Bridgeville Rehabilitation & Care Center

Based on review of resident and staff interviews, Resident Council minutes review, 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 eight of eleven residents (Residents R1, R2, R3, R4, R5, R6, R7, and R8).Findings include:During an interview on 11/5/25, at 5:00 p.m. when asked if he felt the facility maintained enough staff to care for resident needs, Resident R1 stated, No. Resident R1 stated that call light response usually takes a long time. Resident R1 further stated that he receives late medications and is not assisted in and out of bed timely.During an interview on 11/5/25, at 5:03 p.m. when asked if she felt the facility maintained enough staff to care for resident needs, Resident R2 stated, There could be more. During an interview on 11/5/25, at 5:09 p.m. when asked if he felt the facility maintained enough staff to care for resident needs, Resident R3 stated, At times not. During an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility provided policies and documentation, clinical records, and resident and staff interviews, it was determined that the facility failed to protect residents from staff-initiated abuse. This failure resulted in a staff member physically abusing a resident and multiple staff neglecting care of one of four residents reviewed (Resident R9).Findings include:Review of the Resident Assessment Instrument 3.0 User's Manual effective [DATE], indicated that a Brief Interview for Mental Status (BIMS) is a screening test that aids in detecting cognitive impairment. The BIMS total score suggests the following distributions: 13-15: cognitively intact8-12: moderately impaired0-7: severe impairmentThe facility's policy Abuse Prohibition dated [DATE], indicated it is the facility's policy that it prohibits abuse, neglect, mistreatment, etc., for all residents.Review of the clinical record indicated Resident R9 was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS - federally mandated…

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

Based on observations, facility documents, resident, and staff interviews, it was determined that the facility failed to provide a safe, clean, comfortable, and homelike environment on seven of seven nursing units (Leader Unit, C Hall, B Hall, E Hall, G Hall, I Hall and K Hall).Findings included:Review of the facility grievances and review of a complaint indicated that there are not enough clean and available linens, wash cloths and towels available throughout the whole dayDuring an observation on 9/5/25, from 8:40 a.m., through 11:10 a.m., of linen carts throughout the facility there were approximately six sheets, both bottom and top, seven towels and two or three wash cloths on each linen cart, the census is 168 currently. During an observation on 9/5/25, at approximately 10:56 a.m., the laundry staff employee E1 stated that she has not had a second clothes machine for three to four months and cannot keep up with the linens, wash cloths and towels. Laundry Employee E1 stated she is the only staff doing laundry and due to only having one machine. linens are not done after she…

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

Based on observation, review of facility documentation, and staff interviews, it was determined that the facility failed to make certain that equipment was in safe operating condition for one of two wash machines.Findings include:Review of the facility grievances dated 8/22/25, from two separate residents and also related to another resident indicated the lack of clean linens and wash cloths and towels not being available.During an observation on 9/5/25, at approximately 10:56 a.m., the laundry staff employee E1 stated that she has not had a second clothes machine for three to four months and cannot keep up with the linens, wash cloths and towels. Laundry Employee E1 stated she is the only staff doing laundry and due to only having one machine. linens are not done after she leaves and there is not enough. During an interview on 9/5/25, at 12:10 p.m., the Nursing Home Administrator confirmed that the wash machine has been down for a while the facility failed to make certain that equipment was in safe operating condition for one of two wash machines.28 Pa. Code: 201.14(a)…

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

Based on observations, and staff interview, it was determined that the facility failed maintain sanitary conditions to prevent the potential for cross-contamination or foodborne illness in the main kitchen (Main Kitchen).Findings include:During an observation of the kitchen on 8/5/25, from 9:15 a.m., through 9:50 a.m., the following was observed:The dish machine wash cycle was reaching temperature of only 142 degrees Fahrenheit (required to be 150-165 degrees). The rinse cycle reached 160 degrees (required to reach 180-194 degrees).The walk-in cooler fans had a white fuzzy substance on them. This fan blows air directly over food items. During an interview on 8/5/25, at 9:26 a.m., Health Care Services (HCS) corporate Dietary Manager Employee E3 confirmed that the facility failed to maintain sanitary conditions to prevent the potential for cross-contamination or foodborne illness in the main kitchen (Main Kitchen). During a second observation on 8/6/25, from 11:42 a.m., through 12:40 p.m., of the kitchen and tray line service the following was observed: Dietary [NAME] Employee E4 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 a review of facility policies, documents, observations, and staff interviews it was determined that the facility failed to provide a dignified dining experience on 8/5/25, during the breakfast meal service to one of five residents. (Resident R14) on the secure memory care unit. Findings include:A review of facility Resident Rights Under Federal Law policy dated 7/7/25, indicated To treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of there self-esteem and self-worth. The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which provides instructions and guidelines for completing required Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2023, indicated that a BIMS (Brief Interview of Mental Status) is a brief screener that aids in detecting cognitive impairment. Scores from a BIMS assessment suggests the following…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, facility records, resident, and staff interviews, it was determined that the facility failed to make certain call lights were accessible and answered timely for 19 of 21 residents as required (Resident R61, R163, R500, R501, R502, R503, R504, R506, R507, R508, R509, 510, R511, R512, R513, R514, R515, R516, and R517).Findings include:The facility policy Call Lights dated 7/7/25, indicated Patients will have a call light or alternative communication device at each patient's bed side, toilet, and bathing room to allow patients to call for assistance when unattended. Staff will respond to call lights and communication devices promptly. Review of Resident R61's clinical record indicated admission to the facility on 4/28/22. Review of Resident R61's Minimum Data Set (MDS - a periodic assessment of care needs) dated 7/11/25, indicated diagnoses of Alzheimer's disease (destruction of memory and thinking skills), foot drop (inability to lift the front part of the foot), and history of…

