Bedford Post Acute

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 provide accurate and timely documentation related to offering the COVID-19 vaccination for one of 35 residents reviewed (Resident 13).Findings include: A quarterly MDS assessment for Resident 13, dated May 29, 2026, revealed that the resident was cognitively impaired, was admitted to the facility on [DATE], and that she was not offered the influenza or pneumonia vaccine. Review of Resident 13's clinical record revealed no immunization or declination information documented related to the COVID-19 vaccine. Interview with the Nursing Home Administrator on June 16, 2026, revealed that Resident 13 was not offered the covid vaccination and should have been. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(1)(e)(1) Management.

Based on review of the Nursing Assistant job description, facility documents and staff interviews, it was determined that the facility failed to provide Quality Assurance and Performance Improvement (QAPI) training to five of five nurse aides reviewed (Nurse Aides 6, 7, 8, 9, and 10).Findings include: Review of the facility nursing assistant job description indicated that nurse aides were to complete or attend all training and education as assigned and as otherwise required by applicable law, rule, or regulations. Review of Nurse Aide 6's personnel file revealed that she was hired on February 19, 2019. Review of her continuing education transcript revealed that she did not complete any annual education regarding Quality Assurance and Performance Improvement (QAPI) training. Review of Nurse Aide 7's personnel file revealed that she was hired on August 21, 2017. Review of her continuing education transcript revealed that she did not complete any annual education regarding Quality Assurance and Performance Improvement (QAPI) training. Review of Nurse Aide 8's personnel file revealed…

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

Based on review of policies, clinical records, and information provided by the facility, as well as staff interviews, it was determined that the facility failed to ensure that a thorough investigation was completed into the resident's and their family member's concern for one of three residents reviewed (Resident 2).Findings include: The facility's policy regarding complaint grievances, dated February 14, 2025, revealed that the facility ensures complaints regarding the community were resolved in a timely and appropriate manner for employees or residents who have concerns or complaints. A quarterly Minimum Data Set (MDS) assessment (a federally-mandated assessment of a resident's abilities and care needs) for Resident 2, dated September 16, 2025, revealed that the resident was understood, could understand others, was cognitively intact, and had a diagnosis of parkinsonism (syndrome that causes movement symptoms like tremor, stiffness, and slowness of movement).Interview with the Resident 2 on November 12, 2025, at 12:16 p.m. revealed that he was upset when a staff member got water…

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

Based on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that fall/injury prevention interventions were in place for one of 3 residents reviewed (Resident 1).Findings include: A facility policy for fall management, dated February 14, 2025, indicated that the interdisciplinary team reviews falls. The team will discuss and care plan recommended interventions to reduce the potential for additional falls with the resident and/or resident's representative and document in the care plan and progress note. The care plan will be reviewed and/or revised as indicated. The care Kardex will be updated as appropriate. A quarterly Minimum Data Set (MDS) assessment (a federally mandated assessment of a resident's abilities and care needs) for Resident 1, dated July 23, 2025, revealed that the resident was cognitively impaired, was independent with transfers and ambulation, was occasionally incontinent of urine, received therapy, had one fall since her prior assessment with no injury, and had a diagnosis of…

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

Based on review of clinical record reviews, as well as observations and staff interviews, it was determined that the facility failed to complete safety assessments for three of 25 residents reviewed (Residents 9, 17, 36) who used an air mattress. Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 9, dated May 30, 2025, revealed that the resident was cognitively impaired, required assistance with daily care needs, had a Stage 3 pressure ulcer (pressure wound that forms as a result of prolonged pressure involving the fat layers beneath the skin), and had diagnoses that included dementia and Parkinson's Disease (a degenerative brain condition that affects muscle control and movement). Physician's orders for Resident 9, dated December 3, 2024, included an order for the resident to have a low air flow mattress (an inflated mattress for pressure relief) to promote skin integrity. Observations on June 30, 2025, at 11:11 a.m. revealed that Resident 9's bed was equipped with an air mattress; however,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 observations, as well as interviews with staff, it was determined that the facility failed to maintain the confidentiality of medical information for one of 25 residents reviewed (Resident 46). Findings include: The facility's policy regarding general dose preparation and medication administration, dated February 14, 2025, indicated that employees are to observe each resident's privacy and rights in accordance with applicable law (including blocking unnecessary access to the Medication Administration Record). Observations during medication administration on July 2, 2025, at 8:04 a.m. revealed that Registered Nurse 1 walked away from the medication cart in the hallway between rooms [ROOM NUMBERS] to administer medications to Resident 46 in room [ROOM NUMBER], and left the laptop on top of the medication cart open and the Medication Administration Record (MAR) for Resident 46 was visible to staff, residents, and visitors in the hallway. Interview with Registered Nurse 1 on…

