Greenery Center For Rehab And Nursing

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility documents, resident observations and interviews, Resident Council minutes, confidential resident group interview, and grievance review, it was determined that the facility failed to have sufficient nursing staff to provide nursing and related services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of eleven of twenty residents (Resident R21, R26, R56, R63, R64, R86, R117, R118, R119, R120, R121), seven of fourteen confidential group residents (Residents R100, R200, R400, R500, R600, R700, and R900), and for five of six Resident Council monthly meetings (October 2025, November2025, December 2025, and February 2026 and March 2026).Findings Include: Review of the Facility Assessment dated 4/14/25, indicated that the facility will follow state required staffing ratios to meet resident to aide/nurse ppd (per patient day) and would provide care for -Activities of Daily Living: (Bathing, showers, oral/denture care, dressing, eating, support with…

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

Based on review of facility documents and staff interview, it was determined that the facility failed to complete annual performance evaluations for five of five nurse aides (Employees E2, E3, E4, E5, and E6).Finding include: During an interview on 4/10/26, at approximately 10:00 a.m. Human Resources Director Employee E1 confirmed that the facility did not complete performance reviews for Employees E2, E3, E4, E5, and E6. During an interview on 4/10/26, at approximately 3:00 p.m. the Nursing Home Administrator confirmed that the facility failed to provide the required 12 hours annual in-service education within 12 months of their hire date anniversary for five of five nurse aides. 28 Pa. Code: 201.14(a) Responsibility of Licensee.28 Pa. Code: 201.20(a)(b)(c)(d) Staff Development.28 Pa. Code: 211.12(c)(d)(1)(2)(5) Nursing Services.

Based on review of job descriptions, clinical records, and staff interviews, it was determined that the Nursing Home Administrator (NHA) and the Director of Nursing (DON) failed to effectively manage the facility to ensure provider notification of resident changes in condition. This failure resulted in immediate jeopardy for 12 of 21 residents (R2, R4, R16, R33, R37, R46, R47, R56, R70, R80, R97, and R116).Findings include: Review of the facility-provided Nursing Home Administrator (NHA) job description indicated, The Nursing Home Administrator (NHA) is responsible for the overall leadership, management, and operation of The Greenery Center for Rehab and Nursing. This role ensures the delivery of high-quality short-term rehabilitation and long-term care services while maintaining compliance with all federal, state (Pennsylvania), and local regulations. The NHA promotes a resident centered environment focused on clinical excellence, safety, and compass. Review of the facility-provided Director of Nursing (DON) job description indicated, The Director of Nursing (DON) is responsible…

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 select facility policies and procedures, current Centers for Disease Control (CDC) guidelines, clinical record review, and staff interview, it was determined that the facility failed to document each resident was offered a Covid 19 immunization and the resident or resident's representative was provided education regarding the benefits and potential side effects of immunizations, for four of five residents reviewed for immunizations (Residents R20, R24, R31, and R98).Findings include: A review of facility policies, Covid Protocols Post PHE, dated 1/5/26, indicated vaccines are administered in accordance with Centers for Disease Control and Prevention (CDC) recommendations. All residents are encouraged to remain up to date with all recommended Covid 19 vaccine doses. Staff and residents will be educated on the risks/benefits of the Covid vaccination and will be offered the vaccination. A review of the clinical record indicated Resident R20 was admitted to the facility on [DATE], with diagnoses…

