Bryn Mawr Village

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of clinical records, observations of care and services, and interviews with staff, it was determined that the facility failed to consistently provide respiratory care and supplemental oxygen as ordered by the physician for one of one residents reviewed. (Resident R6).Findings include:A review of the clinical record for Resident R6 indicated that the resident was admitted to the facility on [DATE], with diagnoses including cerebral infarction (stroke caused by a blockage), muscle weakness, unspecified dementia, hemiplegia (paralysis of one side of the body), aphasia (impairment of communication), dysphagia (difficulty swallowing), and hypertension (high blood pressure).On February 9, 2026, at 11:03 a.m., an observation with Registered Nurse, Employee E7 confirmed that Resident R6 was receiving oxygen therapy at 1.5 liters per minute. The oxygen tubing was not labeled, and the filter behind the concentrator was dirty, with a layer of dust.On February 12, 2026, at 2:02 p.m., a review of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, review of clinical records, and staff interview it was determined that the facility failed to provide pain management consistent with a resident's assessed needs for one of 12 residents reviewed (Resident R45).Findings Include:Review of facility policy Pain - Clinical Protocol revealed with input from the resident, the physician and staff will establish goals of pain treatment.Review of Resident R45's Minimum Data Set (federally mandated resident assessment and care screening) dated November 15, 2025, revealed the resident was admitted to the facility on [DATE], and had diagnoses of heart failure (a chronic condition in which the heart doesn't pump blood as well as it should), peripheral vascular disease (narrowed arteries that reduce blood flow to the limbs), respiratory failure, and muscle weakness.Review of Resident R45's after visit summary from the hospital dated November 12, 2025, revealed oxycodone 10 milliliters (ml) solution was recommended as needed.Review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy and review of clinical records it was determined that the facility failed to provide pharmaceutical services to meet the needs of each resident for one of 12 residents reviewed. Findings Include:Review of facility policy Medication Shortages/Unavailable Medications revealed when medications are unavailable the licensed nurse will urgently initiate action in cooperation with the attending physician and the pharmacy provider.Continued review of facility policy Medication Shortages/Unavailable Medications revealed a medication shortage is noted the nurse should notify the pharmacy and determine the status of the order. If the next available delivery results in a delay or missed dose in the resident's medication regimen the nurse should retrieve the medication from the emergency stock or request an emergency/stat delivery from the pharmacy. If an emergency delivery/emergency stock is not feasible, the licensed nurse should contact the attending physician and order orders which may…

