Wecare At South Hills Rehabilitation And Nrsg Ctr

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policies, clinical record reviews, and staff interview, it was determined the facility failed to ensure each resident receives proper treatment and services to maintain hearing abilities for five of eight residents reviewed for hearing (Residents R3, R26, R36, R48 and R23). Findings include:Review of the facility policy Consults Policy and Procedures, dated 8/27/25, indicated to ensure all in-facility consults are timely, clinically indicated and in compliance, the facility nursing staff shall notify the attending provider of the consulting provider's recommendations, review the attending physician's acceptance of the recommendation and monitor the compliance with the recommended treatment.Review of the clinical record indicated Resident R3 had been admitted to the facility on [DATE], with diagnoses which included traumatic brain injury, obesity, stroke and heart fibrillation. An MDS (Minimum Data Set- a periodic review of resident needs) dated 11/4/25, indicated the diagnoses remained…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, review of clinical record, review of facility policy, interview with staff and residents, it was determined the facility failed to provide tracheostomy care consistent with professional standards of practice for one resident with a tracheostomy (Resident R25), and failed to provide appropriate respiratory care and maintain respiratory equipment for five of five residents (Resident R25, R41, R50, R65, and R74). Findings include: Review of the facility policy Tracheostomy Care dated 8/27/25, indicated a replacement tracheostomy tube (a hollow tube inserted into a surgical opening in the neck (stoma) directly into the windpipe to provide long-term ventilation) must be available at the bedside at all times. A suction machine must be available at the bedside at all times. Review of the facility policy Departmental (Respiratory Therapy) - Prevention of Infection last reviewed on 8/27/25, indicated that considerations related to oxygen administration include change the oxygen cannula and tubing…

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 interview it was determined that the facility failed to employ a qualified Food Service Director to manage the daily operations of the Dietary Department for 12 out of 12 months (February 2025 through January 2026).Findings include:During an interview on 1/20/26, at approximately 9:00 a.m., the Dietary Supervisor Employee E8 stated she was not certified and that the Dietician only works two days a week in the facility and another two days in another facility.During an interview on 1/20/26, at 11:20 a.m., the Nursing Home Administrator stated that the Registered Dietitian (RD) was not employed full time she comes two times a week.During an interview on 1/20/26, 11:20 a.m., the Nursing Home Administrator (NHA) confirmed that the facility failed to provide documented evidence that Dietary Supervisor Employee E8 met the qualifications for the position of Food Service Director. Pa Code: 201.18(e)(6) Management.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of facility admission documents and staff interview, it was determined that the facility failed to ensure resident rights to make informed decisions and choices in the residents' welfare by making certain residents understand the conditions of a binding arbitration agreement and failed to ensure the agreement is explained to the resident and his or her representative in a form and manner that he or she understands, including in a language the resident and his or her representative understands for two of five residents (Resident R27 and R48).Findings include: Review of the Resident Assessment Instrument 3.0 User ' s Manual effective October 2025 indicated that a Brief Interview for Mental Status (BIMS) is a screening test that aides in detecting cognitive impairment). The BIMS total score suggests the following distributions:13-15: cognitively intact8-12: moderately impaired0-7: severe impairment Review of the facility's admission packet contained the document Alternative Dispute Resolution…

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, observations, and staff interviews, it was determined that the facility failed to maintain infection control practices to prevent the potential for cross contamination while during wound care for one of six residents (Resident R8), failed to maintain two ice machines in a sanitary manner ( A/E wing and B/C wing ice machines), failed to properly monitor residents in room personal refrigerator temperatures for two of two residents (Residents R33 and R64) which created the potential for food borne illness and failed to follow Enhanced Barrier Precautions (EBP) for one of eight residents (Resident R6).Findings include: Review of the facility policy, Dressings, Dry/Clean dated 8/27/25, indicated in the Steps in the Procedure to cleanse hands between glove changes. Review of facility policy Enhanced Barrier Precautions dated 8/27/25, indicated the facility will implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms (MDRO). Examples of…