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

Based on review of facility documents, staff education records, and staff interviews, it was determined that the facility failed to conduct at least 12 hours of in-service education, within 12 months of their hire date anniversary, for nurse aides as required for five of five nurse aides (Employees E2, E3, E4, E5, and E6).Finding include: Review of the Facility Assessment last reviewed 4/15/25, indicated the facility follows all state and federal guidelines for staffing education. Review of the facility provided, Nursing Assistant In-Service Hours document indicated that Nurse Aide (NA) Employees E2, E3, 14, and E5, E6 had the following education: Nurse Aide (NA) Employee E2 had a hire date of 3/7/86, with 2.00 hours in-service education between 3/7/25, and 3/7/26.NA Employee E3 had a hire date of 3/6/20, with 2.00 hours in-service education between 3/6/25, and 3/6/26.NA Employee E4 had a hire date of 9/30/91, with 4.00 hours in-service education between 9/30/24, and 9/30/25.NA Employee E5 had a hire date of 12/21/00, with 4.00 hours in-service education between 12/21/24, 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 review of clinical records and staff interviews, it was determined that facility staff failed to maintain ongoing communication with the dialysis (a machine filters waste, salt and fluid from your blood when your kidneys are no longer healthy enough to do this work adequately) center for one of five residents reviewed (Resident R1).Findings include: Review of the facility policy Dialysis Management reviewed 1/5/26, indicated the facility has designed and implemented processes which strive to ensure the comfort, safety, and appropriate management of hemodialysis residents regardless of if the procedure is performed at the dialysis center. Review of the clinical record indicated Resident R1 was admitted to the facility on [DATE], with diagnoses that included sepsis (overwhelming and life-threatening response to infection that causes organ failure), dependence on renal (kidney) dialysis, and diabetes. Review of the Minimum Data Set (MDS - periodic assessment of care needs) date 1/27/26, indicated 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 policies, observations and staff interview, it was determined that the facility failed to make certain that out of date medications were discarded in one of three medication rooms (North Unit medication room) and failed to properly secure a treatment cart on one of two nursing units (South Unit). Findings include: Review of the facility policy Medication Storage in the Facility, dated [DATE], indicated medications and biologicals are stored safely, securely, and properly. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medication. Also, Outdated, contaminated, or deteriorated medication and those in containers that are cracked, soiled, or without secure closures are immediately removed from inventory. During an observation of the North Unit medication room on [DATE], at 1:40 p.m. revealed:(7) Blood collection tubes with an expiration date of [DATE].(15) Blood collection tubes with an…

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

Based on facility policy review, review of Quality Assurance attendance records, and staff interview, it was determined that the facility failed to conduct Quality Assessment and Assurance (QAA) meetings at least quarterly with all the required committee members for one of three quarterly meetings (Quarter four of 2025).Findings Include: The facility Quality Assurance and Performance Improvement (QAPI) policy dated 1/5/26, indicated the QAPI program is an ongoing comprehensive program that addresses all the systems of care and shall evaluate, monitor, and investigate quality of care in the facility. Meeting, at a minimum, at least quarterly; monthly or more often if needed. Review of Quality assurance and Performance Improvement sign in sheets and attendance records for Quarter Four of 2025, failed to reveal a meeting was held as required. During an interview on 4/10/26, at 10:40 a.m. the Nursing Home Administrator confirmed that the facility failed to conduct Quality Assessment and Assurance (QAA) meetings at least quarterly with all the required committee members for one of four…

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 and staff interviews it was determined that the facility failed to maintain the confidentiality of residents' personal identifiable information on two of three nursing units (North and South Nursing Units) and failed to provide privacy during provision of care on one of three nursing units (North Nursing Unit). Findings include:During an observation on 3/11/26, at 8:57 a.m., the North nurse's station had resident personal identifiable information regarding care and showers taped to desk for any passerby to see.During an observation on 3/11/26, at 9:02 a.m., the South nurse's station had resident identifiable information regarding care lying on the desk for any passerby to see.During an observation on 3/11/26, at 8:52 a.m., Nurse Aide Employee E4 and E5 were observed to have earbuds in while providing care on residents of the North Nursing Unit. During an interview on 3/11/26, at 1:31 p.m., the Assistant Director of Nursing Employee E1 confirmed that the facility failed to maintain the confidentiality of residents' personal identifiable information as required…

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

Based on a review of facility policy, observations and staff interview it was determined that the facility failed to properly store food products in the Main Kitchen, which created the potential for foodborne illness and cross contamination. Findings Include:Review of the facility policy Dietary Food Handling dated 1/5/26, indicated that thermometers must be placed in hot and cold storage areas in accordance with public health standards. Foods must be stored off of the floor. Clean uniforms must be worn daily, and hairnets or caps must be worn in all food service areas.Review of the Pennsylvania Food Code S46.152 indicated employee shall wear hair restraints including beard restraints. All food items will be stored at least six inches off the floor.Review of S483.60(i)(2) - Store, prepare, distribute and serve food in accordance with professional standards for food service safety. Frozen foods must be stored to allow adequate circulation of air around refrigerated products is essential to maintain appropriate food temperatures. Frozen foods must be maintained at a temperature to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and staff interviews, it was determined that the facility failed to provide a safe, clean, comfortable, and homelike environment on three of three nursing units (North, South and [NAME] nursing units). Based on observations and staff interviews, it was determined that the facility failed to provide a safe, clean, comfortable, and homelike environment on two of two nursing units (North and South nursing units).Findings included:During an observation on 3/11/26, at 9:21 a.m., the following was observed:Resident room [ROOM NUMBER](unoccupied) had peeled wallpaper with black mold identified on the walls under the window.Resident room [ROOM NUMBER] had broken drywall areas behind bed B and the unused floor heater panel was broken leaving exposed sharp metal pieces.Resident room [ROOM NUMBER] had a floor heater unit with no cover leaving exposed sharp metal pieces.Floors on both North and South nursing units had broken floor tiles identified which had the potential to cause tripping…