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

Based on review of policies and personnel files, as well as staff interviews, it was determined that the facility failed to ensure that the status of nursing licenses was checked with the State Board of Nursing for two of two nurses reviewed (Registered Nurse 2, Licensed Practical Nurse 3), and failed to complete a Nurse Aide Registry verification for one of three nurse aides reviewed (Nurse Aide 4). Findings include: The facility's policy regarding Abuse, neglect, exploitation, and Misappropriation Prevention prom, dated February 14, 2025, indicated that the facility would conduct employee background checks and would not knowingly employ or otherwise engage any individuals who have had a finding entered into the State Nurse Aide Registry concerning abuse, neglect, exploitation, mistreatment of residents or misappropriation of their property; or have a disciplinary action in effect against his or her professional license by a state licensure body as a result finding of abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property. The personnel…

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

Based on facility policy, clinical record reviews, and resident and staff interviews, it was determined that the facility failed to follow physician's orders related to bowel protocols for one of 25 residents reviewed (Resident 45). Findings include: A facility policy for bowel protocol, dated February 14, 2025, indicated that the facility was to ensure that residents are free from complications secondary to constipation. This would be accomplished through adequate assessment tracking, and treatment as indicated. The evening shift nurse would provide medication as ordered according to the following bowel protocol: Give Milk of Magnesia (MOM - an oral laxative) one time if there is no bowel movement after three days at bedtime. If Milk of Magnesia is ineffective, on day four, give a Dulcolax suppository (a laxative inserted rectally). If both Milk of Magnesia and Dulcolax suppository are ineffective, on day five give a saline enema (a liquid inserted rectally to stimulate a bowel movement). The day shift nurse would monitor the daily bowel record to ensure the residents had received…

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

Based on a review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that physician's recommendations for brace application were followed for one of 25 residents reviewed (Resident 25). Findings include: A Quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 25, dated May 21, 2025, indicated that the resident was cognitively impaired, required moderate assistance for dressing and hygiene, and utilized a walker and a wheelchair. Interview with Resident 25 on June 30, 2025, at 1:29 p.m. revealed that he was to receive a back brace after he had fallen at the facility and broke his back, but he never received it. Hospital discharge records for Resident 25, dated January 5, 2025, revealed that the resident was to have a TLSO Brace (a brace that supports the back and pelvis area to reduce pain and prevent further injury) due to a back fracture. A nursing note for Resident 25, dated January 7, 2025, at 11:27 a.m., revealed that the hospital…

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

Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to maintain accountability for controlled medications (drugs with the potential to be abused) for one of 25 residents reviewed (Resident 17). Findings include: The facility's policy regarding medication administration, dated February 14, 2025, indicated that documentation of narcotic administration will be done in accordance with applicable law including documenting necessary medication administration treatment information on appropriate forms. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a residents abilities and care needs) for Resident 17, dated May 5, 2025, revealed that the resident was cognitively impaired, required extensive assistance with daily care needs, and had diagnosis of Parkinson's (a progressive neurological disease that affects movement), stroke, sarcopenia (a medical condition where there is a loss of muscle mass). Physician's orders for Resident 17, dated September 9, 2024, included an order for the resident to…

