Bristol Health & Rehab Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of clinical records, facility documentation and interviews with staff, it was determined that the Nursing Home Administrator and the Director of Nursing failed to effectively manage the facility related to the elopement of one of six residents reviewed (Residents R1) which resulted in an Immediate Jeopardy situation. Findings include: Review of the job description for the Nursing Home Administrator (NHA) stated that the primary purpose of the NHA's job description is to lead the nursing home facility and is responsible for the overall management and operational oversight of the facility, ensuring that high standards of care are maintained and regulatory requirements are met. This role requires strong leadership, excellent communication skills, and a commitment to providing outstanding care to our residents. Review of the job description for the Director of Nursing (DON) stated that the primary purpose of the Director of Nursing's job description is to oversee nursing services, ensure compliance…

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 the review of clinical record, interview with resident and staff, it was determined that the facility failed to ensure that each resident receive the medications that were ordered for by their physician and do not be administer medications ordered for another resident for 1 of 4 residents reviewed. (Resident R 1) Findings Include: Review of facility policy Administering Medication states that observe the five right in giving each medication, the right resident, the right time, the right medication, the right dose and the right route. Review Physician Orders policy states medication administration record/ treatment administration record the legal medical record for recording medication and treatment. Review of Resident's R1 clinical record, revealed the diagnosis of dementia (progressive degenerative disease of the brain) without behaviors and high blood pressure. Reviewed the investigation reported revealed that on October 5, 2024, at 0900 (9:00 a.m.), resident a [AGE] year-old male with Diagnosis of…

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

Based on observations, review of facility documentation and interviews with staff, it was determined that the facility failed to ensure that meals were served timely on two of three nursing units observed (First floor and Second floor nursing units). Findings include: Review of the facilities policy titled Dining Services Department policy and procedure Manual revealed adequate staffing will be provided to prepare and serve palatable attractive nutritiously meals at proper temperatures and at appropriate times and to support proper sanitary techniques being utilized. At least three daily meals will be provided at regular times comparable to normal mealtimes in the community and the time between a substantial evening meal and breakfast following will not exceed 14 hours. Review of facility documentation titled Mealtimes, revealed that facility mealtimes are as follow: Breakfast at 7:00 A.M., lunch starts at 12:00 P.M. and dinner starts at 5:00 P.M. Observation of first floor dining room wall posting of mealtimes revealed breakfast is served at 8:00 a.m. lunch is served at 11:30 a.m.,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, review of facility policies, review of facility documentation, clinical record review and interviews with staff, it was determined that the facility failed to maintain an effective infection control program related to infection surveillance for two of two residents reviewed with infections (Residents R154 and R33), infection data reporting, enhanced barrier precautions and infection committee meetings, and Enhanced Barrier Precaution for one of one resident reviewed (Resident R165). Findings include: Review of facility policy, Infection Prevention Program dated last reviewed February 24, 2022, revealed that the facility uses a systematic and data-driven method to prevent, track and trend infections, surveil for outbreaks and monitor infection control practices for compliance. Continued review revealed that the Infection Preventionist is responsible for monitoring infections and completing monthly line listings and report forms. The infection prevention program includes staff and 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.

Based on observations, review of facility's policies, interview with staff and resident, it was determined that the facility did not ensure that residents were treated with dignity and respect for 1 of 35 residents reviewed (Resident R62) Findings include: Review of facility investigation report for Resident R65 from February 12, 2024, revealed that the previous administrartor was reported on February 10, 2024, that a licensed nurse Employee E20 called Resident R65 wicked b*!*h. Reviewed investigation for Resident R65 statement on February 10, 2024, revealed [licensed nurse Employee E20] came to my room and didn't knock I asked her to knock, and she pulled open the privacy curtain and didn't close it. She called me a wicked white b*!*h. I was in the hallway. This was Saturday morning. Between 6am-7am. Further reviewed investigation statement from licensed nurse Employee E20 stated did anything happen with [Resident R65] on Saturday morning? Yes, I am always having problem with [Resident R65]. Every night I have to put her on behavior monitoring when you care for B bed. I have 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 clinical record review and staff interview, it was determined that the facility failed to develop and implement an individualized person-centered care plan to address a resident's dementia care needs for one of 35 residents reviewed (Residents R 141). Findings Include: Review of the admission sheet of Resident 141, revealed that Resident R141 was admitted to the facility on [DATE]. Review of Minimum Data Set assessment (MDS- an assessment tool to review all care areas specific to the resident such as a resident's physical, mental or psychosocial needs) dated August 20, 2024, revealed that Resident R 141 had active diagnoses of Non Alzheimer's Dementia (Dementia is not a specific disease but is rather a general term for the impaired ability to remember, think, or make decisions that interferes with doing everyday activities, it is a progressive disease that destroys memory and other important mental functions). Review of MDS revealed that Resident R 141 received Antipsychotic (Antipsychotic medications…