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 and staff interview, it was determined the facility failed to maintain an environment free of potential accident hazards and obstacles for safe mobility and use of mobility assistance devices on two of three nursing units (North and South Nursing Units). Findings include:During observations throughout the day of the survey 3/11/26, from 8:17 a.m., through approximately 5:15 p.m., the hallways of the North and South Nursing units had equipment such as wheelchairs, linen carts, soiled double linen carts, medication carts and lifts in hallways of each unit. These items obstructed continued access to the handrails which are to be used for resident ambulation or mobility assistance and did not create a homelike environment and did not allow unobstructed egress through the halls or for potential emergency staff to access residents. During an interview on 3/11/26, at 5:15 p.m., the Assistant Director of Nursing Employee E1 stated that resident care areas should be maintained in a clean and orderly manner and confirmed the facility failed to maintain an environment free…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on policy review, clinical record review, and resident and staff interviews, it was determined that the facility failed to provide pharmaceutical services to meet the needs of each resident on three of three nursing units (North, South and [NAME] Nursing units). Findings Include:Review of facility policy, Medication Ordering and Receiving from Pharmacy, last reviewed 1/5/26, indicated that the facility maintains a supply of commonly used over the counter medications considered as floor stock to be administered upon receipt of an order from an authorized prescriber.Review of a complaint and a grievance dated January 2026, identified that common over the counter medications are not available. During interviews with three of five nurses who wish to remain anonymous identified that MiraLAX and Prilosec (or generic form) are not available and one resident bought his own MiraLAX so it would be available for him as he has bowel issues. The nurses stated that they have to borrow from each other.During an…

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

Based on review of facility documents, resident council group interviews, and staff interviews, it was determined the facility failed to consistently provide snacks as desired by residents for three of three Nursing Units (North, South and [NAME] Nursing Units). Findings include:Review of the facility policy Greenery Snack Policy dated 1/5/26, indicated that between meal snacks shall be available for residents.During an interview on 3/11/26, at 8:25 a.m., two Nurse Aides who wish to be unknown stated that residents are unhappy and they are not getting snacks at bedtime and the facility is aware.Resident Council Meeting Minutes dated 1/6/26, 2/4/26 and 3/3/26, indicated resident stating that snacks are not being offered or delivered by the Nurse Aides.Review of Food Committee meeting minutes dared 1/5/26, 2/3/26 and 3/2/26, indicated snacks are not being delivered to the residents.During resident interviews, the residents indicated that the snacks are delivered to the floors, but the NAs eat them and/or they are not offered consistently or provided.During an interview on 3/11/26, 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.

Based on staff interviews and observations, it was determined the facility failed to maintain a fully functioning resident call bell system that allows residents to call for staff assistance through a communication system on one of three nursing units (West nursing unit). Findings include:During interviews on 3/11/26, at 9:32 a.m., with staff, Licensed Practical Nurse Employee E8, Nurse Aide Employee E9 and E10 all stated that they have to watch call lights outside of resident rooms because the call light sound system does not work and the shower room call light is constantly alarming.During an observation on 3/11/26, at 9:33 a.m., the shower room light was alarming, a resident had his call light illuminating above his door, but no alarm sound could be heard, and the central light was illuminating the shower room.During an interview on 3/11/26, at 1:46 p.m., the Maintenance Director Employee E1 confirmed that the confirmed that the facility failed to maintain a fully functioning resident call bell system that allows residents to call for staff assistance through a communication…