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

Based on review of facility policies and clinical record reviews, as well as staff interviews, it was determined that the facility failed to ensure that residents were free from unnecessary psychotropic medications (medications that affect the mind, emotions and behavior), by failing to ensure that non-pharmacological (non-medication) behavioral interventions (individualized, non-pharmacological approaches to care) were attempted prior to the administration of as needed antianxiety medications (psychotropic medication used to treat anxiety) for one of 25 residents reviewed (Resident 47). Findings include: The facility's policy regarding psychoactive/psychotropic medication use (any medication that affects brain activities associated with mental processes and behavior), dated February 14, 2025, indicated that psychotropic medication management for the resident will involve identifying person-centered non-pharmacological interventions (unless contraindicated) to minimize or discontinue the use of psychotropic medications. A quarterly Minimum Data Set (MDS) assessment (a mandated…

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

Based on review of facility policies, manufacturer's instructions, and clinical records, as well as observations and staff interviews, it was determined that the facility failed to maintain a medication error rate of less than five percent. Findings include: The facility's policy regarding general dose preparation and medication administration, dated February 14, 2025, indicated that facility staff should crush oral medications only in accordance with pharmacy guidelines. Exceptions to Should Not Crush medications may occur when the physician/prescriber orders are documented in the medical record including a statement explaining why crushing the medication will not adversely affect the resident. The facility is to follow manufacturer medication administration guidelines. Manufacturer's instructions for Oxycontin extended-release tables, dated May 2024, included instructions to swallow the tablets whole. Do not break, crush, chew or dissolve the tablets. Doing so can release all the drug at once increasing the risk for overdose. The medication label included instructions to take…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, as well as observations and staff interviews, it was determined that the facility failed to ensure that medications were properly secured in the medication cart. Findings include: The facility's policy regarding general dose preparation and medication administration, dated February 14, 2025, indicated that the facility should ensure that medication carts are always locked when out of sight or unattended. Observations during medication administration on July 2, 2025, at 8:04 a.m. revealed that Registered Nurse 1 walked away from the medication cart in the hallway between rooms [ROOM NUMBERS] to administer medications to Resident 46 in room [ROOM NUMBER] and left the medication cart unlocked, unattended, and out of sight in the hallway when he entered the resident's room. Interview with Registered Nurse 1 on July 2, 2025, at 8:16 a.m. confirmed that the medication cart was not locked, and it should have been. Interview with the Director of Nursing on July 2, 2025, at 11:09…

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

Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to follow policy/protocols set forth regarding alerting the physician of a resident's change in condition, for one of three residents reviewed (Resident 3). Findings include: The facility's emergency and/or alternative physician care policy, dated February 11, 2025, indicated that if a physician's backup coverage does not respond in a timely manner, then the nursing staff will contact the medical director for assistance. The facility's current after hours tele-health physician guidelines indicated that the average response time for a consult is two to five minutes. If there is no response from a physician within five minutes, staff are to re-create the consult using the orange Contact on Call Clinician button. If no response after a second consult, a support number was to be called. An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 3, dated October 26, 2025, indicated that the resident was…

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

Based on review of work history reports and observations, as well as staff interviews, it was determined that the facility failed to ensure that food was served under sanitary conditions. Findings include: Review of the facility's work history report, dated July 28, 2023, through July 25, 2024, revealed that the vent was inspected and cleaned if necessary monthly with the last time being documented as inspected on July 25, 2024. Observations in the main kitchen during dish washing on July 30, 2024, at 1:28 p.m. revealed that one dietary staff member was placing dirty dishes, cups, utensils, etc. in the dish washer and then another dietary staff member would take the clean dishes, cups, utensils, etc. from the dishwasher and would leave them on the counter beside the dishwasher until she would take the items to be stored. There was a metal shelf that was above and to the left of the dish washer that had clear plastic bins and other miscellaneous items being stored on it. There was a metal shelf next to the oven with clear plastic pitchers on the top shelf. Above the two metal shelves…