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 observation, resident and staff interviews, it was determined that the facility failed to properly secure a medication for one of 12 residents reviewed. (Resident R38).Findings include: A review of Resident R38's clinical record revealed an admission date of January 2, 2026, with a diagnosis of glaucoma (increase eye pressure resulting in the inability of fluid to drain from the inner eye). A review of the physician's order dated January 2, 2026, revealed an order for Dorzolamide HCl ophthalmic solution 2%, instill one drop in both eyes twice daily for glaucoma. On February 9, 2026, at 12:02 p.m., observation revealed the Dorzolamide HCl ophthalmic solution was located in Resident R38's bed. Resident R38 reported that the nurse left the medication at her bedside during the night shift. On February 9, 2026, at 1:59 p.m., an interview was conducted with Resident R38, who reported that at times nursing staff would give (her/him) eye drop medication and Resident R38 would administer the medication (herself/himself). On February 9, 2026, at 2:05 p.m., an observation…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, review of clinical records, observations, and staff interviews it was determined that the facility failed to implement infection control standards related to the use of personal protective equipment and wound care for one of 12 residents reviewed. (Resident R5)Findings Include:Review of memo Enhanced Barrier Precautions in Nursing Homes from the Centers for Medicare & Medicaid Services dated March 20, 2024, revealed enhanced barrier precautions (EBP- involve gown and glove use during high-contact resident care activities ) recommendations include use of EBP for residents with chronic wounds or indwelling medical devices during high-contact resident care activities regardless of their multidrug-resistant organism status.Review of facility policy Wound Care revealed staff should use disposable cloth to establish a clean field on resident's overbed table. The licensed staff should place all items to be used during procedure on the clean field and arrange the supplies so they can…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, review of clinical records, observations, and staff interviews it was determined that the facility failed to ensure the call light was within easy reach for one of 12 residents reviewed (Resident R49). Findings Include:Review of facility policy Answering the Call Light revised October 2010 revealed when the resident is in bed or confined to a chair, the call light should be within easy reach of the resident.Review of Resident R49's comprehensive Minimum Data Set (MDS - federally mandated resident assessment and care screening) dated February 6, 2026, revealed the resident was newly admitted to the facility on [DATE], and had diagnoses of heart failure (a chronic condition in which the heart doesn't pump blood as well as it should), hypoxemia (low blood oxygen levels), need for assistance with personal care, muscle weakness, and abnormalities of gait and mobility.Review of Resident R49's comprehensive care plan dated February 2, 2026, revealed the resident had an activity of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, review of clinical records, review of facility documents and interview with staff and residents, it was determined that the facility failed to investigate an allegation of verbal abuse by two of four residents reviewed. (Resident R1 and Resident R2)Findings include: Review facility policy entitled Abuse Prevention Program dated January 1 2022 and reviewed on November 30 2022, revealed that under section Policy Our residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation this includes but is not limited to freedom from corporal punishment, and voluntary seclusion, verbal, mental, sexual, or physical abuse and physical or chemical restraints not required to treat the resident symptoms. Under section Policy Implementation #6. Identify and assess all possible incidents of abuse. # 7. Investigate and report any allegation of abuse within time frames as required by federal and state requirement. #8. Protect residents during abuse…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, review of facility policy and interview with staff and residents, it was determined that the facility failed to ensure that grievances are addressed in a timely manner for one of four residents reviewed (Resident R1).Review of the facility's policy entitled Grievances/Complaints, Filing revealed that under section Policy Statement residents and their representatives have the right to file grievances either orally or in writing to the facility staff or to the agency designated to hear grievances (i.e. the State Ombudsman). The Administrator and his staff will make prompt efforts to resolve grievances to the satisfaction of the resident and or representative. Under section Policy Interpretation and Implementation #1 Any resident, family member or appointed resident representative may file a grievance or complaint concerning care treatment, behavior of other residents, staff members, theft of property or any other concerns regarding his or her stay at the facility. Grievances also may be…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record reviews and interviews with staff, it was determined that the facility failed to ensure that advanced directives were in place for two of 13 clinical records reviewed (Resident R149 and Resident R26). Findings include: Review of facility Policy on Advance Directives with a most recent revision date of 2016 revealed that under section Policy Statement: Advance directives will be respected in accordance with state law and facility policy. Policy Interpretation and Implementation #1. Upon admission, the resident will be provided with written information concerning the right to refuse or accept medical or surgical treatment and to formulate an advance directive if he or she chooses to do so. #7. Information about whether or not the resident has executed an advance directive shall be displayed prominently in the medical record. #10. The plan of care for each resident will be consistent with his or her documented treatment preferences and/or advance directive. Review of Resident R149's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policies, clinical record review, observations, and staff interviews, it was determined the facility failed to identify the placement of beds against the wall as a restraint three one of 13 residents reviewed. (Residents R247, R248, R249). Findings Include: Review of facility policy titled, Use of Restraints, revised 2017, revealed physical restraints are defined as any manual method or physical or mechanical device, material, or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restrics freedom of movement or restricts normal access to one's body. Further review of policy Use of Restraints revealed the definition of a restraint is based on the functional status of the resident and not the device. If the resident cannot remove a device in the same manner in which the staff applied it given that resident's physical condition, and this restrics his/her typical ability to change postion or place, that device is considered a restraint.…