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

Based on observations, review of clinical records, and interviews with facility staff, it was determined that the facility failed to ensure that it was free of medication error rate of five percent or greater for two of six residents observed during medication administration (Resident R33, and R89). Findings include: On September 4, 2024, at 9:33 a.m., observed that Employee E21, a Licensed Nurse, administered to Resident R89, the medicine, Artificial Tears one drop in each eye. Review of physician order for Resident R89, dated March 26, 2024, revealed an order to administer Pataday Ophthalmic Solution 0.1 % (Olopatadine HCl), instill 1 drop in both eyes, two times a day for Allergic Conjunctivitis. At the time of the observation, interview with Licensed nurse Employee E21, confirmed the above findings. On September 4, 2024, at 10:20 a.m., observed that Employee E22, a Registered Nurse, did not administer to Resident R33, the medicine busPIRone HCl Oral Tablet 5 MG (Buspirone HCl), one tablet by mouth for Anxiety and Depression, even though Employee E22 searched for the medicine…

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, interviews, and clinical record reviews, it was determined that the facility failed to correctly administer medications in accordance with physician orders, for one of six residents' medication administration observed, and one of 32 resident records reviewed resulting in significant medication error ( Resident R159). Findings include: Review of clinical records revealed that Resident R159, was admitted in the facility on July 15, 2024, with diagnoses including Acute Osteomyelitis, Right Ankle and Foot (Osteomyelitis is an infection in a bone. Infections can reach a bone by traveling through the bloodstream or spreading from nearby tissue). Review of Resident R159's nurses note dated August 8, 2024, indicated that on August 7, 2024, during the night shift, instead of the physician ordered medicine, (order dated July 15, 2024), namely Cefepime HCl Solution 1 GM/50ML 1 gram for Diabetic Foot Ulcer, a Licensed Nurse Employee E24, administered the medicine namely, DAPTOmycin Solution Reconstituted 500 MG, intravenously. (Cefepime injection is used to treat…

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

Based on review of facility documentation, observations and resident and staff interviews it was determined that the facility failed to ensure residents were provided meals that honor food preferences for one of three nursing units. First floor). Findings include: Review of facility policy titled Dining Services Department policy and procedure Manual revealed the individual tray assembly tickets will identify all food items appropriate for the resident based on diet order allergies and intolerances and preferences. During meal service, any resident with expressed or observed refusal food will be offered an alternative selection of comparable nutritional value the alternate meal selection will be provided in a timely manner. Review of facility provided menu for September 3, 2024, revealed the lunch menu planned was to be tuna melt sandwich with buttered green peas and tater tots with alternative selection was honey Dijon chicken breast, green beans and parsley rice, both options served with tropical fruit salad. Observation of dining room lunch being served on September 3rd, 2023,…

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, interviews with staff, and review of facility policy, it was determined that the facility did not ensure that food was stores, prepared, distributed, and served in accordance with professional standards for food service safety related to labeling and dating of refrigerated food items and the use of hair nets. Findings include: Review of facility policy titled Dining Services Department policy and procedure Manual revealed adequate staffing will be provided to prepare and serve palatable attractive nutritiously meals at proper temperatures and at appropriate times and to support proper sanitary techniques being utilized. Proper food handling techniques to prevent contamination and temperature maintenance controls will be used for point of service dining. All staff members will have their hair off the shoulders confined in a hair net or cap and facial hair properly restrained. Per standards of the United States Department of Agriculture, Food Safety and Inspection Services (last updated July 2020) regarding Left Overs and Food Safety revealed leftovers can be…