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

Based on review of facility policy, resident council documents, resident council group interview, resident interview, and staff interview it was determined that the facility failed to respond to concerns from resident council and failed to respond to concerns in a timely manner for six out of six months (1/29/25, 2/26/25, 3/26/25, 4/28/25, 5/28/25, and 6/25/25).Findings include:The facilities Resident Council policy dated 11/15/24 with review date of 7/7/25, indicated The designated staff person acts as a liaison between the Council and Center/Community leadership in providing information on concerns, request, and recommendations to the Administrator/Executive Director and the appropriate department manager for attention and response. Responses and rationale will be documented, reviewed by the Administrator/Executive Director, and maintained with the Council Minutes. Review of Resident council minutes dated 1/29/25, 2/26/25, 3/26/25, 4/28/25, 5/28/25, and 6/25/25 identified resident concerns with staff response to call lights. The documentation did not indicate follow-up actions or…

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

Number of residents sampled: Number of residents cited: Based on a review of the resident council minutes, resident council meeting information, resident interviews, observation and staff interview, it was determined that the facility failed to serve food that was palatable and attractive.Findings include:Review of four months of resident council meeting minutes identified residents stating that the food was tasteless and often mush and unattractive on the plate. Buns were mushy because they were placed on plate with liquids.During the Resident Group Meeting held during the survey process on 8/5/25, the consensus of the residents identified that the food was unchanged, that the facility dietary department has not ever addressed the food issues. Food is, at times, not what you asked for.During resident interviews on 8/5/25, two residents that wished to remain anonymous stated that the only complaint they had in the facility was the food taste and how it looked when they received it.During an observation of tray line service on 8/6/25 from 11:42 a.m., through 12:40 p.m., the following…

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

Based on review of facility policy, observations and staff interviews, it was determined that the facility failed to provide a safe, clean, comfortable, and homelike environment within the facility for one of five units.Findings include:Review of the facility policy Center Operations Policies and Procedures: Accommodation of Needs last reviewed on 5/1/25, indicated the resident/patient has the right to a safe, clean, comfortable, and home like environment including, but not limited to, receiving treatment and supports for daily living safely. This includes ensuring that the patient can receive care and services safely and that the physical layout of the Center maximizes patient independence and does not pose a safety riskDuring an interview with Housekeeping Employee E1 on 7/15/25, at approximately 10:17 a.m., Employee E1 provided and explained the seven step cleaning procedure. Step three outlined bathroom cleaning as daily, equipment utilized, products, areas (toilets, sinks, pipes etc ), and directions. During ab observation rounds with the Director of Nursing (DON) on 7/15/25,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of facility policy, clinical records, facility documents, and staff interviews, it was determined that the facility failed to provide appropriate assistance to prevent falls and injury for one of three residents reviewed (Resident R1).Findings include:Review of the facility policy Center Operations Policies and Procedures: Abuse Prohibition last reviewed on 5/1/25, includes the definition of Abuse and Neglect: Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, injury, or mental anguish Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Neglect is defined as the failure, indifference, or disregard of the Center, its employees, or service providers to provide care, comfort, safety, goods and services to a patient that are necessary to avoid physical harm, pain, mental anguish, or emotional…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of facility policy, clinical records, facility documents, and staff interviews, it was determined that the facility failed to provide appropriate assistance to prevent falls and injury, for one of 3 residents reviewed (Resident R1).Findings include:Review of the facility policy Center Operations Policies and Procedures: Accommodation of Needs last reviewed on 5/1/25, indicated the resident/patient has the right to a safe, clean, comfortable, and home like environment including, but not limited to, receiving treatment and support for daily living safely. This includes ensuring that the patient can received care and services safely and that the physical layout of the Center maximizes patient independence and does not pose a safety riskReview of the American Congress of Rehabilitation Medicine - Caregiver Guide and Instructions for Safe Bed Mobility published 4/28/17, indicated the patient should always roll toward you not away from you. Bed mobility refers to activities such as scooting in bed,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 documentation, cited deficiencies from previous surveys, review of plans of correction documentation, and staff interview, it was determined that the facility's Quality Assurance and Performance Improvement (QAPI) program failed to correct previously cited deficiencies. Findings include: Review of the facility policy, Quality Assurance and Performance Improvement (QAPI) Program dated 1/22/25, indicated objectives of the QAPI program include providing a means to establish and implement performance improvement projects to correct identified negative or problematic indicators and to establish systems through which to monitor and evaluate corrective actions. The facility's deficiencies and plan of correction for the State Survey and Certification (Department of Health) for the following surveys, revealed the facility developed a plan of correction that included quality assurance systems to ensure the facility-maintained compliance with cited nursing home regulations. Review of the plan of correction for the survey ending 7/25/24, revealed the following: -…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 and clinical record review and staff interview, it was determined that the facility did not ensure prompt efforts were made to resolve a resident's grievance and/or concerns for one of six residents interviewed (Resident R1). Findings include: A review of the facility policy, Grievance/Concern dated 2/5/25 indicated grievances will be completed in a reasonable expected timeframe. Concerns may be registered by direct outreach to staff and a grievance/concern form will be initiated and submitted to be completed. The facility will investigate the grievance and notify the person filing the grievance of resolution in a timely manner. A review of the clinical record indicated Resident R1 was admitted to the facility on [DATE] with diagnoses that included a fracture of the right arm. A review of a Care Plan Meeting progress note dated 4/24/25, indicated the resident and family were in attendance and indicated a concern with staff not answering call lights. A review of the facility complaint log…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of facility policy, clinical records, and incident investigations, it was determined that the facility failed to ensure that residents are free from misappropriation of property for 18 of 22 residents (Resident R1, R2, R3, R4, R5, R6, R7, R8, R9, R10, R11, R12, R13, R14, R16, R17, and R18 ). Findings include: Review of the facility policy Abuse Prohibition dated 10/24/24, defined misappropriation of resident property as the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent. Review of the clinical record revealed that Resident R18 was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS - periodic assessment of care needs) dated 2/10/25, included diagnoses of chronic kidney disease (gradual loss of kidney function), diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time), and care needed after joint surgery. Review of Section C:…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 state laws, facility policies, clinical records, and staff interviews, it was determined that the facility failed to implement policies and procedures to report allegations of neglect for two of four residents (Resident R2 and R28). Findings include: Review of the Older Adult Protective Services Act of 11/6/87, amended by Act 1997-13, Chapter 7, Section 701, requires any employee or administrator of a facility who suspects abuse is mandated to report the abuse. All reports of abuse should be reported to the local area agency on aging and licensing agencies. Review of the facility policy, Abuse Prohibition dated 10/24/24, indicated that immediately upon receiving information concerning a report of suspected or alleged abuse, mistreatment, or neglect, the facility will perform the following. -Report allegations to the appropriate state and local authority(s) involving neglect, exploitation or mistreatment (including injuries of unknown source), suspected criminal activity, and misappropriation…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 state laws, facility policies, clinical records, and staff interviews, it was determined that it was determined that the facility failed to implement policies and procedures to investigate possible abuse and/or neglect for three of six residents (Resident R2, R28 and R29). Findings include: Review of the facility policy, Abuse Prohibition dated 10/24/24, The Center will identify possible incidents or allegations which need investigation. Injuries of unknown origin will be investigated to determine if abuse or neglect is suspected. Review of the Resident Assessment Instrument 3.0 User's Manual effective October 2024, indicated that a Brief Interview for Mental Status (BIMS) is a screening test that aides in detecting cognitive impairment. The BIMS total score suggests the following distributions: 13-15: cognitively intact 8-12: moderately impaired 0-7: severe impairment Review of the clinical record indicated Resident R2 was admitted to the facility on [DATE]. Review of the Minimum Data Set…

