Providence Health & Rehab Center

Based on review of the facility policy and staff interview, it was determined that the facility failed to implement an antibiotic stewardship program for eight of 12 months (September 2025, through April 2026). Findings include: Review of facility Antimicrobial Stewardship Program policy dated 5/4/26, indicated facility will focus on avoiding unnecessary or inappropriate use. It will be overseen by Infection Preventionist, Medical Director, Pharmacist, nursing, and leadership.Review of facility Infection Prevention and Control Program policy dated 5/4/26, indicated it is the policy to maintain an organized, effective facility-wide program designed to systematically prevent, identify, control, and reduce the risk of acquiring and transmitting infections. To conduct surveillance of communicable disease and infectious outbreaks. Particular focus of the program will be on conducting risk assessment, surveillance, reducing health care associated infections, limiting transmission of disease, immunization, promoting antibiotic stewardship, and reporting as necessary. Review of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy, clinical record review and staff interview, it was determined that the facility failed to provide accurate and timely documentation related to the Pneumonia vaccine for three of five residents (Resident R4, R26, and R72).Findings include: Review of facility policy Resident Vaccination dated 5/4/26, indicated resident or responsible party will be asked about prior vaccinations at admission. Prior doses of influenza, pneumococcal, COVID (respiratory illness), and other vaccines will be documented in the immunization portal in the electronic health record. Vaccinations will be administered by provider's orders. Review of admission record indicated Resident R4 was admitted to the facility on [DATE]. Review of Resident R4's Minimum Data Set (MDS - a periodic assessment of care needs) dated 6/19/26, indicated the diagnoses of diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time), depression, and multiple sclerosis (a disease that affects central…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy and documents, resident and staff interviews, it was determined that the facility staff failed to provide services in the facility with reasonable accommodation of resident needs and preferences for enabler bars for one of five residents (Resident R105).Findings include:Review of the facility policy Facility Resident Handbook last reviewed 5/4/26, indicated reasonable accommodation as the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health and safety of the resident or other residents. Review of the admission record indicated Resident R105 admitted to the facility on [DATE]. Review of Resident R105's Minimum Data Set (MDS- a periodic assessment of care needs) dated 7/27/26, indicated the diagnoses of heart failure (heart doesn't pump blood as well as it should), high blood pressure, and renal insufficiency (a condition in which the kidneys lose the ability to remove…

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

Based on review of facility policy, resident family interviews and documentation, and staff interviews it was determined that the facility failed to assist a resident family with forming a family group for three of three resident families (Resident Family Representatives FR116, FR121, and Resident Family Representative FR300). Findings include: The facility Resident Handbook-resident groups document last reviewed 7/20/26, indicated that the resident has a right to organize and participate in resident groups. The facility must provide a resident or family group, if one exists, with private space, and take reasonable steps, with the approval of the group, to make residents and family members aware of upcoming meetings. The facility must consider the views of a resident or family group and act promptly. Review of the facility family council minutes dated 8/20/25, indicated that families were informed of several upcoming events, families shared suggestions during the meeting, families were thanked for their attendance, and the next family council meeting would be announced at a later…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident clinical records, facility documents, and staff interview it was determined that the facility failed to provide a Skilled Nursing Advanced Beneficiary Notice of Non-coverage (SNF-ABN) with the estimated amount of nursing services that will be charged for one of three sampled resident records (Resident R120).Findings include: Review of Resident R120's admission record indicated he was originally admitted on [DATE]. Review of Resident R120's MDS assessment (Minimum Data Set assessment: MDS -a periodic assessment of resident care needs) dated 6/18/26, indicated he had diagnoses that included artificial hip joint, cellulitis (bacterial infection of the skin causing redness, aches, and swelling), and dysphagia (difficulty swallowing). Review of Resident R120's census document (a form showing room number and payor source) indicated that he was admitted on Medicare Part A on 3/27/26, and his payor changed on 4/19/26 to private pay. Review of Resident R120's social services note dated 4/17/26,…

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

Based on review of facility policy, observations, and staff interview it was determined that the facility failed to maintain the confidentiality of residents' medical information on one of five medication carts (2B Medication Cart). Findings include: Review of facility policy HIPAA Privacy dated 5/4/26, indicated the facility will treat Protected Health Information (PHI) in accordance with these policies. Facility may not use or disclose PHI. During a medication pass observation on 8/4/26, at 9:03 a.m. the Registered Nurse (RN) Employee E13 left the medication cart unattended in the hallway with the computer screen open displaying resident information. During an interview on 8/4/26, at 9:07 a.m. RN Employee E13 confirmed that the 2B Medication Cart computer screen was left unattended with the computer screen open with identifiable information any passerby could see resident personal and confidential information and that the facility failed to maintain the confidentiality of residents' medical information on one of five medication carts (2B Medication Cart). 28 Pa. Code: 201.14(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 observations and staff interview it was determined that the facility failed to provide a clean, safe, comfortable, and homelike environment for one of three floors (Second floor). Findings include: During a tour with the Maintenance Employee E9 on 8/5/26, at 11:00 a.m. on the Second Floor (2B), the following were observed: Resident R171 room was found with a missing part of a baseboard under the window.Left side of the hallway were missing baseboards periodically down the hall.Right side of the hallway were missing baseboards periodically down the hall. During an interview on 8/5/26, at 11:12 a.m. Maintenance Employee E15 stated that the machine must be hitting them and they took them off and confirmed that the facility failed to provide a clean, safe, comfortable, and homelike environment for one of three floors (Second floor). 28 Pa. Code 201.18(b)(3)(e)(2) Management. 28 Pa code 211.12(d)(1) Nursing services.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical record review, and staff interviews, it was determined that the facility failed to identify a bolster (a long, thick cushion) as a possible restraint and failed to assess the functional status of the individual resident to determine if the use of a bolster is a restraint for two of four residents (Residents R2 and R87).Findings include: Review of facility policy Restraint Policy dated 7/20/26, previously dated 5/4/26, indicated a physical and/or chemical restraint will be initiated only after a comprehensive review determines that they are necessary to treat the resident's medical symptoms that warrant their use. A physical restraint is any manual method or physical or mechanical device, material, or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body. Review of the clinical record indicated Resident R2 was admitted to the facility on [DATE]. Review of…

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

Based on review of facility policy, personnel records and staff interview, it was determined that the facility failed to conduct an FBI background check on agency personnel prior to working on the nursing unit for one out of six personnel records (Agency Nurse aide (NA) Employee E20). Findings include: The facility Personnel abuse policy dated 8/25/25, and last reviewed 7/20/26, indicated that the facility will not employe or otherwise engage individual s who have been found guilty of abuse, neglect or mistreatment of residents. It is the policy to undertake background checks of all employees. The facility will do the following prior to hiring a new employee and conduct background checks in accordance with State law. Review of Agency Nurse aide (NA) Employee E20's personnel record indicated he was hired to work at the facility on 7/15/26, his orientation was completed at the facility on 7/15/26, and Agency Nurse aide (NA) Employee E20's worked on two shifts (7/26/26 and 8/1/26). Review of Agency Nurse aide (NA) Employee E20's indicated the staff had lived outside of Pennsylvania…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, resident records, resident council minutes, facility investigation documents, incidents submitted to the local State field office, resident interview, and staff interviews it was determined that the facility failed to submit a report of an allegation of verbal abuse for one of four sampled resident records (Resident R9). Findings include: The facility Personnel abuse policy dated 8/25/25, and last reviewed 7/20/26, indicated that abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also includes deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse. Verbal abuse is the use of oral, written or gestured language that willfully includes disparaging and derogatory terms. All allegations of abuse must…