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

Based on review of facility policy, observations, and staff interview, it was determined that the facility failed maintain sanitary conditions to prevent the potential for cross-contamination or foodborne illness in the main kitchen (Main Kitchen). Findings include: Review of the facility policy Dietary Food Handling, dated 8/9/24, indicated the guidelines for the safe handling, preparation and storage of perishable food and proper environmental cleaning. Thermometers must be placed in hot and cold storage areas and temperatures must be maintained at the the following settings for the items indicated below: Cold food- 45 degrees or below Frozen food- zero degrees or below Hot food- 140 degrees or above All potentially hazardous food must be kept below 45 degrees or above 140 degrees. Food must be stored off the floor Food handlers must be free from communicable diseases, lesions on hands or other exposed body parts. Clean uniforms must be worn daily. Hairnets or caps must be worn in food service areas. Facial hair must be covered. During an observation in the Main Kitchen on 5/5/25,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility documents, observations, and resident and staff interviews it was determined that the facility failed to provide necessary services to maintain grooming and personal hygiene for seven of twelve residents (Residents R500, R503, R504, R505, R507, R16 and R86). Findings include: Review of the facility policy Personal Care Need dated 8/9/24, indicated the facility strives to promote a health environment and prevent infection by meeting the personal care needs of the residents. The facility also provides the needed support when resident performs their activity of daily living (ADLs). Personal care and support include but is not limited to the following: ambulating, assistance with meals, bath/shower, catheter care, denture care, grooming/dressing, mouth care, nail care, peri care, repositioning, restraint releases, shampoo, shave, splints, toileting and transfers. During a resident group interview on 5/6/25, at 10:30 a.m., five of eight residents in attendance stated, they consistently…

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 staff interviews and review of facility provided documentation, it was determined the facility failed to provide a qualified professional to direct the activities program as required from (4/9/24 through 5/9/25). Findings include: §483.24(c)(2) The activities program must be directed by a qualified professional who is a qualified therapeutic recreation specialist or an activities professional. Review of the Activities Director job description indicated, The primary purpose of the job position is to plan, organize, implement, evaluate and direct the activity programs in accordance with current federal, state and local standards governing the facility and as directed by the Administrator, to ensure that the emotional, recreational, and social needs of the residents are met and maintained on an individual basis. Review of the Activity Director's Employee E6 background reveals a Bachelor of Arts, Parks and Recreation Management, no certification, work history, or eligibility, associated to becoming a qualified therapeutic recreation specialist or activities professional. During…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical records, observations and and staff interviews, it was determined that the facility failed to provide ostomy (surgically-made opening that allows waste to pass out of the body) care and services consistent with professional standards of practice for three of four residents (Resident R73, R144, and R300). Findings include: Review of facility policy Ostomy Care (Colostomy, Jejunostomy, Ileostomy, Ileo conduit) (ostomy - surgical opening that allows waste to pass out of the body; colostomy - opening between abdomen and the colon, or large intestines; jejunostomy - opening between abdomen and middle small intestines; ileostomy.- opening between abdomen and lower small intestines.) reviewed 8/9/24, indicated the procedure for ostomy care was to maintain cleanliness and skin integrity, to prevent odors, and to prevent infections, and included the following steps: #1 - Verify physician's orders and nursing care plan. #2 - Gather equipment, don appropriate PPE (personal…

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 interview, the facility failed to ensure medical supplies were properly disposed of and not reused for one of four residents with an ostomy (hole made in abdominal wall to allow urine/feces to pass through); failed to ensure the consistent implementation of infection control procedures during medication administration for one of three observations; and failed to store medications in a safe and sanitary manner for two of three medication carts reviewed (North cart #2, and North cart #1) Findings: Review of facility policy Infection Prevention and Control Program reviewed 8/4/24, indicated the infection prevention and control program is a facility-wide effort involving all disciplines and individuals and is an integral part of the quality assurance and performance improvement program. Review of facility policy Infection Control reviewed 8/4/24, indicated all personnel will be trained on our infection control policies and procedures upon hire and periodically thereafter. Review of facility policy Ostomy Care (Colostomy, Jejunostomy, Ileostomy, Ileo conduit)…