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

Based on review of facility policy, observations, and staff interview, it was determined that the facility failed to make certain that medications were properly secured in one of three medication carts (First-floor medication cart for rooms 100-117) Findings include: Review of the facility policy Security of Medication Cart dated 11/1/24, indicated medication carts must be securely locked at all times when out of the nurse's view. During an observation on 2/8/24, at 2:18 p.m. of the First-floor medication room, the 100-117 medication cart was observed unlocked. The surveyor remained with the medication cart. At approximately 2:22 p.m. the surveyor opened and the medication cart drawers, and observed that the narcotic drawer was not secured. The surveyor reviewed the narcotic book, and narcotic cards. At 2:30 p.m. First Floor Unit Manager was requested to confirm that the medication cart and the narcotic drawer were both unsecured. During an interview on 2/11/25, at approximately 3:00 p.m., the Nursing Home Administrator and the Director of Nursing confirmed that the facility failed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 interview with staff, it was determined that the facility failed to provide discharge planning that focuses on the resident's discharge goals and preparation of resident to be active partners in the discharge planning process that focuses on the resident's discharge planning and process for one of eight residents (Closed Record Resident R1 - CRR1). Findings include: Review of the clinical record indicated CRR1 was admitted to the facility on [DATE], with diagnoses that included multiple fractures (broken bones) including the ribs, right tibia (bone between knee and ankle), displaced vertebrae in cervical spine (bone fracture with fragments shifted out of alignment in the neck), and traumatic pneumothorax (air between the chest wall and the lung causing partial or complete lung collapse). Review of CRR1's Minimum Data Set (MDS-a periodic assessment of care needs) dated 2/21/25, indicated the diagnoses remain current. Review of a physician order dated 2/19/25,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of facility policy, resident interview, observations, and staff interview it was determined the facility failed to assess the clinical appropriateness of medication self-administration for three of 11 residents (Resident R2, R3, and R4). Findings include: Review of facility policy Medication Administration reviewed August 2024, indicated residents are allowed to self-administer medications when specifically authorized by the prescriber, the nursing care center ' s Interdisciplinary Team (IDT), and in accordance with procedures for self-administration of medications and state regulations. The resident is always observed after administration to ensure the dose was completely ingested. Review of the clinical record indicated Resident R2 was admitted to the facility on [DATE], with diagnoses that included high blood pressure, congestive heart failure (CHF - progressive heart disease that affects pumping action of the heart muscles), and depression. During an interview and observation on 2/24/25, at…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, resident and staff interviews, it was determined that the facility failed to make certain that showers and baths were provided for one of three residents (Resident R1). Findings include: Review of facility policy Activities of Daily Living (ADLs) reviewed 10/24/24, indicated based on the comprehensive assessment of a resident and consistent with the resident's needs and choices, the facility must provide the necessary care and services to ensure that a resident's ADL abilities are maintained or improved and do not diminish unless due to unavoidable circumstances of the resident's clinical condition. ADLs include bathing, dressing, grooming, toileting, transferring, eating, walking, speech, and language. Review of facility policy Resident Rights Under Federal Law reviewed August 2024, indicated residents have the fundamental right to considerate care that safeguards their personal dignity along with respecting cultural, social, and spiritual values. 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 interview, it was determined that the facility failed to make certain that residents are free of significant medication errors for one of 11 residents (Resident R5). This was identified as past non-compliance. Findings include: Review of facility policy Medication Administration reviewed August 2024, indicated prior to administration, review and confirm medication orders for each individual resident. Medications are administered in accordance with written orders of the prescriber. Review of facility policy Medication Errors reviewed August 2024, indicated the facility shall ensure medications will be administered according to prescriber ' s orders. To prevent medication errors and ensure safe medication administration, nurses should verify the right medication, dose, route, and time of administration. Review of a clinical record indicated Resident R5 was admitted to the facility on [DATE], with diagnoses that included pain in right shoulder,…