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, review of facility documentation and interviews with staff, it was determined that the facility failed to ensure that the QAA (Quality Assessment and Assurance) committee meets at least quarterly to coordinate and evaluate activities under the QAPI (Quality Assurance and Performance Improvement) program as required. Findings include: Review of facility policy, QAPI (Quality Assurance and Performance Improvement) Plan undated, revealed that, The facility will have a QAPI meeting every month and that, Quarterly data will be reviewed over a quarter time frame on monthly meetings following the end of a quarter. Review of facility documentation related to QAPI meetings revealed that meetings were conducted in January, July and August 2024. Documentation included attendance logs of the QAA committee, data analysis of quality measures, analysis of resident care and performance improvement projects. There was no documentation available for review at the time of the survey related to QAPI meetings for any other months in 2024. Interview on September 9,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policies, review of facility documentation, clinical record reviews and interviews with staff, it was determined that the facility failed to maintain an effective antibiotic stewardship program for two of two of residents reviewed for antibiotics (Residents R154 and R33). Findings include: Review of facility policy, Antibiotic Stewardship Overview dated revised March 11, 2022, revealed, The facility will provide surveillance, tracking, trending and reporting to the leadership team to optimize the use of antibiotics in this facility. Continued review revealed, Provide standardized practices for the care of a resident suspected of an infection and/or one in which antibiotics are initiated. Standardized practices are comprised of a group of broad interventions to improve antibiotic use including but not limited to: Evaluation and reporting clinical signs and symptoms improvement; optimizing the use of diagnostic testing; and implementing an antibiotic review process (antibiotic time-out)…

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 interviews with staff, it was determined that the facility failed to designate one or more individuals as the infection preventionist who work at least part time at the facility. Findings include: Review of facility policy, Infection Prevention Program dated last reviewed February 24, 2022, revealed, that an Infection Preventionist is a nurse, epidemiologist, public health professional, microbiologist, physician, or other health professional who works to prevent germs from spreading within the healthcare facility and is qualified by training and experience to oversee the infection prevention program for the facility. Continued review revealed that the Infection Preventionist's responsibilities include infection surveillance including tracking, trending and identification of specific organisms; reporting of infectious outbreaks; compliance review, provides staff education and feedback; completes the line listing of infections; completes monthly report forms and reports findings to the QAPI (Quality Assurance Performance improvement) committee.…

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 interviews with staff, it was determined that the facility failed to equip corridors with safe handrails on each side, for two of three nursing units observed (First and Second floor nursing units). Findings include: Observation of the First Floor Nursing Unit on September 3, 2024, at 10:05 a.m. revealed the following: The handrail by room [ROOM NUMBER] was broken and top part coming off. The handrail by room [ROOM NUMBER] was broken. Observation of the Second Floor Nursing Unit on September 3, 2024, at 12:51 p.m. revealed the following: The handrail by room [ROOM NUMBER] was cracked with exposed sharp edges; The handrail by room [ROOM NUMBER] was broken and covered with tape; and The handrail between rooms [ROOM NUMBERS] was missing. Interview on September 3, 2024, at 2:00 p.m. the Nursing Home Administrator confirmed that handrails were broken or missing and that a full audit of all handrails would be conducted. Interview on September 4, 2024, at 2:37 p.m. 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility documents, facility policy, clinical records, and staff interview, it was determined that the facility failed to conduct a thorough investigation of a misappropriation of medication to rule out neglect for one of 3 residents (Resident R1). Findings include: Review of facility policy Pennsylvania Abuse, Neglect and Misappropriation undated, indicated neglect is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Review of the clinical record indicated Resident R1 was admitted to the facility on [DATE], with diagnosis of fracture of unspecified part of neck of left femur, acute kidney failure, postlaminectomy syndrome; difficult in walking, need assistance with personal care, neuromuscular dysfunctional of bladder, urinary tract infection. Review of Resident R1's Minimum Data Set (MDS - a periodic assessment of care needs) dated July 21, 2024,…