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 RAI (Resident Assessment Instrument), clinical records, and staff interviews it was determined that the facility failed to make certain that resident assessments were accurate for one of three residents (Resident R164).Findings include: The Resident Assessment Instrument (RAI) User's Manual, which gives instructions for completing Minimum Data Set (MDS) assessments (periodic assessments of resident care needs), dated September 2025, indicated the following: Section O0110 - Special Treatments, Procedures, and Programs - Check all of the following treatments, procedures, and programs that were performed. D1 Suctioning (clean or sterile medical procedure used to clear thick mucus and secretions from the trachea and lower airway when a resident cannot cough them up) performed while a resident of this facility and within the last 14 days. Review of the admission record indicated Resident R164 admitted to the facility on [DATE]. Review of Resident R164's MDS dated [DATE], indicated the diagnoses…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of clinical records and staff interviews, it was determined that the facility failed to develop and implement a baseline care plan to include instructions needed to provide effective and person-centered care of the resident for one of three residents reviewed (Resident R181).Findings include: Review of the facility's Interim Baseline Care Plan Policy dated 5/4/26, indicated that within 48 hours of admission, the facility will develop and implement an interim/baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident until a comprehensive assessment can be completed. Review of the admission record indicated Resident R181 admitted to the facility on [DATE], with the diagnoses of pneumonitis (lung infection due to inhalation of food and vomit), stroke (damage to the brain from an interruption of blood supply), and hemiplegia (paralysis of one side of the body). Review of Resident R181's physician order dated 7/31/26,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical records, and staff interviews, it was determined that the facility failed to make certain that residents received proper treatment for pressure ulcers/injuries (PU/PI's - injuries to skin and underlying tissue resulting from prolonged pressure on the skin) for two of four residents (Resident R8 and R181). Findings include: Review of the facility's Pressure Injury Prevention and Management Policy, dated 5/4/26, indicated residents admitted with existing pressure injuries will receive necessary treatment and services consistent with professional standards of practice, to promote healing and prevent infection. Pressure injuries identified will be assessed initially and at least weekly thereafter until closed. All assessments will include the following elements: -Location and stage (if pressure injury);-Size (length and width, location and extent of any undermining or tunneling/sinus tract;-Exudate (drainage) if present, the type, color, odor, and appropriate…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical record review, observation, and staff interview, it was determined that the facility failed to ensure that residents with an enteral feeding tube (G- Tube, a tube inserted in the stomach through the abdomen) received appropriate treatment and services to prevent potential complications for one of three residents (Resident R181). Findings include: Review of the facility's policy Continuous or Non-bolus Timed Tube Feeding Procedure dated 5/4/26, indicated nurses will administer enteral feeding (liquid nutrition) as ordered by the physician through a regulated tube feeding set with volumetric control or via pump. Rinse syringe with hot water after each use. Discard and replace syringe and other reusable supplies every day. Date reusable supplies. Review of the admission record indicated Resident R181 admitted to the facility on [DATE], with the diagnoses of pneumonitis (lung infection due to inhalation of food and vomit), stroke (damage to the brain from an interruption…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical records, staff interviews, and resident observations it was determined that the facility failed to include care and management of a PICC line (peripherally inserted central catheter - a long thin flexible tube inserted into a vein in the upper arm and threaded to a large vein near the heart) consistent with professional standards of practice for one of two residents (Resident R181).Findings include: Review of the facility policy Central Vascular Access Device Flushing and Locking dated 5/4/26, indicated a prescriber order is required to flush/lock a catheter. The order must include flushing/locking agent, strength/concentration, volume (amount), and frequency. Documentation in the medical record includes, but is not limited to date and time, prescribed flushing/locking agent, site assessment, resident response to the procedure and/or medication, and patient significant other teaching. Review of the admission record indicated Resident R181 admitted to the facility on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, review of clinical record, review of facility policy, interview with staff and resident, it was determined the facility failed to provide respiratory care consistent with professional standards of practice for one of three residents receiving oxygen (Resident R80) and failed to provide tracheostomy care consistent with professional standards of practice for one of three residents (Resident R164). Findings include: Review of the facility's Oxygen Administration (all routes) Policy dated 5/4/26, indicated nurses will administer oxygen via the specified route as ordered by a provider. When oxygen not in use, store dry oxygen tubing, nasal cannula or trach mask in plastic bag. Change tubing, mask, cannula weekly and document in the Electronic Health Record (E.H.R.). Review of the facility's Tracheostomy Care Policy dated 5/4/26, indicated tracheostomy (a surgical opening made through the front of the neck into the windpipe/trachea) care, including changing the inner cannula will be performed…

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

Based on review of facility documents and staff interview, it was determined that the facility failed to accurately complete the Facility Assessment. Findings include: A review of the Facility Assessment, dated 7/15/26, revealed the facility did not complete the template to indicate accurate information on the skill sets that are necessary to provide the level and types of care needed for the resident population; including specific medical equipment currently in use.The equipment that failed to be included in the facility's medical equipment section included: Automated External Defibrillator (AED a portable lifesaving device), Tracheostomy care and management, Life Vest (a wearable cardioverter defibrillator for residents at risk of sudden cardiac death), Wound Vac machines (a negative pressure system used for wound healing), and glucometer devices (portable machines used to check capillary blood sugar). During an interview on 8/7/26, at approximately 12:07 p.m. the Nursing Home Administrator confirmed that the facility failed to accurately complete the Facility Assessment. 28 Pa.…

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

Based on review of facility documentation, results of previous survey, and results of the current survey, it was determined that the facility 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 deficiencies.Findings include: The facility deficiencies and plans of correction for a State Survey and Certification (Department of Health) survey ending August 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. Findings of the current survey ending August 7, 2026, included deficiencies that were repeated from the previous survey of August 22, 2025, which are as follows: F604, F609, F628, F700, F880, F883, and PA1020. During an interview on 8/6/26, at 3:00 p.m. the Nursing Home Administrator confirmed that the facility had multiple repeat deficiencies from the previous survey, and that the facility failed to correct…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, review of facility documentation, and staff interviews, it was determined that the facility failed to make certain that equipment was in safe operating condition for two of two crash carts (a cart that contains supplies in the event of an emergency) for two of six nursing units (Nursing units 1B and 2B). Findings include: Review of the facility's Emergency Equipment Check Policy dated [DATE], indicated emergency equipment/cart(s) will be checked daily and items which are outdated or opened will be replaced. The cart will be restocked promptly after any use. If a breakaway lock system is used, the cart will be checked daily to ensure the lock is intact. Contents will be checked monthly for expired items, assuming the cart is not accessed in the interim. During an observation of the facilities crash cart, located on the 2B Second Floor, on [DATE], at 9:40 a.m. revealed the following supplies to be expired: (1) Ambu bag (a handheld manual resuscitator used to provide positive 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 facility in-service documentation, personnel files, and staff interviews, it was determined that the facility failed to provide training on Quality Assurance and Performance Improvement (QAPI) for one of five staff members (Registered Nurse (RN) Employee E22).Findings include: Review of RN Employee E22's personnel file indicated a date of hire on 7/1/23. Review of RN Employee E22's personnel file did not include annual in-service training on QAPI from 1/1/25 through 12/31/25. During an interview on 8/5/26, at 2:17 p.m. Assistant Director of Nursing Employee E10 confirmed that the facility failed to provide training on QAPI for one of five staff members (RN Employee E22). 28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa. Code: 201.20(a) Staff development.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of closed clinical record review and staff interviews, it was determined that the facility failed to involve the resident's representative in the treatment decision and communicate treatment decision involving testing for one of three sampled residents (Closed Resident Record CR1).Findings include: Review of Closed Resident Record CR1's admission record indicated he was admitted on [DATE]. Review of Closed Resident Record CR1's MDS assessment (Minimum Data Set assessment: MDS -a periodic assessment of resident care needs) dated 5/18/26, indicated he had diagnoses that included diabetes (a metabolic disorder impacting organ function related to glucose levels in the human body), chronic kidney disease (a loss of kidney function resulting in the swelling of feet, fatigue, high blood pressure and changes in urination), and anxiety disorder (a medical condition creating a sense of acute fear, restlessness, and worry). Review of Closed Resident Record CR1's care plans, indicated to assist with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on 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 and revised to reflect the resident's specific care needs for one of three sampled resident records (Closed Resident Record CR1).Findings include: The facility Comprehensive care planning policy dated 2/24/26 and last reviewed 5/4/26, indicated that a plan of care will be established and updated as indicated for every resident. The care plan is reviewed on an ongoing basis and revised as indicated by the residents' needs, wishes or change in condition. Review of Closed Resident Record CR1's admission record indicated he was admitted on [DATE]. Review of Closed Resident Record CR1's MDS assessment (Minimum Data Set assessment: MDS -a periodic assessment of resident care needs) dated 5/18/26, indicated he had diagnoses that included diabetes (a metabolic disorder impacting organ function related to glucose levels in the human body),…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, closed resident clinical records and staff interviews, it was determined that the facility failed to complete a comprehensive activity assessment to ascertain resident's activity interest and preferences for one of three closed resident records (Closed Resident Record CR2).Findings include: The facility Life enrichment interview, assessment documentation policy dated 4/21/26, and last reviewed 5/4/26, indicated that the life enrichment director will complete interviews, periodic assessments, care planning and documentation. The Life Enrichment Director will meet with each new admission into the community and complete the initial life enrichment interview which will be used to develop a plan of care that reflects the choices and interest of the residents. The welcome note is completed within 24 business hours. Review of Closed Resident Record CR2's admission record indicated she was admitted on [DATE]. Review of Closed Resident Record CR2's MDS assessment (Minimum Data Set…

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 files and staff interview, it was determined that the facility failed to employ a full-time qualified social worker from February 16, 2026, through present.Findings include: Review of Social Worker Employee E12's personnel file indicated a Bachelor of Science degree and a Certified Therapeutic Recreation Specialist certificate. Review of the resume for Social Worker Employee E12 indicated education that included bachelor's degree coursework in Recreational Therapy. During an interview on 5/21/26, at 1:30 p.m. with the Nursing Home Administrator indicated that the Bachelor of Science degree and Certified Therapeutic Recreation Specialist certificate qualified the employee for the position of social worker. During an interview on 5/21/26, at 1:33 p.m. the Nursing Home Administrator refused to confirmed that the Social Worker Employee E12 failed to have a minimum of a bachelor's degree in social work or a bachelor's degree in a human services field including, but not limited to, sociology, gerontology, special education, rehabilitation counseling, and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical records, and staff interviews, it was determined that the facility failed to develop person-centered comprehensive care plans to meet resident care needs for three of three residents identified as an elopement (resident exits to an unsupervised and unauthorized location without staff's knowledge) risk (Residents R2, R3, and R4).Findings include: Review of facility policy Comprehensive Care Planning dated 5/4/26, indicated 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. These plans will be focused on resident choices and abilities with the intent of maintaining or improving resident functional abilities and quality of life. Review of the clinical record indicated Resident R2 was admitted to the facility on [DATE]. Review of Resident R2's Minimum Data Set (MDS - a periodic…