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

Based on review of facility policy, observations and staff interviews, it was determined that the facility failed to properly secure medication and treatment carts for two of five carts observed (600 hall medication cart, and 100/200 hall treatment cart). Findings include: Review of facility policy Storage of Medications reviewed August 2024, indicated medications and biologicals are stored properly. The medication supply shall be accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. During an observation on 2/24/25, at 10:22 a.m. 600 hall medication cart was located in the 600 hall unlocked and unattended. During an interview on 2/24/25, at 10:22 a.m. Registered Nurse (RN) Employee E3 confirmed the medication cart should have been secured when unattended. During an observation on 2/24/25, at 10:30 a.m. 100/200 hall treatment cart was located by the nurses station unlocked and unattended. During an interview on 2/24/25, at 10:30 a.m. Licensed Practical Nurse, Employee E4 confirmed the treatment cart should…

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

Based on observations, staff interviews, and review of facility activities calendars, it was determined that the facility failed to provide sufficient activities on weekdays and weekends in the secured unit (B Hall). Findings included: Review of the facility policy Resident Rights Under Federal Law reviewed August 2024, indicated residents have the fundamental right to considerate care that safeguards their personal dignity along with respecting cultural, social, and spiritual values. The facility will comply with resident rights under federal law. #1 Resident Rights - The resident has the right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility. The facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his/her quality of life, recognizing each resident ' s individuality. The facility must provide equal access to quality care regardless of diagnosis, severity of condition, or payment source.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, resident records, observation, and staff interview it was determined that the facility failed to uphold the privacy and dignity of two of three residents reviewed utilizing an indwelling urinary catheter (foley - a thin rubber tube inserted either through the urethra or suprapubic [abdomen] to allow for bladder drainage) (Residents R1 and R2). In addition, the facility failed to uphold the resident's rights to voice grievances without fear of retaliation for four of 17 residents reviewed (Residents R700, R701, R702, and R703) who wish to remain anonymous. Findings include: Review of the facility policy Resident Rights Under Federal Law last reviewed 8/12/24, indicated residents have the fundamental right to considerate care that safeguards the personal dignity along with respecting cultural, social, and spiritual values. The resident has a right to a dignified existence, self-determination, and communication with and access to persons and se ices inside and outside 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 facility policy, personnel records, and staff interview it was determined that the facility failed to complete annual performance evaluations for five out of five nurse aides (NA Employee E1, E2, E3, E4, and E5). Findings include: Review of facility provided performance evaluations revealed the following: Nurse Aide (NA) Employee E1 had a hire date of 2/2/21, failed to have a performance evaluation between 2/2/23, and 2/2/24. A performance review dated 9/8/22, was provided. NA Employee E2 had a hire date of 1/4/22, failed to have a performance evaluation between 1/4/23, and 1/4/24. An undated performance review was provided. NA Employee E3 had a hire date of 4/20/21, failed to have a performance evaluation between 4/20/23, and 4/20/24. NA Employee E4 had a hire date of 3/22/22, failed to have a performance evaluation between 3/22/23, and 3/22/24. NA Employee E5 had a hire date of 3/30/17, failed to have a performance evaluation between 3/30/23, and 3/30/24. A performance review dated 7/8/22, was provided. During an interview on 8/23/24, at 10:40 a.m. the Director…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 resident and staff interviews and observations it was determined that the facility failed to provide sufficient portions of food products for seven of 16 residents (Resident R9, R11, R23, R46, R62, R64, and R65). Findings include: During an interview on 8/19/24, at approximately 10:40 a.m. Resident R65 stated that he felt that the portions were not enough and sometimes it has no taste. During an interview on 8/19/24, at approximately 10:55 a.m. Resident R9 stated that the food was cold, that it doesn't have good flavor, and the portions are not large enough. During an interview on 8/19/24, at approximately 11:07 a.m. Resident R46 stated that food is cold when it arrives and makes it less appealing to eat, portions are very small. During an interview on 8/19/24, at approximately 11:22 a.m. Resident R23 stated that the food arrives cold, there is not enough in the portion, and the food has no taste. During an interview on 8/21/24, at approximately 10:25 a.m. Resident R64 stated the meal portions are small. During an interview on 8/21/24, at approximately 11:00…