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, staff interview, and review of facility policy, it was determined that the faciltiy failed to ensure that a baseline care plan was developed for one of 13 residents reviewed. (Resident R149) Findings include: Review of facility policy on care plan, Comprehensive-Person Centered revealed that. Under Section Policy Statement, a comprehensive person-centered care plan that includes measurable objectives and timetables to meet the residents physical, psychological and functional needs is developed and implemented for each resident. Under section Policy Interpretation and Implementation. Revealed that. #1 The interdisciplinary team, in conjunction with the resident and his or her family or legal representative, develops and implements a comprehensive person-centered care plan for each resident. #7. The comprehensive person-centered care plan: #a. includes measurable objectives and time frames. #b. describes the services that are to be furnished to attain or maintain the resident's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, review of clinical record, observations, and staff interviews, it was determined that the facility failed to develop comprehensive care plan for one of thirteen residents reviewed related to weight changes(Resident R33). Findings Include: Review of facility policy on care plan, Comprehensive-Person Centered revealed that. Under Section Policy Statement, a comprehensive person-centered care plan that includes measurable objectives and timetables to meet the residents physical, psychological and functional needs is developed and implemented for each resident. Under section Policy Interpretation and Implementation. Revealed that. #1 The interdisciplinary team, in conjunction with the resident and his or her family or legal representative, develops and implements a comprehensive person-centered care plan for each resident. #7. The comprehensive person-centered care plan: #a. includes measurable objectives and time frames. #b. describes the services that are to be furnished to…

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

Based on clinical record review, resident and staff interviews, it was determined that the facility failed to provide services to maintain adequate grooming of residents that required staff assistance with activities of daily living for two of 13 residents reviewed (Resident R243, R244). Findings include: Clinical record review revealed Resident R243 was admitted to the facility February 15, 2025 with a diagnosis that included but not limited to chondrocalcinosis (form of arthritis that causes sudden episodes of pain and swelling in joints), lack of coordination, and cognitive communication deficit. Review of Resident R243's Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs), dated February 27, 2025, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 7 indicating severe cognitive impairment. Observation on March 04, 2025 at 12:05 p.m. revealed Resident R243's beard was not adequately groomed. Interview on March 04, 12:07 p.m. with Resident R243 and Resident R243's family member revealed resident has not 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 review of clinical records, facility policies and interviews with staff, it was determined that the facility failed to provide necessary treatment and services, consistent with professional standards of practice and physician orders, to promote healing of pressure ulcers and prevent development of pressure ulcers for one of 13 residents reviewed for pressure ulcer. (Resident R1) Findings include: Review of Resident R1's clinical record revealed that Resident R1 was admitted to the facility on [DATE] with diagnoses that included but not limited to fracture of lower end of left femur (break in the thigh bone), closed fracture with routine healing, and muscle weakness. Review of Resident R1's Minimum Data Set (MDS - federally mandated resident assessment and care screening) dated February 10, 2025, revealed in section GG00130 Resident R1 was dependent for ability to roll from lying on back to left and right side, and return to lying on back on the bed. Further review revealed in section M0150, Resident R1 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 staff interviews and review of clinical records, it was determined that the facility failed to ensure that weekly weights were obtained as ordered by physician for 2 out of 13 residents reviewed (Resident R1, Resident R33). Findings include: Review of Resident R1's clinical record revealed that Resident R1 was admitted to the facility on [DATE] with diagnoses that included but not limited to fracture of lower end of left femur (break in the thigh bone), closed fracture with routine healing, and muscle weakness. Review of Resident R1's clinical record revealed a physician's order dated February 12, 2025 for resident to be weighed weekly x 4 weeks, then monthly. Review of Resident R1's weight record revealed the the resident was weighted at the time admission on [DATE]- 129.0 pounds. Continued review of weight record revealed no documented evidence that the resident was weighted weekly as ordered by the physician. Review of Resident R1's clinical record revealed no documented evidence that Resident R1 had…

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 interviews, it was determined that the facility failed to follow recommendations to maintain acceptable parameters of nutrition for a resident receiving enteral nutrition for one of two residents reviewed. (Resident R33) Findings include: Review of Resident R33's clinical record revealed that Resident R33 was admitted to the facility on [DATE] with diagnoses that included but not limited to Pleural effusion (build up of fluid in lungs), muscle weakness, dysphagia (difficulty swallowing) and cognitive communication deficit. Review of Resident R33's care plan revealed that resident requires tube feeding related to dysphagia (difficulty swallowing) and intervention initiated for Registered Dietitian to evaluate quarterly and as needed, monitor caloric intake, estimate needs and make recommendations for changes to tube feeding as needed. Review of Resident R33's clinical record revealed a physician order dated December 30, 2024 for one time a day Jevity 1.5 (tube feed) at 20…