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 reviewof clinical record, review of facility documentation and interview with staff, it was determined that the facility failed to ensure that hospital recommendation were address for one of three clinical records reviewed. (Resident R1) Findings include: Review of Resident R1's clinical record revealed that the resident was admitted to the facility on [DATE], with diagnosis of fracture of unspecified part of neck of left femur, acute kidney failure, postlaminectomy syndrome (chronic pain following back surgery); difficult in walking, need assistance with personal care, neuromuscular dysfunctional of bladder, urinary tract infection. Review of Resident R1's Minimum Data Set (MDS - a periodic assessment of care needs) dated July 21, 2024, revealed a Brief Interview for Mental Status (BIMS) of 15 which indicated that the resident was cognitively intact. Continued review Resident R1's clinical record revealed that the resident developed a right heel suspected deep tissue injury on January 31, 2024. Review…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, observation, and staff interview, it was determined that the facility failed to provide treatment and interventions to promote the healing of pressure ulcers for one of three sampled residents with pressure ulcers. (Resident 1) Findings include: Review of Resident R1's clinical record revealed that the resident was admitted to the facility on [DATE], with diagnosis of fracture of unspecified part of neck of left femur, acute kidney failure, postlaminectomy syndrome (condition characterized by chronic pain following back surgery); difficult in walking, need assistance with personal care, neuromuscular dysfunctional of bladder, urinary tract infection. Review of Resident R1's Minimum Data Set (MDS - a periodic assessment of care needs) dated July 21, 2024, revealed a Brief Interview for Mental Status (BIMS) of 15 which indicated that the resident was cognitively intact. Continued review Resident R1's clinical record revealed that the resident developed a right heel suspected deep…

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, resident and staff interview, and a review of facility documentation, it was determined that the facility was not maintaining an effective pest control program. Findings include: During the entrance meeting with Administrator, Employee E1 on December 11, 2023, at 9:30 p.m. revealed facility has two pest control companies doing treatment at the facility. The local pest control company did twice a week treatment and a second pest control company was from out of state. Review of the pest control log it was confirmed that the last treatment was complete on December 8, 2023, treating room [ROOM NUMBER]. room [ROOM NUMBER] was last treated on November 8, 2023, from flies. There was no documentation of any residents refusing of having their room treated. On December 11, 2023, at 12:29 p.m. an interview with Resident R7 resigning in room [ROOM NUMBER] revealed that he/she saw a live roach in the middle of his room. On December 11, 2023, at 12:33 p.m. an interview with Resident R5 resigning in room…

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 interviews with staff, it was determined that the facility did not ensure that food was stored, prepared, distributed, and served in accordance with professional standards for food service safety. Findings include: Review of facility policy titled, Food Storage: Cold Foods dated April 2018, indicated that Freezer temperatures will be maintained at a temperature of 0 F or below. An accurate thermometer will be kept in each refrigerator and freezer. A written record of daily temperatures will be recorded. All foods will be stored wrapped or in covered containers, labeled and dated, and arranged in a manner to prevent cross contamination. Observations in the walk-in freezer with Employee E14, Food Service Director, on November 27, 2023, 9:45 a.m. revealed that the freezer thermometer was indicating a temperature of 36-degree Fahrenheit (F). There were multiple boxes and bags of different food items in the freezer including the meat items which were soft to touch. Interview with Employee E14 on November 27, 2023, 9:45 a.m. stated 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.

Review of facility documentation and interview with residents, it was determined that the facility failed to ensure that residents preferences were honored on two of two floors. (2nd floor) Findings include: Review of 'Unit 2 activity calendar' for November 2023 revealed the following scheduled activities for November 28, 2023: 10:00 am coffee social 11:30 fresh air 1:30 calming coloring 2:30 fresh air/karaoke 2:45 manicures 4:00 room visits Interview with Resident R66, on November 27, 2023 at 11:30 am, revealed that staff do not assist her with going out for fresh air. Resident R66 stated that she would prefer to have fresh air breaks in non-smoking area since she is non-smoker. Interview with facility's Activities Director, Employee E11, on November 27, 2023, revealed that non-smoking residents are using smoking patio for fresh air breaks. Employee E11 stated that nursing aides are responsible for taking residents on second floor unit out for fresh air breaks. Interview with nursing staff on second floor unit, Employees E6, E7, E8, E9 and E10, on November 28, 2023 at 11:45 am,…