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

Based on a review of facility policies, observations and staff interviews it was determined that the facility failed to properly store food products, failed to verify the washing temperature of the dish machine, failed to maintain the air gap and drain pipe for the ice machine, and failed to to make certain dietary staff wear proper hair restraints in the Main Kitchen (Main Kitchen), which created the potential for foodborne illness. Findings Include: Review of the facility policy Machine Warewashing and Sanitation, dated 1/3/24, indicated that the facility high temperature machine wash cycle ranges between 150 degrees to 165 degrees, the final rinse temperature is a minimum of 180 degrees. Manufacturer's specifications are followed. Temperatures are recorded after each use/meal. If temperatures fall below the standard for either wash or rinse, the Director of Dining Services is notified. Review of the facility policy Ice Machine Cleaning/Inspection dated 1/3/24, indicated that all ice machines are cleaned and inspected quarterly. During the inspection, staff are to make certain 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 policy review, documentation and review of Centers for Disease Control (CDC) guidelines for Legionella (bacteria that causes disease found in contaminated water) control, and staff interviews it was determined that the facility failed to maintain a comprehensive program for water management to monitor the potential development and spread of Legionella and failed to implement control measures for Legionella within the facility for eleven of twelve months (September 2023 through July 2024). Findings Include: Review of the facility policy Water Management dated 1/3/24, previously dated 1/24/23, indicated the facility will utilize water management practices to reduce the risk of growth and spread of Legionella and other opportunistic pathogens in building water systems. Core Elements of the Water Management Plan are: 1. Establish Water Management Plan team. 2. Describe Center's water system using text and flow diagram. 3. Risk assessment with control methods and corrective actions. 4. Monitoring control measures. 5. Corrective actions. 6. Verification and validation. 7.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, documents, clinical records and staff interviews, it was determined that the facility failed to make certain a resident was free from abuse and neglect for 20 of 24 residents reviewed (Resident R47, R58, R4, R23, R18, CR401, R104, R16, R12, R22, R89, R76, R96, R7, R51, CR402, R96, R37, R20 and R403). Findings include: The facility's policy Abuse Prohibition dated 1/3/24, with a previous review date of 1/24/23, indicated it is the facility's policy that it prohibits abuse, neglect, mistreatment, etc., for all residents. The facility implements a program through he screening of potential hires, training employees, prevention of occurrences, identification of possible incidents or allegations that need investigated, investigation of incidents and allegations, protection of residents during investigations and reporting of incidents, investigations and facility responses to the results of the investigations. Review of the clinical record indicated that Resident R47 was admitted…

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

Based on review of facility documents, and staff interview, it was determined that the facility failed to ensure that residents were free from misappropriation (the act of stealing something that you have been trusted to care for and using it for yourself) of medications for two of three residents reviewed (Residents R47 and R129). Findings include: Review of facility policy Abuse Prohibition dated 1/3/24, indicated the facility prohibits abuse, mistreatment, neglect and misappropriation of property. Review of a facility provided documents dated 11/12/24, indicated that the facility had identified a drug diversion and misappropriation of property when Pharmacist Employee E37 contacted the Director of Nursing about narcotics(drugs that affect mood or behaviors and is consumed for non medical purposes) of four tablets of Xanax (benzodiazepine- anti anxiety), five tablets of Oxycodone (opioid pain medication) and 3 tablets of Morphine IR (pain medication-severe) not being placed into the emergency medication machine (Omnicell) after Licensed Practical Nurse Employee E38 signed the form…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 resident council meeting minutes, facility concern/grievance log and clinical records, and resident and staff interviews, it was determined that the facility failed to identify and/or investigate potential abuse and/or neglect for five of eight residents(Resident R2, R47, R58, R4 and R23). Findings include: The facility's policy Abuse Prohibition dated 1/3/24, with a previous review date of 1/24/23, indicated it is the facility's policy that it prohibits abuse, neglect, mistreatment, etc., for all residents. The facility implements a program through he screening of potential hires, training employees, prevention of occurrences, identification of possible incidents or allegations that need investigated, investigation of incidents and allegations, protection of residents during investigations and reporting of incidents, investigations and facility responses to the results of the investigations. Review of clinical record indicated that Resident R2 was admitted to the…

