Pine View Healthcare And Rehabilitation Center

Based on review of the Resident Assessment Instrument User's Manual and residents' clinical records, as well as staff interviews, it was determined that the facility failed to complete accurate Minimum Data Set assessments for four of 65 residents reviewed (Residents 9, 10, 34, and 111).Findings include: The Resident Assessment Instrument (RAI) User's Manual, which gives instructions for completing Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2024, revealed that Section N0450D (antipsychotic medication review) was to be checked (1) yes, if a physician documented a GDR (gradual dose reduction-process involves slowly tapering a patient's medication to see if their symptoms can be managed with a lower dose or if the drug can be discontinued entirely) as clinically contraindicated. Physician's orders for Resident 9 dated May 21, 2025, included for the Resident to receive 0.5 milligrams (mg) of Risperdal (an antipsychotic medication) two times a day. Review of psychiatric consults for Resident 9 dated June 11, 2025, 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 policies and clinical records, as well as staff interviews, it was determined that the facility failed to develop and implement an individualized care plan for one of 65 residents reviewed (Resident 13). Findings include:The facility's policy regarding care plans, dated March 12, 2025, indicated that a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Care plan interventions are chosen based on relevant clinical data and decision making. Assessments of residents are ongoing, and care plans are revised as information about the residents and the residents' conditions change. The interdisciplinary team reviews and updates the care plan when there has been a significant change in condition, when the desired outcome has not been met, when the resident has been readmitted from the hospital and at least quarterly, in conjunction with the required quarterly Minimum Data Set (MDS) assessment.A quarterly Minimum Data…

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

Based on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that a resident's care plan was updated/revised to reflect the resident's specific care needs for two of 65 residents reviewed (Residents 5 and 13).Findings include:The facility's policy regarding care plans, dated March 12, 2025, indicated that a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Care plan interventions are chosen based on relevant clinical data and decision making. Assessments of residents are ongoing, and care plans are revised as information about the residents and the residents' conditions change. The interdisciplinary team reviews and updates the care plan when there has been a significant change in condition, when the desired outcome has not been met, when the resident has been readmitted from the hospital and at least quarterly, in conjunction with the required…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that interventions were in place to prevent urinary tract infections for one of 65 residents reviewed (Resident 13) who had an indwelling urinary catheter.Findings include:The facility's policy regarding indwelling urinary catheters (a flexible tube inserted and held in the bladder to drain urine), dated March 12, 2025, revealed that catheter drainage bags were to be kept off the floor.A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 14, dated July 9, 2025, revealed that the resident was cognitively impaired, incontinent of bladder, and had urinary tract infections.Physician's orders for Resident 11, dated August 19, 2025, included an order for the resident to have an indwelling urinary catheter due to a pressure ulcer.Observations of Resident 14 on August 26, 2025, at 2:27 p.m. revealed 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 manufacturer's instructions and clinical records, as well as observations and staff interviews, it was determined that the facility failed to maintain a medication administration error rate of less than five percent. Findings include:Observations during medication administration on August 24, 2025, revealed that two medication administration errors were made during 25 opportunities for error, resulting in a medication administration error rate of 8.00 percent.Current manufacturer's directions for use of Advair (Fluticasone-Salmeterol) Inhalation Aerosol Powder (used to treat chronic obstructive pulmonary disease (COPD) and Asthma) revealed that serious side effects including thrush (a fungal infection in the mouth and throat) can occur. Rinse the mouth with water without swallowing after use to reduce the chance of getting thrush.Physician's orders for Resident 66, dated January 24, 2025, included an order for the resident to receive 100-50 micrograms of Fluticasone-Salmeterol Inhalation Aerosol Powder with instructions to inhale 1 puff orally twice daily for…