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, it was determined that the facility failed to ensure a clean, homelike environment for two of two nursing floors of 32 residents reviewed. (Rooms 105, 120, 128, 131 and 211) Findings include: Observations of room [ROOM NUMBER] on first floor unit, on November 27, 2023 at 10:30 am, revealed stained privacy curtain, stained ceiling above bed A, and stained bed linens on bed B. Resident R3's unclean personal laundry was observed stored behind television. Observations of room [ROOM NUMBER] on second floor unit on November 27, 2023 at 11:00 am revealed stained privacy curtain. Observation of room [ROOM NUMBER] on first floor unit on November 27, 2023 at 11:07 a.m. revealed an air conditioner with chipped painted on top of it and the wall above it had paint peeling off. Observation of room [ROOM NUMBER] on the first floor unit on November 27, 2023 at 1:05 p.m. reaveled two wholes unrepaired on the exterior of the bathroom door. Observation of room [ROOM NUMBER] on the first floor unit on…

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

Based on review of facility policy, observations, and interviews with residents and staff, it was determined that the facility failed to ensure a formal grievance process was in place for one of 32 residents reviewed (Resident R108). Findings Include: Review of facility policy titled Resident Grievances with a review date of May 5, 2019 states, The facility will make available to all residents posting in a prominent location in the facility information of the right to file grievances orally or in writing; the right to file grievances anonymously; contact information for the Grievance Official; a reasonable timeframe for completing the review of the grievance, the right to obtain a written decision regarding the grievance; and contact information for independent entities with whom grievances may be filed. Further review of facility policy revealed The Grievance Official will meet with the resident and inform the resident of the results of the investigation and how the resident's grievance was resolved or will be resolved, if applicable. Interview held with Resident R108 on November…

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 records, observations, and staff interviews, it was determined that the facility failed to update care plans to meet care needs for three of 32 residents reviewed (R90, R127, R135) Findings Include: Review of the care plan policy titled Plan of Care Review undated reads, It is the policy of this facility to provide resident centered care that meets psychological, physical and emotional needs and concerns of residents. Safety is a primary concern for our residents, staff and visitors. The purpose of the policy is to provide guidance to the facility to support the inclusion of the resident or resident representatives in all aspects of person-centered care planning and that this planning includes the provision or services to enable the resident to live with dignity and support the resident's goals, choices, and preferences including, but not limited to, goals related to their daily routines and goals to potentially return to a community setting. Review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, review of clinical record, review of facilty policy and staff interviews, it was determined that the facility failed to provide appropriate respiratory care and services for two of two residents reviewed (Residents R65 and Resident R28). Findings include: Review of an undated facility policy Oxygen Medical Gas Use, revealed that Oxygen will be ordered by a physician or other authorized provider. Will have a physician/provider's order for the oxygen including route of administration, liters per minutes and the frequency of use. Pure oxygen is irritating to mucus membranes, humidification may be requited for comfort. Review of the clinical record revealed that Resident R65 was admitted to the facility on [DATE], with diagnoses of Chronic Obstructive Pulmonary Disease (COPD), (a group of diseases that cause airflow blockage and breathing-related problems). A review of Resident R65's clinical record revealed a physician order, dated October 29, 2023 for Oxygen at 3 liters / min via Nasal…

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 the review of facility documentation and staff interview, it was determined that the facility failed to ensure that nursing staff possessed the appropriate competencies and skill sets related to the care of residents with tracheostomy (a surgical airway management procedure which consists of making an incision on the anterior aspect of the neck and opening a direct airway through an incision in the trachea) and PICC and Midline line ( a tube placed in a large vein in the neck, chest, groin, or arm to give fluids, blood, or medications or to do medical tests quickly) dressing changes for 20 of 20 staff reviewed (Employee 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49 and 50) Findings include: A review of the facility documentation revealed that the facility had four residents with Midline and PICC line catheters who received care and services from staff including site assessment, medication administration and dressing changes. A review of facility documentation revealed that the facility provided care of a resident with tracheostomy from April…