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

Based on review of the Resident Assessment Instrument User's Manual, clinical records, and staff interview, it was determined that the facility failed to make certain that comprehensive Minimum Data Set assessments were completed accurately for four of 15 residents (Resident R19, R69, R76, and R104). Findings include: The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which gives instructions for completing Minimum Data Set Assessments (MDS - periodic assessment of care needs) dated October 2023 indicated: -Section C, C0100, Brief Interview for Mental Status: Resident interview should be conducted because the resident is at least sometimes understood verbally, in writing, or using another method, and if an interpreter is needed, one is available. -Section D, D0100, Resident Mood Interview: Resident interview should be conducted because the resident is at least sometimes understood verbally, in writing, or using another method, and if an interpreter is needed, one is available. -Resident R19 had an MDS completion date of 6/2/24. Review of Section B:…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 comprehensive care plans to meet resident care needs for three of eight residents (Resident R3, R12, and R45). Findings include: Review of facility policy Person-Centered Care Plan dated 1/3/24, previously reviewed 1/24/23, indicated the care plan must be customized to each individual patient's preferences and needs. Review of Resident R3's admission record indicated she was originally admitted to the facility on [DATE], and readmitted [DATE]. Review of the Minimum Data Set (MDS - periodic assessment of resident care needs) dated 8/9/24, included diagnoses of chronic obstructive pulmonary disease (COPD, a group of progressive lung disorders characterized by increasing breathlessness), high blood pressure, and history of falling. Review of a progress note dated 12/19/23, at 2:00 p.m. indicated, CNA (nurse aide) alerted staff that while doing care resident rolled out of bed and landed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 interview, it was determined that the facility failed to provide adequate supervision during bed mobility and transfers for three of eight residents (Resident R5, R3, and R39). Findings include: Review of the facility policy Safe Resident Handling/Transfer Equipment dated 1/3/24, previously reviewed 1/24/23, indicated patients will be assessed upon admission and on an ongoing basis to determine the patient's ability to transfer and reposition and the need for safe resident handling equipment. The policy further stated that two trained persons are required to operate a total lift or sit to stand lift, regardless if manufacturer instructions state only one person is needed. Review of Resident R5's admission record indicated she was originally admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS - periodic assessment of resident care needs) dated 8/9/24, included diagnoses of spastic quadriplegic cerebral palsy (group of disorders…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of clinical records, and staff interview, it was determined that the facility failed to implement procedures to ensure availability of prescribed medications for two of five residents (Residents R104 and R59). Findings include: Review of the facility policy Provider Pharmacy Requirements dated 1/3/24, previously reviewed 1/24/23, indicated the facility will provide regular and reliable pharmaceutical services, to provide residents with prescription and non-prescription medications, services, and related equipment and supplies. Review of the clinical record indicated Resident R104 was admitted to the facility on [DATE]. Review of Resident R104's Minimum Data Set (MDS - a mandated assessment of a resident's abilities and care needs) dated 8/5/24, included diagnoses dementia (a group of symptoms that affects memory, thinking and interferes with daily life), diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time), and Parkinson's disease (neuromuscular…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to make certain education regarding the pneumococcal immunization and/or the opportunity to receive the immunization was offered to three of seven residents (Residents R19, R133, and R138). Findings include: Review of the facility policy Pneumococcal Vaccination dated 1/18/24, indicated the facility will provide the opportunity to receive the appropriate pneumococcal vaccine to all patients/ residents. Review of the admission Record indicated that Resident R19 was admitted to the facility on [DATE]. Review of Resident R19's Pneumococcal Vaccine Informed Consent form, dated 3/23/24, revealed Resident R19's responsible party indicated, May give vaccine if recommended by attending (provider). Review of Resident R19's clinical record failed to reveal any documentation that the appropriateness of Resident R19 receiving the pneumococcal vaccine was ever evaluated by the provider. Review of the…

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

Based on review of facility policy, personnel in-service training records, and staff interview, it was determined that the facility failed to provide training on the prevention of abuse, neglect, and misappropriation for three of ten staff members (Employee E5, E7, and E8). Findings include: Review of the facility policy, In-service Training dated 1/3/24, previously reviewed 1/24/23, indicated the facility will provide in-service training for all personnel on a regularly scheduled basis. All mandatory in-service training requirements must be completed annually as a condition of employment. Review of facility provided documents and training records revealed the following staff members did not have documented training on the prevention of abuse, neglect, and misappropriation. Nurse Aide (NA) E5 had a hire date of 3/30/17, failed to have the prevention of abuse, neglect, and misappropriation in-service education between 3/30/23, and 3/30/24. Social Work Employee E7 had a hire date of 6/1/21, failed to have the prevention of abuse, neglect, and misappropriation in-service education…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 two of five nurse aides (Employees E2 and E5). Finding include: Review of the facility policy, In-service Training dated 1/3/24, previously reviewed 1/24/23, indicated the facility will provide in-service training for all personnel on a regularly scheduled basis. All mandatory in-service training requirements must be completed annually as a condition of employment. Review of Nurse Aide (NA) Employees E2 and E5's education records with hire date greater than 12 months revealed the following: NA Employee E2 had a hire date of 2/21/21, with approximately six hours, five minutes of in-service education between 2/21/23, and 2/21/24. NA Employee E5 had a hire date of 3/30/17, with approximately eight hours, 20 minutes of in-service education between 3/30/23, and 3/30/24. During an interview on 8/23/24, at 10:40 a.m. the Director of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of resident fund account statements clinical record, and staff interview, it was determined that the faciltiy failed to convey resident funds in within 30 days for one of two residents reviewed (Closed Record Resident CR400). Findings include: A review of the financial account indicated that Closed Record Resident CR400 discharged home on [DATE]. Review of Closed Record Resident CR400's account managed by the facility revealed that $2950.00 was left in the account at the time of discharge. Further review revealed a check was made payable to the resident for $2795.30 after Closed Record Resident CR400 discharged on 8/2/24, eight months after discharge. During an interview on 8/20/24, at 11:10 a.m., Business Office Manager Employee E25 confirmed that the facility failed to release the monies to Closed Record Resident CR400 within 30 days, 28 Pa. Code 201.18(b)(20(3)(e)(1) Management. 28 Pa. Code 201.29(a) Resident rights.

