Eden Nursing & Rehabilitation Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policies, clinical record review, and staff interview, it was determined that the facility failed to make certain resident medication regimens were free from potentially unnecessary psychotropic (substances that act on the brain to alter cognition, perception, and mood) medications for two of four residents (Residents R33 and R46). Findings include: Review of facility policy Psychotropic Medication Use dated 5/19/25, indicated residents do not receive psychotropic medications that are not clinically indicated and necessary to treat a specific condition documented in the medical record. Medications in the following categories are considered psychotropic medications and are subject to prescribing, monitoring, and review requirements specific to psychotropic medications: anti-psychotics, anti-depressants, anti-anxiety medications, and hypnotics/sedatives. Review of facility policy Medication Regimen Reviews dated 5/19/25, indicated a licensed pharmacist reviews the medication regimen 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 clinical record review, and staff interview, it was determined that the facility failed to ensure that residents with an enteral feeding tube (a tube inserted in the stomach through the abdomen) received appropriate treatment and services to prevent potential complications for one of four residents (Residents R31). Findings include: Review of the clinical record indicated Resident R31 was admitted to the facility on [DATE]. Review of clinical record revealed that Resident R31 had a physician order for Enteral Feed Nutren 2.0 (a high calorie nutritional formula 375 milliliters (ml) twice a day and 250 ml daily dated 3/7/25, and discontinued on 4/1/25. Review of Resident R31's Minimum Data Set (MDS - a periodic assessment of care needs) dated 4/1/25, indicated diagnoses of cancer, malnutrition, and depression. Section K0520 indicated that resident received nutrition from a feeding tube while a resident. Review of clinical record indicated that Resident R31 was sent to the hospital on 4/1/25, and returned…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, observations, staff interviews, and clinical record review, it was determined that the facility failed to provide appropriate respiratory care for two of two residents (Resident R30 and R38). Findings include: Review of facility policy Administering Medications through a small volume (handheld) Nebulizer (a device that converts liquid medication into an inhalable mist) dated 5/19/25, indicated to ensure that equipment is completely dry and store in a plastic bag when not in use. Review of the clinical record indicated Resident R30 was admitted to the facility on [DATE]. Review of Resident R30's Minimum Data Set (MDS - a periodic assessment of care needs) dated 5/27/25, indicated diagnoses of high blood pressure, atrial fibrillation (disease of the heart characterized by irregular and often faster heartbeat), and asthma (condition where the airways narrow and swell). Review of a physician order dated 1/28/24, indicated to provide albuterol sulfate nebulization solution (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.

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 three residents (Resident R34). Findings include: Review of facility policy Hemodialysis dated 5/19/25, indicated the facility will ensure that each resident receives care and services for the provision of hemodialysis consistent with professional standards of practice. This will include ongoing communication and collaboration with the dialysis facility regarding dialysis care and services. The licensed nurse will communicate to the dialysis facility via telephone communication or written format, such as a dialysis communication form or other form. Review of the clinical record indicated Resident R34 was admitted to the facility on [DATE]. Review of Resident R34's Minimum…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, resident clinical records, and staff interviews, it was determined that the facility failed to ensure a resident received appropriate behavioral health services to maintain the highest practicable well-being for one of two sampled residents (Resident R58). Findings include: The facility Trauma informed care and culturally competent care policy last reviewed 5/19/25, indicated that trauma-informed care is an approach to delivering care that involves understanding, recognizing and responding to the effects of all types of trauma. A trauma-informed approach to care delivery recognizes the widespread impact and signs and symptoms of trauma in residents, and incorporates knowledge about trauma into care plans, policies, procedures and practices to avoid re-traumatization. Traumatic events which may affect residents during their lifetime include: physical, sexual and emotional abuse, neglect, and interpersonal or community violence. Developing individualized care plans that…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of 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 one of five residents (Resident R1). Findings include: Review of Residents R1's admission record indicated the resident was admitted on [DATE], and readmitted [DATE], with diagnoses of anemia (a condition in which the number of red blood cells is lower than normal), renal failure (occurs when the kidneys are no longer able to filter waste products from blood effectively), and osteoarthritis (a degenerative joint disease that occurs when the cartilage that cushions the joints wears down over time, leading to pain, stiffness, and loss of mobility.) Review of Residents R1's Minimum Data Set (MDS - a periodic assessment of care needs) dated 2/26/25, indicated the diagnoses were current. Review of Resident R1's progress note dated 4/14/25, indicated at 7:20 p.m. Licensed Practical Nurse (LPN), Employee E1 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 clinical record review and interviews with staff, it was determined that the facility did not ensure that a physician assessment was timely completed after a fall for one of four residents reviewed (Resident R1). Findings include: Review of Residents R1's admission record indicated the resident was admitted on [DATE], and readmitted [DATE], with diagnoses of anemia (a condition in which the number of red blood cells is lower than normal), renal failure (occurs when the kidneys are no longer able to filter waste products from blood effectively), and osteoarthritis (a degenerative joint disease that occurs when the cartilage that cushions the joints wears down over time, leading to pain, stiffness, and loss of mobility.) Review of Residents R1's Minimum Data Set (MDS - a periodic assessment of care needs) dated 2/26/25, indicated the diagnoses were current. Review of Resident R1's progress note dated 4/14/25, indicated at 7:20 p.m. Licensed Practical Nurse (LPN), Employee E1 was called to Resident R1's…