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 interviews with staff, it was determined that the facility failed to provide appropriate respiratory care services related to changing and labelling respiratory equipment's and administering oxygen as ordered by the physician for two of thirteen residents reviewed. (Residents R146 and R149). Findings Include: A review of the facility policy titled Oxygen Administration The purpose of this procedure is to provide guidelines for safe oxygen administration. Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration. Review of Resident R146's clinical record revealed that Resident R146 was admitted to the facility February 23, 2025, with diagnoses of but not limited to Acute Respiratory Failure, COPD (Chronic Obstructive Pulmonary Disease), and Anemia (low blood count) Review of Resident R146's physician orders revealed an order for O2 (Oxygen) at 2L (liters)/min via NC (nasal Cannula), continuously every shift…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, review of clinical record, and staff interview, it was determined that the facility failed to ensure that appropriate pain management was provided to a resident consistent with standards of professional practice for one of thirteen residents reviewed (Resident R148). Findings include: Review of thefacility policy entitled Pain assessment and management revealed that under section Purpose: The purpose of this procedure is to help the staff identify pain in the resident and to develop interventions that are consistent with the resident's goals and needs and that address the underlying causes of pain. Under Section General Guidelines: #1 The pain management program is based on facility wide commitment to appropriate assessment and treatment of pain, based on professional standards of practice, the comprehensive care plan and the resident's choices related to pain management. #2. Pain management is defined as the process of alleviating the residents pain based on his or her…

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 record review and interview with resident and staff it was determined that the facility failed to ensure the safe and effective use of medications in a manner that minimizes medication-related adverse consequences or events related to drug allergies for one of thirteen residents reviewed. (Resident R148) Findings include: Review of Resident R148's clinical record revealed that Resident R148 was admitted to the facility on [DATE] with diagnoses of but not limited to: Spinal Stenosis, Low Back Pain, Pain in Leg, Chronic Pain Syndrome, Allergy Review of Resident R148's list of allergies revealed that resident R148 was allergic to and the allergic reaction the following medications: Allergen: Fentanyl (opioid) Reaction Manifestation: Anaphylaxis, Hives, Shortness of breath, Angio-edema Severity: Severe Allergen: Hydrocodone (opioid) Reaction Manifestation: Hives, Itching Severity: Unknown Allergen: Hydromorphone (opioid) Reaction Manifestation: Anaphylaxis, Hives, SOB (shortness of breath), Angio-edema…

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

Based on observations, interviews with staff, and a review of facility procedures, it was determined that the facility did not ensure that food was stored in accordance with professional standards for food service safety. Findings include: Review of facility undated dating and labeling procedure guide revealed that all items in the refrigerator must be dated and labeled with a date, use by date, initials, and item name. An initial tour of the main kitchen was conducted on May 3, 2034, at 8:56 a.m. with the facility Administrator, Employee E1, and Kitchen Supervisor, Employee E3. Observations revealed that the main cook was not wearing a hair net while cooking in the main kitchen area. Observations in the main refrigerator revealed all items were dated with one date, March 28, 2024, including defrosted pork loins, cheddar cheese, mozzarella cheese, and yogurt. Interview with the kitchen supervisor, Employee E3 revealed that the day, March 28, 2024, indicated the open date. Further observations revealed that pulled ham was dated May 25, 2024, and the cheese was dated April 1, 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 the review of facility documentation, review of personnel files and interview with staff, it was determined that the facility did not ensure that a nurse aide had a minimum of 12-hour annual training to ensure continuing competence as required for five of five employees reviewed. (Employee E15, E16, E17, E18 and E19) Finding include: A request was made to the facility Nursing Home Administrator and Director of Nursing for annual training records for five nursing assistants, Employees E15, E16, E17, E18 and E19 on May 8, 2024, at 10:15 a.m. Facility did not submit training records for Employees E15, E16, E17, E18 and E19. Interview with the facility Administrator on May 8, 2024, at 1:30 p.m. confirmed that the facility did not track, and complete annual in-service as required by the training requirements for nursing assistants. 28 Pa. Code 201.18(b)(1)(3) Management 28 Pa. 211.12(c) Nursing services