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

Based on review of the facility's plans of correction for previous surveys, and the results of the current survey, it was determined that the facility's Quality Assurance Performance Improvement (QAPI) committee failed to correct quality deficiencies and ensure that plans to improve the delivery of care and services effectively addressed recurring deficiencies. Findings include: The facility's deficiencies and plans of corrections for a State Survey and Certification (Department of Health) survey ending August 17, 2023, and a complaint investigation survey ending March 27, 2024, revealed that the facility developed plans of correction that included quality assurance systems to ensure that the facility-maintained compliance with cited nursing home regulations. The results of the current survey, ending August 1, 2024, identified repeated deficiencies related to a failure to ensure the accuracy of Minimum Data Set (MDS) assessments (a federally-mandated assessment of a resident's abilities and care needs), developing care plans, care plan timing and revision, storage, and labeling 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, review of clinical records, observations, and staff interviews, it was determined that the facility failed to maintain the dignity of three of 33 residents reviewed (Residents 48, 65, 67) who had an indwelling urinary catheter. Findings include: A facility policy for considerate and respectful treatment, dated March 1, 2024, indicated that staff will refrain from practices that are demeaning to patients, such as keeping urinary catheter bags uncovered. An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 48, dated July 15, 2024, indicated that the resident was understood and able to understand others, required substantial to moderate assistance with personal hygiene care, had an indwelling urinary catheter, and had diagnoses that included renal insufficiency. Physician's orders for Resident 48, dated July 13, 2024, included for staff to place a foley catheter (flexible catheter used to drain urine from…

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

Based on clinical record reviews and staff interviews, it was determined that the facility failed to notify the resident and legal guardian in writing regarding the reason for hospitalization for two of 33 residents reviewed (Residents 19, 22). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 19, dated June 4, 2024, revealed that the resident was understood, could understand others, and had a diagnosis which included Parkinson's disease, dementia, and chronic obstructive pulmonary disease (COPD - a common lung disease causing restricted airflow and breathing problems). Physician's orders for Resident 19, dated June 19, 2024, included an order for the resident to be sent to the emergency department for evaluation and treatment. A nursing note for Resident 19, dated June 19, 2024, at 10:26 p.m., revealed that the nurse aide yelled to the writer that the resident was choking. The physician was notified of the situation, and the resident was transferred to the emergency department via emergency…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the Resident Assessment Instrument (RAI) User's Manual and clinical records, as well as staff interviews, it was determined that the facility failed to complete accurate comprehensive Minimum Data Set assessments for two of 33 residents reviewed (Residents 51, 64). Findings include: The RAI User's Manual, dated October 2023, revealed that Section N0415I1 Antiplatelet (a group of medicines that stop blood cells (called platelets) from sticking together and forming a blood clots) Medications was to be coded if an antiplatelet medication was taken by the resident at any time during the seven-day look-back period. Physician's orders for Resident 51, dated August 24, 2023, included an order for the resident to receive 75 milligrams (mg) of Plavix (an antiplatelet) one time a day for clot prevention. Review of the Medication Administration Record (MAR) for Resident 51, dated June and July 2024, revealed that staff had administered the 75 mg of Plavix to the resident on June 27, 2024, through July 4,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 policies and clinical records, as well as staff interviews, it was determined that the facility failed to develop comprehensive care plans that included specific and individualized interventions to address resident care needs for five of 33 residents reviewed (Residents 18, 21, 23, 66, 68). Findings include: The facility's policy regarding person-centered care plans, dated March 15, 2024, revealed that a comprehensive person-centered care plan must be developed for each resident and must describe the services that were to be furnished, any specialized services or specialized rehabilitative services the facility would provide, and any service not provided due to refusal of treatment. A quarterly Minimum Data Set (MDS) assessment (a federally-mandated assessment of a resident's abilities and care needs) for Resident 18, dated May 11, 2024, revealed that the resident was usually understood, could usually understand others, and had a diagnosis which included Multi Drug Resistant Organism (MDRO -…