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, facility records, resident, and staff interviews, it was determined that the facility failed to make certain call bells were answered timely for five of eight residents as required (Resident R500, R503, R505, R506, and R507). Findings include: The facility policy Call Light Protocol dated 8/9/24, indicated; answer call lights in a reasonable amount of time, determine resident/patient's request, and respond to request, if unable to meet request obtain assistance from caregiver that can meet request. During a resident group interview on 5/06/25, at 10:30 a.m., five of eight residents in attendance stated, they consistently wait one half hour or longer for their call light to be responded to. The residents in attendance expressed frustration regarding the wait time. The residents stated they have reported this at their resident council meeting. During a resident group interview on 5/06/25, at 10:30 a.m., three of eight residents in attendance stated, their roommate consistently wait one half hour or longer for their call light to be responded to,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, facility documentation and clinical record review, and staff interviews it was determined that the facility failed to investigate potential neglect for one of 11 residents (Resident R300). Findings include: Review of facility policy Abuse, Neglect, Misappropriation of Resident Property, Injury of Unknown Origin reviewed 8/9/24, indicated reports of abuse will be promptly and thoroughly investigated. The facility should immediately report all such allegations to the Department of Health. Neglect is defined as failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. Review of facility policy Ostomy Care (Colostomy, Jejunostomy, Ileostomy, Ileo conduit) (ostomy - surgical opening that allows waste to pass out of the body; colostomy - opening between abdomen and the colon, or large intestines; jejunostomy - opening between abdomen and middle small intestines; ileostomy.- opening between abdomen and lower small intestines.) reviewed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, resident clinical record, personnel record, and staff interview it was determined that the facility failed fully investigate an allegation of neglect for one out of three resident records (Resident R300). Findings include: Review of facility policy Abuse, Neglect, Misappropriation of Resident Property, Injury of Unknown Origin reviewed 8/9/24, indicated reports of abuse will be promptly and thoroughly investigated. The facility should immediately report all such allegations to the Department of Health. Neglect is defined as failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which provides instructions and guidelines for completing required Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2019, indicated that a BIMS (Brief Interview of Mental Status) is a brief screener that aids…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of facility policy, clinical records, and staff interview, it was determined that the facility failed to develop a baseline care plan for two of four residents (Resident R144 and R193). Findings include: Review of facility policy Care Plan Protocol dated 8/9/24, indicated that upon admission (unless a comprehensive POC (plan of care) is already in place a baseline poc (BPOC) will be reviewed with the resident and/or resident representative within 72 hours. The BPOC will remain in place until a comprehensive POC is completed. Review of the clinical record indicated Resident R144 was admitted to the facility on [DATE],with diagnoses which included a colostomy. Review of the clinical record failed to indicate a baseline care plan was developed for colostomy care. Review of the clinical record indicated Resident R193 was admitted to the facility on [DATE], with diagnoses that included dementia (group of symptoms affecting memory, thinking and social abilities), and high blood pressure. Review 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical records, and staff interviews, it was determined that the facility failed to develop and implement a comprehensive care plan to meet care needs for one of five residents (Residents R142). Findings include: Review of facility policy Comprehensive Care Plans last reviewed on 8/9/25, indicated that facility will develop and implement a comprehensive person-centered care plan for each resident, consistent with individualized needs for residents which are identified within seven days of admission. Review of the clinical record indicated Resident R142 was admitted to the facility on [DATE]. Review of Resident R142's Minimum Data Set (MDS - a periodic assessment of care needs) dated 4/18/25, indicated diagnoses of legal blindness, anemia (low levels of iron in the blood), and spinal stenosis. Review of Resident R142's plan of care dated 5/2/25, did not include development of goals and interventions to reflect the resident's blindness diagnosis. During an interview on 5/6/25,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy, clinical record review and interviews with staff, it was determined that the facility failed to revise the comprehensive care plan to reflect resident's current needs for two of eight residents (Residents R17 and R18). Findings include: Review of facility policy Comprehensive Care Plans last reviewed on 8/9/25, indicated that facility will develop and implement a comprehensive person-centered care plan for each resident, consistent with individualized needs for residents which are identified within 7 days of admission. The care plan will be reviewed and updated as appropriate/determined by the IDT(Interdisciplinary Team) to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. Review of the admission record indicated Resident R17 was admitted to the facility on [DATE]. Review of Resident R17's Minimum Data Set (MDS - a periodic assessment of care needs) dated 3/19/25, indicated diagnoses of Alzheimer's dementia, Diabetes and weakness.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical record review, observations and staff interviews, it was determined that the facility failed to make certain that residents were provided appropriate treatment and care for one of three residents receiving enteral feedings (Resident R35). Findings include: Review of the facility policy Physician Orders dated 8/9/24, indicated that the facility will have orders for resident immediate care upon their admission to the facility. Review of the facility policy Enteral Feeding, dated 8/9/24, indicated that staff must verify the physician orders and prepare the feeding according to physician orders. Staff are to contact the physician and Registered Dietician to obtain orders for assure caloric needs are being met. Review of the clinical record indicated Resident R35 was admitted to the facility on [DATE]. Review of Resident R35's Minimum Data Set (MDS - a periodic assessment of care needs) dated 4/18/25, indicated diagnoses of a stoke affecting her dominant side, cognitive…