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

Based on review of facility policy, education literature, clinical record review, and staff interviews, it was determined that the facility failed to recognize and report timely suspicions of sexual abuse for one of three residents (Resident R1) until it was actually witnessed by a staff member. Findings include: Review of the United States Code of Federal Regulations (CFR), 42 CFR §483.5. Sexual abuse includes, but is not limited to: -Unwanted intimate touching of any kind especially of breasts or perineal area (are located between the thighs, including the anus and the scrotum or vagina); -All types of sexual assault or battery, such as rape, sodomy (sexual intercourse involving anal or oral copulation), and coerced (persuasion of a person to do something by the use of force or threats) nudity; -Forced observation of masturbation and/or pornography; and -Taking sexually explicit photographs and/or audio/video recordings of a resident(s) and maintaining and/or distributing them. This would include, but is not limited to, nudity, fondling, and/or intercourse involving a 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 clinical record and facility document review and staff interview, it was determined that the facility failed to provide the necessary services and failed to make certain appropriate treatment, and services for dementia were provided to ensure safety for one of three residents (Resident R1). Findings include: Review of the facility Dementia-Clinical Protocol policy last reviewed 3/4/25, indicated for an individual with a confirmed dementia diagnosis, the interdisciplinary team will identify a resident-care centered care plan to maximize remaining function and quality of life. Review of the facility Visitation policy dated 3/4/25, indicated incidents of any visitors' disruptive behavior are documented in the resident's record. Some visitations may be subject to reasonable clinical and safety restrictions that protect the health, security, and/or rights of the facility's residents. Review of the admission record indicated Resident R1 admitted to the facility on [DATE]. Review of Resident R1's Minimum Data…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 and Director of Nursing did not effectively manage the facility to make certain that necessary care and services were provided to residents to prevent sexual abuse. Findings include: Review of CFR §483.70 Administration. A facility must be administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Based on the findings in this report that identified that the facility failed to protect Resident R1 from sexual abuse and prevent psychosocial and/or physical harm and physical discomfort that resulted in actual harm for Resident R1. The facility failed to provide fundamental principal that applies to treatment and care provided to facility residents. The facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice, facility policies, and resident rights. 28 Pa…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, facility documents and staff and resident interview, it was determined that the facility failed to provide dental services to meet the needs of residents for three of four residents reviewed (Residents CR1, R2, and R3). Findings include: Review of the facility Dental Examination/Assessment policy dated 1/9/25, indicated each resident shall be offered dental services as needed. Review of the facility Dental Services policy dated 1/9/25, indicated routine and emergency dental services are available to meet the resident's oral health services in accordance with the resident's assessment and plan of care. Routine and 24-hour emergency dental services are provided to the residents through a contract agreement with a licensed dentist that comes to the facility monthly, referral to the resident's personal dentist, referral to community dentist, or referral to other health care organizations that provide dental services. It was indicated selected dentists must be able to provide…

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

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 notify the family of a change in condition in a timely manner for one of three residents (Resident CR1). Findings include: Review of facility policy Change in a Resident's Condition or Status, dated 1/9/25, indicated that the physician and resident representative will be notified promptly when there has been a significant change in the resident's physical/emotional/mental conditions, and a need to alter the resident's medical treatment. Notification must occur with 24 hours of a change occurring in a resident's medical condition or status. Review of the clinical record revealed that Resident CR1 was admitted to the facility on [DATE], with diagnoses of cerebral infarction (occurs when the supply of blood to the brain is reduced or blocked completely, which prevents brain tissue from getting oxygen and nutrients), ileostomy (a surgical procedure that connects your ileum to your abdominal…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 schedule an appointment for outside services in a timely manner for one of three residents reviewed (Resident CR1). Findings include: Review of the clinical record revealed that Resident CR1 was admitted to the facility on [DATE], with diagnoses of cerebral infarction (occurs when the supply of blood to the brain is reduced or blocked completely, which prevents brain tissue from getting oxygen and nutrients), high blood pressure, and aphasia (a disorder that affects how you communicate). Review of Resident CR1's MDS (Minimum Data Set, periodic assessment of resident care needs) dated 11/2/24, indicated diagnoses were current. Review of Resident CR1's clinical record revealed on 12/9/24, a nurse aide notified LPN, Employee E1 of blood noted in the resident's colostomy bag. LPN, Employee E1 assessed the resident and confirmed the resident had a moderate amount of blood mixed with dark brown…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of resident records, admission documentation and staff interview, it was determined that the facility failed to maintain admission documentation three two of seven residents (Resident R1, R2, R3). Findings include: Review of Resident R96 was admitted [DATE] with diagnoses that include cytomegaloviral disease (common virus that infects people of all ages and can cause a range of symptoms), diabetes mellitus and protein calorie malnutrition. 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 R1 admission MDS assessment (Minimum Data Set assessment MDS- a periodic assessment of resident care needs) dated 12/3/24 indicated the resident was assessed as having a BIMS score of 11, which indicates…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and staff interview, it was determined that the facility failed to properly label and date food products on the nursing unit pantries which created the potential for cross contamination in the designated kitchen pantries. Findings include: During an observation of 3rd floor nursing pantry refrigerator, the following was observed: - 1 [NAME] milkshake no label or date - 1 cottage cheese/fruit no label or date - 1 Celsius no label or date - 1 acai bowl in freezer no label or date - 1 frozen sandwich no label or date - 1 pumpkin cheesecake ice cream no label or date 3rd floor nursing pantry storage - 2 bowls of raisin bran no label or date - 1 box of donuts no label or date 2nd floor nursing pantry storage - 1 container of ramen, cup, no label or date - 1 square package of ramen, no label or date During an interview on 12/19/24 at 10:35 a.m., Licensed Practical Nurse (LPN) Employee E1 confirmed that the facility failed to properly label and date food products which created the potential 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, review of clinical documentation and staff interview it was determined the facility failed to have accurate narcotic count sheets from shift to shift, failed to document the disposition of narcotics accurately, and failed to identify discrepancies between Medication Administration Records and narcotics count sheets for three of five closed record residents (CR Resident R1, CR2, and CR3). Review of facility policy Management of Controlled Drugs, dated 8/24/23, indicated Schedule II to V controlled drugs must be disposed of in accordance with federal and state regulations. Review of facility documentation shift count ( a tool used for nursing to confirm the narcotic count is accurate shift to shift ongoing/off-going) for 3rd floor indicated the following: 10/6/24 status of count: blank with no response - no nurse coming on duty signature 10/16/24 no nurse coming on duty signature 10/17/24 no nurse going off duty signature 10/18/24 no nurse going off duty signature 10/22/24 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 resident interviews, staff interviews, resident council minutes, and grievance review, it was determined that the facility failed to have sufficient nursing staff to provide nursing and related services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of four of eight residents (Resident R11, R28, R32, and R69). Findings Include: Review of the facility's PBJ Staffing Data Report Quarter 4 2023 (July 1 - September 30) indicted the facility was triggered for one star staffing rating and excessively low weekend staffing. Review of the facility's PBJ Staffing Data Report Quarter 2 2024 (January 1 - March 31) indicted the facility was triggered for one star staffing rating and excessively low weekend staffing. Review of the facility's Resident Council Minutes dated 3/5/24, indicated a resident had a concern that the aides do not answer the call bells. It was indicated it can take 20 minutes for staff to answer a call light. Review of the facility's Resident Council Minutes dated 4/2/24, indicated residents had a concern for aides taking…