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, clinical records and staff interviews, it was determined that the Nursing Home Administrator (NHA) and the Director of Nursing (DON) failed to effectively manage the facility by failing to ensure proper supervision for a resident (Resident R1) resulting in an elopement (resident exits to an unsupervised and unauthorized location without staff's knowledge) from the facility on 5/10/26, which created an immediate jeopardy situation for all residents identified as an elopement risk.Findings include: The job description for the Nursing Home Administrator specified the primary purpose of the job position is to lead, direct, and manage the overall operations of the community in accordance with policies and procedures and current federal, state and local standards, guidelines and regulations that govern the community. As the Administrator, it is your responsibility to organize, develop and direct resources to maintain the highest degree of quality care is maintained for each resident at all times. The Administrator will also plan, implement and achieve…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, facility documentation, resident records, resident interview and staff interviews, it was determined that the facility neglected to provide goods and services for one out of five sampled records (Resident R1). The deficiency is cited as past non-compliance. Findings include: The facility Resident abuse policy dated 7/2/25 and last reviewed 10/28/25, indicated that the facility will not tolerate abuse, neglect, mistreatment, exploitation of residents and misappropriation of resident property. Neglect is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. The facility General dose preparation and mediation administration policy dated 11/15/24 and last reviewed 10/28/25, indicated prior to administration of medication, facility staff should take all measures required by facility policy and applicable including the following: verify each…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, resident clinical records, facility documentation, resident interview, and staff interview, it was determined that the facility failed to make certain significant medications are administered as ordered by the physician for one of five sampled residents (Resident R1).Findings include: The facility General dose preparation and mediation administration policy dated 11/15/24 and last reviewed 10/28/25, indicated prior to administration of medication, facility staff should take all measures required by facility policy and applicable including the following: verify each time a medication is administered that it is the correction medication, at the correct dose, at the correct route, at the correct rate, and at the correct time for the correct resident. Review of Resident R1's admission record indicated he was originally admitted on [DATE]. Review of Resident R1's MDS assessment (Minimum Data Set assessment: MDS -a periodic assessment of resident care needs) dated 11/26/25,…

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 admission notice packet, observations, and staff interview, it was determined that the facility failed to accommodate the shower needs for one of five residents (Resident R1).Findings include:Review of the facility's admission notice packet indicated residents have the right to have their personal needs and preferences provided for to the extent that they do not interfere with the rights of other residents of the nursing facility.Review of the clinical record indicated Resident R1 was admitted to the facility on [DATE].Review of Resident R1's Minimum Data Set (MDS - a periodic assessment of care needs) dated 11/19/25, indicated diagnoses of high blood pressure, osteoporosis (condition when the bones become brittle and fragile), and diabetes (a long-term condition in which the body has trouble controlling blood sugar and using it for energy). Review of Resident R1's current physician orders indicated shower twice weekly on Sunday, and Thursday during the 3:00 p.m. - 11:00 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical record, observations, and interviews with staff and residents, the facility failed to provide appropriate care and treatment post fall for one of three residents (Closed Record Resident CR1). Findings:Review of the facility policy Fall Prevention and Management Policy dated 10/28/25, indicated providers will be consulted regarding risks and interventions, feedback, and any further approaches recommended.Review of the admission sheet indicated Resident CR1 admitted to the facility on [DATE].Review of Resident CR1's Minimum Data Set (MDS - a periodic assessment of care needs) dated 12/19/25, indicated the diagnoses of anemia (the blood doesn't have enough healthy red blood cells), diabetes (a long-term condition in which the body has trouble controlling blood sugar and using it for energy), and Alzheimer's Disease with late onset (a progressive disease that destroys memory and other important mental functions). Section C0500 Brief Interview for Mental Status (BIMS - is…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical record review, observations, and staff interviews, it was determined that the facility failed to ensure a resident with limited mobility receives appropriate services, equipment, and assistance to maintain or improve mobility for one of three residents (Residents R2).Findings include:Review of the facility policy Splint Issuance Policy dated 10/28/25, indicated splints shall be issued or fabricated with a provider's order and therapist must evaluate patient to determine need for splint, fit and issuance. Patient splint schedule will be communicated to the multidisciplinary team and documented in the care plan.Review of the clinical record indicated Resident R2 was admitted to the facility on [DATE].Review of Resident R2's Minimum Data Set (MDS - a periodic assessment of care needs) dated 11/4/25, indicated diagnoses of high blood pressure, stroke (damage to the brain from an interruption of blood supply), and hemiplegia (paralysis of one side of the body).Review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of facility policy, clinical records, and staff interview, it was determined that the facility failed to develop care plans that included instructions to provide person centered care for six of 34 residents (Resident R3, Resident R8, Resident R55, Resident R63, Resident R148, and Resident R151).Findings include: Review of facility policy Comprehensive Care Planning dated 7/3/25, indicated an interdisciplinary plan of care will be established and updated as indicated for every resident in accordance with state and federal regulatory requirements. The facility will develop 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. These plans will be focused on resident choice and abilities with the intact of maintaining or improving resident functional abilities and quality of life. The comprehensive care plan will be developed within…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical records, and staff interviews, it was determined that the facility failed to notify physicians of abnormal Capillary Blood Glucose (CBG) readings as per physician's order for one of three sampled residents (Residents R148) and failed to provide comprehensive skin assessments and provide appropriate care and treatment for two of five residents (Resident R31 and Residents R38) reviewed with skin condition concerns and failed to follow physician orders for vitals for one of five resident (Resident R2). Findings include: § 483.25 Quality of care Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents’ choices. Review of facility policy Skin and Wound Care Best Practices dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, review of facility documentation, review of clinical records, and staff interview, it was determined that the facility failed to identify and assess a resident for smoking safety in a timely manner for two of two residents (Residents R79 and R98), failed to reassess a resident after an elopement (resident exits to an unsupervised or unauthorized area without the facility's knowledge), and failed to develop a comprehensive care plan with interventions to address the potential for elopement for one of three residents (Resident R110).Findings include: Review of the facility policy Resident Smoking Policy dated 7/3/25, and previously dated 1/19/24, indicated that during the admission process, nursing will ask residents if they smoke or have a desire/intent to smoke while in the facility. Anyone answering yes is further assessed for smoking safety awareness and the need for reasonable physical or safety accommodations. The assessment is completed thereafter on readmission,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to maintain accurate resident care plans and conduct ongoing accurate assessments to ensure that bedrails were used to meet residents' needs and the risks associated with bedrail usage for three of three residents (Residents R4, R54, and R95).Findings include: Review of facility policy Bed Rail dated 7/3/25, and previously dated 1/19/24, indicated if a bed or side rail or bar is used, the facility will evaluate the potential risks associated with the use of bed rails including entrapment, prior to bed rail installation using the Bed and Bed Rail Safety Inspection Checklist. Review of the clinical record indicated Resident R4 was admitted to the facility on [DATE]. Review of Resident R4's Minimum Data Set (MDS - a periodic assessment of care needs) dated 5/14/25, indicated diagnoses of high blood pressure, hemiplegia (paralysis on one side of the body), and depression. During…