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

Based on review of manufacturer's instructions, as well as observations and staff interviews, it was determined that the facility failed to date an opened multidose vial of Aplisol tuberculin (TB) solution (used to test for tuberculosis infection) in one of two medication storage area refrigerators reviewed (1 Main) and failed to provide a separately-locked, permanently-affixed compartment in the refrigerator for the storage of controlled drugs (medications that have the potential to be abused) in two of two medication storage area refrigerators reviewed (1 main and 2 West).Findings include: Manufacturer's instructions for Aplisol TB solution, dated November 2013, indicated that vials in use more than 30 days should be discarded due to possible oxidation and degradation which may affect potency. Observations of the facility's medication storage area refrigerator on 1 Main, on August 26, 2025, at 11:01 a.m. revealed an opened and undated vial of Aplisol TB solution. The narcotic box in the refrigerator was fixed to the shelf and did not contain any narcotic medications; however, 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 upon review of personnel records, it was determined the facility failed to obtain an FBI clearance for one of one employee reviewed (Employee E6). Findings include: Review of Employee E6's personnel file revealed Employee E6 was hired on April 24, 2024 and indicated they had not resided within the Commonwealth of Pennsylvania during the previous two years. Further review of Employee E6's personnel file failed to reveal evidence of an FBI background clearance. Interview with Employee E3 on August 28, 2024, at 11:00 a.m. revealed that the facility failed to obtain an FBI background clearance for Employee E6. The above information was conveyed to the Nursing Home Administrator and Director of Nursing on August 28, 2024, at 11:15 a.m. 28 Pa. Code 201.18(b)(1)(2) Management Previously cited 9/26/2023, 1/17/2024

Based on review of the facility's policy, clinical records, and staff interviews, it was determined the facility failed to comprehensively investigate an unknown injury for one of the three residents reviewed (Resident 146). Findings include: Review of the facility's policy titled Abuse Prevention Program revised in 2016, revealed, the administrator will ensure that all injuries are investigated. Injury of unknown source is defined as an injury that meets the following: The injury was not observed by any person, or the source of the injury could not be explained by the resident. The Director of Nursing (DON) or a designee will assess all injuries and document clinical findings in the clinical record. The investigator will compile a list of all personnel, including consultants, contract employees, visitors, family members, etc., who had contact with residents during the past 48 hours. Review of Resident 146's diagnoses including Alzheimer's disease (irreversible, progressive degenerative disease of the brain, resulting in loss of reality contact and functioning ability), Psychosis…

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

Based on clinical record review and staff interview, it was determined the facility failed to timely obtain a urine specimen for testing according to physician orders for one of 32 residents reviewed. (Resident 58) Findings include: Review of Resident 58's clinical record revealed a progress note dated July 30, 2024, at 2:01 p.m. which indicated During afternoon rounds, resident appeared lethargic; resident will answer to name being called but more confused than (his/her) regular baseline. Resident will occasionally jerk but is unaware of jerking when asked. Call placed to MD (Medical Doctor), spoke to NP (Nurse Practitioner); NP stated MD will be notified. Awaiting call back. Further review of Resident 58's progress notes revealed on July 31, 2024, at 2:47 p.m. Still awaiting call from MD about resident confusion and not being (his/her) regular baseline. Resident occasionally jerk and appears to be more confused than normal. Review of Resident 58's August 2024 physician orders revealed an order dated August 2, 2024, UA/CS ASAP [urinalysis/culture and sensitivity as soon as…

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

Based on review of clinical records, facility documentation, observations and staff interview it was determined the facility failed to provide care and services to prevent the development and/or worsening of pressure ulcer and promote healing for one of 31 residents sampled (Resident 103). Findings include: Review of Resident 103's clinical record revealed the resident was admitted to the facility was on August 20, 2021, with diagnoses that included Muscle Weakness (decrease in muscle strength), Dysphagia following cerebral infraction (difficulty swallowing after stroke), Hemiplegia and Hemiparesis following cerebral infraction affecting right dominant side (paralysis of the entire right side of the body), Gastrostomy status (tube feed), bedridden (confined to bed), and Type 2 Diabetes Mellitus (long-term condition where the body doesn't properly regulate and use sugar). Review of Resident 103's clinical record revealed a progress note dated April 29, 2024, at 4:42 a.m. Resident have some redness around stoma (site where peg tube enters the body), G/T (Gastrostomy tube) is…