Based on observation, interview with staff, and review of facility policy, it was determined that the facility failed to maintain confidentiality of residents' medical records and provide privacy to a resident during incontinence care for two of 12 residents reviewed (Resident R30 and R41). Findings include: Review of facility policy titled, HIPPA Training Program revised 2007, revealed that the facility staff must ensure the confidentiality if residents protected information. Interview with Resident R22's Power of Attorney (POA), on May 6, 2024, at 1:39 p.m. revealed that she had requested her mother's Resident R22's, medical records on March 27, 2024. On March 28, 2024, she had received her mothers' medical records which contained Resident R30's medical information. Resident R22's POA provided pictures of Resident R30's protected health information to the surveyor, in the conference room. Review of facility documentation titled, Disclosure/release of prohibited health information and interview with the Medical Records Staff, Employee E4, confirmed that Resident R22's medical…

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 record review and interviews with staff, it was determined that the facility failed to follow the physician orders related to weekly weights for one of 13 residents reviewed (Residents R37). Findings include: Review of facility policy titled, Weight Assessment and Intervention, revised September 2008, revealed that the multidisciplinary team will strive to prevent, monitor, and intervene for undesirable weight loss for residents. Nursing will measure resident weights weekly for two weeks on admission. Review of physician orders for Resident R37 revealed an order dated, April 27, 2024, for weekly weights x 4 weeks; in the morning every Friday. Review of Resident R37's clinical records revealed the last registered weight of 170.5 pounds on April 26, 2024. Interview with the Registered Dietitian, Employee E6, on May 7, 2024, at 2:07 p.m. confirmed that there were no further documented weights for Resident R37. Further interview revealed that after immediately reweighing Resident R37 on May 7, 2024, his weight registered 157 pounds.…

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

Based on review of facility policies, review of clinical records, observations and resident, resident representative and staff interviews, it was determined that the facility failed to ensure that foot care needs were provided timely for one of 13 residents reviewed (Resident R38). Findings include: Review of care plan for Resident R38 dated April 3, 2024, revealed that the resident required assistance for Activities of Daily Living functions. Observation of Resident R38 on May 3, 2024 at 10:33 a.m., revealed that the resident had long and thick toenails on both feet. Resident R38's representative statedat the time of the observation that he asked staff to consult a podiatrist at least five times but no response was received. Interview with Director of Nursing (DON) on May 7, 2024 at 12:00 p.m. confirmed that resident's toe nails were long and a podiatrist should have consulted. He also confirmed that there was no appointment made for Resident R38. DON also stated facility had a podiatry service physician that comes into the building as needed and for emergency. Review of progress…

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, facility policy and interviews with staff, it was determined that the facility did not ensure that a physician assessment was completed related to unplanned weight loss for one of 3 residents with weight loss reviewed (Resident R21). Findings include: Review of facility policy Weight Assessment and Intervention dated September 2008, revealed that Weight Assessment The nursing staff will measure resident weights on admission, the next day, and weekly for two weeks thereafter. The threshold for significant unplanned and undesired weight loss will be based on the following criteria [where percentage of body weight loss = (usual weight- actual weight) (usual weight) x 100): 1 month -5% weight loss is significant; greater than 5% is severe a. 3 months =7.5% weight loss is significant; greater than 7.5% is severe. 6 months - 10% weight loss is significant; greater than 10% is severe. The Physician and the multidisciplinary team will identify conditions and medications that may be causing anorexia, weight loss or increasing the risk of weight loss. Review…