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, observations, and staff interviews, it was determined that the facility failed to properly store medications in three of three medications rooms (2A, ), and one of four medication carts (3A Medication Cart).Findings include: Review of facility policy Storage and Expiration Dating of Medications and Biologicals dated 7/3/25, and previously dated 1/19/24, indicated that the facility should ensure that only authorized facility staff should have possession of the keys, access cards, electronic codes, or combinations which open medication storage areas. Facility should ensure all medications and biologicals, including treatment items, are securely stored in a locked cabinet/cart or locked medication room that is inaccessible by residents and visitors. Facility should ensure medications and biologicals that 1) have an expired date on the label; 2) have been retained longer than recommended by manufacturer or supplier guidelines; or 3) have been contaminated or deteriorated, are…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, observations, and staff interviews, it was determined that the facility failed to prevent potential of cross contamination in one of three medication refrigerators (2B medication refrigerator), failed to implement infection control practices to prevent cross contamination during a dressing change for one of three residents (Resident R82), and failed to implement an infection control program that included a system of surveillance to identify possible communicable diseases or infections for four of 11 months (September 2024, October 2024, November 2024, and December 2024).Findings include: Review of facility policy Storage and Expiration Dating of Medications and Biologicals dated 7/3/25, and previously dated 1/19/24, indicated that the facility should ensure food is not to be stored in the refrigerator, freezer, or general storage areas where medications and biologicals are stored. Review of facility policy Clean Dry Dressing Change dated 7/3/25, indicated where sterile…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to make certain that an influenza immunization was offered to one of five residents (Resident R33), and failed to make certain that a pneumococcal immunization was offered to two of five residents (Residents R5 and R118).Findings include: Review of facility policy Resident Vaccination Policy dated 7/3/25, and previously dated 1/19/24, indicated influenza, pneumococcal, and COVID vaccination will be administered per provided orders. Consents/refusals/medical ineligibility will be documented in the electronic health record. Review of the clinical record indicated Resident R5 was admitted to the facility on [DATE]. Review of Resident R5's Minimum Data Set (MDS - a periodic assessment of care needs) dated 8/2/25, indicated diagnoses of high blood pressure, depression, and anxiety. Question O0300 Pneumococcal Vaccine indicated Resident R5's Pneumococcal vaccination is not up to date. The reason…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy, observation and staff interview, it was determined that the facility failed to ensure that care was provided in a manner which maintained resident dignity for one of three residents (Resident R82).Findings include: Review of a booklet titled Know Your Rights as a Nursing Home Resident provided to residents upon admission to the facility indicated residents have the right to privacy and to be treated with dignity and respect. Review of the clinical record indicated Resident R82 was admitted to the facility on [DATE]. Review of Resident R82's [NAME] Data Set (MDS - a periodic assessment of care needs) dated 6/4/25, indicated diagnoses of high blood pressure, chronic obstructive pulmonary disease (COPD, a group of progressive lung disorders characterized by increasing breathlessness), and hypothyroidism (when the thyroid gland does not produce enough thyroid hormone). Review of the facility provided pressure ulcer list indicated Resident R82 developed a pressure ulcer (injury to skin 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 resident and staff interview it was determined that the facility failed to respond to resident concerns and grievances identified during resident council meeting. Findings include: Federal Regulation includes:S483.10(f)(5) The resident has a right to organize and participate in resident groups in the facility.(i)The facility must provide a resident or family group, if one exists, with private space; and take reasonable steps, with the approval of the group, to make residents and family members aware of upcoming meetings in a timely manner.(ii)Staff, visitors, or other guests may attend resident group or family group meetings only at the respective group's invitation.(iii)The facility must provide a designated staff person who is approved by the resident or family group and the facility and who is responsible for providing assistance and responding to written requests that result from group meetings.(iv)The facility must consider the views of a resident or family group and act promptly upon the grievances and recommendations of such groups concerning issues of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policies and clinical records, observations and staff interviews it was determined that the facility failed to identify a bolster (a long, thick cushion) as a possible restraint, and failed to assess the functional status of the individual resident to determine if the use of a bolster is a restraint for one of four residents (Resident R76).Findings include: Review of facility policy Restraint Policy dated 7/3/25, last dated 1/19/24, indicated physical and/or chemical restraints will be initiated only after a comprehensive review determines that they are necessary to treat the resident's medical symptoms that warrant their use. Use the Enabler Restraint Observation to determine if the device restricts the resident's freedom of movement. Before proceeding with the device identified as a restraint, the interdisciplinary team evaluates factors leading to the consideration of the device, determines that all the resident's needs are being met and the need to restraint is not due to unmet…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy, clinical record review and staff interviews, it was determined that the facility failed to ensure that residents medication regime was free from unnecessary psychotropic medication for two of three residents (Resident R8 and Resident R63).Findings include: Review of facility policy Psychoactive Medication Policy dated 7/3/25, indicated all residents receiving psychoactive medication(s) will have their behaviors, effectiveness of interventions (pharmacological and non-pharmacological) and potential for a gradual dose reduction of psychoactive medications monitored and documented. Review of the clinical record indicated Resident R8 was admitted to the facility on [DATE]. Review of Resident R8's Minimum Data Set (MDS - a periodic assessment of care needs) dated 6/19/25, indicated diagnoses of left hip fracture, diabetes mellitus (group of diseases that affect how the body uses blood sugar (glucose)), and chronic kidney disease. Review of Resident R8's physician orders dated 1/10/25,…

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, facility documents, and staff interviews, it was determined that the facility failed to report an allegation of neglect within 24 hours to the local state field office for two of three residents (Resident R2 and Resident R33).Findings include: Review of facility policy Abuse, Neglect, and Exploitation dated 7/3/25, indicated that the facility will not tolerate abuse, neglect, mistreatment, exploitation of resident, and misappropriation of resident property by anyone. It is the facility's policy to investigate all allegations, suspicions and incidents of abuse, neglect, involuntary seclusion, intimidation, exploitation of residents, misappropriation of resident property and injuries of unknown source. Facility staff must immediately report all such allegations to the 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 this policy.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, facility documents, clinical record reviews and staff interviews, it was determined that the facility failed to initiate a thorough investigation for allegations of neglect for two of three residents (Residents R2 and Resident R33). Findings include: Review of facility policy Abuse, Neglect, and Exploitation dated 7/3/25, indicated that the facility will not tolerate abuse, neglect, mistreatment, exploitation of resident, and misappropriation of resident property by anyone. It is the facility's policy to investigate all allegations, suspicions and incidents of abuse, neglect, involuntary seclusion, intimidation, exploitation of residents, misappropriation of resident property and injuries of unknown source. Facility staff must immediately report all such allegations to the 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 this…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to make certain that the necessary resident information was communicated to the receiving health care provider for two of two residents sampled with facility-initiated transfers (Residents R4 and R114), and failed to notify the resident or resident's representative of the facility bed-hold policy (an agreement for the facility to hold a bed for an agreed upon rate during a hospitalization) for two of two resident hospital transfers (Residents R4, and R114).Findings include: Review of facility policy Resident Discharge/Transfer Letter Policy dated 7/3/25, and previously reviewed 1/19/24, indicated that the resident or responsible party will receive a bed hold notice along with the discharge/transfer letter. A copy of the completed bed hold notice will be scanned into the electronic chart and filed in business file with certified receipt attached if applicable, with copy of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of facility policy, Resident Assessment Instrument (RAI) User's Manual, clinical records, and staff interviews, it was determined that the facility failed to ensure Minimum Data Set (MDS - a periodic assessment of care needs) assessments accurately reflected the resident's status for two of five residents (Residents R79 and R95).Findings include: The Resident Assessment Instrument (RAI) User's Manual, which gives instructions for completing Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2024, indicated the following instructions:N0350, Insulin: enter in Item N0350A, the number of days during the 7-day look-back period (or since admission/entry or reentry if less than 7 days) that insulin injections were received.O0110K1, Hospice care: code residents identified as being in a hospice program for terminally ill persons where an array of services is provided for the palliation and management of terminal illness and related…