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

Based on review of facility policies, observations and staff interview, it was determined the facility failed to properly serve food in a sanitary manner to prevent foodborne illness in the Main Kitchen. Findings include: Review of facility policy Sanitation dated 8/24/23, indicated all utensils, shelves and equipment shall be kept clean, maintained in good repair. During an observation in Main Kitchen on 8/4/24, at 11:30 a.m. State Agency was standing at the tray line and felt water dripping onto their shoulder. During an interview on 8/4/24, at 11:30 a.m. State Agency enquired as to where the water was coming from and Dietary Aide Employee E12 replied: It's from the air conditioning vents. During an observation on 8/4/24, at 11:31 a.m. air conditioning ductwork is noted to be approximately one to two feet behind the tray line. Four vents on the ductwork have condensation on the outside of them and are spaced throughout the length of the tray line. All of the four vents appeared to have water dripping from them at sporadic intervals. Directly underneath the ductwork, and dripping…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, observations, and staff interviews, it was determined that the Nursing Home Administrator (NHA) and Director of Nursing (DON) did not effectively manage the facility to make certain that necessary care and services were provided to residents to ensure safe resident mobility transfers. Findings include: The job description for the Nursing Home Administrator specified the primary purpose of the job position is to manage the Facility in accordance with current applicable federal, state, and local standards, guidelines, and regulations that govern long-term care facilities. To follow all facility policies and apply them uniformly to all employees. To ensure the highest degree of quality care is provided to our residents at all times. The job description of the Director of Nursing specified the primary purpose of the job position is to plan, organize, develop, and direct the overall operation of the Nursing Service Department in accordance with current federal, state, and local standards, guidelines, and regulations that govern…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 documents it was determined that the facility failed to ensure sufficient nursing staff to comply with state laws regarding mandated minimum staffing requirements. Findings include: Review of 28 PA Code Commonwealth of Pennsylvania Long Term Care Licensure Regulations, §211.12, dated 7/1/23, indicated the following subsections. (f.1) In addition to the director of nursing services, a facility shall provide all of the following: (2) Effective July 1, 2023, a minimum of 1 nurse aide per 12 residents during the day, 1 nurse aide per 12 residents during the evening, and 1 nurse aide per 20 residents overnight. (4) Effective July 1, 2023, a minimum of 1 LPN (licensed practical nurse) per 25 residents during the day, 1 LPN per 30 residents during the evening, and 1 LPN per 40 residents overnight. (i) A minimum number of general nursing care hours shall be provided for each 24-hour period as follows: (1) Effective July 1, 2023, the total number of hours of general nursing care provided in each 24-hour period shall, when totaled for the entire facility, be 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of 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 five residents sampled with facility-initiated transfers (Residents R6, R44, R51, R62, and R83). Findings include: Review of the clinical record indicated Resident R6 was admitted to the facility on [DATE]. Review of Resident R6's MDS (Minimum Data Set, periodic assessment of resident care needs) dated 5/14/24, indicated diagnoses of high blood pressure, bipolar disorder (a mental condition marked by alternating periods of elation and depression), and diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time). Review of Resident 6's clinical record revealed that the resident was transferred to the hospital on 4/30/24, and returned to the facility on 5/2/24. Review of Resident R6's clinical record revealed no documented evidence that the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of 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 three of three residents (Residents R51, R62, and R83). Findings include: Review of facility policy Transfer or Discharge Notice dated 8/24/23, indicated a resident and/or his or her representative will be given a thirty-day advance notice of an impending transfer or discharge from our facility. Under the following circumstances, the notice will be given as soon as it is practicable but before the transfer or discharge: an immediate transfer or discharge is required by the resident's urgent medical needs. A copy of these notices will be sent to the Office of the State Long-Term Care Ombudsman. Review of the clinical record indicated Resident R51 was admitted to the facility on [DATE]. Review of Resident R51's MDS dated [DATE], indicated diagnoses of high blood pressure, septicemia…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 five resident hospital transfers (Residents R6, R44, R51, R62, and R83). Findings include: Review of facility policy Bed-Holds and Returns dated 8/24/23, indicated prior to transfers and therapeutic leaves, residents or resident representatives will be informed in writing of the bed-hold and return policy. Review of the clinical record indicated Resident R6 was admitted to the facility on [DATE]. Review of Resident R6's MDS (Minimum Data Set, periodic assessment of resident care needs) dated 5/14/24, indicated diagnoses of high blood pressure, bipolar disorder (a mental condition marked by alternating periods of elation and depression), and diabetes (a metabolic disorder in which the body has high…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 interviews and observations, and staff interview it was determined that the facility failed to provide a beautician services for four of seven residents (Residents R6, R24, R32, and R61). Findings include: The facility Activities of Daily Living (ADLs), Supporting policy last reviewed 8/24/23, indicated residents will be provided with care, treatment, and services appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). It was indicated residents who are unable to carry out ADLs independently will be provided with the appropriate support and assistance with hygiene, including grooming. The facility admission Packet dated 6/1/19, indicated the facility will provide a styling salon and a hairdresser if available on Thursdays. Review of admission record indicated Resident R32 was admitted to the facility on [DATE], with diagnoses of anxiety, depression, and muscle weakness. During an interview on 8/4/24, at 9:37 a.m. Resident R32…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 conduct ongoing accurate assessments to ensure that bedrails were used to meet residents' needs and the risks associated with bedrail usage for four of four residents (Residents R7, R21, R37, and R79). Findings include: Review of facility policy Proper Use of Side Rails dated 8/24/23, indicated an assessment will be made to determine if the resident's symptoms, risk of entrapment and reason for using side rails. When used for mobility or transfer, an assessment will include a review of the resident's bed mobility, ability to change positions, risk of entrapment from the use of side rails, and that the bed's dimensions are appropriate for the resident's size and weight. Review of the clinical record indicated Resident R7 was admitted to the facility on [DATE]. Review of Resident R7's Minimum Data Set (MDS - a periodic assessment of care needs) dated 5/2/24, 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 clinical record review, observations, and staff interview, it was determined the facility failed to provide appropriate care and services to residents receiving medications via feeding tube for two of three residents reviewed (Residents R23 and R29). Finding include: Review of facility policy Enteral Nutrition (nutrition provided via a tube inserted into the stomach) dated 5/18/24, indicated adequate nutritional support through enteral nutrition is provided to residents as ordered. The nurse confirms that orders for enteral nutrition are complete. Complete orders include the enteral nutrition product, and instructions for flushing. Review of Resident R23's clinical record indicated the resident was admitted [DATE], and readmitted [DATE], with diagnoses of metabolic encephalopathy, anxiety, and encounter for attention to gastrostomy. Review of Resident R23's care plan dated 12/27/19, indicated the resident requires a tube feeding due to dysphagia (difficulty swallowing). It was indicated the resident 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.