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

Based on facility policy, clinical record review, and staff interview, it was determined the facility failed to obtain and monitor weights for one of 12 residents reviewed for nutrition (Resident 83). Findings include: Review of facility policy, Weight and Weight Change Management, revised 2024, revealed each patient will be weighed monthly or more frequently as deemed necessary by Physician's order, Dietitian, or IDT [interdisciplinary team]. Residents with a suspected weight change (per MDS [Minimum Data Set - periodic assessment of resident needs] guidelines) will have a re-weight completed in a timely manner. All confirmed re-weights will be documented in the electronic medical record. Review of Resident 83's clinical record revealed a weight of 164.4 pounds on July 3, 2024. Resident's weight was recorded as 150.0 pounds on August 1, 2024, a loss of 14.4 pounds or 8.8%. Further review of the clinical record revealed a weight change note on August 16, 2024, (15 days after the weight was obtained) indicated the resident triggered for a significant weight loss over 30 days 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 hospital records review, clinical records review, and staff interview, it was determined that the facility failed to ensure appropriate diagnosis for Antipsychotic medication and failed to attempt nonpharmacological intervention and appropriate indication for administration of as-needed anti-anxiety medication for one of five residents reviewed (Resident 73). Findings include: Review of Resident 73's physician orders dated June 18, 2024, revealed an order for Lorazepam (Anti-anxiety medication) 0.5 mg one tablet every 12 hours as needed for agitation. Review of Resident 73's June 2024, Medication Administration Record (MAR) revealed from June 18, 2024, until June 24, 2024, the resident was administered as-needed Lorazepam five times. Review of Resident 73's clinical records revealed that aside from agitation there were no appropriate indications as to why Lorazepam was administered to the resident. Additional review failed to reveal that non-pharmacological interventions were attempted before administering Lorazepam to Resident 73. Interview conducted with 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.

Based on clinical records review, and interviews with resident and staff interviews, it was determined that the facility failed to ensure an order for NPO (nothing per mouth) before a procedure was followed for one of the two residents reviewed (Resident R1). Findings include: Review of Resident R1's clinical record revealed Resident R1 was admitted to the facility with a diagnosis of Atrial Fibrillation (irregular heartbeat), awaiting hip surgery, and Intellectual disability. Review of Resident R1's admission Minimum Data Set (MDS- A standardized assessment tool that measures health status in long-term care residents) dated January 3, 2024, revealed resident's cognition was intact. Review of the nursing progress notes dated February 22, 2024, at 2:39 p.m., revealed resident returned from a Cardiologist (A physician who specializes in heart conditions) appointment. The note revealed that the resident was scheduled for a Transesophageal Echocardiogram (TEE- An ultrasound that provides highly detailed images of the heart and its internal structure) on February 28, 2024, at [Hospital…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interviews, it was determined that the facility failed to maintain an environment that was safe and sanitary in three of 11 rooms observed on the 3rd Floor Unit (rooms [ROOM NUMBER]) Findings include: Observation on the 3rd-floor unit room [ROOM NUMBER] conducted on January 17, 2023, at 10:30 a.m., revealed the following: Scattered dried light brown substance drips on the wall behind the resident's bed; multiple dried brown substance on the floor by the resident's bed, and dried brown substance on the wall near the bathroom door. In addition, the wall behind the resident's bed was observed with an uncovered electrical socket. Observation on the 3rd-floor unit room [ROOM NUMBER] conducted on January 17, 2024, at 10:35 a.m., revealed a dried light brown sticky and a dried dark brown sticky substance by the side of bed A floor, both approximately 1 foot in size. In addition, a light brown dried sticky substance approximately two feet in size was observed on the floor on the foot side of 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the Resident Assessment Instrument User's Manual and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that comprehensive admission and annual Minimum Data Set assessments were completed in the required timeframe for 12 of 89 residents reviewed (Residents 50, 54, 62, 72, 89, 90, 91, 107, 112, 127, 144, 145). Findings include: 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 2019, indicated that an admission MDS assessment was to be completed no later than 14 days following admission. An admission MDS assessment for Resident 107 revealed that the resident was admitted to the facility on [DATE], and the resident's admission MDS assessment was dated as completed on May 24, 2018, which was 16 days after admission. An admission MDS…