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, staff interviews, and review of facility activities calendars, it was determined that the facility failed to provide sufficient activities to meet their interests and support the physical, mental, and psychosocial well-being of each resident on two out of five days observed on the Third Floor Memory Impaired unit (8/18/25 and 8/19/25).Based on facility policy, observations, review of facility activities calendars, and staff interviews, it was determined that the facility failed to provide sufficient activities to meet the interests of resident on two out five days observed on the Third Floor Memory impaired unit (8/18/25 and 8/19/25). Findings include: The facility Life enrichment program policy dated 5/4/23, last reviewed 7/3/25, indicated that an ongoing resident-centered life program, based on comprehensive assessments and care plans. The program will be designed to meet the interest (hobbies, cultural preferences) and the abilities of each resident. Programs will be scheduled and offered seven days a week, including evenings and weekends.During…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical records, observations, and staff interview, it was determined that the facility failed to individualize care plans to address the resident specific nutritional concerns for two of six residents (Resident R10, and R76) and, failed to properly monitor weight and nutrition status by failing to obtain weights for one of three residents (Residents R10). Findings include: Review of the facility, Resident Weight Policy dated 7/3/25, and previously dated 1/19/24, indicated that weights will be obtained routinely in order to monitor nutritional health over time. Each resident's weight will be determined upon admission/readmission to the facility, weekly for the first four weeks after admission/readmission, and monthly or more often if risk is identified, or as ordered. Review of facility policy Comprehensive Care Planning dated 7/3/25, previously dated 1/19/24, indicated the care plan is reviewed on an ongoing basis and revised as indicated by the resident's needs, wishes, or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of resident clinical records, facility policy and staff interview it was determined the facility failed to provide consistent and complete communication with the dialysis (a machine that filters wastes, salts, and fluid from your blood when your kidneys are no longer healthy enough to do this work adequately) center for one of two residents (Resident R110), and failed to develop a comprehensive person-centered care plan to address resident needs for one of two residents (Resident R110).Findings include: Review of facility policy Hemodialysis Care dated 7/3/25, previously dated 1/19/24, indicated communication between the dialysis provider and facility staff will occur before and after each hemodialysis treatment and as needed. Review of the clinical record indicated Resident R110 was admitted to the facility on [DATE]. Review of Resident R110's MDS dated [DATE], indicated diagnoses of high blood pressure, End-Stage Renal Disease (ESRD, an inability of the kidneys to filter the blood), and muscle…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy and clinical records, family and staff interviews it was determined that the facility failed to make certain that residents are free of significant medication errors for two of two residents (Resident R2 and Resident R33). Findings include: Review of facility policy General Dose Preparation and Mediation Administration, dated 7/3/25, indicated prior to the administration of medication, facility staff should take all measures required, including, but not limited to the following: - verify each time a medication is administered that it is the correct mediation, at the correct dose, at the correct route, at the correct rate, and the correct time, for the correct resident, - confirm that the MAR (medication administration record) reflects the most recent medication order, - Check the expiration date of the mediation, - Check for allergies to the medication; and - if necessary, obtain vital signs. During medication administration, facility staff should take all measures required…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of facility policy, resident clinical records, and staff interview, it was determined the facility failed to ensure the coordination of hospice services with facility services to meet the needs of each resident for end of life care for two of three residents (Resident R10, and R95). Findings include: Review of the facility policy Hospice Care Policy dated 7/3/25, and previously dated 1/19/24, indicated that the facility will ensure that the resident's written plan of care includes both the most recent hospice plan of care and a description of the services furnished by the facility to attain or maintain the resident's highest practicable physical, mental, and psychosocial wellbeing. Review of Resident R10's admission record indicated she was initially admitted to the facility on [DATE]. Review of Resident R10's Minimum Data Set (MDS- periodic assessment of care needs) assessment dated [DATE], included diagnoses of anemia (too little iron in the body causing fatigue), dementia (a group of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to provide accurate and timely documentation related to offering the COVID-19 vaccination for two of five residents (Residents R5 and R33).Findings include: Review of facility policy Resident Vaccination Policy dated 7/3/25, and previously dated 1/19/24, indicated influenza, pneumococcal, and COVID vaccination will be administered per provided orders. Consents/refusals/medical ineligibility will be documented in the electronic health record. Review of the clinical record indicated Resident R5 was admitted to the facility on [DATE]. Review of Resident R5's Minimum Data Set (MDS - a periodic assessment of care needs) dated 8/2/25, indicated diagnoses of high blood pressure, depression, and anxiety. Question O0350 was coded no for Resident's COVID-19 vaccination is up to date. Review of Resident R5's clinical record failed to include documentation that the COVID-19 vaccination was offered 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 facility policy, facility documentation, clinical record review, and staff interview it was determined that the facility failed to ensure that residents are free from misappropriation of resident property for 15 of 15 resident (Resident R1, R2, R3, R4, R5, R6, R7, R8, R9, R10, R11, R12, R13, R14, R15 and R16). Findings include: Review of facility policy Abuse, Neglect, and Exploitation dated 3/10/25, indicated: The facility will not tolerate abuse, neglect, mistreatment, exploitation of residents, and misappropriation of resident property by anyone. Misappropriation the deliberate, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without consent. Review of facility documentation investigation witness statement dated 5/15/25, Licensed Practical Nurse Employee E2, indicated the following: I went to count with LPN Employee E1 from the daylight shift. When we walked into the med room she popped 2 Xanax (alprazolam ) out of a residents card, I asked what they were doing because the Residents Xanax is prn and they only get one.…

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 documentation, the facility failed to train an employee in abuse for one of three employees (LPN Employee E1). Findings include: Review of facility training documentation for LPN Employee E1 failed to include a current (completed within the year ) abuse, neglect misappropriation training. The most recent training provided was from 2022. During an interview on 6/18/25, at approximately 3:45 p.m. the Nursing Home Administrator confirmed that the facility failed to ensure abuse training for LPN Employee E1. 28 Pa. Code 201.20 a(5)b Staff development 28 Pa. Code 201.29 (c) Resident rights

Based on review of facility documentation, and staff interview it was determined that the facility failed to report an allegation of misappropriation. Findings include: Review of facility policy Abuse, Neglect, and Exploitation dated 3/10/25, indicated: The facility will not tolerate abuse, neglect, mistreatment, exploitation of residents, and misappropriation of resident property by anyone. Misappropriation the deliberate, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without consent. Review of facility documentation investigation witness statement (from Licensed Practical Nurse Employee E2 ), dated 5/15/25, indicated the following: I went to count with the LPN Employee E1 from the daylight shift. When we walked into the med room she popped 2 Xanax (alprazolam ) out of a residents card, I asked what they were doing because the Residents Xanax is prn and they only get one. LPN Employee E1 stated, I was going to give them one earlier, I'll give it to them now and you can give them one later. I counted with LPN Employee E1 and the count 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 facility policy, and facility documents and staff interviews it was determined that the facility failed to document, resolve, and provide response to resident and/or their responsible party regarding concerns for ten of 13 grievances in March 2025. Findings include: Review of the facility Resident Grievances and Concerns Policy dated 3/10/25, indicated Time Frame: the grievance review will be completed in a reasonable time frame consistent with the type of grievance, but in no event will the review exceed thirty days. Review of March 2025, facility provided Grievance log indicated there were a total of 13 resident entries and as of 5/15/25, at 2:00 p.m. ten had no date of parties informed of findings or disposition completed. Interview on 5/15/25, at 2:00 p.m. the Nursing Home Administrator confirmed that the facility provided grievance logs indicated the facility failed to document, resolve, and provide response to resident and/or their responsible party regarding concerns for ten of 13 grievances in March 2025. 28 Pa. Code 201.14(b) Responsibility of licensee.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, record review, and resident and staff interviews, and observations it was determined that the facility failed to provide a resident environment free of potential accidental hazards for two of six hallways (2A and 2B). Findings include. Review of the Code of Federal Regulations (CFR) §483.25(d) Accidents. The facility must ensure that - §483.25(d)(1) The resident environment remains as free of accident hazards as is possible. Review of the facility Hot Beverage Policy dated 3/10/25, indicated hot beverages have the potential to cause an injury, and will be handled carefully. Personal beverage heating devices are not permitted due to the ongoing risk of scalding and for those who may inadvertently gain access to such devices. Hot beverages will not be left unattended for resident self-service. Appropriate supervision will be provided for residents with decreased safety awareness, physical limitation and or self-feeding deficits that could place them at risk for burns/scalds.…