Based on review of facility policy, staff education records, and staff interviews, it was determined that the facility failed to conduct at least 12 hours of in-service education, within 12 months of their hire date anniversary, for nurse aides as required for five of five nurse aides (NA Employees E4, E21, E22, E23, and E24) Finding include: A review of the facility policy In-Service Training Program, Nurse Aide dated 8/24/23, indicated all nurse aide personnel participate in regularly scheduled in-service training. Annual in-services include, but not limited to: - No less than 12 hours in-service hours per employment year Review of NA Employee E4's facility provided staff list indicated he was hired on 7/21/20. Review of NA Employee E4's training record for 7/21/23, through 7/21/24, indicated only 10 hours of in-service training. Review of NA Employee E21's facility provided staff list indicated she was hired on 9/30/91. Review of NA Employee E21's training record for 9/30/22, through 9/30/23, indicated only 9.5 hours of in-service training. Review of NA Employee E22's facility…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, employee education records, and staff interview, it was determined that the facility failed to provide training on behavioral health for five of five staff members (Nurse Aide Employee E4, E21, E22, E23, and E24). Findings include: Review of the Facility Assessment dated, First Quarter, indicated staff training/education will be completed by all nursing staff and will be an ongoing-annual training requirement. Education listed included, but not limited to: - Behavioral Health Review of the policy In-Service Training Program, Nurse Aide dated 8/24/23 indicated that all personnel are required to attend regularly scheduled in-service training. Records are filed in the employee ' s personnel file or are maintained by the department supervisor. Review of Nurse Aide (NA) Employee E4's facility provided staff list indicated she was hired on 7/21/20. Review of NA Employee E4's training record for 7/21/23, through 7/21/24, did not include training on behavioral health. Review of Nurse Aide (NA) Employee E21's facility provided staff list indicated she…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, observations, resident interview, and employee interviews it was determined that the facility failed to accommodate the needs of a resident with a visual impairment for one of two residents (Resident R32). Findings include: Review of admission record indicated Resident R32 was admitted to the facility on [DATE], with diagnoses of anxiety, depression, and muscle weakness. Review of the Minimum Data Set (MDS-periodic assessment of care needs) dated 5/17/24, indicated the diagnoses were current. Review of section GG: Function Abilities and Goals indicated Resident R32 requires set-up and clean-up assistance with eating. Review of Resident R32's care plan dated 7/17/24, indicated the resident has impaired visual function due to macular degeneration (an eye disease that affects central vision). During an interview on 8/4/24, at 9:37 a.m. Resident R32 stated she went blind about two months ago. Resident R32 indicated staff leave her meal trays on her table, and some staff don't tell…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policies, clinical records, facility submitted documents, observations, and staff interview, it was determined that the facility failed to provide services to create an environment free from neglect for one of six residents (Resident R29). Findings include: Review of facility policy Pressure Ulcers/Skin Breakdown-Clinical Protocol last reviewed 8/24/23, indicated the physician will order pertinent wound treatments, and guide the care plan as appropriate. Review of facility policy Wound Care dated 8/24/23, indicated the following information should be recorded in the resident's medical record: the type of wound care given, the date and time the wound care was given, the name and title of the individual performing the wound care, if the resident refused the treatment and the reason(s) why, and the signature and title of the person recording the data. Review of Resident R29's clinical record indicated the resident was admitted [DATE]. Review of Resident R29's Minimum Data Set (MDS- 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility documents, facility policy, clinical records, and staff interviews, 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 two residents (Resident R47), and failed to properly screen an employee by completing a State background check prior to hire for two of five personnel records (Nursing Assistant (NA) Employee E19 and Registered Nurse (RN) Employee E20). Findings include: Review of facility policy Abuse and Neglect - Clinical Protocol dated 8/24/23, indicated neglect is defined as 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 staff, with the physician's input as needed, will investigate alleged abuse and neglect to clarify what happened and identify possible causes. Review of facility policy Background Screening…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, investigation documentations, and staff interviews, it was determined that the facility failed to conduct a thorough investigation to rule out neglect for one of two residents (Resident R47). Findings include: Review of facility policy Abuse and Neglect - Clinical Protocol dated 8/24/23, indicated neglect is defined as 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 staff, with the physician's input as needed, will investigate alleged abuse and neglect to clarify what happened and identify possible causes. Review of the clinical record indicated Resident R47 was admitted to the facility on [DATE]. Review of Resident R47's Minimum Data Set (MDS - a periodic assessment of care needs) dated 7/10/24, indicated diagnoses of high blood pressure, atrial fibrillation (disease of the heart characterized by…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 physician of abnormal glucose readings via a Capillary Blood Glucose (CBG) level as per physicians order for two of four residents (Resident R62 and R83). Findings include: The Centers for Disease Control defines diabetes as: Diabetes Mellitus is a chronic (long-lasting) health condition that affects how your body turns food into energy. Most of the food you eat is broken down into sugar (also called glucose) and released into your bloodstream. When your blood sugar goes up, it signals your pancreas to release insulin. Insulin acts like a key to let the blood sugar into your body's cells for use as energy. If you have diabetes, your body either doesn't make enough insulin or can't use the insulin it makes as well as it should. When there isn't enough insulin or cells stop responding to insulin, too much blood sugar stays in your bloodstream. Over time, that can cause serious health…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical record review, observations, and staff interview, it was determined that the facility failed to provide prescribed pressure ulcer treatment and services consistent with professional standards of practice for two of two residents (Residents R7 and R29). Findings include: Review of facility policy Pressure Ulcers/Skin Breakdown-Clinical Protocol last reviewed 8/24/23, indicated the physician will order pertinent wound treatments, and guide the care plan as appropriate. Review of facility policy Care Plans, Comprehensive Person-Centered last reviewed 8/24/23, indicated it is the facility policy to develop and implement a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident ' s physical, psychosocial and functional needs for each resident. Review of facility policy Wound Care dated 8/23/23, indicated the following information should be recorded in the resident's medical record: the type of wound care given, 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 review, observation, clinical record review, and staff interviews, it was determined that the facility failed to monitor colostomy site and services consistent with professional standards of practice and failed to implement the colostomy care plan for one of three residents reviewed (Resident R65). Findings include: Review of facility policy Colostomy and Ileostomy Care dated 8/24/23, indicated the purpose of this procedure is to provide guidelines that will aid in preventing exposure of the resident ' s skin to fecal matter. Notify the supervisor of any abnormal findings. When evaluating the condition of the residents ' skin, note the following: - Breaks in the skin - Redness - Signs of infection (heat, swelling, pain, redness, and drainage Review of facility policy Care Plans, Comprehensive Person-Centered last reviewed 8/24/23, indicated it is the facility policy to develop and implement a comprehensive, person-centered care plan that includes measurable objectives and timetables 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.