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, review of facility documentation, and interview with staff and resident, it was determined that facility failed to utilize and implement non-pharmacological approaches to care in accordance with the resident's abilities, customary daily routine, interests, preferences, and choices on one of 32 residents reviewed. (Resident R7) Findings include: Review of facility's policy 'Behavior Management General,' indicates that problematic behaviors include yelling/screaming and interdisciplinary team is to complete care plan and involve social services and activities departments as appropriate, review pharmacological and non-pharmacological interventions, and include resident specific interventions. Review of Residents R7's clinical records revealed diagnosis of cognitive communication deficit, aphasia, schizoaffective disorder, anxiety, bipolar and major depressive disorder. Review of Resident R7's care plan revealed that resident had a behavior problem related to refusals with taking medications at times including insulin, taking showers, obtaining blood work 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, interviews with residents and staff, and review of resident documentation, it was determined that the facility failed to routinely offer evening snacks to residents. Findings Include: Review of facility policy titled Snacks with a revision date of September 2017 states, Snacks and beverages will be provided as identified in the individual plans of care. Bedtime (a.k.a HS) snacks will be provided for all residents. Additional snacks and beverages will be available upon request for all residents who want to eat at non-traditional times. Further review of the policy states, 3. Snacks will be assembled, labeled, and dated in accordance with the individual plan of care for each resident and those items will be delivered to patient care areas in a timely manner. Interview with Resident R21 on December 4, 2023 at 10:34 a.m. revealed the resident was diabetic and had not been receiving a snack in the evening. The resident stated that she will save items from breakfast like cereal or yogurt to have for a snack in the evening. Observation of Resident R21…

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, interviews with staff, and review of clinical records, it was determined that the facility failed to ensure that neurological checks were documented one of 32 residents reviewed. (Resident R144). Findings include: Review of the facility policy titled, Neurological Checks (Neuro-checks) revised June 21, 2018 states, It is the policy of this facility to provide resident centered care that meets the psychological, physical and emotional needs and concerns of the residents. Safety is a primary concern for residents, staff and visitors. The purpose of this policy is to guide the nurse in performing neurological checks, usually performed after a head injury or suspicion of a head injury from falls or blows to the head, but may be performed for other reasons in which there is a concern for vascular events included but not limited to cardiovascular accident (CVA or stroke), seizure activity, and brain infections. Further review of the facility policy revealed under Documentation: Complete the Post Fall Assessment, If the resident hit their head or 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 clinical records, facility policies and procedures, and interviews with staff, it was determined that the facility failed to ensure that the physician ordered hospice care was provided for one of 32 residents reviewed. (R105). Findings include: Review of the Hospice Policy of the Facility, Policy #: NS-1178-01, revealed; End of life care or hospice care is a valuable resource to families and residents and will be provided while the resident is in the facility at the request of the resident, responsible party/family, and physician. The facility is responsible for working with hospice care services to provide the optimum benefits for end-of-life care including pain relief, custodial care, and resident preferences to the extent possible. Communication between the facility staff and the hospice care staff is an integral part of this partnership. Review of the clinical record for Resident R105 revealed that the resident was admitted to the facility on [DATE], with diagnoses of Colostomy Status, (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 policies, review of clinical records and interview with residents and staff, it was determined that the facility failed to ensure that medical consultations with specialists were scheduled for one of nine residents reviewed. (Resident R1) Findings include: Review of policy titled Provisions of Physician Ordered Services stated that the attending physician shall authenticate orders for the care and treatment of assigned residents, including orders from consulting prescribers. Continued review of this policy stated qualified nursing personal will summit timely requests for physician ordered services (laboratory, radiology, consultations) to the appropriate entity. Review of Facilities Transport Policy stated the facility must provide the resident centered care that meets the psychosocial, physical, and emotional needs and concerns of the residents. The facility will assist the resident in making transportation arrangements to and from the source of any needed service, such as a dental visit, or physician visits in the event of the resident requires such…