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 documentation and interviews with staff it was determined that the facility failed to maintain and implement an effective, quality assurance and performance improvement program that focuses on outcome as required by failing to implement a QAPI for staffing for LPN's. Finding include: Review of Plan of Correction for PA State tag 5530 indicated: Facility Administration will ensure a minimum of one license practical nurse per 25 residents during day shift and 30 residents during the evening shift. The facility staffing schedule was reviewed to ensure that it provided the necessary coverage of License practical nurses per regulation. To prevent this from happening again the facility Administrator, Director of Nursing and Scheduler will conduct a staffing meeting to review staffing ratios weekly times four weeks then monthly times two month. Regional Director of Clinical Services will educate the facility Administrator, Director of Nursing and scheduler on the LPN staffing ratios implemented on 07/01/2023. The Nursing Home Administrator or designee will…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policies, job descriptions, documents, clinical records, and staff interviews, it was determined that the facility failed to protect residents from verbal abuse and mental anguish for one of five residents reviewed (Resident CR2), and failed to provide necessary services of medication administration for 29 of 29 residents on the Memory Impaired Unit (Residents R16, R27, R29, R30, R32, R54, R55, R60, R71, R72, R73, R75, R76, R83, R84, R89, R90, R91, R93, R97, R100, R101, R103, R107, R110, R116, R117, R118, and R121. Findings include: Review of facility policy entitled Pennsylvania Resident Abuse, dated 6/1/24, indicated that the facility will not tolerate abuse, neglect, mistreatment, exploitation of residents, and misappropriation of resident property by anyone. It is the facilities policy to investigate all allegations, suspicions and incidents of abuse, neglect, involuntary seclusion, intimidation, exploitation of residents, misappropriation of resident property and injuries of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical records, facility documents, and staff interview, it was determined that the facility failed to fully investigate alleged allegation of abuse/neglect for 30 of 30 residents (Residents R16, R20, R27, R29, R30, R32, R54, R55, R60, R71, R72, R73, R75, R76, R83, R84, R89, R90, R91, R93, R97, R100, R101, R103, R107, R110, R116, R117, R118, and R121). Findings include: Review of the facility policy Pennsylvania Resident Abuse, dated 6/1/24, indicated that the facility will not tolerate abuse, neglect, mistreatment, exploitation of residents, and misappropriation of resident property by anyone. It is the facilities policy to investigate all allegations, suspicions and incidents of abuse, neglect, involuntary seclusion, intimidation, exploitation of residents, misappropriation of resident property and injuries of unknown source. Review of the clinical record indicated Resident R20 was admitted to the facility on [DATE]. Review of Resident R20's MDS dated [DATE], indicated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to make certain that the necessary resident information was communicated to the receiving health care provider for five of six residents sampled with facility-initiated transfers (Residents R7, R9, R21, R56 and R58). Findings include: Review of facility policy Resident Discharge/Transfer Letter Policy dated 6/1/24, indicated the designee will complete the appropriate forms. Review of the clinical record indicated Resident R7 was admitted to the facility on [DATE]. Review of Resident R7's MDS (Minimum Data Set, periodic assessment of resident care needs) dated 8/6/24, indicated diagnoses of diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time), and major depressive disorder. Review of the clinical record indicated Resident R7 was transferred to the hospital on 5/13/24, and returned to the facility on 5/18/24. Review of Resident R7's clinical…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical record review, and staff interviews, it was determined that the facility failed to provide a transfer notice to a representative of the Office of the Long-Term Care Ombudsman Division for five of six residents (Residents R7, R9, R21, R56, and R58). Findings include: Review of facility policy Resident Discharge-Transfer Letter Policy dated 6/1/24, indicated staff designee will assure original discharge-transfer letter is given to resident or guardian. Copies will be sent to Ombudsman Office and scanned into the electronic chart. For emergency transfers, one list can be sent to the Ombudsman at the end of the month. Review of the clinical record indicated Resident R7 was admitted to the facility on [DATE]. Review of Resident R7's MDS (Minimum Data Set, periodic assessment of resident care needs) dated 8/6/24, indicated diagnoses of diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time), and major depressive disorder. Review…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical record review, and staff interviews, it was determined that the facility failed to notify the resident or resident's representative of the facility bed-hold policy (an agreement for the facility to hold a bed for an agreed upon rate during a hospitalization) for five of six resident hospital transfers (Resident R7, R9, R21, R56, and R58). Findings Include: Review of facility policy Resident Discharge-Transfer Letter Policy dated 6/1/24, indicated the resident or responsible party will receive a bed hold notice along with the discharge-transfer letter. Bed hold notices can be found in the electronic records. Review of the clinical record indicated Resident R7 was admitted to the facility on [DATE]. Review of Resident R7's MDS (Minimum Data Set, periodic assessment of resident care needs) dated 8/6/24, indicated diagnoses of diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time), and major depressive disorder. Review of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical records, and staff interview, it was determined the facility failed to update a care plan for four of eighteen residents (Residents R63, R66, R98, and R111) to accurately reflect the current status of the resident and care needs. Findings include: Review of the facility policy Comprehensive Care Planning Policy indicates the facility must develop a comprehensive Person-Centered Care Plan for each resident that includes measurable objectives and timetables to meet the resident's medical, nursing, and mental/psychosocial needs. Review of the admission record indicated Resident R63 admitted to the facility on [DATE], with the diagnoses of type 2 diabetes mellitus, chronic kidney disease, and major depressive disorder. Review of Resident R63's MDS (Minimum Data Set (MDS) assessments - periodic assessments of resident care needs), Section I dated 6/18/24, indicated the diagnoses were current. Review of Resident R63's physician orders indicated wander guard bracelet 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, observations, and staff interview, it was determined that the facility failed to provide necessary supervision and monitoring of potential resident accidents for 29 of 29 residents on the Memory Impaired Unit (Residents R16, R27, R29, R30, R32, R54, R55, R60, R71, R72, R73, R75, R76, R83, R84, R89, R90, R91, R93, R97, R100, R101, R103, R107, R110, R116, R117, R118, and R121), and failed to assess and implement interventions to prevent the potential for elopement for one of two resident (Resident R233) reviewed. Findings include: Review of the facility policy Incident/Accident Policy dated 6/1/24, indicated an incident/accident is any occurrence which is not consistent with the routine care of a particular resident. Review of facility policy Elopement/Unauthorized Absence Policy dated 6/1/24, indicated that the facility will identify residents with the potential and/or actual risk factors for elopement and protect the resident through development and implementation of safety…

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

Based on review of facility documents and staff interview, it was determined that the facility failed to conduct Quality Assessment and Assurance (QAA) meetings at least quarterly with all of the required committee members for three of four quarterly meetings (October 2023, February 2024, and April 2024). Findings include: Review of the CFR (Code of Federal Regulations) §483.75(g) Quality assessment and assurance. §483.75(g) Quality assessment and assurance. §483.75(g)(1) A facility must maintain a quality assessment and assurance committee consisting at a minimum of: (i) The director of nursing services; (ii) The Medical Director or his/her designee; (iii) At least three other members of the facility's staff, at least one of who must be the administrator, owner, a board member or other individual in a leadership role; and (iv) The infection Preventionist. Review of Quality Assurance and Performance Improvement (QAPI) sign-in sheets and attendance records for quarterly meetings held 10/20/23, 2/22/23, and 4/25/24, did not indicate that the facility's Medical Director attended these…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policies, clinical record review, observation, and staff interview, it was determined the facility failed to implement measures to prevent the potential for cross contamination during a dressing change for one of two residents (Resident R12), failed to track Enhanced Barrier Precaution (EBP, a type of precautions used to take care of residents) for four of four residents (R53, R64, R81, and R109), failed to follow proper use of personal protective equipment (PPE) for one of three units (Unit one), failed to implement an infection control program that included a system of surveillance to identify possible communicable diseases or infections for ten of ten months (November 2023 - August 2024), and failed to ensure that a comprehensive resident care plan was developed related to infection precautions for 5 of 5 residents (R2, R56, R58, R64, and R81). Findings include: Review of facility policy Clean Dressing Change Policy dated 6/1/24, indicated wounds will be dressed using clean technique which…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, closed clinical records, resident fund account statements and staff interview it was determined that the facility failed to convey resident funds in accordance with State law and closed accounts upon death in a timely manner for one of four closed resident records (Closed Resident Records CR1). Findings include: The facility admission Assessment policy dated last reviewed 6/1/24, indicated that available funds in the account will be distributed within 60 days of death. Review of Closed Resident Records CR1's admission record indicated she was admitted on [DATE], with diagnoses that included congestive heart failure, gastro-esophageal reflux disease, and constipation. Review of Closed Resident Records CR1's MDS assessment (Minimum Data Set--MDS assessment: a periodic assessment of resident care needs) dated 4/26/24, indicated that the diagnoses were the most recent upon review. Review of Closed Resident Records CR1's nurse progress notes dated 5/12/24, indicated that staff was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical records, and staff interview, it was determined that the facility failed to notify a medical provider of a change in condition for one out of four residents (Resident R111). Findings include: Review of facility policy Change in Condition dated 6/1/24, indicated the Physician/Provider and Resident/Family/Responsible Party will be notified when there has been an accident or incident involving the resident. Review of the admission record indicated Resident R111 was admitted to the facility on [DATE]. Review of Resident R111's Minimum Data Set (MDS- a periodic assessment of care needs) dated 8/13/24, indicated the diagnoses of dementia (a general term for loss of memory, language, problem solving and other thinking abilities that are severe enough to interfere with daily life), stroke (damage to the brain from an interruption of blood supply), and high blood pressure. Review of Resident R111's event report dated 8/23/24, at 12:46 p.m. indicated on 8/22/24, medications…

