Bryn Mawr Extended Care Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, review of facility policies, clinical record reviews, and interviews with residents and staff, it was determined that the facility failed to provide an ongoing program to support residents in their choice of activities designed to meet the interests and physical, mental and psychosocial well-being on two of two nursing units. (1st and 2nd Floor) Findings include Review of facility policy titled Life Enrichment Programming Policy last revised May 4, 2023 revealed that it is the facilities policy to maintain an ongoing resident centered life enrichment program based on comprehensive assessments and care plans. The program will be designed to meet the interest including hobbies and preferences, and the abilities of each resident including their physical common mental, emotional, social, spiritual, psychosocial and leisure needs. This life enrichment (activities) program will create opportunities for each resident to have a meaningful life by supporting his or her domains of wellness. The life…

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 interviews, review of clinical records, and the review of facility documentation and policy, it was determined that the facility did not ensure residents were free from verbal abuse for one of 28 resident records reviewed (Resident R46). Finding includes: Review of the facility's policy titled Abuse, Neglect and Exploitation revised on July 11, 2024, states that the facility will not tolerate abuse, neglect, mistreatment, exploitation of residents. The same policy defines verbal abuse as a use of oral language that willfully includes disparaging and derogatory terms to residents or their families, or within hearing distance , regardless of their age, ability comprehend, or disability. Resident R46 was last admitted to the facility on [DATE], diagnosed with high blood pressure chronic kidney disease, type II diabetes, dementia with other behavioral disturbance, cognitive communication deficit, history of transient ischemic attack (TIA- cerebral infarction) without residual deficits, delusional disorder,…

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 resident and staff and review of clinical records and facility policy, it was determined the facility did not ensure a baseline care plan was developed with interventions to prevent pressure injury or trauma for one resident diagnosed with diabetes of 28 residents reviewed. (Resident R86) Findings include: Review of the facility's policy for Comprehensive Care Planning revised March 2025 states, The facility will develop a comprehensive person centered care plan for each resident that includes measurable goals and timetables to meet the resident's medical, nursing, mental, and psychosocial needs identified in the comprehensive assessment. The policy further states that a baseline care plan will be developed within the first 48 hours of admission to ensure the residents needs are met until the comprehensive care plan is completed. Review of Resident R86's admission Minimum Data Set (MDS- is a standardized assessment tool used to evaluate resident functional status, cognitive abilities, and health conditions to develop care plans 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.