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 records, employee personnel records, staff interviews, and clinical records, it was determined that the facility failed to ensure nursing staff possessed the necessary competencies and skills to provide care in accordance with the resident's care plan and individual needs to promote resident safety and comfort during care for one of four residents reviewed (Residents R300). Findings included: Review of facility policy Ostomy Care (Colostomy, Jejunostomy, Ileostomy, Ileo conduit) (ostomy - surgical opening that allows waste to pass out of the body; colostomy - opening between abdomen and the colon, or large intestines; jejunostomy - opening between abdomen and middle small intestines; ileostomy.- opening between abdomen and lower small intestines.) reviewed 8/9/24, indicated the procedure for ostomy care was to maintain cleanliness and skin integrity, to prevent odors, and to prevent infections, and included the following steps: #1 - Verify physician's orders and nursing care plan. #2…

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

Based on a review of facility policies, documents, clinical documentation, observations and staff interview it was determined that the facility failed to assess a resident receiving enteral feedings in a timely manner and failed to approve the planned menu for four of four menu cycle weeks. (Menu Cycle Week One, Two, Three and Four). Findings Include: Review of the Registered Dietician job description provided from the facility, with a policy review date of 8/9/25, indicated that the Dietician is to implement, coordinate and evaluate the medical nutrition therapy for the residents, provide resident and family education,provide nutritional assessment and consultation to assist in planning, organizing and directing the food an nutritional services of the facility.The Dietician is to assist in developing preliminary and comprehensive assessments of the dietary needs of each resident including a written dietary plan of care that identifies the dietary problems/needs of the resident and the goals to be accomplished. Review of the facility four week cycle menu Diet Spreadsheets revealed…

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 maintain complete and accurate documentation for one of seven residents (Residents R144). Findings include: Review of the facility policy Episodic and Narrative Documentation dated 8/9/24, indicated that documentation will occur in the nurses progress notes to reflect a change in status, event, or notification of the responsible party or Physician. A single narrative entry will occur for the following episodes including admission, objective facts, response to treatment and resident responses. Review of Resident R144's clinical admission record indicated that resident was admitted to the facility on [DATE]. Review of Resident R144's admission clinical record documentation dated 5/2/25, stated Ileostomy present, Ileostomy stoma WNL(within normal limits). Ileostomy stoma care provided. Review of Resident R144's physician order dated 5/6/25, did not include care for the Ileostomy. Review of plan of care initiated 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 review of facility policy, clinical records, and staff interview, it was determined that the facility failed to notify physicians of increased capillary blood glucose (CBG) levels for three of seven residents (Resident R2, R3, and R4). Findings include: Review of the facility policy Physician Communication/Change in Condition dated 8/9/24, indicated to notify a physician for glucose levels if: 1. Follow specific physician orders if present; or 2. Greater than 300 mg/dl (milligrams per deciliter) in a diabetic patient not using sliding-scale insulin; or 3. Greater than 450 mg/dl (or machine registers hi) in a diabetic patient using sliding scale insulin. Review of the clinical record indicated Resident R2 was admitted to the facility on [DATE]. Review of Resident R2's facility diagnoses list included heart failure (a progressive heart disease that affects pumping action of the heart muscles) and diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time). 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 review of facility policy, observations, and staff interview, it was determined that the facility failed to make certain that medications were properly stored and/or disposed of in two of three medication carts (North One and North Three medication carts). Findings include: Review of facility policy Medication Storage in the Facility dated 8/9/24, stated that medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. All medications dispensed by the pharmacy are stored in the container with the pharmacy label. Outdated, contaminated, or deteriorated medications are immediately removed from inventory, disposed of according to procedures for medications disposal, and reordered from the pharmacy if a current order exists. Additionally, the policy stated, the nurse shall place a date opened sticker on the medication and enter the date opened and the new date of expiration, if applicable. Review of the U.S. FDA approved prescribing information for Lantus (a type of long-acting insulin) dated 05/2019,…