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 and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that Quarterly Minimum Data Set assessments were completed within the required timeframe for 56 of 89 residents reviewed (Residents 2, 9 16, 17, 18, 22, 23, 25, 31, 32, 33, 38, 39, 42, 49, 54, 55, 57, 59, 63, 67, 68, 69, 71, 74, 78, 82, 83, 85, 86, 90, 94, 97, 98, 101, 102, 104, 106, 109, 114, 115, 117, 119, 120, 122, 123, 124, 126, 127, 128, 129, 130, 134, 136, 137, 138). Findings include: 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 residents' abilities and care needs), dated October 2019, indicated that the completion date for a quarterly assessment is the Assessment Reference Date (ARD - the last day of an assessment's look-back period) plus 14 days. A quarterly assessment is due every 92 days (ARD of most recent assessment + 92 days). A quarterly MDS…

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, clinical records, and staff interviews, it was determined that the facility failed to develop a comprehensive care plan that included specific and individualized interventions to address the care needs for five of 89 residents reviewed (Residents 2, 22, 48, 51, 115). Findings include: A facility policy for Comprehensive Person-Centered Care Plans, dated April 21, 2023, included that care plans would be resident centered to express the needs of the residents. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 2, dated August 9, 2023, revealed that the resident was cognitively impaired, required extensive assistance with daily care needs, was receiving supplemental oxygen, and had diagnosis that included Alzheimer's disease and congestive heart failure (condition when heart does not pump blood as efficiently as it should). Physician's orders for Resident 2, dated July 6, 2023, included that the resident receive 2 liters per minute (L/min) of oxygen for shortness of breath…

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 polices and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that residents received care and treatment in accordance with professional standards of practice, by failing to ensure that physician's orders were followed for four of 89 residents reviewed (Residents 2, 47, 98, 139). Findings include: The facility's policy regarding medication administration, dated April 21, 2023, revealed that medications are administered in accordance with prescriber orders, including any required timeframe. The following information is checked/verified for each resident prior to administering medications: Vital signs, if necessary. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 2, dated August 9, 2023, revealed that the resident was cognitively impaired, required extensive assistance with daily care needs, and had diagnosis that included Alzheimer's disease and congestive heart failure (condition when heart does not pump blood as efficiently as it…

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

Based on review of clinical records, as well as staff interviews, it was determined that the facility failed to ensure that physician's orders were followed for an indwelling urinary catheter for one of 89 residents reviewed (Resident 39). Findings include: A Quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 39, dated August 21, 2023, revealed that the resident was understood, could understand, required extensive assistance from staff for his daily care tasks, and had an indwelling urinary catheter. Physician's orders for Resident 39, dated November 24, 2022, included an order for staff to monitor the resident's suprapubic foley catheter (a tube inserted through the lower abdominal wall into the bladder to drain urine) every shift. Resident 39's clinical record and Treatment Administration Records (TAR's) for August and September 2023 revealed no documented evidence that the resident's suprapubic foley catheter was monitored during the day shift on August 18, 20, 30, 2023, and September 20, 2023; during 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, as well as staff interviews, it was determined that the facility failed to obtain weekly weights as requested by the dietician for one of 89 residents reviewed (Resident 132). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 132, dated August 30, 2023, revealed that he had clear speech; was usually understood and could understand; required extensive assist of one for bed mobility, transfers, dressing, toileting and personal hygiene; was frequently incontinent of bowel and bladder; and weighed 155 pounds, indicating a loss of 5 percent or more and was not on a prescribed weight-loss regimen. A nutrition care plan for Resident 132, dated August 24, 2023, indicated that the resident had a history of weight loss and that he would maintain an adequate nutritional status. Interventions included observing for signs of malnutrition, determining individual likes and dislikes, and to weigh…

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

Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure the accountability of controlled medications (drugs with the potential to be abused) for one of 89 residents reviewed (Resident 22). Findings include: The facility's medication administration policy, dated April 1, 2023, indicated that the individual administering the medication documented in the electronic MAR (medication administration record). A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 22, dated August 25, 2023, revealed that the resident was cognitively intact, required extensive assistance to total dependence from staff for daily care needs, had pain frequently, received pain medication routinely and as-needed, and received an opioid (a controlled pain medication). Physician's orders, dated March 10, 2023, included orders for the resident to receive 50 milligrams (mg) of Tramadol (a narcotic pain medication) every six hours as needed for a pain rating of 6 to 10 (on 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 policies and observations, as well as resident and staff interviews, it was determined that the facility failed to serve palatable food that was at appropriate temperatures. Findings include: The facility's policy regarding food temperatures, dated April 21, 2023, revealed that the service temperature of hot foods to residents would be within the range of 120-140 degrees Fahrenheit (F) based on the resident's preference and cold foods were to be served to the residents at 45 degrees F. Interview with Resident 14 on September 23, 2023, at 2:05 p.m. revealed that the food was terrible and that she rarely gets any food that is edible. Interview with Resident 49 on September 23, 2023, at 2:34 p.m. revealed that the food is terrible and that she has been served moldy bread for her peanut butter sandwiches. She stated that the food often tastes old and stale. Interview with Resident 63 on September 23, 2023, at 1:40 p.m. revealed that the food is terrible and that she often skips the meals and eats a peanut butter sandwich. Interview with Resident 72 on September 23,…