Based on review of facility policies and documentation, clinical record review, interview with staff, and observations, it was determined that the facility failed to ensure that a licensed nurse maintained professional standards of quality of care for one of four residents reviewed. This failure resulted in delay of medical treatment relating to one resident not receiving medications timely. (Resident R 41) Findings include: Review of facility document titled General Dose Preparation and Medication Administration revised April 4, 2024, revealed that prior to medication administration , the facility staff should take all measures required by the facility policy and applicable law, including but not limited to verifying each time a medication is administered and that it is the correct medication, correct dose correct route at the correct rate, at the correct time and for the correct resident. Further review of this policy states that medication must be administered within timeframes specified by the facility policy or manufacturers information. Review of facility policy titled…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of clinical records, observations, and staff and resident interviews, it was determined that the facility failed to timely provide assistance with incontinence care for one of 35 residents reviewed (Resident R9). Findings Include: Review of Resident R9's clinical record revealed a quarterly Minimum Data Set Assessment (MDS - federally mandated resident assessment and care screening) dated February 28, 2025, that indicated the resident was able to make her needs known, cognitively intact, and had diagnoses of anxiety, depression, and muscle weakness. Further review of Resident R9's MDS dated [DATE], revealed the resident was always urinary/bowel incontinent (loss of bowel and bladder control) and required substantial/maximal assistance (helper does more than half the effort) with toileting hygiene (the ability to maintain perineal hygiene, adjust clothes before and after voiding or having a bowel movement). Interview on April 8, 2025, at 10:33 a.m. with Resident R9 revealed the resident had 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 observation, interviews with resident and staff, review of clinical records, and facility documentation, it was determined the facility failed to implement interventions to prevent the development of diabetic wound. This failure placed Resident R86 at risk for developing a diabetic wound to the right heel, requiring debridement and antibiotic therapy for one of 28 clinical records reviewed (Resident R86). Finding includes: Review of Resident R86's admission Minimum Data Set (MDS- standardized assessment tool used to evaluate resident functional status, cognitive abilities, and health conditions) dated February 26, 2025, revealed the resident was assessed as cognitively impaired with fluctuating inattention, and disorganized thinking. Continued review of the MDS revealed the resident had bilateral lower extremity impairment, and used a wheelchair to ambulate. Resident R86 needed substantial assistant for hygiene (able to do less than half the effort) and needed partial or moderate assistance with bed mobility. Review of Resident R86's MDS assessment included diagnoses of 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 policy, review of clinical records, resident and staff interview and observation, it was determined that the facility failed to provide an environment that is free from accident and hazards relating to adequate supervision and smoking safety. Findings include: Review of facility policy titled resident smoking policy last revised December 20, 2022 revealed facility has established residents smoking processes that take into account both smoking and non-smoking residents and that comply with applicable federal, state and local laws and regulations regarding smoking areas and smoking safety. Review of facility policy reveal resident who smoke will be required to sign a safe smoking and agree to abide by the rule regarding safe smoking or they will forfeit the privilege. Residents may only smoke on designate locations. Required supervision will smoke only at designated times independent smokers may smoke at any time but must sign out. Residents who smoke or desire to smoke will be required to sign a safe smoking contract and agree to abide by the rules…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of clinical records, facility policy and interviews with staff, it was determined that the facility failed to ensure that a follow- up appointment was scheduled with an urologist for a resident with an an indwelling urinary catheter for one of 28 resident records reviewed (Resident R121). Findings include: Review of the facility's policy titled, Continence Management Program revised on June 7, 2023, states the facility will provide services to restore or improve normal bladder function. Resident R121 was admitted to the facility on [DATE], diagnosed with benign prostate hyperplasia with lower urinary tract symptoms (an enlarge prostate gland that can cause various urinary problems). Review of Resident R121's nursing note dated December 14, 2024 stated Resident R121 failed to urinate for eight hours on the 7-3 shift. The nurse assessed the resident's abdomen noting it was distended and painful when palpated. The nurse received orders to straight catherize Resident R121 (to manually insert a tube…

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 ensure the identified pharmacy review irregularities were implemented for one of five residents reviewed (Resident R63). Findings Include: Review of facility policy on Medication Regimen Review (MRR) Section Procedure, #9 revealed that the facility should encourage the physician/provider or other responsible parties receiving the MRR (Medical Record) and the Director of Nursing to act upon the recommendations contained within the MRR. #9.1 For those issues that require physician/prescriber intervention, facility should encourage physician/prescriber to either accept and act upon the recommendations contained within the MRR or reject all or some of the recommendations contained in the MMR and provide an explanation as to why the recommendation was rejected. #9.2 The attending physician should document in the resident's health record that the identified irregularity has been reviewed and what if any action is taken to address it. #9.2.2 If the attending physician…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, review of facility documentation and interviews with residents and staff, it was determined that the facility failed to ensure that meals were served timely for one of 28 residents reviewed (Residents R47) Findings include: Review of Resident R47's clinical record revealed that resident was admitted to the facility on [DATE], with diagnoses of but not limited to Type 2 Diabetes (failure of the body to produce insulin), and Anemia (low red blood count). Review of Resident R47's quarterly MDS (minimum data set- a federally required assessment completed at a specific interval) dated March 11, 2025, section C0500 BIMS (brief interview for mental status) revealed a score of 15 suggesting that Resident R47 was cognitively intact. Review of physician's order revealed an order dated August 21, 2024, to: Monitor meal consumption during mealtimes. Further review of physician's order revealed an order dated March 21, 2025, for No added salt large portion diet. Review of April 2025 MAR (Medication…