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

Based on observation, staff interviews, and review of facility policy, it was determined that the facility failed to ensure that all drugs and biologicals used in the facility were stored in accordance with professional standards for one of one medication storage rooms observed (first floor cart A and second floor medication storage room). Findings include: Observation of the facility east medication storage room on May 6, 2024, at 10:14 a.m., revealed that the storage room was open. The door had a lock, but it was left unlocked. Observation inside the medication storage room revealed that there was a medication refrigerator with medications. The refrigerator had metal hooks for locks, but the lock was missing. Interview with Employee E11, Licensed Practical Nurse, on May 6, 2024, at 10:14 a.m. confirmed that the medication storage room and the refrigerator was unlocked. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code. 211.12(c) Nursing services 28 Pa. Code 211.12 (d)(1) Nursing services.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, review of the facility's planned written menus, menu extensions, and facility policy, and staff interviews, it was determined that the facility failed to follow approved vegetarian diet to ensure nutritional adequacy for one of 13 residents reviewed. (Resident R21) Findings included: Review of an undated facility policy Vegetarian Diet revealed that, The vegetarian Diet accommodates the food preference of the individuals avoiding certain animal food in their diet. Upon admission, the nursing will submit a Tray Card Slip to the dietary department denoting the physician's order for vegetarian diet. The patient will be placed on a vegetarian diet. Review of facility documentation revealed that the facility had a vegetarian extension of the cycle menu. Review of an admission nutritional assessment dated [DATE], revealed that the resident was on a vegetarian and on a cardiac diet. Resident weighed 132 pounds with a BMI of 20.7, with an estimated calorie need of 2000-2200 kcal 63-83 g of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility documentation, observations, and staff interviews, it was determined that the facility failed to provide food that accommodates resident allergies, intolerances, and preferences for one of 13 residents reviewed. (Resident R37) Findings Include: Review of Resident R37's admission nutrition assessment dated [DATE], revealed that the resident had a lactose allergy and intolerance to lactose. Review of physician orders dated April 18, 2024, revealed an order for lactose intolerance, no milk. Further review of resident's nutrition assessment dated [DATE], revealed that Resident R37 had a lactose allergy and intolerance. Further review revealed an order dated May 2, 2024, for fortified foods one time a day for nutritional supplement Super Cereal. Interview with Resident R37 and his wife, on May 3, 2024, at 2:07 p.m. revealed that Resident R37 cannot tolerate a single dairy product. Further interview revealed that the resident had requested a nutritional supplement, Boost Breeze (fruit…

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 record, observations, and staff and resident interviews, it was determined that the facility failed provide food items consistent with the prescribed diet order for two of 10 residents observed during dining (Resident R25, R14). Findings Include: Review of facility policy, Therapeutic Diets, undated, revealed that 'therapeutic diets are prepared and served as ordered by the attending physician. Review of physician orders for Resident R25 confirmed an order dated, October 14, 2022, for health shake three times a day and double portions dated August 24, 2024. Observations during dining, on May 6, 2024, at 12:57 p.m. revealed Resident R25's meal ticket indicated that the resident was ordered to receive double portions and a mighty shake supplement. Observations revealed resident was not served a double portion lunch meal which consisted of ham, and a mighty shake supplement. Review of physician orders for Resident 14 confirmed an order dated October 14, 2022, for a Health Shake. Observation of dining, on May 6, 2024, at 12:57 p.m.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on 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 failing to ensure that one of three residents reviewed (Resident R20) was provided with nutritional interventions, timely nutritional assessments, notification to the resident's physican of the resident's weight loss, and that the resident was provided an appropriate vegetarian diet. This failure resulted in Resident R20 experiencing unplanned significant weight loss of 43 pounds in 5 months and in an Immediate Jeopardy situation. (Resident R20) Findings include: Review of the job description for the Nursing Home Administrator revealed, The The Administrator establish and maintain systems that are effective and efficient to operate the facility in a manner to safely meet residents needs in compliance with federal, state and local requirements; establish and maintain systems that are effective…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policies, clinical record reviews, and interviews with staff, it was determined that the facility failed to maintain sufficient documentation regarding the basis for the discharge for one of five records reviewed (Resident CL1). Findings include: Review of Resident CL1's discharge MDS (Minimum Data Set - a mandatory periodic resident assessment tool) dated January 26, 2024, revealed that the resident was admitted to the facility on [DATE], and had BIMS score of 15, indicating that the resident was cognitively intact. Interview conducted on February 14, 2024, at 11:30 a.m. with the Social Worker, Employee E3, revealed that the resident's daughter had called Employee E3 on Friday, January 26, 2024, and requested for her mother to be discharged that day. Social Worker, Employee E3 told the daughter that she cannot be discharged today because there is no doctor in the building and that the discharge process would have to take place on Monday, January 2, 2024. Social Worker, Employee E3,…

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.