Based on a review of facility provided documents it was determined that facility failed to ensure sufficient nurse aide 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. (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 minimum of 2.87 hours of direct resident care for each resident. Review of facility surveys completed since 7/1/23, through 7/2/24, revealed the following: Survey of 7/21/23: -Failed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, and resident and staff interviews, it was determined that the facility failed to provide a clean and comfortable environment for residents on three of seven nursing units (B Hall, Harmony, and Pinnacle Nursing Units). Findings include: Review of facility policy Cubicle Curtain Cleaning reviewed 1/3/24, indicated cubicle curtains will be inspected and cleaned. If curtains are stained or torn, remove immediately and replace. During observations on the B Hall nursing unit on 4/25/24 between 10:30 a.m. and 11:00 a.m., revealed the following: room [ROOM NUMBER] - privacy curtain with brown substance. room [ROOM NUMBER] - privacy curtain with brown substance on it, and brown smears on the bathroom door. room [ROOM NUMBER] - bathroom shower curtain with stains. room [ROOM NUMBER] - bathroom shower dirty, and privacy curtain with brown stains. room [ROOM NUMBER] - bathroom shower curtain with yellow stains room [ROOM NUMBER] - bathroom shower curtain with yellow stains, and reddish-brown stains on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy review, clinical and facility record review, facility submitted documents, and staff interviews, it was determined that the facility failed to provide adequate supervision to prevent elopement for one of five residents (Resident R1). This was identified as past non-compliance. Review of the facility policy Elopement of Patient dated 1/24/23, indicated residents will be evaluated for elopement upon admission, readmission, quarterly, and with a change in condition as part of the clinical assessment process. Those determined to be at risk will receive appropriate interventions to reduce risk and minimize injury. Review of the clinical record revealed Resident R1 was admitted to the facility on [DATE], with admitting diagnoses of dementia (a group of symptoms that affects memory, thinking and interferes with daily life), syncope (fainting or passing out), and history of falling. Review of an Elopement Risk Assessment completed on 3/27/24, at 7:23 p.m. indicated Resident R1 was at risk 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 observations and resident and staff interviews, it was determined that the facility failed to accommodate the call bell needs of one of five residents (Resident R1). Findings include: Review of the clinical record indicated that Resident R1 was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS - a period assessment of care needs) dated 8/16/23, indicated diagnoses of hypertension (high blood pressure), glaucoma (a group of eye conditions that can cause blindness), and malnutrition (lack of sufficient nutrients in the body). Review of Section G: Functional Status indicated Resident R1 required extensive assistance with bed mobility, transfers, dressing, toilet use, and personal hygiene. During an observation on 11/14/23, at 9:44 a.m. Resident R1 was observed lying in bed with his call light placed on a chair to the right of the bed, completely out of the resident's visual sight and reach. During an interview on 11/14/23, at 9:57 a.m. Registered Nurse (RN) Employee E1 confirmed 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 clinical record review, observations, and staff interviews, it was determined that the facility failed to ensure that residents receive proper treatment and assistive devices to maintain hearing abilities for one of five residents (Resident R1). Findings include: Review of Title 42 Code of Federal Regulations (CFR) §483.25(a) Vision and hearing states to ensure that residents receive proper treatment and assistive devices to maintain vision and hearing abilities. Review of the clinical record indicated that Resident R1 was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS - a period assessment of care needs) dated 8/16/23, indicated diagnoses of hypertension (high blood pressure), glaucoma (a group of eye conditions that can cause blindness), and malnutrition (lack of sufficient nutrients in the body). Review of Section B: Hearing, Speech, and Vision, indicated a hearing aid is used by Resident R1. The MDS also indicated that when the hearing aid was used (Question B0800) 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 review of facility policy and clinical records, and staff interview, it was determined that the facility failed to make certain medications were administered as ordered by the physician for 16 of 117 residents (Residents R1, R2, R3, R4, R5, R6, R7, R8, R9, R10, R11, R12, R13, R14, R15, and R16). Findings include: A review of facility policy General Dose Preparation and Medication Administration dated 1/24/23, indicated facility staff should comply with facility policy, applicable law and state operations manual when administering medications and verify medications will be administered with the correct medication, correct dose, correct route, correct rate, and correct time for the correct resident. A review of the clinical record indicated that Resident R1 was admitted to the facility on [DATE], with diagnoses that included dementia and hypothyroidism (low thyroid levels). A review of a physician order dated 8/1/23, indicated to give levothyroxine (hormone that treats hypothyroidism) 50 MCG (micrograms)…