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 admission documents and staff interview, it was determined that the facility failed to ensure resident rights to make informed decisions and choices about important aspects of residents' health, safety and welfare by making certain residents understand the Notice of Medicare Non-Coverage (NOMNC) form and failed to ensure the agreement is explained to the resident and his or her representative in a form and manner that he or she understands for one of three residents (Resident R14). Findings include: Review of the Resident Assessment Instrument 3.0 User's Manual effective October 2019 indicated that a Brief Interview for Mental Status (BIMS), is a screening test that aides in detecting cognitive impairment. The BIMS total score suggests the following distributions: 13-15: cognitively intact 8-12: moderately impaired 0-7: severe impairment Review of Resident R14's admission record indicated the resident was admitted to the facility 3/20/24. Review of Resident R14's demographic information available in the electronic medical record indicated that Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of the RAI (Resident Assessment Instrument), clinical records, and staff interviews it was determined that the facility failed to make certain that resident assessments were accurate for two of twelve residents (Residents R52, and R111). Findings include: The Resident Assessment Instrument (RAI) User's Manual, which gives instructions for completing Minimum Data Set (MDS) assessments (periodic assessments of resident care needs), dated September 2024, indicated the following: Section I Active Diagnoses in the last seven days - Check all that apply. Section O Special Treatments, Procedures and Programs. While a resident of this facility and within the last 14 days. C1. Oxygen therapy. Review of the admission record indicated Resident R52 admitted to the facility on [DATE]. Review of Resident R52's MDS dated [DATE], indicated the diagnoses of Alzheimer's Disease (a progressive disease that destroys memory and other important mental functions), heart failure (heart doesn't pump blood as well as it…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, clinical record review, and staff interviews, it was determined that the facility failed to notify a physician of abnormal glucose readings as per physician's order for one out of three sampled residents (Resident R21), and failed to make certain that residents were provided appropriate treatment and service for non-pressure wound dressing orders for one of twelve residents (Resident R66). Findings include: Review of Resident R21's admission record indicated he was admitted on [DATE], with diagnoses that included diabetes (metabolic disorder impacting organ function related to glucose levels in the human body), Hemiplegia and hemiparesis following other cerebrovascular disease, and protein-calorie malnutrition. Review of Resident R21's quarterly MDS assessment (MDS-Minimum Data Set assessment: periodic assessment of resident care needs) dated 8/21/24 , indicated that the diagnoses were current upon review. Review of Resident R21's care plan indicated to administer medication as per medical…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of Resident Assessment Instrument (RAI) User's Manual, clinical records, and staff interviews, it was determined that the facility failed to ensure that MDS assessments accurately reflected the resident's status and failed to ensure that a comprehensive resident care plan was developed related to pressure wounds for one of four residents (Residents R2). Findings include: The Resident Assessment Instrument (RAI) User's Manual, which gives instructions for completing Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2023, indicated the following instructions: -Section M: Skin Conditions, Document the risk, presence, appearance, and change of pressure ulcer as well as other skin ulcers, wounds, or lesions. Also includes treatment categories related to skin injury or avoiding injury. Review of the clinical record revealed that Resident R2 was admitted to the facility on [DATE]. Review of Resident R2's MDS (Minimum Data Set, periodic…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy, clinical record review, and interview, the facility failed to ensure that appropriate treatment and services were provided for two of three residents with an indwelling urinary catheter (Residents R49 and R107). Findings include: Review of facility policy Indwelling Urinary Catheter Care Procedure dated 6/1/24, indicated to check drainage tubing and bag to ensure that the catheter is draining properly, and no kinks are present. The urinary drainage bag must be placed below the bladder level but not on the floor. Ensure drainage bag is covered with privacy/dignity cover. Resident R49 was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS - a periodic assessment of care needs) dated 7/17/24, indicated diagnoses of obstructive uropathy (structural hindrance of normal urine flow), diabetes (a long-term condition in which the body has trouble controlling blood sugar and using it for energy), and heart failure (heart doesn't pump blood as well as it should). Section H…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, clinical record review and interview, the facility failed to provide specialized care needs for the provision of respiratory care in accordance with professional standards of practice for three of four residents (Residents R52, R60, and R101). Findings include: Review of facility policy Oxygen Administration (all routes) Policy dated 6/1/24, indicated the staff are to change tubing, mask, cannula (small tubes in nose to administer oxygen) weekly and document according to facility policy. When oxygen not in use, store dry oxygen tubing, nasal cannula, or mask in a plastic bag. Review of admission record indicated Resident R52 was admitted to the facility on [DATE]. Review of Resident R52's Minimum Data Set (MDS - a periodic assessment of care needs) dated 7/19/24, indicated the diagnoses of Alzheimer's Disease (a progressive disease that destroys memory and other important mental functions), heart failure (heart doesn't pump blood as well as it should), and respiratory failure (a serious…

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

Based on observations, clinical record review, resident and staff interviews, it was determined that the facility failed to have sufficient nursing staff to provide nursing and related services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of 29 of 29 residents on the Memory Impaired Unit (Residents R16, R27, R29, R30, R32, R54, R55, R60, R71, R72, R73, R75, R76, R83, R84, R89, R90, R91, R93, R97, R100, R101, R103, R107, R110, R116, R117, R118, and R121). Findings Include: Review of the facility policy Dayforce Scheduling Policy dated 6/1/24, indicated Administrators, department leaders and all staff members are to be proficient in the use of Dayforce and use all its scheduling capabilities to ensure adequate staffing levels are maintained. Review of the facility Registered Nurse Supervisor job description dated 6/1/24, indicated essential functions to include accurately administer medications and treatment to residents per Physician orders. Follows all required protocols, policies, and regulations related to medication administration.…

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

Based on review of facility policy, observations and staff interview it was determined that the facility failed to date opened medications and properly store medications in one of three medication carts observed (Cart 2A and 2C). Findings include: Review of facility policy Storage and Expiration Dating of Medications and Biologicals dated 6/1/24, indicated once any medication or biological package is opened, facility should follow manufacturer/supplier guidelines with respect to expiration dates for opened medications. Facility staff should record the date opened on the primary medication container (vial, bottle, inhaler) when the medication has a shortened expiration date once opened. Observation on 9/9/24, at 11:02 a.m. the medication cart for 2A and 2C indicated the following medications stored in the drawer without a date and time indicating date opened as required: -Resident R120's Lantus Pen (prefilled pen to inject long-acting insulin under the skin) and Lispro Pen (a short acting, manmade version of human insulin) , -Resident R231's Lispro Pen, -Resident R8's timolol eye…

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

Based on review of the facility's infection control policies and procedures and staff interview, it was determined that the facility failed to implement an antibiotic stewardship program for ten of ten months (November 2023 through August 2024). Findings include: Review of facility policy Antimicrobial Stewardship Program Policy dated 6/1/24, indicated antimicrobial stewardship will focus on improving antibiotic/antimicrobial use by avoiding unnecessary or inappropriate antibiotics. The antimicrobial stewardship program will be reviewed annually and as needed. The antimicrobial stewardship process will be overseen and managed by the Infection Preventionist (IP) who works collaboratively with the medical director, consulting pharmacist, nursing, and administrative leadership. Review of the facility's Infection Control surveillance for November 2023 through August 2024, failed to include documentation to indicate that antibiotic monitoring was completed. During an interview on 9/12/24, at 9:30 a.m., the IP Employee E9 was unable to locate and provide documentation to indicate that…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy review, clinical and facility record review, facility submitted documents, and staff interviews, it was determined that the facility failed to provide adequate supervision to prevent elopement for one of five residents (Resident R1). This was identified as past non-compliance. Findings include: Review of the facility policy Elopement/Unauthorized Absence Policy dated 6/1/24, indicated the facility will identify residents with potentiation and/or actual risk factors for elopement and protect the resident through development and implementation of safety interventions. Review of the Resident Assessment Instrument 3.0 User's Manual effective October 2019, indicated that a Brief Interview for Mental Status (BIMS), is a screening test that aides in detecting cognitive impairment). The BIMS total score suggests the following distributions: 13-15: cognitively intact 8-12: moderately impaired 0-7: severe impairment Review of the clinical record revealed Resident R1 was originally admitted to 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 Resident Council Minutes and staff interviews, it was determined that the facility failed to provide adequate staffing for the number and acuity of the residents for five of seven months (11/23, 12/23, 2/24, 4/24, and 5/24) and failed to meet the potential needs of all residents. Findings include: During an observation on 5/28/24, at 11:00 am it was revealed that the facility provided staffing for the Third Floor Nursing Unit (Memory Impaired Unit/MIU) for the time period of 7:00 am to 11:00 am as follows, unit census was 41 residents, staffing consisted of two Licenseed Practical Nurses (LPN), and 3 Nursing Assistants (NA). The MIU is a secured unit that residents require close supervision and assistance. A review of facility list for residents requiring feeding assistance residing on the MIU revealed that 14 of the 41 residents required assistance or monitoring during meal service. During an interview on 5/28/24, at 3:05 pm the Director of Nursing confirmed that the facility does not provide nurse staffing based on nursing units and the acuity level…

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 make certain that two of two Food and Nutrition Staff members with facial hair properly restrain facial hair in the Main Kitchen. (Main Kitchen) Findings include: A review of facility policy Employee Sanitary Practices dated 1/19/24, indicated that Food and Nutrition Staff members are required to properly restrain their hair including facial hair. During an observation of the lunch meal service on 5/28/24, at 11:50 am it was observed that Assistant Food Service Director Employee E7 and Food Service Aide Employee E8 failed to properly restrain hair by wearing a beard guard. During an interview on 5/28/24, at 12:00 pm Food Service Director Employee E6 confirmed that Assistant Food Service Director Employee E7 and Food Service Aide Employee E8 failed to properly restrain their facial hair while working in the Main Kitchen. PA Code: 211.6(c)(d)(f) Dietary Services

During a review of facility documents and staff interviews it was determined that the facility failed to develop and implement a policy and procedure for dispensing medication to residents who were leaving the facility on an extended Leave of Absence (LOA) and a method to monitor and reconcile the administration of narcotics for two of three alleged misappropriation of two resident's property (Resident R2 and Resident R6) Findings include: A review of the facility documents revealed that the facility had three incidents of alleged medication diversion since 11/2023. During the investigation of alleged misappropriation of resident property (medication diversion) it was determined that the facility failed to provide documented evidence of a procedure for the dispersing of medication to a resident that was leaving the facility on an extended LOA and the required medication during their period away from the facility. During the investigation of alleged medication diversion on 11/29/23, documented on 12/11/23, regarding Resident R2 it was determined that the facility had not completed an…

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 four week cycle menu, Resident Council Minutes, and Staff interviews, it was determined that the facility failed to provide alternative menu selections of equal or greater nutrient value and appeal to the residents for the lunch and dinner meals for the four week cycle menu. (Four Week Cycle Menu) Findings include: During an observation of the displayed Four week cycle menu it was revealed that the facility failed to offer alternative menu selections of equal or greater nutrient value and appeal to the residents for the lunch and dinner meals as required. A review of Resident Council Minutes revealed the following: * On 2/28/24, Resident R5 stated she wants regular food, there are too many sandwiches, would like soup, there is not much variety. Resident R4 stated would like the old menu back and would like to choose. * On 3/28/24, Resident R2 stated the food sucks, she wants the old menu back and she doesn't get what she wants. * On 4/24/24, Resident R4 stated that she gets the same thing every day, she never gets anything different. Resident R7 stated…