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

Based on a review of facility policy, observations, and staff interviews, 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 which relays the call directly to a staff member or to a centralized staff work area in two of five rooms (Resident R10 and R46).Findings include: To ensure accessibility, the ADA (Americans with Disabilities Act) Standards for Accessible Design dated 9/15/10, indicated that emergency call system pull cords must be accessible to individuals with disabilities, ensuring they can reach the activation point from a seated or fallen position. While specific string length is not explicitly defined in inches by the ADA, the cord must be reachable, the operating mechanism must be within the ADA reach range of 15 to 48 inches from the floor Review of the facility policy Call System, Residents dated 8/27/25, indicated, Each resident is provided with a means to call staff directly for assistance from his/her bed, from toileting/bathing facilities…

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 staff interview, it was determined that the facility failed to protect a resident from neglect for one of three residents resulting in pain and the need for Xray's to rule out possible injuries/ fractures for one of three residents (Resident R11).Findings include:Review of the facility policy Abuse and Neglect dated 8/27/25, indicated that neglect is the failure of the facility to provide services to a resident that are necessary to avoid physical harm, pain or mental anguish. Review of the clinical record indicated that Resident R11 was admitted to the facility on [DATE] with diagnoses which included Alzheimer's dementia, obstructive uropathy, glaucoma, obesity, lack of coordination, and history of right open repair internal fixation of right hip (ORIF). An MDS (Minimum Data Set- a periodic review of a resident care needs) dated 10/24/25, indicated the diagnoses remained current. An MDS dated [DATE], Section G0110 (bed mobility) indicated bed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of facility policy, information provided by the facility, clinical records and staff interview, it was determined the facility failed to promptly conduct a thorough investigation to rule out neglect and implement corrective action and submit the results of the completed investigation to the State Survey Agency within five working days of the incident as evidenced by one of three residents reviewed (Resident R11).Findings include:Review of the facility policy Abuse and Neglect dated 8/27/25, indicated that neglect is the failure of the facility to provide services to a resident that are necessary to avoid physical harm, pain or mental anguish. Staff and management will help to identify situations that might constitute neglect. The facility will investigate alleged abuse and neglect to clarify what happened and identify possible causes. Review of the facility policy Abuse, Neglect, Exploitation or Misappropriation- Reporting and Investigating dated 8/27/25, indicated that all reports of resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of clinical records, facility provided documentation and staff interviews, it was determined that the facility failed to make certain each resident received adequate supervision and assistance to prevent accidents for one of three residents (Resident R11).Findings include:Review of the clinical record indicated that Resident R11 was admitted to the facility on [DATE]m with diagnoses which included Alzheimer's dementia, obstructive uropathy, glaucoma, obesity, lack of coordination, and history of right open repair internal fixation of right hip (ORIF). An MDS (Minimum Data Set- a periodic review of a resident care needs) dated 10/24/25, indicated the diagnoses remained current. An MDS dated [DATE], Section G0110 (bed mobility) indicated bed mobility as total assistance of two staff. Section GG0170 How much assistance required to perform task) indicated substantial/maximum assistance for turning left and right in bed. During an interview on 1/21/26, at 10:00 a.m., Nurse Aide (NA) Employee E6 stated…

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 records, and staff interviews, it was determined that the facility failed to provide prescribed treatment and services related to an implanted venous port (a small implantable device placed under the skin usually in the chest to provide reliable long term venous access) for one of three residents (Resident R73), and failed to properly care for total parenteral nutrition (TPN - a method of delivering essential nutrients - fats, proteins, carbohydrates, electrolytes, and vitamins directly into the bloodstream via an intravenous (IV) catheter, bypassing the digestive system)for one of three residents (Resident R74).Findings include:Review of the facility policy Implanted Venous Port - Accessing dated 8/27/25, indicated to cover needle and access site with transparent sterile dressing when the port is accessed. Label dressing with date, time, and initials of the person who is performing the procedure.Review of the facility policy Total Parenteral Nutrition dated…