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 interviews, and review of clinical records, it was determined the facility failed to provide outside services for one of 28 resident records reviewed (Resident R117). Findings include: Resident R117 was admitted [DATE] diagnosed with Polymyalgia rheumatica (PMR a rheumatic inflammatory disorder characterized by muscle pain and stiffness, primarily in the shoulders and hips, often accompanied by fatigue and systemic symptoms, like fever and weight loss.) Review of Resident R117's progress note dated March 26, 2025 indicated the resident's physiatrist recommended a rheumatology consultation. The note further stated the physician was in agreement. Continue review of Resident R117's clinical record revealed no evidence an appointment for a rheumotolgist was scheduled. This was confirmed with the Unit Manager Employee E5 on April 9, 2025, at 3:00 p.m. 28 Pa. Code 201.14 (a) Responsibility of licensee.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews with staff, and review of clinical records, it was determined that the facility failed to ensure that hospice documentation was complete for one of 28 residents reviewed. (Resident R54) Findings include: Resident R54 was readmitted to the facility [DATE], with diagnosed with Senile degeneration of brain, not elsewhere classified, Major depressive disorder, generalized anxiety disorder, Unspecified psychosis not due to a substance or known physiological condition, hypertension, Unspecified glaucoma, Vitamin B deficiency, unspecified, Muscle weakness (generalized), and abnormalities of gait and mobility. Review of Resident R54 physician orders revealed the resident was placed on hospice, [DATE]. Review of the most resent hospice plan of care, and recertification period had expired. Continue review of Resident R54's hospice documentation revealed incomplete/missing correspondence from the hospice staff providing care. The Nursing home administrator confirmed on [DATE], at 2:00 p.m. Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, review of facility policies, review of facility documentation, review of clinical records, and staff interviews, it was determined that the facility failed to establish an effective infection control program related to use of personal protective equipment with enhanced barrier precautions for two of four residents reviewed. (Resident R499 and R10) Findings include: Review of Resident R499's clinical record revealed that this resident has diagnosis' including sepsis, acute kidney failure, dysphasia (difficulty swallowing foods or liquids) peritoneal abscess (collection of pus in the abdominal cavity) delirium (disturbance in mental abilities that result in confused thinking) retention of urine(A blockage that prevents urine from leaving the bladder) and malnutrition . Review of Resident R499's care plan dated April 4, 2025, revealed that resident has a diagnosis of Clostridium Difficile. (C-Diff-highly contagious bacteria that can cause serious infections of the colon). Review of 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 observation, review of facility policy and interview with staff, it was determined that the facility did not ensure personal privacy and confidentiality related to signage for enhanced barrier precautions for 5 of 8 residents on transmission based precautions (Residents R56, R126, R117, R88 and R61). Finding include: Review of facility policy, title Resident Rights, revised September 3, 2020, revealed, It is the facility's policy to comply with all Resident Rights, and to communicate these rights to residents and their designated representatives in a language they can understand. Review of facility policy, Transmission Based Precautions and Isolation policy, last revised April 14, 2024 revealed: Enhanced Barrier Precautions (EBP). EBP are intended to prevent transmission of multi-drug resistant organisms (MDROs) via contaminated hands and clothing of healthcare workers to highrisk residents. EBP are indicated for high contact care activities for residents with chronic wounds and indwelling devices (such as central lines, urinary catheters and trachs) and for all those…

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 resident interviews, it was determined that the facility failed to ensure menus were followed for 10 of 28 clinical records reviewed (Resident R32, R35, R43, R57, R99, R122 and R440R40, R59 and R109). Finding include: During lunchtime on October 29, 2024, at 1:08 p.m. Resident R109 complained that she did not order the chicken she was served and was given cranberry juice that she stated she was unable to drink. Review of Resident R109's lunch ticket indicated the resident requested roast beef, brown gravy, creamed spinach, and egg noodles. Also included on the lunch ticket was a request that indicated no cranberry juice. Interview with Resident R59 on October 29, 2024, at 3:00 p.m. stated he always gets the wrong meal and never gets what he asks for. Review of the grievance log revealed Resident R40 complained the kitchen serves the wrong food. Interview with Resident R40 on October 30, 2024, confirmed this still continues. During resident council on October 30, 2024 at 1:00 p.m. with seven residents ( Resident R32, R35,…

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, review of facility policies and procedures and interviews with staff, it was determined that the facility failed to promptly notify resident's physician of a fall with injury resulting in hospitalization during a leave of absence from the facility for one of six residents reviewed (Resident R6). Findings include: Review of facility policy titled Resident Change in Condition Policy dated June 27, 2024, revealed The licensed nurse will recognize and intervene in the event of a change in resident condition. The Physician/Provider and the Family/Responsible Party will be notified as soon as the nurse has identified the change in condition and the resident is stable. A Significant Change of Condition is a decline or improvement in the resident's status that: 1. Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical intervention[s]; and/or one that 2. Impacts more than one area of the resident's health status; and/or one that 3. Requires interdisciplinary review and/or revision to the care…