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

Based on a review of facility policies, facility documents and staff interviews it was determined that the facility failed to timely report an alleged incident and properly investigate allegations of misappropriation of resident property which failed to prevent reoccurrence of similar events for one of three incidents. (Resident R2) Finding include: A review of facility policy Abuse, Neglect and Exploitation dated 8/31/23, indicated that the facility does not tolerate misappropriation of resident property by anyone. The facility investigates all allegations and incidents of misappropriation. Facility staff immediately reports allegations to the Administrator/Abuse coordinator. A review of facility policy Resident Leave of Absence dated 8/31/23, indicated that for leave of absences (LOA) extending beyond a midnight period the resident will be provided all necessary medications. They will only be given the amounts and dosages needed for the length of the absence. A review of facility documents revealed that the facility had three incidents of alleged medication diversion since…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of facility policies, documents, observations, and staff interviews, it was determined that the facility failed to accurately document resident activities of daily living (ADL) for one of three residents. (Resident R6). Findings include: A review of facility policy Clinical Documentation dated 8/31/23, and 1/19/24, indicated that provisions of ADL care will be documented each shift by staff providing the care. This shall include but not limited to, documention of food intake, toileting, ambulation, bathing, dressing and transferring. During a review of Resident R6's medical record it was revealed that the resident was readmitted to the facility on [DATE], with diagnosis of hemiplegia and hemiparesis following a stroke (Hemiplegia is a symptom that involves one-sided paralysis. Hemiplegia affects either the right or left side of your body), diabetes, heart disease and chronic pain. During a review of Resident R6's Physical Therapy Plan of Treatment Record dated 8/24/23, it was 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, review of resident medical records and staff interviews it was determined that the facility failed to properly transfer one of three residents. (Resident R6) Findings include: During a review of Resident R6's medical record (Face Sheet) it was revealed that the resident was readmitted to the facility on [DATE], with diagnosis of hemiplegia and hemiparesis following a stroke.( Hemiplegia is a symptom that involves one-sided paralysis. Hemiplegia affects either the right or left side of your body.), diabetes, heart disease, and chronic pain. During a review of Resident R6's Physical Therapy Plan of Treatment Record date 8/24/23, it was revealed that Resident R6 required the use of a hoyer lift for transfers. During a review Resident R6's Point of Care History Record for the time period of 5/1/24, through 5/28/24, it was revealed that the facility provided one nurse staff member support for transfers on the following dates: 5/2/24, 5/7/24, 5/21/24, 5/23/24, and 5/26/24. During a staff…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical records, facility investigation documentation, and staff interviews, it was determined that the facility failed to ensure that a resident was free of neglect during transportation in a wheelchair for one out two sampled residents (Resident R5). This deficiency is cited as past non-compliance. Findings include: Review of facility policy entitled Pennsylvania Resident Abuse, dated 1/19/24, indicated that the facility will not tolerate abuse, neglect, mistreatment, exploitation of residents, and misappropriation of resident property by anyone. It is the facilities policy to investigate all allegations, suspicions and incidents of abuse, neglect, involuntary seclusion, intimidation, exploitation of residents, misappropriation of resident property and injuries of unknown source. Neglect is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical records, observations and staff interviews it was determined that the facility failed to ensure that residents received neurological assessments after an incident involving an unwitnessed fall for two of four sampled residents (Residents R1 and Resident R2). Findings include: The facility Incident and accident policy dated 11/7/22, last reviewed 1/19/24, indicated that any accident is any occurrence which is not consistent with the routine care of a resident. Following all unusual occurrences, a complete set of vitals will be taken every 72-hours. Documentation regarding post-incident response and symptoms will be completed every shift for 72-hours post occurrence. Review of Residents R1's admission record indicated she was admitted on [DATE], and last re-admitted on [DATE]. Review of Residents R1's MDS assessment (Minimum Data Set assessment: MDS -a periodic assessment of resident care needs) dated 2/14/24, indicated she had diagnoses that included a history of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility documents, observations, and staff interview, it was determined that the facility failed to have appropriate personal protective equipment (PPE) to prevent cross-contamination for one of four residents with respiratory infection. Findings include: Review of facility policy Guidance in Managing Respiratory Illness & Outbreaks dated 8/31/23, indicated preadmission (referrals with known illness) obtain any testing results Respiratory Syncytial Virus (RSV), and determine room availability. Ensure transmission based precautions isolation is in place. Use combined contact/droplet precautions sign for respiratory illnesses - RSV until 24 hours after resolution of symptoms. Review of facility policy Transmission Based Precautions dated 8/31/23, indicated: -Transmission based precautions are always used in addition to Standard Precautions. -Contact precautions intended to prevent transmission of infectious agents which are spread by direct or indirect contact with the patient or the patient's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical records, observation and interviews with staff, it was determined that the facility failed to make certain that residents were monitored, assessed, and received the necessary services to prevent pressure ulcers/wounds from developing or worsening for three of six residents (Residents R2, R3, and R4). Findings include: Review of facility policy Skin and Wound Care Best Practices dated 8/31/23, indicated on admission the nurse will conduct a full body assessment. A second full body assessment will be scheduled within the first 24 hours of admission. The licensed nurse will complete a weekly skin check. Review of admission record indicated Resident R1 admitted to the facility on [DATE]. Review of Resident R1's Minimum Data Set (MDS- a periodic assessment of care needs) dated 10/10/23, indicated the diagnoses of arthritis, high blood pressure, and Dementia (a group of symptoms that affects memory, thinking and interferes with daily life). Review of Resident R1's care plan…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, observations, resident council group meeting, resident and staff interview it was determined that the facility failed to answer call bells in a timely manner for one of four residents observed on the first floor nursing unit (Residents R1). Findings include: Review of the facility Resident Communication System and Call Light Policy dated 8/31/23, indicated staff will respond to call lights promptly. If staff have promised the resident they will return with an item or information, they should do so promptly. Review of Resident Council Group Minutes dated 12/19/23, indicated call lights get turned off and then they never come back and that they are short staffed. Review of Resident Council Group Minutes dated 11/28/23, indicated: - Staffing is poor. -Daylight is always staffed and evening is not. -Staff are always running from room to room. -Sometimes they do not have enough help. -Call lights are being turned off. -Staff will say I'll be right back with you and then they don't…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy and clinical records and staff interview, it was determined that the facility failed to implement written policies and procedures to prohibit and prevent abuse, neglect, and exploitation of residents for one of three incidents reviewed (Resident R2). Findings include: A review of the facility policy Pennsylvania Resident Abuse dated 8/31/23, indicated the facility's policy to investigate all allegations, suspicions and incidents of abuse, neglect, involuntary seclusion, intimidation, exploitation of residents, misappropriation of resident property and injuries of unknown source. If the event that caused the allegation involves an allegation of abuse or serious bodily injury, it should be reported to the Department of Health immediately, but no later than two hours after the allegation is made. Review of admission record indicated Resident R2 admitted to the facility on [DATE]. Review of Resident R2's Minimum Data Set (MDS- a periodic assessment of care needs) dated 10/10/23,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical records, facility incident documents, resident, and staff interviews, it was determined that the facility failed to report an allegation of abuse within two hours for one of three residents (Resident R2). Findings include: A review of the facility policy Pennsylvania Resident Abuse dated 8/31/23, indicated the facility's policy to investigate all allegations, suspicions and incidents of abuse, neglect, involuntary seclusion, intimidation, exploitation of residents, misappropriation of resident property and injuries of unknown source. If the event that caused the allegation involves an allegation of abuse or serious bodily injury, it should be reported to the Department of Health immediately, but no later than two hours after the allegation is made. Review of admission record indicated Resident R2 admitted to the facility on [DATE]. Review of Resident R2's Minimum Data Set (MDS- a periodic assessment of care needs) dated 10/10/23, indicated the diagnoses of arthritis,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical records, facility documents, and staff interview, it was determined that the facility failed to fully investigate an allegation of abuse for one of three residents (Resident R2). Findings include: Review of the facility policy Pennsylvania Resident Abuse dated 8/31/23, indicated the person investigating should generally take the following actions: interview the resident, the accused, all witnesses, and employees who worked closely with the accused employee and/or alleged victim. Obtain written statements from the resident, if possible, the accused and each witness. Evidence of the investigation should be documented. Review of admission record indicated Resident R2 admitted to the facility on [DATE]. Review of Resident R2's Minimum Data Set (MDS- a periodic assessment of care needs) dated 10/10/23, indicated the diagnoses of arthritis, high blood pressure, and Dementia (a group of symptoms that affects memory, thinking and interferes with daily life). Review of…

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