Holy Family Manor

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of facility documentation, clinical record review, and staff interview, it was determined that the facility failed to inform a resident and/or responsible party, in advance, of a treatment and treatment options prior to receiving psychotropic medication for one of 19 sampled residents. (Resident 67)Findings include: Review of facility documentation entitled, Informed Consent for Psychotropic Medication Use, revealed that before receiving any psychotropic medication, an informed consent must be obtained. The resident or responsible party was to receive information and education regarding the benefits and potential side effects of the psychotropic medication. Clinical record review revealed that Resident 67 was admitted to the facility on [DATE], and had diagnoses that included metabolic encephalopathy (brain dysfunction), dementia, and anxiety. The Minimum Data Set assessment dated [DATE], indicated that the resident had cognitive impairment and displayed symptoms of feeling depressed 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 facility policy review, clinical record review, observation, and staff interview, it was determined that the facility failed to assess a resident's capability to self-administer medications for one of 19 sampled residents. (Resident 60)Findings include: Review of facility policy entitled, Self-Administration of Medications/Bedside Medication Storage, last reviewed April 28, 2026, revealed that a resident may exercise the right to self-administer medications when determined that this practice is safe. It was the responsibility of the Interdisciplinary Team to determine the following issues with regards to resident self-administration of medications: resident safety to self-administer medications, location of medication administration, determine who will be responsible for storage, and documentation of medication administration. If the resident indicated a desire to self-administer his or her medications, the Interdisciplinary Team would complete the Self-Administration of Medications UDA (User Defined…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 review, clinical record review, and staff interview, it was determined that the facility failed to ensure that the responsible party was notified of a change in condition for one of 19 sampled residents. (Resident 67)Findings include: Review of the facility policy entitled, Change in Condition- Notification of Change, dated April 28, 2026, revealed the resident and the resident's legal representative/family, would be notified of any change in condition which included a change in behavior, medications, activities of daily living, a new onset of pain, and a change in treatment. Clinical record review revealed that Resident 67 had diagnoses that included metabolic encephalopathy (brain dysfunction), dementia, and muscle weakness. Review of a nurse's note dated May 13, 2025, revealed the physician was notified and made aware that the resident was incontinent, had a change in behavior, and complained of pain when urinating. The nurse further noted that the physician directed staff to obtain a stat (immediate) urine sample for urinalysis to rule out an infection.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 review and staff interview, it was determined that the facility failed to offer non-pharmacological interventions prior to the administration of as needed anti-anxiety medications for one of 19 sampled residents. (Resident 67)Findings include: Review of the facility policy entitled, Change in Condition- Notification of Change, dated April 28, 2026, revealed the resident and the resident's legal representative/family, would be notified of any change in condition which included a change in behavior, medications, activities of daily living, a new onset of pain, and a change in treatment. Clinical record review revealed that Resident 67 had diagnoses that included metabolic encephalopathy (brain dysfunction), dementia, and muscle weakness. Review of a nurse's note dated May 13, 2025, revealed the physician was notified and made aware that the resident was incontinent, had a change in behavior, and complained of pain when urinating. The nurse further noted that the physician directed staff to obtain a stat (immediate) urine sample for urinalysis to rule out 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 facility policy review, personnel file review, and staff interview, it was determined that the facility failed to complete a reference check and verify a professional license/registration status prior to the start of employment for three of five newly hired employees. (Employees 3, 4, 5)Findings include:A review of the facility policy entitled, Resident Abuse Prevention and Reporting Reasonable Suspicion of a Crime, dated April 28, 2026, revealed that the facility was to conduct screenings for potential hires for a history of abuse, neglect, or mistreatment of residents, which included checking the appropriate licensing boards and registries for verification of license/certification to ensure the license was in good standing. Employee 3 (E3) had been working in the facility as a license practical nurse since April 15, 2026. There was no evidence that the facility submitted an inquiry to the state licensure board prior to E3 working among residents in the facility. Employee 4 (E4) had been working in the facility as a license practical nurse since April 6, 2026. There was no…