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

Based on review of policies and manufacturer's instructions, as well as observations and staff interviews, it was determined that the facility failed to store food in accordance with professional standards of food service safety by failing to properly label and date refrigerated foods, to secure a door leading to the outside, and to ensure that ice was made and stored in sanitary ice machines for one of two ice machines reviewed (2 [NAME] unit). Findings include: The facility's policy regarding food storage, dated April 21, 2023, revealed that leftover food was to be stored in covered containers or wrapped carefully and securely. Each item was to be clearly labeled and dated before being refrigerated. Observations in the reach-in refrigerator on September 23, 2023, at 9:07 a.m. revealed that there was a package of chicken breast and a package of multiple hot dogs that were wrapped in cellophane and were not labeled or dated. Observations on September 23, 2023, at 9:14 a.m. revealed there was a door to the outside that was propped open with a plastic milk crate and no staff were…

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

Based on review of policies and clinical records, as well as observations and staff interviews, it was determined that facility failed to determine if residents were safe to self-administer medications for one of 89 residents reviewed (Resident 42). Findings include: The facility's medication administration policy, dated April 1, 2023, indicated that residents may self administer their own medications only if the attending physician, in conjunction with the Interdisciplinary Care Planning Team, have determined that they may have the decision-making capability to do so safely. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 42, dated September 21, 2023, indicated that the resident was cognitively impaired, required limited assistance from staff with eating, and had diagnoses that included dementia. Physician's orders, dated March 8, 2022, included orders for the resident to receive one multi-vitamin daily. The resident's record contained no documented evidence that an evaluation was completed to determine if…

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

Based on review of policies, Pennsylvania laws and personnel records, as well as staff interviews, it was determined that the facility failed to ensure that Pennsylvania State Police background checks were completed for one of five employees reviewed (Nurse Aide 2). Findings include: The facility's policy regarding criminal background checks, dated April 21, 2023, revealed that the personnel/human resources director, or other designee, will conduct background checks, reference checks, and criminal conviction checks (including finger printing as may be required by state law) on all potential employees and contract personnel who meet the criteria for direct-access employee, as stated above. Such investigation will be initiated within two days of an offer of employment or contract agreement. Chapter 5, Section 502(a)(1) of Pennsylvania Act 169, dated December 18, 1996, indicated that a criminal history report was to be obtained from the State Police for all applicants. Section 501 defined State Police as The Pennsylvania State Police. Section 506 indicated that the facility could…

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

Based on clinical record reviews and staff interviews, it was determined that the facility failed to transmit Minimum Data Set (MDS) assessments to the required electronic system, the Centers for Medicare and Medicaid Services (CMS) Quality Improvement and Evaluation System (QIES) Assessment Submission and Processing (ASAP) System, within 14 days of completion for eight of 89 residents reviewed (Residents 2, 13, 18, 91, 96, 132, 139, 147). Findings include: 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 (federally-mandated assessments of a resident's abilities and care needs), dated October 2019, indicated that comprehensive MDS assessments must be transmitted electronically within 14 days of the Care Plan Completion Date (V0200C2 + 14 days). All other MDS assessments must be submitted within 14 days of the MDS Completion Date (Z0500B + 14 days). Section Z0500B of an entry tracking MDS assessment for Resident 2 revealed that the MDS assessment was…