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

Based on clinical record review and interviews with staff, it was determined that the facility failed to accurately complete a resident assessment related to discharge status for one of 27 residents reviewed (Resident R129). Findings include: Review of Resident R129's progress note revealed a nursing note dated July 31, 2024, which stated, resident discharged to home. Review of Resident R129's discharge Minimum Data Set (MDS- assessment of resident care needs) dated July 31, 2024, revealed that the residents discharge status was coded, Short term general hospital (acute hospital). Interview with the Registered Nurse Assessment Coordinator, conducted on November 1, 2024, at 11:30 a.m. confirmed that the MDS discharge status, dated July 31, 2024, for Resident R129 was coded inaccurately. 28 Pa. Code 201.14(a) Responsibility of licensee 2 Pa. Code 211.5(f) Medical records

Based upon review of clinical records and interviews with family and review of facility documentation, it was determined that the facility did not ensure resident requiring continuous oxygen therapy received such services per the physician orders for one of 28 resident records reviewed (Resident R1). Findings include: Review of Resident R1's clinical record revealed that the resident was initially admitted to the facility in September 2022 for acute respiratory failure with hypoxia. Review of the grievance log revealed Resident R1's family indicated during a visit they observed the resident without the oxygen mask, stating it was the third time this month. Review of the Resident R1's October 2024 physician orders revealed an order for 2 liters of oxygen to be given continuously via nasal canula and to check the concentrator to endure functioning and appropriate setting. Statement received by the nursing assistant indicated on May 14, 2024, she removed the oxygen mask while giving care and forgot to replace the mask. 28 Pa. Code 211.12(d)(1) Nursing services 28 Pa. Code 211.12(d)(5)…

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

Based on clinical record review and staff interview, it was determined that the facility failed to ensure that laboratory studies were promptly obtained as ordered by the physician for one of 28 clinical records reviewed (Resident R107). Findings include: Review of Resident R107's physician progress note dated October 18, 2024, indicated that resident had complained of headache, dizziness, and lightheadedness. Resident's nurse practitioner was notified and ordered for lab work, CBC (complete blood count), CMP (complete metabolic panel), Urine culture and sensitivity, and electrocardiogram (EKG). Further review of Resident R107's clinical records revealed the staff collected the urine sample on October 19, 2024, at night shift however it was not set to the lab in a timely manner. Continued review of Resident R107's clinical records revealed the staff recollected the urine sample on October 21, 2024, and sent to the lab. Review of clinical record for Resident R107 revealed no evidence that the staff obtained the result or inquired about the result of urine test result sent on October…

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, clinical record review and staff interviews, it was determined that the facility failed to ensure that resident's physician was notified about abnormal laboratory test results for one of 28 residents reviewed (Resident R107). Findings include: Review of Resident R107's physician progress note dated October 18, 2024, indicated that resident had complained of headache, dizziness, and lightheadedness. Resident's nurse practitioner was notified and ordered for lab work, CBC (complete blood count), CMP (complete metabolic panel), Urine culture and sensitivity, and electrocardiogram (EKG). Review of Resident R107's progress note dated October 19, 2024, indicated that the lab work was obtained, and the results were pending. Review of resident's clinical record including paper record and electronic record available at the facility revealed no evidence that the lab results which was ordered on October 18, 2024, were available to review. Interview with the Registered Nurse, Employee E5 on October 31, 2024, at 11:28 a.m. stated the lab work 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 observations and staff interviews, it was determined that the facility failed to ensure that resident bathrooms were equipped with the appropriate call bell system for one out of 28 residents reviewed (Resident R21) Findings include: During an observation in Resident R21's on rooms on October 29, 2024, at 1:44 p.m. revealed that there was no wired call bell in residents' room, the wires were removed from the wall. Further observation revealed that there was a tap bell in the room across from resident's foot of the bed, which was out of reach for the resident who was laying in the bed. Resident R21 stated she uses the bell to call for staff and no one responds. Further observation revealed that resident pressed the tap bell at 1.49 p.m. Resident stated she needed to be changed as she had an incontinence episode. Staff did not respond until 1:58 p.m. and the surveyor observed staff at the nurse's station. Employee E4 who was assigned staff for Resident R21 stated she saw the bell sitting across from the resident when she was in her room before, but she thought the 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 review of personnel files and interviews with staff, it was determined that the facility failed to ensure that nurse aides received at least 12 hours of continuing education per year as required for three of five nurse aide personnel files reviewed (Employees E6). Findings include: A copy of five nurse aide employee educational record was requested to the facility administrator on November 1, 2024, at 9:30 a.m. Review of personnel files for Employees E6, Certified Nursing Assistant, revealed that there was no evidence that the employees completed at least 12 hours of continuing education per year as required. Interview on November 1, 2024, at 1:00 p.m. the Nursing Home Administrator revealed that there were no 12-hour educational records for Employees E6 at the time of the survey. 28 Pa Code 201.19(7) Personnel policies and procedures 28 Pa Code 201.20(d) Staff development