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

Based on review of clinical records, as well as staff interviews, it was determined that the facility failed to ensure that a resident's care plan was updated/revised to reflect the resident's specific care needs for one of 33 residents reviewed (Resident 48). Findings include: An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's care needs and abilities) for Resident 48, dated July 15, 2024, indicated that the resident was understood and could understand others, required assistance with personal care needs, was dependent on staff for toileting needs, and had diagnoses that included chronic kidney disease. Physician's orders for Resident 48, dated July 13, 2024, included an order for the staff to insert a foley catheter (flexible tube that drains urine from the bladder into a bag outside the body) for urinary drainage. The current care plan for Resident 48, dated July 9, 2024, indicated that the resident was incontinent of urine. An active care plan, dated July 14, 2024, indicated that the resident had an indwelling foley catheter. Observations 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 clinical record reviews and staff interviews, it was determined that the facility failed to ensure that a discharge summary, including a recapitulation of the resident's stay, was completed for one of two discharged residents reviewed (Resident 63). Findings include: A nursing note for Resident 63, dated May 1, 2024, revealed that the resident was discharged from the facility at approximately 10:15 a.m. Verbal and written discharge instructions/medications were provided to resident and the resident's son. As of August 1, 2024, there was no documented evidence that a discharge summary that included a recapitulation of the resident's stay was completed for Resident 63. Interview with Medical Records Coordinator on August 1, 2024, at 5:50 p.m. confirmed that there was no documented evidence that a discharge summary was completed for Resident 63. 28 Pa. Code 211.5(d) Clinical Records.

Based on review of clinical records, as well as staff interviews, it was determined that the facility failed to ensure that physicians orders were followed for two of 33 residents reviewed (Residents 44, 68). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 44, dated May 4, 2024, revealed that the resident was understood and could understand, required assistance from staff for care needs, and had a diagnosis which included dementia. A fall investigation for Resident 44, dated April 25, 2024, at 7:19 p.m., indicated that the resident was observed sitting on the floor. She tried to transfer herself from the wheelchair to the bed without assistance. The resident hit the back of her head on the front wheel of the wheelchair. An assessment was completed and her oxygen saturation (the percentage of oxygen circulating in the blood-with a normal range being greater than 92) was in the low 70's. The physician was notified that of the fall, and orders were received to start neurological checks…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, as well as staff interviews, it was determined that the facility failed to ensure that physician's orders were obtained for an indwelling urinary catheter for one of 33 residents reviewed (Resident 65). Findings include: Clinical record review for Resident 65, including nurses notes, revealed that the resident was admitted on [DATE]; had diagnoses that included urinary retention; and had a foley catheter (tube placed in the body to drain and collect urine from the bladder). There was no documented evidence that a physician's order was obtained to indicate that the resident required a foley catheter. The care plan for Resident 65, dated July 24, 2024, indicated that the resident required an indwelling foley catheter because of urinary retention. Nurse's notes for Resident 65, dated July 22, 2024, at 3:15 p.m., revealed that the resident arrived at the facility for admission by ambulance and had a urinary catheter intact for urinary retention. A nurse's note, dated July 28,…

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

Based on review of personnel files, as well as staff interviews, it was determined that the facility failed to ensure that nurse aide performance evaluations were completed annually based on hire dates for two of five nurse aides reviewed (Nurse Aide 2, Nurse Aide 5). Findings include: A list of nurse aides provided by the facility revealed that based on their months and days of hire, an annual performance evaluation for Nurse Aide 2 was due January 20, 2024. As of July 31, 2024, there was no documented evidence that the annual performance evaluation was completed as required for Nurse Aide 2. A list of nurse aides provided by the facility revealed that based on their months and days of hire, an annual performance evaluation for Nurse Aide 5 was due May 13, 2024. As of July 31, 2024, there was no documented evidence that the annual performance evaluation was completed as required for Nurse Aide 5. Interview with the Nursing Home Administrator on July 31, 2024, at 2:03 p.m. confirmed that there was no evidence that the annual performance evaluation for Nurse Aide 2 and Nurse Aide 5…

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

Based on review of manufacturer's instructions, facility policies, and clinical records, as well as observations and staff interviews, it was determined that the facility failed to label multi-dose containers of eye drops with the date they were opened in one of two medication carts reviewed (Cart 2). Findings include: Manufacturer's directions for the use of Latanoprost Ophthalmic Solution 0.005 percent (used for the reduction of elevated fluid pressure of the eye), dated November 3, 2023, revealed that once a bottle is opened for use, it may be stored at room temperature for six weeks. The facility's policy regarding the storage of medication, dated March 15, 2024, revealed that medications are stored properly, following manufacturer's or provider pharmacy recommendations, to keep their integrity and to support safe, effective drug administration. Physician's orders for Resident 65, dated July 22, 2023, included an order for the resident to receive one drop of Latanoprost Ophthalmic Solution 0.005 percent in both eyes at nightly at bedtime. Observations of the Cart 2 medication…

