered Nurse 3 on November 15,…

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 policies and clinical records, as well as staff interviews, it was determined that the facility failed to follow recommendations from a wound consultation for one of 13 residents reviewed (Resident 3). Findings include: An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 3, dated October 3, 2023, indicated that he was cognitively intact, required substantial assistance for his care needs, and had pressure ulcers (skin breakdown caused by prolonged, unrelieved pressure). A care plan, dated October 3, 2023, indicated that wound dressings were to be applied as ordered. A wound consultation for Resident 3, dated November 1, 2023 revealed that the resident had a Stage 3 (full thickness tissue loss) pressure sore on his left heel that measured 1.5 x 1.3 x 0.1 centimeters (cm). The plan was to cleanse the wound with normal saline (sterile salt and water), apply medical grade honey (honey-containing treatment used to heal wounds) to the base of the wound, and secure it with gauze daily and as needed.…

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 policies, observations, and staff interviews, it was determined that the facility failed to serve food that was palatable and at proper temperatures. Findings include: The facility's policy regarding food temperatures, dated July 1, 2023, revealed that hot foods were to be plated at 135 degrees Fahrenheit (F) and were to be palatable at the point of delivery. The temperature of potentially hazardous cold foods were to be served at a temperature of 41 degrees Fahrenheit or below. The posted menu for November 15, 2023, revealed that the lunch meal was corn chowder soup, soft beef tacos, churros, milk, and coffee. A test tray for the lunch meal on the 300 nursing unit on November 15, 2023, revealed that the cart left the kitchen at 12:49 p.m., arrived on the nursing unit at 12:50 p.m., and the last resident was served at 1:09 p.m. The test tray was tasted at 1:10 p.m. and the soft beef taco was 119 degrees F and had excessive grease, the churro was hard and crunchy and tasted bland, and the milk was 60 degrees F and was not cold to taste. Interview with the Dietary…

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 and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that residents were positioned appropriately while eating for one of 13 residents reviewed (Resident 10). Findings include: The facility's policy regarding dining experience at mealtimes, dated July 1, 2023, indicated that positioning and assistance at mealtime must be appropriate for individual needs and that tray tables will be at the appropriate height and position. A significant change Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 10, dated October 12, 2023, indicated that the resident was cognitively impaired and required staff to set her up for meals. The resident's care plan, dated October 12, 2023, indicated that the resident was at risk for nutritional problems, including weight loss. Observations of Resident 10 on November 15, 2023, at 1:00 p.m. revealed that the resident was sitting in her specialized chair with her feet elevated and tight against the…

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

Based on clinical record reviews, and staff interviews, it was determined that the facility failed to ensure that a safe environment was provided for one of 13 residents reviewed (Resident 1). Findings include: The facility's policy regarding bedside care, dated July 1, 2023, revealed that the resident's care plan will be reviewed to assess for any special needs of the resident. An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated August 16, 2023, indicated that the resident was sometimes understood and sometimes understands others, required the extensive assistance of two for ambulation and transfers, and extensive assistance of two for bathing and toileting. A nursing note for Resident 1, dated October 6, 2023, revealed that the resident was found on the floor by her bed after the nursing assistant left the resident alone to change the bath water in the bathroom. The nursing assistant had been providing the resident with a bed bath and although the resident's care plan required two staff for care, she…

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 and clinical record reviews, as well as observations and staff interviews, it was determined that the facility failed to provide timely incontinence care for one of 13 residents reviewed (Resident 10). Findings include: The facility's policy for perineal care, dated July 1, 2023, indicated that clinical staff would provide perineal care when necessary. A significant change Minimum Data Set (MDS) assessment (a federally-mandated assessment of the resident's abilities and care needs) for Resident 10, dated October 12, 2023, indicated that the resident was cognitively impaired and was dependent on staff for daily care needs, including toileting. Resident 10's care plan, dated September 21, 2023, indicated that the resident was medicated with a diuretic (water pill) and that she has the potential for altered skin and that staff are to provide incontinence care and toileting as needed. Observations of Resident 10 on November 15, 2023, at 12:20 p.m. revealed that the resident was seated in the dining area and that she was sleeping. At 12:27 p.m. the…

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

Based on clinical record reviews and staff interviews, it was determined that the facility failed to ensure that the residents were free from unnecessary medications for one of 13 residents reviewed (Resident 11). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 11, dated August 8, 2023, revealed that the resident was cognitively impaired and had diagnoses that included hypertension (high blood pressure). Physician's orders, dated October 24, 2023, included an order for the resident to receive 100 milligrams (mg) of Aldactone (water pill) once a day. The order was entered in Resident 11's clinical record; however, this order was for another resident. The Medication Administration Record (MAR) for October 2023 revealed that Resident 11 received Aldactone on October 25, 26, and 27, 2023. A disciplinary action form, dated October 27, 2023, revealed that staff had transcribed the physician's order incorrectly (wrong person) and Resident 11 received Aldactone. A nursing note, dated October 27,…

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 policies and clinical records, as well as observations and resident and staff interviews, it was determined that the facility failed to ensure that call bells were within reach for three of 41 residents reviewed (Residents 6, 65, 76). Findings include: A review of the facility's Resident Communication System and Call Light Policy, dated January 13, 2023, included that it is the policy of the facility to provide residents with a means of communicating with staff. A call system is installed in each resident room and toilet/bath areas. Each resident will be shown how to use the call bell. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's care needs and abilities) for Resident 6, dated August 2, 2023, revealed that the resident was understood and able to understand others, required extensive assistance from staff for personal care needs, was receiving supplemental oxygen, and had diagnosis that included chronic obstructive pulmonary disease (COPD - lung disease that causes difficulty breathing). Observation of Resident 6 on September…

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 clinical records and grievance records, as well as resident and staff interviews, it was determined that the facility failed to make ongoing efforts to resolve a grievance regarding mechanical lifts. Findings include: Resident council meeting minutes, dated July 2023, indicated that the residents were frustrated with the mechanical lifts not working or having dead batteries frequently causing the residents to be stuck in bed. A meeting with a group of residents on September 6, 2023, at 1:00 p.m. revealed that the residents are unable to get out of bed most weekends because the mechanical lift batteries are dead. They stated that they have requested more lift machines or more batteries in order to prevent this from happening again. They stated that this had been occurring since at least June 2023. Interview with the Nursing Home Administrator on September 8, 2023, at 11:28 a.m. confirmed that staff were telling the residents they could not get out of bed because the lift machine batteries were dead. The staff were educated not to tell the residents they could not…

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

Based on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that each resident was assessed, offered and/or received the pneumococcal immunizations for two of 41 residents reviewed (Residents 8, 11). Findings include: The facility's policy regarding pneumococcal vaccine, dated January 13, 2023, revealed that pneumococcal vaccinations will be offered to all residents and administered per provider orders. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 8, dated June 13, 2023, indicated that the resident was cognitively impaired and required assistance from staff for her daily care tasks. Section O0300 B (Pneumococcal Vacination) revealed that the resident was not up to date and that the resident was not offered the pneumococcal vaccine. There was no documented evidence that the facility offered or administered the pneumococcal vaccines to the resident or that the resident refused the vaccination. A quarterly MDS assessment for…

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.