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 resident record review and staff interviews, it was determined that the facility failed to provide a trauma survivor with trauma informed care to eliminate or mitigate triggers that may cause re-traumatization of the resident for two of four residents (Resident R7 and R33). Findings include: Review of the facility policy Trauma Informed Care and Culturally Competent Care dated 8/27/25, indicated the purpose is to address the needs of trauma survivors by minimizing triggers and/or re-traumatization. Review of the admission record indicated Resident R7 admitted to the facility on [DATE]. Review of Resident R7's Minimum Data Set (MDS - a periodic assessment of care needs) dated 11/10/25, indicated the diagnoses of post-traumatic stress disorder (PTSD - a psychiatric disorder that may occur in persons that have witnessed a traumatic event causing intense, disturbing thoughts and feelings related to the experience), dementia (a general term for loss of memory, language, problem solving and other thinking…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to conduct accurate assessments to ensure that bedrails were used to meet residents' needs and the risks associated with bedrail usage for one of two residents (Residents R78).Findings include:Review of facility policy Bed Safety and Bed Rails dated 8/27/25, indicated the use of bed rails or side rails is prohibited unless the criteria for use of bed rails have been met, including attempts to use alternatives, interdisciplinary evaluation, resident assessment, and informed consent. Review of the clinical record indicated Resident R78 was admitted to the facility on [DATE], with diagnoses that include Schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly), bipolar (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs), and paralytic syndrome (rapid onset of paralysis).Review of Resident R78'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, resident clinical records, and staff interviews, it was determined that the facility failed to ensure a resident received appropriate behavioral health services to maintain the highest practicable well-being for one of two sampled residents (Resident R33).Findings include:Review of the facility policy Behavioral health Services dated 8/27/25, indicated behavioral health services are provided to residents as needed as part of the interdisciplinary, person-centered approach to care.Review of the admission record indicated Resident R33 admitted to the facility on [DATE].Review of Resident R33's Minimum Data Set (MDS - a periodic assessment of care needs) dated 1/14/26, indicated the diagnoses of heart failure (heart doesn't pump blood as well as it should), anxiety, and depression.Review of Resident R33's current care plan indicated resident has a behavior problem of requesting staff to purchase gift cards for an online friend and requesting staff take her to the store 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 observation, review of facility policy, resident interviews, clinical records, and staff interview, it was determined that the facility failed to make certain that residents are free of significant medication errors for one of five residents observed (Resident R73).Findings include:Review of the facility policy Adverse Consequences and Medication Errors dated 8/27/25, indicated a medication error is defined as the preparation or administration of drugs or biological which is not in accordance with physician's orders, manufacturer's specifications, or accepted professional standards and principles of the professional providing services. Examples include omission - a drug is ordered but not administered.Review of the clinical record indicated Resident R73 was admitted to the facility on [DATE], with the diagnoses of chronic obstructive pulmonary disease (COPD- a group of diseases that block airflow and make it hard to breathe), heart failure (heart doesn't pump blood as well as it should), and high blood…

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 interviews, it was determined that the facility failed to store medications properly, for one of two medication carts (A side medication cart).Findings include:Review of the facility policy Storage of Medications dated 8/27/25, indicated the facility stores all drugs and biologicals in a safe, secure, and orderly manner.During an observation on 1/20/26, at 2:58 p.m. the A side medication cart indicated the following medications opened and not dated as required:-Budesonide inhalation suspension (medication that reduces airway inflammation)-Ipratropium bromide (medication that acts as a bronchodilator) - two boxes-Trelegy Ellipta (medication that's inhaled to treat chronic respiratory illness)-Lantus insulin pen (long-acting insulin used to regulate blood sugar)Interview on 1/20/26, at 2:58 p.m. Registered Nurse (RN) Employee E2 confirmed the medications listed were opened and not dated as required.Interview on 1/20/26, at 3:00 p.m. the Director of Nursing confirmed that the facility failed to store medications properly,…

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 residents' financial account records and staff interview, it was determined that the facility failed to return resident funds within 30 days of discharge/death to the appropriate party for one of five residents sampled (Resident R1 and Resident R2).Findings include: Review of the clinical record indicated Resident R1 was admitted to the facility on [DATE], with diagnoses that included cancer, high blood pressure, and diabetes. Review of facility documents revealed Resident R1 expired (passes away) on [DATE], at 6:41 a.m. During an interview on [DATE], at 12:30 p.m. Business Office Employee E1 stated the facility does not handle billing on site, the company uses the third-party company Wellsky. They stated, as of [DATE], Resident R1's responsible party was due a refund of $385.00. Review of an email provided by Business Office Employee E1, indicated Resident R1's family contacted the facility on [DATE], at 12:22 p.m. to inquire about the refund owed. The family had made…

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

Based on review of facility documentation, clinical records, staff interviews and resident interviews it was determined the facility failed to submit, document and/or follow-up on concerns/grievances presented by staff and residents (staff and residents wished to remain anonymous).Finding include:Review of Federal Regulation 483.10(i)(1) The resident has the right to voice grievances to the facility or other agency or entity that hears grievances without discrimination or reprisal and without fear of discrimination or reprisal. Such grievances include those with respect to care and treatments which has been furnished as well as that which has not been furnished, the behavior of staff and of other residents, and other concerns regarding their LTC facility stay.Review of facility policy, Skilled Nursing Facility Grievance Policy dated 1/27/25, revealed the facility is committed to maintaining transparent, fair, and accessible grievance process. Every grievance will be addressed promptly and appropriately, in accordance with federal and state regulations. Residents and their…

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.