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

Based on review of facility policy, observations, and staff interview, it was determined that the facility failed to maintain the confidentiality of residents' medical information for one of three medication carts (North One medication cart). Findings include: Review of the facility policy Confidentiality and Non-Disclosure Agreement dated 8/9/24, indicated for staff Not to leave your computer terminal or workstation unattended without logging off or using your system ' s screensaver function before leaving your work area. During an observation of the North One medication cart 11/1/24, at 2:12 p.m. the medication cart was in the hall, unattended by staff. The computer screen was open to a resident record, visible to persons in the hallway. During an interview on 11/1/24, at 2:17 p.m. Licensed Practical Nurse Employee E1 confirmed that she had stepped away from the computer without locking to screen to maintain privacy. During an interview on 11/7/24, at approximately 2:00 p.m. the Nursing Home Administrator confirmed that the facility failed to maintain the confidentiality 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, observations and staff interviews it was determined that the facility failed to provide a clean, safe, comfortable, and homelike environment for two of four residents (Resident R1 and R2). Findings include: Review of the facility policy Resident Rights dated 8/9/24, indicated the facility recognizes the resident right to a quality of life that supports privacy, confidentiality, dignity independent expression, choice, and decision making, consistent with State law and Federal regulation. Review of Title 42 Code of Federal Regulations §483.10(i) Safe Environment. The resident has a right to a safe, clean, comfortable, and homelike environment, including but not limited to receiving treatment and supports for daily living safely. §483.10(i)(2) Housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior. Review of the admission record indicated Resident R1 was admitted to the facility on [DATE]. Review of Resident R1's Minimum Data Set…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy review, clinical and facility record review, facility submitted documents, and staff interviews, it was determined that the facility failed to provide adequate supervision to prevent elopement for one of four residents (Resident R2). This was identified as past non-compliance. Findings include: Review of the facility policy Elopement Preventions and Management; Unsafe Wandering and Exit Seeking Behavior dated 4/22/24, defined elopement as when a cognitively impaired resident leaves the physical structure of the facility unattended and with without staff knowledge or not within residents sight. The policy further stated that the facility will identify residents at risk for unsafe wandering and exit seeking behavior, and develop individualized prevention and management interventions based on assessment. Review of the Resident Assessment Instrument 3.0 User's Manual effective October 2019, indicated that a Brief Interview for Mental Status (BIMS), is a screening test that aides in detecting…

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 and staff interviews, it was determined that the facility failed to provide transportation for a scheduled appointment for one of three residents (Resident R1). Findings include: Review of the clinical record indicated that Resident R1 was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS, periodic assessment of resident care needs) dated 4/10/24, included diagnoses of diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time) and heart failure (a progressive heart disease that affects pumping action of the heart muscles). Review of a physician's order dated 4/26/24, indicated that on 5/20/24, Resident R1 had an appointment at an eye doctor. Review of Resident R1's clinical record failed to include documentation that Resident R1 was taken to that appointment. Review of information submitted by Resident R1's family indicated that when she asked the facility if Resident R1 had gone to the appointment, they were…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the Resident Assessment Instrument User's Manual and clinical records, and staff interview, it was determined that the facility failed to make certain that comprehensive Minimum Data Set assessments were accurate and fully completed for eight of nine residents without a BIMS assessment completed (Resident R26, R28, R57, R67, R74, R75, and R91), and two of eight for inaccurate resident assessments. Findings include: The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which gives instructions for completing Minimum Data Set Assessments (MDS - periodic assessment of care needs) dated October 2018, and updated October 2023, indicated that Section C: Cognitive Patterns, Question C0100 Should Brief Interview for Mental Status Be Conducted? (BIMS) should be coded as 0 if the resident is rarely/never understood, or it should be coded 1, and the BIMS assessment should be completed if the resident is at least sometimes understood. Section D: Mood, Question D0100 Should…