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

Based on review of the Resident Assessment Instrument User's Manual and clinical records, as well as staff interviews, it was determined that the facility failed to complete accurate Minimum Data Set assessments for three of 89 residents reviewed (Residents 2, 78, 98). Findings include: The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which provides guidance and instructions for the completion of Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2019, indicated that the intent of Section N was to record the number of days, during the seven days of the assessment period, that any type of injection, insulin, and/or select medications were received by the resident. Section N0410F was to be coded with the number of days the resident received an antibiotic. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 2, dated August 9, 2023, revealed that the resident was cognitively impaired, required extensive assistance 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 review of policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that care plans were updated to reflect changes in residents' care needs for three of 89 residents reviewed (Residents 51, 78, 79). Findings include: The facility's policy regarding care plans, dated April 21, 2023, indicated that the resident's care plan would be update or revised when the resident's care changed. A quarterly MDS assessment for Resident 51, dated August 4, 2023, indicated that the resident was cognitively impaired, had an indwelling urinary catheter (a tube inserted and held in the bladder to drain urine), and received an anticoagulant (blood thinning) medication. Resident 51's current care plan indicated that the resident used a diuretic (water pill) related to hypertension. Review of Resident 51's Medication Administration Record (MAR) for September 2023 revealed that the resident was not receiving a diuretic medication. A quarterly MDS assessment for Resident 79, dated July 20, 2023, indicated that the resident was…

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

Based on review of manufacturer's instructions and clinical records, as well as observations and staff interviews, it was determined that the facility failed to maintain a medication administration error rate of less than five percent. Findings include: Observations during medication administration on September 24, 2023, revealed that four medication administration errors were made during 25 opportunities for error, resulting in a medication administration error rate of 16 percent. Physician's orders for Resident 139, dated August 27, 2023, included an order for the resident to receive one 5 mg tablet of Midodrine (used to treat low blood pressure) two times a day and staff was to hold for a systolic blood pressure (SBP-top number of a blood pressure reading) greater than 130 millimeters of mercury (mmHg). Observations during medication administration on September 24, 2023, at 8:55 a.m. revealed that Licensed Practical Nurse 3 placed Resident 139's Midodrine into a medication souffle cup with her other medications. She took the medication souffle cup containing the 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 review of the facility's plans of correction for previous surveys, and the results of the current survey, it was determined that the facility's Quality Assurance Performance Improvement (QAPI) committee failed to correct quality deficiencies and ensure that plans to improve the delivery of care and services effectively addressed recurring deficiencies. Findings include: The facility's deficiencies and plans of correction for a State Survey and Certification (Department of Health) surveys ending September 2, 2022, and December 20, 2022, revealed that the facility developed plans of correction that included quality assurance systems to ensure that the facility maintained compliance with cited nursing home regulations. The results of the current survey, ending September 26, 2023, identified repeated deficiencies related to revising care plans, quality of care, nutrition/hydration status, and infection control. The facility's plan of correction for a deficiency regarding revising care plans, cited during the survey ending September 2, 2022, revealed that the facility developed…

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

Based on review of facility policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that proper infection control practices were followed while administering medications for one of 89 residents reviewed (Resident 139). Findings include: The facility's medication administration policy, dated April 21, 2023, indicated that staff was to follow established facility infection control procedures (e.g., handwashing, antiseptic technique, gloves, isolation precautions, etc.) for the administration of medications as applicable. Physician's orders for Resident 139, dated September 19, 2023, included an order for the resident to receive one one milligram (mg) tablet of Clonazepam (used to treat panic disorder) every 12 hours for anxiety. Observations during medication administration on September 24, 2023, at 8:55 a.m. revealed that while preparing medications for Resident 139, Licensed Practical Nurse 3 removed the Clonazepam from the medication blister package into her bare hand and then placed the medication into 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 and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that each resident was offered and/or received the pneumococcal immunizations for four of 89 residents reviewed (Residents 19, 117, 125, 137). Findings include: The facility's policy regarding pneumococcal vaccines, dated April 21, 2023, indicated that prior to admission, all residents will be assessed for eligibility to receive the pneumococcal vaccine series, and when indicated, will be offered the vaccine within thirty days of admission to the facility unless medically contraindicated or the resident has already been vaccinated. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 19, dated August 3, 2023, revealed that the resident was usually understood and could usually understand others, required limited assistance with personal hygiene needs, was not up to date on his pneumococcal vaccine, and was not offered a pneumococcal vaccine. Review of the immunization records…

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.