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 obtain a diagnosis for hospice services and 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 R65, and R79) and failed to obtain a physicians order to admit to hospice for one of three residents (R65). Findings include: Review of the facility policy Hospice Program dated 8/24/23, indicated that it is the responsibility of the facility to meet the resident's personal care and nursing needs in coordination with hospice representative, and ensure that the level of care provided is appropriately based on the individual resident's needs. These responsibilities include communicating with the hospice provider to ensure that the needs of the resident are addressed and met 24 hours per day, and that the hospice coordinated care plan shall be revised and updated as necessary to reflect…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 implement infection control measures and implement enhanced barrier precautions for residents who required tube feedings for two of three residents (Residents R23, and R29). Findings include: Review of facility policy Enhanced Barrier Precautions dated 8/24/23, indicated it is the facility's policy to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms. It was indicated staff will receive training on enhanced barrier precautions and an order for enhanced barrier precautions must be implemented for any residents with feeding tubes. Review of Resident R23's clinical record indicated the resident was admitted [DATE], and readmitted [DATE], with diagnoses of metabolic encephalopathy, anxiety, and encounter for attention to gastrostomy. Review of Resident R23's Minimum Data Set (MDS- a periodic assessment of resident care…

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

Based on a review of facility policies, Food Committee Minutes, cycle menus, Always Available Menu, and staff interviews, it was determined that the facility failed to offer alternative menu selections based on resident preferences for four of four weeks of the Spring/Summer cycle menu (Week One, Week Two, Week Three, and Week Four). Findings include: A review of facility policy Offering Food Replacements at Meal Time dated 8/24/23, indicated that each resident will receive appropriate nutrition when a food replacement is offered. Options should be appealing. Residents are encouraged to verbalize their choice of substitution . A list of items that will be available for food replacement at all meals accompanies this policy. (Note: there is no evidence of an Always Available food replacement list attached to this policy ) A review of facility policy Food and Nutrition Services dated 8/24/23, indicated that each resident is provided a well balanced diet taking into consideration the preferences of each resident. Reasonable efforts will be made to accommodate resident choices 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 policies, observations and staff interview it was determined that the facility failed to store all drugs and biologicals in a safe, secure, and orderly manner for two of three nursing units (First and Second floor). Findings include: Review of the facility policy Storage of Medications dated 8/24/23, indicated the facility stores all drugs and biologicals in a safe, secure, and orderly manner. Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing drugs and biologicals are locked when not in use. Unlocked medication carts are not left unattended. During an observation and interview on 4/23/24, at 2:44 p.m. the medication fridge on the first floor was observed to be unlocked. LPN, Employee E2 stated the medication fridge should not be left unlocked and confirmed the facility failed to store all drugs and biologicals in a safe, secure, and orderly manner. During an observation and interview on 4/23/24, at 2:55 p.m. the Second Floor medication room was observed to be open and not locked. The…