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

Based on observations and interview, the facility failed to store medications in a safe and sanitary manner for one of three medication carts reviewed (Team #2 North). Findings: During an observation on 5/23/24, at 8:20 a.m., Team #2 North medication cart contained three of eight insulin pens in compartments unbagged, posing the risk of cross-contamination. During an interview at that time, Licensed Practical Nurse (LPN) Employee E3 confirmed the insulin pens were not placed back in the available bags in the medication drawer. During an interview on 5/23/24 at 8:26 a.m. the Director of Nursing confirmed the facility failed to prevent the risk of cross-contamination by storing insulin pens unbagged in the medication carts for Team #2 North medication carts. 28 Pa code 201.14(a)Responsibility of licensee. 28 Pa code 211.12(d)(1) Nursing services.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of clinical records and staff interview it was determined that the facility failed to provide care and services according to accepted standards of clinical practice in the identification of a resident's diagnosis of schizoaffective disorder for one resident of two residents (Resident R34). Findings include: Review of the American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders (DSM-5), Fifth Edition, Schizoaffective Disorder, Diagnostic Criteria included, but is not limited to: A. An uninterrupted period of illness during which there is a major mood episode (major depressive or manic) concurrent with Criterion-A of schizophrenia: --Two (or more) of the following, each present for a significant portion of time during a one-month period (or less if successfully treated). At least one of these must be (1), (2), or (3): --1. Delusions. --2. Hallucinations. --3. Disorganized speech (e.g., frequent derailment or incoherence). --4. Grossly disorganized or catatonic…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of clinical records and staff interviews, it was determined that facility staff failed to maintain ongoing communication with the dialysis (a machine filters wastes, salts and fluid from your blood when your kidneys are no longer healthy enough to do this work adequately) center for one of four residents reviewed (Resident R23). Findings include: A review of the clinical record indicated that Resident R23 was admitted to the facility on [DATE], with diagnoses that included end-stage renal disease (ESRD - the kidneys permanently fail to work), diabetes, and anxiety. A review of the Minimum Data Set (MDS - periodic assessment of care needs) date 3/20/24, indicated the diagnoses remain current. A review of a physician ' s order dated 4/24/24, indicated Resident R23 was to receive dialysis three days a week on Monday, Wednesday, and Fridays. Review of a care plan failed to reveal interventions related to dialysis. During an interview on 5/23/24, at 2:15 p.m. Resident R23 stated she does not take any…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical records, and staff interview, it was determined that the facility failed to notify physicians of increased capillary blood glucose (CBG) levels for three of seven residents (Resident R1, R4, and R18). Findings include: Review of the facility policy Physician Communication/Change in Condition dated 6/1/23, indicated to notify a physician for glucose levels to: 1. Follow specific physician orders if present; or 2. Greater than 300 mg/dl (milligrams per deciliter) in a diabetic patient not using sliding-scale insulin; or 3. Greater than 450 mg/dl (or machine registers hi) in a diabetic patient using sliding scale insulin. Review of the clinical record indicated Resident R1 was admitted to the facility on [DATE]. Review of Resident R1's Minimum Data Set (MDS - a mandated assessment of a resident's abilities and care needs) dated 1/22/24, included diagnoses of end stage renal disease (ESRD, an inability of the kidneys to filter the blood) and diabetes (a metabolic 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 resident observations and interviews, and grievance review, it was determined that the facility failed to have sufficient nursing staff to provide nursing and related services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of 13 of 15 residents (Resident R1, R2, R5, R6, R7, R8, R9, R10, R11, R12, R13, R14, R15, R16, and R17). Findings include: During an observation on 2/23/24, at 4:25 p.m., Resident R2 stated, when asked about facility staffing and care, There's not enough care. They are slow coming. When asked if he had ever soiled himself while waiting for care, Resident R2 stated, Instead of coming, you crap in your diaper, and live with it. During an interview on 2/23/24, at 4:28 p.m., when asked about facility staffing and care, Resident R5 stated, The staff has to bust their balls. During an interview on 2/23/24, at 4:32 p.m., when asked about facility staffing and care, Resident R6 stated, Usually ok, but you have to wait if they are busy. During an interview on 2/23/24, at 4:34 p.m., when asked about facility staffing 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 review of clinical records, and staff interview, it was determined that the facility failed to implement procedures to ensure availability of prescribed medications for three of four residents (Residents R1, R2, and R3). Findings include: Review of facility policy Medication Ordering and Prescribing dated 6/21/23, indicated that residents receive newly ordered medications in a timely manner. Review of Resident R1's admission record indicated he was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS - periodic assessment of care needs) dated 1/24/24, included diagnoses of end stage renal disease (ESRD, an inability of the kidneys to filter the blood), heart failure (a progressive heart disease that affects pumping action of the heart muscles), and diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time). Review of hospital discharge paperwork dated 1/16/24, at 11:41 a.m. indicated that Resident R1 was to be ordered the following scheduled…

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, observations and staff interview, it determined the facility failed to maintain sanitary conditions to prevent the potential for cross contamination during lunch time tray line. Findings include: Review of facility policy Safe Food Handling reviewed 6/21/23, indicated all facility staff involved in the preparation and service of food adheres to safe food handling techniques, and food is served with clean, sanitized utensils. During an observation on 9/20/23, at 12:43 p.m. the following was observed: -At 12:43 p.m. [NAME] Employee E1, while wearing plastic gloves, used long-handled ladle to serve vegetables, used a scoop to serve mashed potatoes, then proceeded to pick up a piece of country fries steak with her gloved hands and placed on resident's tray. -At 12:44 p.m. [NAME] Employee E1, while wearing the same plastic gloves, proceeded to prepare the next resident tray, touched the long-handled ladle, the scoop, and picked up another piece of country fried steak with her gloved hands. This was observed twice during this time. -At 12:45 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.