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

Based on review of facility policies and residents' clinical records, as well as staff interviews, it was determined that the facility failed to ensure that the designated interdisciplinary team member obtained the required information from the contracted hospice provider for two of 33 residents reviewed (Residents 29, 34) who received hospice services. Findings include: The facility's policy regarding hospice (specialized care that provides physical comfort and emotional, social and spiritual support for people nearing the end of life), dated March 15, 2024, indicated that the designated interdisciplinary team member will be responsible for obtaining the following from the hospice: most recent hospice plan of care; hospice election form, and the physician's certification and recertification of terminal illness (a form signed by the resident's hospice physician and specific to each patient). An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 29, dated May 19, 2024, revealed that the resident was rarely…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 established infection control guidelines, facility policy, and residents' clinical records, as well as observations and staff interviews, it was determined that the facility failed to follow infection control guidelines from the Centers for Medicare/Medicaid Services (CMS) and the Centers for Disease Control (CDC) to reduce the spread of infections and prevent cross-contamination for one of 33 residents reviewed (Resident 21). Findings include: CDC guidance on isolation precautions and Implementation of Personal Protective Equipment (PPE) use in Nursing Homes to Prevent Spread of Multidrug-Resistant Organisms (MDRO's - bacteria that have become resistant to certain antibiotics, and these antibiotics can no longer be used to control or kill the bacteria), dated July 12, 2022, indicates that MDRO transmission is common in skilled nursing facilities, contributing to substantial resident morbidity and mortality and increased healthcare costs. Enhanced Barrier Precautions (EBP) are an infection control intervention designed to reduce transmission of resistant organisms…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 a list of nurse aides currently employed by the facility, including their hire dates and training hours, as well as staff interviews, it was determined that the facility failed to ensure that nurse aides had 12 hours of in-service training annually for three of five nurse aides reviewed (Nurse Aide 1, Nurse Aide 2, Nurse Aide 3). Findings include: A list of nurse aides provided by the facility revealed that based on their months and days of hire: Nurse Aide 1 should have received at least 12 hours of in-service training between June 11, 2023, and June 11, 2024. However, there was no documented evidence that she received at least 12 hours of in-service training as required. Nurse Aide 2 should have received at least 12 hours of in-service training between January 20, 2023, and January 20, 2024. However, there was no documented evidence that she received at least 12 hours of in-service training as required. Nurse Aide 3 should have received at least 12 hours of in-service training between January 16, 2023, and January 16, 2024. However, there was no documented…

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

Based on review of policies, resident council meeting minutes, and facility grievance/complaint logs, as well as staff interviews, it was determined that the facility failed to follow its grievance policies regarding maintaining a log of all grievances received and failed to ensure that grievances were responded to in a timely manner for one of seven residents reviewed (Resident 4), and failed to include the steps taken to investigate the grievance, a summary of the pertinent findings or conclusion regarding the resident's concerns, or any corrective action taken or to be taken by the facility as a result of the grievance for one of seven residents reviewed (Resident 7). Findings include: The facility's policy regarding grievances/complaints, dated February 28, 2024, indicated that upon receipt of the grievance/concern, the grievance/concern form will be initiated by the staff member receiving the concern and documented on the grievance/concern log. The department manager will contact the person filing the grievance to acknowledge receipt, investigate the grievance, take corrective…

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

Based on review of facility policy and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that a resident's care plan was updated/revised to reflect the resident's specific care needs for one of seven residents reviewed (Resident 2). Findings include: A facility policy regarding plans of care, dated February 28, 2024, revealed that the care plan must be customized to each individual patient's preferences and needs. The care plan will be reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments, and as needed to reflect the response to care and changing needs and goals. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 2, dated February 20, 2024, revealed that the resident was understood, could understand, and had diagnoses that included seizures and traumatic brain injury (TBI - an injury that affects how the brain works). A care plan for the resident, dated March 4, 2024, revealed…

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