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 the review of facility policies, review of clinical records and interview with staff, it was determined that the facility failed to notify the resident and the resident's representative(s) of the transfer to the hospital and the reasons for the transfer in a timely manner, in writing and in a language and manner they understood after a selected resident was transferred to the hospital for one of two residents reviewed. (Resident R3) Findings Include: Review of MDS (Minimum Data Set-Assessment of resident care needs) for Resident R2 dated May 16, 2023, revealed that the resident had a BIMS score of 3 which indicated that the cognitive status was severely impaired. Review of nursing note for Resident R3 dated May 22, 2023, revealed that the resident was observed with increased lethargy, abnormal labs, and hyperglycemia (increased blood sugar). Physician and family notified, and resident was sent to the hospital for evaluation. Further review of nursing note dated May 22, 2023, revealed that the resident was admitted to the hospital. Review of clinical record revealed 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 a review of clinical records, facility documentation and staff interview, it was determined that the facility failed to develop, re-evaluate and implement an individualized discharge plan for two of four residents reviewed (Resident R1 and R2). Findings Include: Review of facility care plan Discharge Planning dated July 7, 2020, revealed, A process that generally begins on admission and involves identifying each resident's discharge goals and needs, developing and implementing interventions to address them, and continuously evaluating them throughout the resident's stay to ensure a successful discharge. Procedure: 1) The discharge planning process must be consistent with the discharge rights set forth at 483.15(b) as applicable and 2) Ensure that the discharge needs of each resident are identified and result in the development of a discharge plan for each resident. Work with the clinical team to assure all needs have been identified 3) Include regular re-evaluation of residents to identify changes that require modification of the discharge plan. The discharge plan must be…

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, staff interviews, review of employee job descriptions, employee credentials and current staffing of the facility's food and nutrition services department, it was determined that the facility failed to ensure the appropriate services of a full-time qualified dietician. Findings include: Review of job description for Clinical Dietician II revealed that Job Duties and Responsibilities 1. Completes quarterly and annual nutrition assessments on all residents by following the Nutrition care Process guidelines. Documents pertinent interventions regarding malnutrition, significant weight changes, and skin abnormalities according to facility policies. 2. Develop and implement nutrition interventions for all new admission and residents at high nutritional risk by documenting medical and nutrition-related data, providing individualized education, and monitoring daily intakes that contribute to the overall progress in relation to the plan of care and that comply with national standards. 3. Effectively…

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

Based on clinical record review, observations and resident and staff interviews, it was determined that the facility failed to ensure each resident was served food that accommodates resident's preferences for one of 5 residents reviewed (Resident R2). Findings include: Interview with Resident R2 on August 9, 2023, at 10:30 a.m. stated he did not always receive foods that he orders, and kitchen always sent wrong food for him. Resident R2 stated was ordered double portion and he did not always receive it. Review of Resident R2's physician orders dated August 1, 2023, revealed that the resident was ordered double potion regular diet for nutrition. Observation of Resident R2's lunch tray on August 9, 2023, at 12:30 p.m. revealed that the resident was eating in his room. It was revealed that the resident was not provided a double portion size lunch. An interview with the Licenses Nurse, Employee E5, on August 9, 2023, at 12:30 p.m. confirmed that Resident R2 did not receive double portion as ordered. 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.10(c) Resident care policies

Based on observations, review of the consulting pest control reports, review of facility documentations, and interviews with staff and residents, it was determined that the facility failed to maintain an effective pest control program in the resident care areas for one of three nursing units reviewed. (1st Floor) Findings include: Review of pest control operators report dated August 2, 2023, revealed that there was activity in fly lights and technicians noted kitchen exit door propped open which can alleviate rodent entry into the building. All door not in use should remain closed to prevent entry. Interview with Resident R3 on August 9, 2023, at 10:00 a.m. stated there was flies in her room. She stated she had this problem for a while without any improvement. At the time of the interview, it was observed that there was a fly flying in her room. Review of grievance form filed by Resident R3's family dated November 15, 2022, revealed that the resident was admitted to a Third-floor room with flies, roaches and mice. An observation of Resident R4 on August 9, 2023, at 10:00 a.m with…

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

Based on observations of the physical environment, reviews of the pest control operator's reports, and interviews with residents, staff, and family member, it was determined that the facility failed to maintain an effective pest control program to ensure that the facility was free of pests for two nursing units (First floor and Second floor) Findings include: Observation conducted on January 23, 2023, at 9:58 a.m. of the First floor nursing unit revealed crawling roach in the men's room. On January 23, 2023, at 12:07 p.m. gnats were observed in the conference room on the First floor unit. Review of Resident Council Minutes Noted for the months of November 2022- January 2023 revealed that residents did report concerns with mice being in the building. An interview with Resident R8 on January 24, 2023, at 9:37 a.m. reported that he observed a mouse in his room a couple of days ago. An interview with a family member of Resident R172 on January 23, 2023, at 1:37 p.m. revealed that a month ago this family member observed mouse droppings in a drawer that had no food items stored.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, clinical record review and staff interviews, it was determined that the facility failed to ensure that a comprehensive, person-centered care plan was developed related to an indwelling urinary catheter and that a care plan was implemented related to nutrition for two of the 34 residents reviewed (Residents R267 and Resident R7). Findings include: Based on the policy titled Care Plan Overview states the purpose of the policy is to provide guidance to the facility to support the inclusion of the resident or resident representative in all aspects of person-center care planning and that this planning includes the provision of services to enable the resident to live with dignity and support the resident's goals, choices and preferences. A review of Resident 267's clinical record revealed diagnoses of acute renal failure (sudden inability of the kidney to filter waste from the blood). Review of Resident 267's nursing documentation dated, January 15, 2023, revealed that Resident R267 became…