Based on observation, a review of facility documentation and resident and staff interviews, it was determined that the facility failed to ensure that a safe and comfortable environment was maintained on one of four nursing care units (B wing). Findings include: An interview was conducted with Resident R1 on August 22, 2024, at 11:00 a.m. The resident's assigned room in on the B wing, located on the first floor of the facility. The resident stated that the temperature in the hallway was uncomfortable cold and that she has to keep her room door closed. The resident confirmed that she communicated her concern to the nursing supervisor and also during a resident council meeting. An observation tour was conducted of the B wing nursing care unit on August 22, 2024 in the company of the director of maintenance. The temperature of the hallway was checked and it registered at 69 degrees. The director of maintenance stated that the fire doors at each end of the B wing hallway were closed due to the magnetic door lock system malfunctioning. This created a compartment that prevented airflow and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on 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 ensuring that Cardio Pulmonary Resuscitation (CPR) was provided in accordance with established facility policy for one of eleven residents reviewed (Resident 207), which resulted in an Immediate Jeopardy situation. Findings include: Review of the job description for the Nursing Home Administrator (NHA) revealed under positron summary that the NHA is to lead and direct the overall operations of the nursing faciltiy in accordance with the community policies and procedures, customer and resident needs, and both State and Federal guidelines. To maintain excellent care for the residents/patients and achieve the faciltiy's business objective. Monitoring each department's activities, ensuring that each department attains and maintains compliance with State and Federal requirements. Review of the job…

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 interviews with staff, it was determined that the Nursing Home Administrator failed to effectively manage the facility related to ensuring that the dish machine dispensed the proper level of sanitizing solution to sanitizing food service equipment. The facility failed to ensure that there was proper water pressure to maintain water in the three compartment sink, to sanitizing the food service equipment which resulted in an Immediate Jeopardy situation for one of one kitchens serving 128 residents. Findings include: Review of the job description for the Nursing Home Administrator revealed that the Nursing Home Administrator is to lead and direct the overall operations of the nursing faciltiy in accordance with the community policies procedures, customer and resident needs and both Sate and Federal guidelines. To maintain excellent care for the residents/ patients and achieve the faciltiy's business objective. As the Administrator, you are delegated to administrative authority, responsibility and accountability…

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 reviews of facility menus, meal tray tickets and interviews with residents and staff, it was determined that menus were not prepared in advance to meet the nutritional needs of each resident and followed for seven of ten residents reviewed with specific food adversions. The facility failed to ensure that food was availble for the facility emergency menu as planned. (Residents R78, R119, R99, R17, R22, R97, R28 and R68) Findings include: A review of the facility's menus for October 2023 through Janaury, 2024 with the registered dietitian, Employee E5, at 1:15 p.m., on January 30, 2024 revealed that the facility had breakfast meats planned periodically for service to the residents. The menus only offered pork sausage and bacon or pork gravy for the planned breakfast meats throughout October, 2023 to January 2024. There were no substitutes of turkey, chicken or beef for the breakfast meats. Interview with the registered dietitian, Employee 5 and the dietary cook Employee E13 at 1:30 on January 30, 2024 revealed that the facility purchases pork products only for breakfast meats…