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

Based on facility policy review, clinical record review, and staff interview, it was determined that the facility failed to provide ongoing assessment and monitoring for one of one sampled residents receiving dialysis (process of removing excess toxins and water from the blood). (Resident 24)Findings include:A review of the facility policy entitled, Dialysis, last reviewed April 28, 2026, revealed that staff were to complete the pre-dialysis portion of the dialysis communication form that provided information regarding the resident's ongoing status to send with the resident to dialysis, including the resident's pre-dialysis weight and vital signs. Clinical record review revealed that Resident 24 had diagnoses that included end-stage renal (kidney) disease and dependence on renal dialysis and had a physician's order for the facility to provide dialysis three days per week. There was a lack of evidence to support that Resident 24's pre-dialysis weight was obtained and documented on the dialysis communication forms that were to be completed before leaving for dialysis on 24 of 36…

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

Based on observation and staff interview, it was determined that the facility failed to store food in a sanitary manner in one of three resident dining rooms. (Second floor)Findings include: Observation in the Second Floor resident dining room on May 31, 2026, at 1:30 p.m., revealed areas of dark red discoloration along the length of the bottom shelf of the reach-in refrigerator, in addition to a puddle of water and soaked dish cloth. There was a carafe with water that was not dated. There was a carton of chocolate milk with a use by date of May 30, 2026. There was a plastic container with tartar sauce packets in it that had a thick layer of a dried white substance on the outside of the container. There was a bread knife directly touching a shelf in the cooler. In an interview on May 31, 2026, at 1:30 p.m., the Food Operations Manager confirmed that the water should have been dated, the expired milk removed, and that the knife was used to cut sandwiches and left in the reach-in cooler and should have been sent to the for washing and sanitizing. 28 Pa. Code 201.14(a) Responsibility…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 review, resident interview, and observation, it was determined that the facility failed to provide timely assistance with care in a manner that maintained dignity for two of 24 sampled residents. (Residents 30, 86) Findings include: Clinical record review revealed that Resident 30 had mild cognitive impairment and required assistance from staff to get out of bed. According to the care plan, she also had depressed mood and would call out at times. The care plan indicated that staff was to respond to her requests for care and allow the resident to make decisions about her activities. On June 4, 2024, at 10:09 a.m., the resident was observed in bed and her call light was on. The resident stated, I want to get out of bed. Between 10:09 and 10:38 a.m., the call light remained on, and several staff members walked by the room without assisting the resident. At 10:38 a.m., a staff member turned off the call light and left the room without assisting the resident. The resident began to call out, Help me! until staff assisted her at 11:07 a.m. Clinical record 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.

Based on clinical record review and observation, it was determined that the facility failed to implement physician's orders for one of 24 sampled residents. (Resident 45) Findings include: Clinical record review revealed that Resident 45 had diagnoses that included muscle weakness, dementia, and Parkinson's disease. Review of the Minimum Data Set assessment, dated May 15, 2024, revealed that the resident had cognitive impairment. Review of the care plan revealed the resident has a potential for impaired skin integrity and staff was to apply Dermasaver gloves (gloves for skin protection) to both arms while the resident was in the wheelchair. On June 18, 2023, a physician ordered that staff to apply a Tubigrip (an elastic bandage for support) to the right hand under the Dermasaver glove. On June 4, 2024, at 1:12 p.m. and 2:07 p.m., and again on June 5, 2024, at 10:47 a.m. and 12:25 p.m., Resident 45 was observed in a wheelchair without the Dermasaver gloves or Tubigrip in place. There was no documented evidence that the resident had refused application of the Dermasaver gloves 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.

Based on review of the LPN (Licensed Practical Nurse) Act, clinical record review and staff interviw, it was determined that the facility failed to ensure that professional standards of quality regarding the administration of physician prescribed medications was followed for one of four residents that received medication. (Resident 1) Findings include: Pa. Code Title 49 Professional and Vocational Standards Department of State Chapter 21, State Board of Nursing 21.145 Function of the Licensed Practical Nurse states that the LPN is prepared to functions as a member of the health care team based on preparation, knowledge, skills and understanding of past experiences in nursing situations and the LPN administers medications and carries out the therapeutic treatments ordered for the patient. Clinical record review revealed that Resident 1 had diagnoses that included COPD (chronic obstructive pulmonary disease), anxiety and hypotension. Clinical record review revealed that on January 31, 2024, at 9:40 p.m. LPN 1 failed to identify Resident 1 by name band identification, photo…

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