Finding include:Review of the facility policy Abuse and Neglect-Clinical Protocol dated 1/27/25, previously reviewed 10/23/24, indicated abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical conditions, cause physical harm, pain, or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology.Review of the facility policy Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating dated 1/27/25, previously reviewed 10/23/24, indicates all reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft misappropriation of resident property are reported to local, state, 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 facility policy and documents, clinical records, and staff interview, it was determined that the facility failed to implement policies and procedures to investigate allegations of abuse for four of 61 residents (Resident R2, R3, R5, and R6). This failure resulted in a resident with a known history of sexually inappropriate behavior touching non-consenting residents.Findings include:Review of facility policy Abuse, Neglect, Exploitation or Misappropriation dated 1/27/25, indicated All allegations are thoroughly investigated.Review of the clinical record indicated Resident R3 was admitted to the facility on [DATE].Review of the Minimum Data Set (MDS - periodic assessment of resident care needs) dated 7/7/25, included diagnoses of heart failure (a progressive heart disease that affects pumping action of the heart muscles) and physical debility. Review of Section C: Cognitive Patterns indicated Resident R3 was cognitively intact.Review of an electronic communication dated 8/12/25, provided to both…

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 job descriptions, clinical records and staff interviews, it was determined that the Nursing Home Administrator (NHA) and the Director of Nursing (DON) failed to protect residents from resident-to-resident sexual abuse. This failure resulted in a resident with a known history of sexually inappropriate behavior touching a non-consenting resident, which created an Immediate Jeopardy for five of 67 residents (Resident R2, R3, R4, R5, R6).Findings include:Review of the facility-provided Nursing Home Administrator (NHA) job description indicated, The primary purpose of the job position is to manage the Facility in accordance with current applicable federal, state, and local standards, guidelines, and regulations that govern long-term care facilities. To follow all facility policies and apply them uniformly to all employees. To ensure the highest degree of quality care is provided to our residents at all times.Review of the facility-provided Director of Nursing (DON) job description indicated, To plan, organize, develop and direct the overall operation of the Nursing…

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

Based on review of facility documentation, cited deficiencies from previous surveys, review of plan of correction documentation, and staff interview, it was determined that the facility's Quality Assurance and Performance Improvement (QAPI) program failed to correct previously cited deficiencies. This has the potential to affect 5 of 67 residents.Finding include:Review of the facility policy Quality Assurance and Performance Improvement (QAPI) Program dated 1/27/25, indicated objectives of the QAPI program include providing a means to measure current and potential indicators for outcomes of care and quality of life; establish and implement performance improvement projects to correct identified negative or problematic indicators; reinforce and build upon effective systems and processes related to the delivery of quality care and services; and establish systems through which to monitor and evaluate corrective actions.Review of the facility's deficiencies and plan of corrections for the State Survey and Certification (Department of Health) survey ending 2/3/25, revealed the facility…

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 that the facility failed to post complete and current contact information for the Grievance Officer in the facility on three of three nursing units (Bird Room (Main area near dining room), Solarium C and Solarium E).Findings include:During an observation completed 8/21/25, through 8/22/25, of the Bird Room (common area), the facility failed to reveal the address and email contact information for Adult Protective Services and the Office of the State Long-Term Care Ombudsman program along with the Grievance Officer for the facility, observations revealed in Solarium C and Solarium E common areas, the facility failed to reveal the correct contact information for the Grievance Officer.During an interview on 8/22/25, at approximately 2:50 p.m., the Nursing Home Administrator and Director of Nursing confirmed that the facility failed to post complete contact information for Adult Protective Services, State Long-Term Care Ombudsman, and the Grievance Officer as required in one resident common area and failure to list an updated…