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 policies and procedures and clinical records, resident and staff interviews, and a review of facility documentation, it was determined that the facility failed to provide food and drink that was palatable and served at satisfying temperatures for six of 32 residents reviewed (Residents R125, R63, R5, R68, R17 and R131). Findings include: A review of the policy titled Food and nutrition: food production and food safety dated June 10, 2022 it was indicated that the dietary staff were responsible for serving hot foods to the residents at a temperature range of 130 to 155 degrees Fahrenheit. This policy also indicated that cold foods were to be served to the residents at a temperature of 41 degrees Fahrenheit. The goal of the dietary services were for hot food and beverages and cold foods and fluids to be palatable at point of delivery to the residents. A review of Test Tray Form, revealed that the standard temperature for hot foods, including entrée and starch, on tray line was 135…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and resident and staff interviews, it was determined that the facility failed to maintain the facility in a clean, comfortable, and homelike condition on one of two nursing floors (First Floor) and a feeding pump was maintain in sanitary condition for on one of two tube feedings pumps observed (Resident R47). Findings include: Observations during the initial tour of the facility on January 29, 2024, revealed the following concerns: Observations on January 29, 2024, at 10:25 a.m., in room [ROOM NUMBER] revealed the chair rail behind bed (window bed) was broken revealing sharp, jagged edges, and the raised commode seat over the toilet was soiled in several places with dark brownish substance, especially on the grey chute in the center. Observations on January 29, 2024, at 10:35 a.m., in the hallway in B wing revealed a tan colored hand rail with several spots that had deep groves and scratches on the surface and a dark brown colored paint on these areas in five or more spots along both sides…

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 of care and services and interviews with staff, it was determined that the facility failed to develop and implement a care plan for one of five residents reviewed for activites of daily living. (Resident R98) Findings include: Clinical record review for Resident R98 revealed that this resident was dependant on staff for activities of daily living (transfer, mobility, dressing, toileting, bathing, grooming, oral care). The occupational therapy department documented on July 26, 2023 that the nursing staff were educated about passive range of motion exercises, chair and bed positioning and how to use orthotic devices for Resident R98. Review of the resident's current care plan revealed that there was no care plan developed for transfers out of bed. Resident R98 was observed spending time in bed during the days of the survey Janaury 29, 2024 through February 1, 2024. Continued review of the resident's care plan revealed that there was no care plan developed for PROM (passive range of motion) stretching for upper and lower extremities 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, resident and staff interview, it was determined that the facility failed to ensure that a resident was transferred out of bed as ordered by the physician for one of 32 residents reviewed. (Resident R110) Findings include: Review of clinical record review for Resident R110 revealed that the resident was admitted to the facility on [DATE], with diagnosis of acute hematogenous osteomyelitis (one of the most common forms of bone infection (osteomyelitis) where the bacteria travel in the bloodstream from another infected site and get lodged into the bone.) Further review of Resident R110's physician's orders revealed an order dated July 21, 2023, for the use of a hoyer lift (mechanical device use to transfer a person from one surface to another) for functional transfers. Review of Resident R110's care plan revealed an intervention initiated on January 26, 2023, for Hoyer lift for transfers. Interview with Resident R110 on January 29, 2023, at 10:30 a.m. revealed that she had been…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, observations and staff interview, it was determined that the facility failed to provide services necessary to maintain adequate personal hygiene and grooming of residents dependent on staff for assistance with these activities of daily living for two out of 32 residents reviewed (Resident R26 and R129). Findings include: Review of clinical records of Resident R26 indicated that R26 was admitted to the facility on [DATE], with diagnoses including Paranoid Schizophrenia (positive symptoms of schizophrenia, including delusions and hallucinations; these debilitating symptoms blur the line between what is real and what is not, making it difficult for the person to lead a typical life), and Anxiety Disorder (A mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities). During an interview on January 29, 2024, at 9:59 a.m., Resident R26 stated that the resident did not get a bath on January 29, 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.