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, reviews of resident clinical records, facility policies and procedures, and interviews with staff and residents, it was determined that the facility failed to follow physician orders related to an indwelling urinary cather for one of 34 residents reviewed. (Resident R27) Findings include: Review of the clinical records of Resident R27 revealed that the resident was admitted to the facility on [DATE] with the diagnoses of Dementia (group of conditions characterized by impairment of at least two brain functions, such as memory and judgment), and Neuromuscular Dysfunction of Bladder (a person lacks bladder control due to brain, spinal cord or nerve problems). On January 25, 2023, at 1:56 p.m. Resident R27 was observed with a suprapubic urinary catheter with 18 FR (French) size, and 30 cc balloon. (A Suprapubic Catheter is a surgically created connection between the urinary bladder and the skin used to drain urine from the bladder in individuals with obstruction of normal urinary 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 observation, clinical record review and staff interview, it was determined that the facility failed to to administered intravenous therapy in accordance with professional standards of practice for one of one resident receiving intravenous therapy. (Resident R216) Findings include: Review of the clinical records of Resident R216 revealed that the resident was admitted to the facility on [DATE], with diagnoses of Endocarditis (an infection of the heart's inner lining, usually involving the heart valves, usually occurs when germs from elsewhere in the body travel through the blood and attach to damaged areas of the heart), Methicillin Susceptible Staphylococcus Aureus Infection-MSSA ( an infection caused by a type of bacteria commonly found on the surface of the skin, such as the inside of the nose, transmitted through skin-to-skin contact, most often from touching something that contains the bacteria and then spreading it to the hands), and Sepsis (chemicals released in the bloodstream to fight 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 clinical record review, observation and staff interview, it was determined that the facility failed to to follow physican orders related to the tracheostomy care for one of one resident review with a tracheostomy. (Resident R30) Findings include: Review of Resident R30's clinical records revealed that the resident was admitted to the facility on [DATE], with diagnoses of Chronic Obstructive Pulmonary Disease-COPD (a group of lung diseases that block airflow and make it difficult to breathe), Chronic Respiratory Failure with Hypoxia (occurs when the body is unable to remove enough carbon dioxide from the blood), and Malignant Neoplasm of Larynx (Cancer of the Larynx, or Voice Box). Review of physician order, dated November 30, 2022, for Resident R27, indicated for Trach Change to downsize to Shiley 4 CFS, as needed (Trach is a short-form-word to indicate Tracheostomy; Tracheostomy is a hole that surgeons make through the front of the neck into the windpipe (trachea); a tracheostomy tube is placed into…

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 of the Food and Nutrition Services, reviews of policies and procedures, food committee meeting minutes, and interviews with residents, it was determined that the facility failed to ensure that each resident received foods and beverages that were at appetizing temperatures. Findings include: The facility's policy regarding meal temperatures, dated September 2017, Healthcare Service Group, Inc. and its subsidiaries Food: Preparation revealed that The Dining Service Director/ Cook(s) will be responsible for food preparation techniques which minimize the amount of time that food items are exposed to temperatures greater than 41 degrees Fahrenheit and or less than 135 degrees Fahrenheit or per state regulation. On January 25, 2023, at 12:54 p.m. a test tray was conducted in the presence of the Food Director, Employee E9, which revealed that the temperatures of the hot foods tested were below the facility's established policy of 135 degrees Fahrenheit and the temperature of the cold foods tested were above 41 degrees Fahrenheit at the point of service for 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.