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

Based on a review of facility policies, observations, and staff interviews, it was determined that the facility failed to properly label and date food and clean refrigerators in two of four nursing unit refrigerators (Pinnacle, and Harmony nursing units) creating the potential for food-borne illness. Findings include: A review of facility policy Food: Safe Handling for Foods from Visitors, reviewed 1/24/23, indicated that foods brought in from an outside source will be in a sealed container and labeled with the resident's name and the current date. Perform daily monitoring for refrigerated storage duration, and discard of any food items that have been stored for greater than or equal to 7 days. Refrigerators should be cleaned weekly. During an observation on 7/20/23 at 3:50 p.m., the Pinnacle Unit refrigerator contained a Styrofoam container with a sandwich in it with no date, and a plastic container with no name or date that contained spaghetti that had a green, fuzzy substance on top of the spaghetti. The pantry self also had four plastic bowls of cereal without dates. During an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on policy and clinical record review and resident and staff interviews, it was determined that the facility failed to make certain that showers were consistently provided for three of 20 residents (Resident R10, R12, R40). Findings include: Review of facility policy Activities of Daily Living dated 1/24/23, indicated that based on the comprehensive assessment of a patient and consistent with the patient's needs and choices, the Center must provide the necessary care and services to ensure that a patient's activities of daily living (ADL) abilities are maintained or improved and do not diminish. ADLS include hygiene- bathing, dressing, grooming, and oral care. Review of Resident R10's admission record indicated that Resident R10 was admitted to the facility on [DATE], with diagnoses that included chronic obstruction pulmonary disease, morbid (severe) obesity (chronic disease in which a person has a body mass index (BMI) of 40 or higher or a BMI of 35 or higher and is experiencing obesity-related 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 facility policy review and resident interviews, it was determined that the facility failed to provide care in an environment that promotes prompt assistance to meet resident care needs for one of five incontinent residents. (Resident R10) Findings include: Review of the facility policy Accommodation of Needs indicated the facility physical environment and staff behaviors should be directed towards assisting the patient in maintaining and/or achieving independent functioning, dignity, and well being to the extent possible in accordance with the patient's own needs and preferences. Review of Resident R10's admission record indicated the resident was admitted to the facility on [DATE], with diagnoses that included lung disease, (severe) obesity (chronic disease in which a person has a body mass index (BMI) of 40 or higher or a BMI of 35 or higher and is experiencing obesity-related health conditions), and dependence on other enabling machines and devices. Resident R10 is alert and oriented and able to make…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, observation, and staff interview, it was determined that the facility failed to ensure confidentiality of personal health information for two of 40 residents (Resident R16, and R21). Findings include: Based on the facility 2023 Welcome Packet, provided to residents at admission, residents have the right to be informed, make their own decisions, and have personal information kept private. Review of clinical record revealed that Resident R16 was admitted to the facility on [DATE]. Review of Resident R16's MDS (Minimum Data Set, periodic assessment of resident care needs) dated 5/13/23, indicated diagnoses that included traumatic brain injury (a disruption in the normal function of the brain), malnutrition (lack of sufficient nutrients in the body), and dysphagia (difficulty swallowing). During an observation on 7/19/23, at 11:01 a.m., a sign was noted to be taped to the wall above Resident R16's bed that read Nectar Thick Liquids (liquids that have slightly more body than…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, review of facility documentation, resident interview, review of clinical records and staff interview, it was determined that the facility failed to assess residents for smoking safety for one of five residents (Resident R117). Findings include: Review of the facility policy Smoking dated 1/24/23, indicated that the admitting nurse will perform a smoking evaluation on each resident who chooses to smoke. Residents will be re-evaluated quarterly and with a change in condition. Review of the facility Smoking List, provided on 7/18/23, indicated that Resident R117 was a current smoker. Review of the clinical record revealed that Resident R117 was originally admitted to the facility on [DATE]. Review of Resident R117's MDS (Minimum Data Set, periodic assessment of resident care needs) dated 6/29/23, indicated diagnoses of diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time), end stage renal disease (ESRD, an inability of the kidneys…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy and clinical record and staff interview it was determined that the facility failed to make certain consistent dialysis communication was maintained for one of one dialysis residents. (Resident R117). Findings include: Review of the facility policy Dialysis: Hemodialysis (HD)- Communication and Documentation dated 1/24/23, indicated that Center staff will communicate with the certified dialysis facility regarding the ongoing assessment of the resident's condition by monitoring for complications before and after HD treatments received at a certified dialysis facility. Upon return of the resident to the center, a licensed nurse will review the certified dialysis facility communication: evaluate/observe the residents and complete the post-hemodialysis treatment section on the Hemodialysis Communication Record. Review of the clinical record revealed that Resident R117 was admitted to the facility on [DATE]. Review of Resident R117's MDS (Minimum Data Set, periodic assessment of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy and clinical records and interview with staff, it was determined that the facility failed to make certain each resident's drug regimen is free from unnecessary drugs when used without adequate indication for use for one of five residents (Resident R10). Findings include: A review of the clinical record indicated Resident R10 was admitted to the facility on [DATE], with diagnoses that included COPD (chronic obstruction pulmonary disease), morbid (severe) obesity (chronic disease in which a person has a body mass index (BMI) of 40 or higher or a BMI of 35 or higher and is experiencing obesity-related health conditions), chronic pain, and dependence on other enabling machines and devices. Based on review of the facility policy Medication Administration: oral reviewed 1/24/23, indicated that the medication order on the medication administration record (MAR) should be used to verify the medication label for correct patient, drug, dose, route, and time. A review of the physician…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, facility document review and staff interviews, it was determined that the facility failed to maintain an infection prevention and control program, which ensured proper cleaning and disinfecting of glucometers (a device used to test the amount of sugar in a person's blood) to prevent the potential for cross-contamination for two of three residents observed (Resident R20, and R42) as required. Findings include: Review of the facility policy titled Fingerstick Glucose Measurement dated 6/15/22, indicated that staff should clean and disinfect meter before use with EPA approved disinfectant, following the manufactures instruction, and clean and disinfect meter after use with EPA approved disinfectant following the manufacture instructions. Review of the Centers for Disease Control and Prevention document Infection Prevention during Blood Glucose Monitoring and Insulin Administration reviewed 3/2/11, indicated that if blood glucose meters must be shared, the device should be cleaned 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.