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

Based on review of policies and personnel files, as well as staff interviews, it was determined that the facility failed to implement its abuse prohibition policies regarding verifying new employees' standing with the Pennsylvania Nurse Aide Registry for one of four new employees reviewed (Nurse Aide, Employee E5) and failed to ensure that reference checks were obtained prior to hire for one of four Nurse Aide files reviewed (Nurse Aide, Employee E5) Findings include: The facility's policy regarding abuse prohibition, dated 8/24/23, indicated that the facility was to screen employees and would not employ or otherwise engage individuals who have had a finding entered into the State Nurse Aide Registry. In addition to inquiry of the Pennsylvania Nurse Aide Registry or licensing authorities, the facility should check information from previous and/or current employers and make reasonable efforts to uncover information about any past criminal prosecutions. Pre-employment screenings would include drug screening, criminal background checks, certification or license verification, 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, clinical records, facility documents, and staff interviews, it was determined that the facility failed to ensure residents were provided food that accommodates resident's allergies for one of 7 residents reviewed. (Resident R1) Findings include: Review of facility policy Food Allergies and Intolerances dated 8.24.23, indicated residents with food allergies and/or intolerances are identified upon admission and offered food substitutions of similar appeal and nutritional value. Steps are taken to prevent resident exposure to the allergen(s). Review of facilities current Certified Nursing Assistant's (NA) job description indicated the purpose of your job position is to provide each of your assigned residents with routine daily nursing care and services in accordance with the resident's assessment and care plan and as may be directed by your supervisor in accordance with the requirements of the policies and procedures of this facility in accordance with current federal, state, and local standards governing the facility. Review of the clinical record…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of employee files and staff interviews, it was determined that the facility failed to ensure that certified nurse aides received registry verification following the expiration of nurse aide registration for one of four nurse aides (Employees E1). Findings include: Review of the Event Reporting System report submitted to the Department of Health on [DATE], indicated Nurse Aide (NA), Employee E1's registration was noted to be expired. It stated Nurse Aide, Employee E1 was hired on [DATE]. Her certification expired on [DATE]. The original issue date was [DATE]. NA, Employee E1 was working the weekend program. She was notified and immediately removed from the schedule and given the contact information for certification renewal. Review of Nurse Aide, Employee E1's personnel record indicated she was hired on [DATE], and revealed a Pennsylvania Department of Health Nurse Aide Registration for Employee E1, effective [DATE], and expired on [DATE]. Review of facility's Daily Staffing Sheet dated [DATE],…

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

Based on review of facility policy, personnel files and staff interviews it was determined that the facility failed to complete annual performance evaluations for one out of five personnel files (Employee E1). Findings include: Review of Nurse Aide (NA), Employee E1's personnel record indicated she was hired on 11/7/22. A further review of Nurse Aide, Employee E1's personnel record indicated the facility failed to complete a performance evaluation within 12 months. NA, Employee E2 performance evaluation for the year 2022-2023, was completed by 11/7/23. During an interview on 2/16/24, at 1:38 p.m. Licensed Practical Nurse, Employee E2 confirmed Nurse Aide, Employee E1's performance evaluation for 2022-2023, was not included in NA, Employee E1's personnel record. During an interview on 2/16/24, at 1:58 p.m. the Director of Nursing confirmed the facility was unable to locate and provide evidence that NA, Employee E1's annual performance evaluation was completed by 11/7/23. During an interview on 2/16/24, at 2:05 a.m. the Nursing Home Administrator confirmed that the facility failed 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.

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 maintain a complete and accurate accounting of controlled medications (medications with the potential to be abused) for four of 34 residents reviewed (Residents 2, 4, 6, 8). This deficiency was cited as past non-compliance. Findings include: The facility's policy regarding medication administration, dated [DATE], indicated that the residents would be medicated in accordance with the physician's orders. Physician's orders for Resident 2, dated [DATE], included an order for the resident to receive 0.5 milligrams (mg) of Ativan (a controlled narcotic medication) every four hours as needed for restlessness and 1 mg every 3 hours as needed for restlessness. A physician's order, dated [DATE], was for the resident to have 10 mg of Morphine (a controlled narcotic pain medication) every four hours as needed for pain or shortness of breath. A physician's order, dated [DATE], included an order for…

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

Based on review of facility policies, manufacturer's instructions, meal schedules, and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that it was free from significant medication errors for one of 34 residents reviewed (Resident 6). This deficiency was cited as past non-compliance. Findings include: The facility's medication administration policy, dated September 5, 2019, indicated that prescribed medications were to be administered in accordance with physician's orders. Resident 6's controlled drug record, dated December 2019, revealed that the resident received 1 milligram (mg) Ativan Concentrate on December 5 2019. However, there was no active physician's order for the resident to receive this medication. A nurse's note for Resident 6, dated December 5, 2019, at 9:37 p.m. revealed that Registered Nurse 1 medicated the resident with 20 mg Morphine concentrate at that time. However, there was no physician's order for the resident to receive that medication. Interview with the Director of Nursing on December 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.

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 were checked with the State Board of Nursing for one of one newly hired nurses (Registered Nurse 1) and failed to ensure that references were checked from previous employers and/or current employers for one of one newly hired nurses reviewed (Registered Nurse 1). This deficiency was cited as past non-compliance. Findings include: The facility's policy regarding abuse, neglect, and exploitation of residents, dated September 5, 2019, indicated that the facility screens potential employees to determine their appropriateness in working with individuals with specific conditions and needs. Screens all potential employees for any previous history of abuse, neglect or mistreating of residents as defined by applicable requirements. Checks references and obtains pertinent information from previous and current employers. Appropriate licensing and certifying boards are contacted as required. The personnel file for Registered Nurse…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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's policies, clinical records, and personnel files, as well as staff interviews, it was determined that the facility failed to ensure that all alleged violations involving abuse were reported to the State Survey Agency (Department of Health) for one of 34 residents reviewed (Resident 25). This deficiency was cited as past non-compliance. Findings include: The facility's policy regarding abuse, neglect, and exploitation of residents, dated September 5, 2019, indicated that once an allegation of abuse has been made, the supervisor who initially received the report must inform the Nursing Home Administrator/Director of Nursing as soon as possible and initiate gathering requested information. An investigation MUST be directed by the Nursing Home Administrator/designee immediately and no later than twenty-four hours of their knowledge of the alleged incident. The Nursing Home Adminstrator, Director of Nursing or designee will notify the appropriate state agencies per state regulations. Should the investigation reveal that abuse occurred, the Nursing Home…

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

Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to conduct a thorough investigation to rule out abuse or misappropriation as the possible cause of a change in condition for one of 34 residents reviewed (Resident 25). This deficiency was cited as past non-compliance. Findings include: The facility's policy regarding abuse, neglect, and exploitation of residents, dated September 5, 2019, indicated that once an allegation of abuse has been made, the supervisor who initially received the report must inform the Nursing Home Administrator/Director of Nursing as soon as possible and initiate gathering requested information. An investigation MUST be directed by the Nursing Home Administrator/designee immediately and no later than twenty-four hours of their knowledge of the alleged incident. Witness reports will be in writing. Witnesses will be required to sign and date such reports. A copy of such reports must be attached to the abuse investigation report form. The Nursing Home Administrator/Director of Nursing 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.

Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that residents received care and treatment in accordance with professional standards of practice by failing to ensure that physicians' orders were followed, and failed to ensure that hypoglycemia protocols were followed as ordered by the physician for two of 34 residents reviewed (Residents 10, 25). This deficiency was cited as past non-compliance. Findings include: The facility's policy regarding diabetic management protocol, dated September 5, 2019, revealed that residents who have diabetes will receive care according to acceptable standards of care focused on maintaining blood glucose control and preventing both acute and chronic complications. Signs and symptoms of hypoglycemia (low blood glucose level) may include the following: irritable/changes in behavior, altered sleep, pale moist skin, confusion, numbness of tongue and lips, unconsciousness, change in function, stupor, convulsion, excessive hunger, weakness, dizziness, coma, tachycardia (fast…

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

Based on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that residents' clinical records were complete and accurately documented for one of 34 residents reviewed (Resident 25). This deficiency was cited as past non-compliance. Findings include: The facility's policy regarding diabetic management protocol, dated September 5, 2019, revealed that residents that have diabetes will receive care according to acceptable standards of care focused on maintaining blood glucose control and preventing both acute and chronic complications. Signs and symptoms of hypoglycemia (low blood glucose level) may include the following: irritable/changes in behavior, altered sleep, pale moist skin, confusion, numbness of tongue and lips, unconsciousness, change in function, stupor, convulsion, excessive hunger, weakness, dizziness, coma, tachycardia (fast heart rate), trembling, restless, headache, slurred speech, blurred vision or impaired vision. If the blood glucose is less than 50 milligrams (mg)/deciliter (dL) (normal…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 injuries of unknown origin for one of two residents (Resident R1). Findings include: A review of the facility's Abuse Investigations policy dated 8/24/23, indicated injuries of unknown origin will be thoroughly investigated. Interviews of the person reporting the incident, any witnesses, the resident, staff members and volunteers on all shifts who had contact with the resident during the period of the alleged incident, interview of the resident's roommate, family members, visitors, and interviews of other residents to whom the accused employee provides care or services must be conducted. Review of the clinical record revealed that Resident R1 was admitted to the facility on [DATE], with diagnosis that included vascular dementia (problems with reasoning, planning, judgment, memory, and other thought processes caused by brain damage from impaired blood flow…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policies, observations, clinical record review, and staff interview, it was determined that the facility failed to provide appropriate respiratory care for five of seven residents (Residents R3, R37, R49, R60, and R84). Findings include: Review of the facility's policy Nasal Cannula dated 8/24/23, indicated that the nasal cannula (tubing used to provide supplemental oxygen that is inserted into the nostrils), and humidification bottle should be labeled with date of initial set up and that nasal cannula and humidification bottle must be changed every 7 days and that the nasal cannula and humidification bottle must be labeled with the date. Review of the clinical record indicated that Resident R84 was admitted to the facility on [DATE]. Review of Resident R84's Minimum Data Set (MDS - periodic assessment of care needs) dated 7/9/23, indicated diagnoses of chronic obstructive pulmonary disease (COPD, a group of progressive lung disorders characterized by increasing breathlessness),…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, observations, and staff interview it was determined that the facility failed to assess five of ten residents for the use of bed rails (Residents R2, R15, R24, R48, and R67). Findings Include: Review of the facility policy Bed Safety reviewed 8/24/23, indicated if side rails are used, there shall be an interdisciplinary assessment of the resident, consultation with the Attending Physician and input from the resident and/or legal representative. Review of admission record indicated Resident R2 was admitted to the facility on [DATE]. Review Resident R2's Minimum Data Set (MDS - a periodic assessment of care needs) dated 8/9/23/23, indicated the diagnoses of high blood pressure, heart failure (heart doesn't pump blood as well as it should), and diabetes (too much sugar in the blood). Review of Resident R2's physician orders dated 12/28/22, indicated quarter side rails to promote independence and bed mobility. Review of Resident R2's Side Rail/Grab Bar Review - V2 dated 3/9/23,…

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.

Based on review of facility policy, infection control documentation and staff interview, it was determined that the facility failed to implement an infection control program that included a system of surveillance to identify possible communicable diseases or infections for four of 12 months (October 2022 - January 2023). Findings include: Review of infection control documentation for the previous 12 months (September 2022 - September 2023) failed to reveal surveillance for tracking infections for residents and staff, a system for recording incidents, or an annual review of the infection prevention and control program for four of 12 months (October 2022 - January 2023). During an interview on 9/7/23, at 12:00 p.m. the Assistant Director of Nursing Employee E4 confirmed that the facility failed to implement an effective infection control plan as required for the months of October 2022 - January 2023. 28 Pa. Code 201.14(a) Responsibility of Licensee. 28 Pa. Code 201.18(b)(1)(e)(1) Management. 28 Pa. Code 211.12 (d)(1)2)(3) Nursing Services.