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. Findings include: On January 30, 2024, at 10:01 a.m., observed that Employee E12, a Licensed Nurse, administered Mucinex DM 600 mg- 30 mg-extended release 12 hr, to Resident R100. Review of physician order for R100 indicated an order for Mucinex Oral Tablet Extended Release 12 Hour (Guaifenesin), Give 600 mg by mouth two times a day for cough. Further review of Physician order for R100 indicated an order, dated August 14, 2023, to administer Insulin Lispro Injection Solution 100 Unit/ML (Insulin Lispro), Inject as per sliding scale If 60-150+)U, Call MD if <60; 151-200= 2U: 201-250=4U; 251-300=6U; 301-350=8U;351-400=10U; Over 400 call MD; Subcutaneously before meals for DM2 (Diabetes Mellitus). Review of Medication Administration Record on January 30, 2024, at 10:11 a.m., revealed that the insulin was not administered to R100, as ordered on January 30, 2024, at 8 a.m., or at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record and policy and procedure reviews and interviews with staff, it was determined that the facility failed to ensure that clinical records were accurate for one of 32 residents reviewed. (Resident R121) Findings include: Review of Resident R121's clinical record revealed that the resident was admitted to the facility on [DATE] wit the diagnoses of high blood pressure, heart failure altered mental status, Type Two Diabetes, morbidly obese, unspecified psychosis and chronic pulmonary disease. Review of the psychiatry note dated January 30, 2024, revealed an order for Risperdal solution for bipolar disorder. Review of Resident R121 clinical record revealed no documentation to indicate that the resident had a diagnosis of bipolar disorder. 28 Pa. Code 211.5(f) Clinical records

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility documentation and staff interview, it was determined that the facility failed to provide a safe discharge for one of three clinical records reviewed (Residents R1). Findings include: Review of the facility policy Short Peripheral Intravenous Catheter (PIVC, is a hollow metal needle positioned inside a catheter, generally inserted in superficial veins) Removal, Revised June 1, 2021, states that a short PIVC must be removed/replaced when clinically indicated, such as at the completion of IV therapy. Review of Resident R1's electronic medical record revealed that the resident was admitted on [DATE], from the hospital where he was being treated for a urinary tract infection and sepsis (an infection of the blood stream resulting in a cluster of symptoms such as drop in a blood pressure, increase in heart rate and fever), and that the treatment included IV (intrvenous) antibiotics. Further review of Resident R1's electronic medical record revealed a November 3, 2023, physician's order to start a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff interview, it was determined that the facility failed to protect one of seven residents reviewed for exploitation of resident's personal funds. (Resident R1) Findings include: Review of clinical records of Resident R1 revealed that the resident was admitted to the facility on [DATE], with the diagnoses of Anxiety Disorder (it involves persistent and excessive worry that interferes with daily activities), Depression (Depression causes feelings of sadness and/or a loss of interest in activities an individual once enjoyed), and Cerebral Palsy (a group of disorders that affect a person's ability to move and maintain balance and posture). Review of Social Service Initial Assessment note, dated October 16, 2023, revealed Resident R1 was alert, awake, and oriented to person, place, and time, able to make needs known, and independent with decision making. On October 24, 2023, R1 complained that one of the nurses had made copies of his Credit Cards and Driver's License. On…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff interview, it was determined that the facility failed to notify the resident's physician of the resident who was on a blood thinner medication of bleeding from a skin tears for one of seven residents reviewed. (Resident R2) Findings include: Review of clinical records of Resident R2 revealed that the resident was admitted to the facility on [DATE], with Anxiety Disorder (it involves persistent and excessive worry that interferes with daily activities), Cerebral Infarction ( it occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it. A lack of adequate blood supply to brain cells deprives them of oxygen and vital nutrients which can cause parts of the brain to die off), and End Stage Renal Disease (is a medical condition in which a person's kidneys cease functioning on a permanent basis leading to the need for a regular course of long-term dialysis or a kidney transplant to maintain life). Review of the 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 observation, staff and resident interview, review of clinical documents and review of facility policy, it was determined that the facility failed to provide alternative food options and the facility failed to provide milk substitute that accommodates resident intolerances for for one of thirteen residents observed . (Resident R1) Findings: Review of facility policy on Meal Identification and Food Preferences Policy with revision date of September 21, 2022, revealed that under section Policy A meal identification and food preferences card will be used to properly identify each individual's needs including food and beverage preferences. Meal ID Cart/ticket will be printed timely from a data base and disposed of after meal. Under section Procedure The director of food and nutrition services or designee will visit a newly admitted individual to obtain food and beverage preferences, dislikes and food allergies/intolerances before a permanent meal ID card/ticket is written, a temporary meal ID card/ticket containing individual's name, room number, and diet order may be used until…

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.