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 provide the opportunity to formulate an advance directive (a written instruction such as a living will or durable power of attorney for health care for when the individual is incapacitated) for two of three residents reviewed (Resident R6, and R73). Findings include: A review of the facility policy Advanced Directives last reviewed 8/24/23, indicated that upon admission, the resident will be provided with information concerning the right to refuse or accept medical or surgical treatment and to formulate an advance directive if he or she chooses to do so, If the resident is incapacitated and unable to receive information about his or her right to formulate an advance directive, the information may be provided to the resident ' s legal representative. A review of the medical record indicated Resident R6 was admitted to the facility on [DATE], with diagnoses that included Parkinson's disease…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, and staff interview, it was determined that the facility failed to maintain a clean homelike environment for three of eight resident rooms (Resident R37, R47, and R67). Findings Include: Review of the facility policy Quality of Life - Homelike Environment last reviewed 8/24/23, indicated the residents are provided with a safe, clean, comfortable, and homelike environment. Review of the admission record indicated Resident R37 admitted to the facility on [DATE]. Review of Resident R37's Minimum Data Set (MDS- a periodic assessment of care needs) dated 6/6/23, indicated the diagnoses of Chronic obstructive pulmonary disease (COPD a lung disease that blocks airflow and makes it difficult to breathe), diabetes (too much sugar in the blood), and quadriplegia (paralysis of all four limbs). Observation of Resident R37's room on 9/5/23, at 9:32 a.m. indicated debris on the floor (dirt, crumbs) and the perimeter of the doorway with extensive grime. Interview on 9/5/23, at 9:34 a.m. Nursing Assistant…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 record, facility policy, and staff interview, it was determined that the facility failed to develop a baseline care plan that included risk for wandering and interventions needed to provide effective and person-centered care for one of twelve residents (Resident R193). Findings include: The facility policy Care Plans-Baseline last reviewed 8/24/23, indicated a baseline care plan to meet the resident's immediate needs shall be developed within forty-eight hours of the resident's admission. Review of the admission record indicated Resident R198 was admitted to the facility on [DATE], with the diagnoses of senile degeneration of the brain (loss of intellectual ability), cancer of the skin, and cancer of the prostate. Review of Resident R193's Elopement Risk Screen dated 7/14/23, at 8:58 p.m. indicated mental status as disoriented occasionally, or orientation not determined, independent mobility-ambulates (walks), wanders through facility or prior residence, but does not leave interior…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policies, clinical records and staff interviews, it was determined that the facility failed to develop a comprehensive care plan for one of four residents (Resident R15). Findings include: A review of facility policy Care Plans, Comprehensive Person-Centered reviewed 8/24/23, indicated a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. Review of the admission record indicated Resident R15 admitted to the facility on [DATE]. Review of Resident R15's Minimum Data Set (MDS - a periodic assessment of care needs) dated 8/9/23, indicated the diagnoses of cerebral palsy (a congenital disorder of movement, muscle tone or posture due to abnormal brain development), seizure disorder, and epilepsy (brain'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 a review of facility policy, resident clinical record review, and staff interview, it was determined the facility failed to ensure that a resident's care plan was updated and revised to reflect the resident's specific care needs for two of twelve residents (Resident R8 and R73) Findings include: Review of the facility policy Care plans, Comprehensive Person -Centered dated 8/24/23, indicated that care plans will include measurable objectives and timetables to meet the resident ' s physical, psychosocial and functional needs. Care plans are revised as information about the resident and the resident ' s condition change. Review of the admission record indicated Resident R8 was admitted to the facility on [DATE]. Review of Resident R8's MDS assessment (MDS-Minimum Data Set assessment: periodic assessment of resident care needs) dated 8/8/23, indicated diagnoses that included heart failure, cerebral vascular accident (an event that occurs when something blocks blood supply to part of the brain or when 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of clinical records, facility policy, and staff interview, it was determined that the facility failed to obtain physician orders for a nothing my mouth (NPO) oral diet order for one of four residents (Resident R73), and failed to notify the physician of decreased Capillary Blood Glucose (CBG) levels and failed to assess a resident with hypoglycemia (low blood glucose), for one of five residents (Resident R43) Findings include: Review of the facility policy Therapeutic Diets dated 8/24/23, indicated that a diet must be prescribed by the resident ' s attending physician. The attending physician may delegate this task to a registered or licensed dietitian as permitted by state law. The Centers for Disease Control defines diabetes as: Diabetes Mellitus is a chronic (long-lasting) health condition that affects how your body turns food into energy. Most of the food you eat is broken down into sugar (also called glucose) and released into your bloodstream. Hypoglycemia is a condition that occurs when…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, resident interviews, and staff interviews, it was determined that the facility failed to make certain each resident received timely identification of wandering risk that resulted in an elopement (resident exits to an unsupervised or unauthorized area without the facility's knowledge) for one of four residents (Resident R193). Findings include: Review of facility policy Wandering and Elopements reviewed 8/24/23, indicated the facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents. Review of facility policy Elopement of Resident reviewed 8/24/23, indicated all residents will be screened on admission for elopement risk. 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…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 assessment, facility Nurse Aide job descriptions, personnel files and staff interviews it was determined that the facility failed to complete annual performance evaluations for four out of five personnel files (Nurse Aide Employee E9, Nurse Aide Employee E10, Nurse Aide Employee 11, and Nurse Aide Employee E12). Findings include: Review of facilities current Certified Nursing Assistant job description indicated the purpose of the position is to provide each of your assigned residents with routine nursing care and services in accordance with the requirements of the policies and procedures of this facility in accordance with current federal, state, and local standards governing the facility. Review of the Facility Assessment, updated third quarter 2023, indicated that each position shall have a job description, and each job description shall have requirements outlined, including professional licensure and certification. Staff competencies are ensured during the person's training and on-boarding process. Annually, each staff members shall receive a…

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

Based on review of facility records and staff interviews, it was determined that the facility failed to have a designated Infection Preventionist (IP) qualified with specialized training in infection prevention and control for three of twelve months (April 2023 - June 2023). Findings include: Review of facility document 2023 Infection Preventionist Timeline on 9/8/23, identified that from April 8, 2023 - June 7,2023, the facility was without a designated Infection Preventionist. Interview on 9/8/23, at 2:45 p.m. the Director of Nursing confirmed that the facility was without a designated Infection Preventionist from April 8, 2023 - June 7,2023. 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.12(d)(1)(5) Nursing services