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 Resident Assessment Instrument (RAI) User's Manual, facility policy, clinical records, and staff interviews, it was determined that the facility failed to develop comprehensive care plans to meet resident care needs for residents to be in a relationship for four of 67 residents (Residents R1, R7, R21, and R35).Finding include:Review of the facility policy Care Planning/ Interdisciplinary Care Planning Team dated 1/27/25, previously reviewed 10/23/24, indicated the Care Planning/Interdisciplinary Team shall serve as the authority for overseeing resident care services. The committee shall function as an advisory committee to the Quality Assessment and Assurance Committee. A comprehensive, person-centered care plan for each resident that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessments.Review of Resident R1's admission record indicated he was admitted to the facility on [DATE]…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record and facility document review and staff interview, it was determined that the facility failed to provide the necessary services to meet the psychosocial needs resulting in the commitment of resident-to-resident sexual abuse for one of two residents with unmonitored hypersexual behaviors (Resident R1). Findings include:Review of the facility, Behavior Management Policy revised 1/27/25, indicated, Patients exhibiting behavioral symptoms will be individually evaluated. The interdisciplinary team will identify underlying medical, physical, functional, psychosocial, emotional, psychiatric, or environmental causes that contribute to the resident's behavior(s).Review of the Resident Assessment Instrument 3.0 User's Manual, effective October 2024, indicated that a Brief Interview for Mental Status (BIMS) is a screening test that aides in detecting cognitive impairment. The BIMS total score suggests the following distributions: 13-15: cognitively intact8-12: moderately impaired0-7: severe…

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,facility submitted documents, and staff interview, it was determined that the facility failed to report an allegation of abuse in the required timeframe for one of nine residents (Resident R29). Finding include: Review of facility policy Abuse and Neglect dated 10/23/24, indicated abuse is the failure of the facility, its employees or service providers to provide goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. All allegations of abuse of unknown source must be reported immediately to the Administrator, Director of Nursing, and to the applicable State Agency. All serious incidents involving a resident will be reported to the Department of Health (State Agency) field office within 24 hours. Review of the clinical record indicated Resident R29 was admitted to the facility on [DATE]. Review of Resident R29's Minimum Data Set (MDS-a periodic assessment of are needs) dated 11/14/24, indicated 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.

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 make certain call light tubes were in reach for one of two residents with a breath activated call light response system (Resident R53). Findings include: The facility policy Call Light Response dated 10/23/24, indicated to ensure a call bell or alternative device will be accessible to each resident while in their room, toilet, or bathing area. Review of Resident R53's clinical record indicated admission to the facility on [DATE], and readmitted on [DATE]. Review of Resident R53's Minimum Data Set (MDS - a periodic assessment of care needs) dated 11/4/24, indicated diagnoses of dementia (a group of symptoms that affects memory, thinking and interferes with daily life), muscle weakness, and rheumatoid arthritis (chronic, painful inflammatory disorder affecting many joints, including those in the hands and feet). Review of Section GG: Functional Abilities, indicated that Resident R53 has range…

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 resident council minutes, resident and group interviews and interviews with staff and facility policy, it was determined the facility failed to ensure the residents were offered a private group meeting during resident council for 10 of 10 residents interviewed (Resident R10, R19, R26, R31, R40, R43, R50, R52, R54, R56). Finding include: Review of the facility policy titled, Resident Council reviewed 10/23/24, states the facility will provide space, privacy and support to conduct meetings. During Resident Group with ten alert and oriented residents on 2/5/25, at 1:00 p.m. Resident R10 and R43 indicated during resident council some of the members did not like to use their name if there was a concern or problem so the facility doesn't get told. Members of the resident council were asked , during the time they meet would it be more beneficial to meet in private than in the main dining room where staff and other residents continuously walk through and can hear the meeting going on, thus allowing residents to voice their concerns and the president can then take 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, clinical records, and staff interview, it was determined that the facility failed to notify resident representative and/or medical providers of a change in condition for two of six residents (Resident R29 and R62). Findings include: Review of the policy Health, Medical Condition and Treatment Options, Informing Resident Of, dated 10/23/24, indicated the responsible party or guardian is to be notified when there has been any change in condition, such as the diagnosis of an infection and the start of antibiotics. Review of the Resident Assessment Instrument 3.0 User's Manual effective October 2024, indicated that a Brief Interview for Mental Status (BIMS), is a screening test that aides in detecting cognitive impairment. The BIMS total score suggests the following distributions: 13-15: cognitively intact 8-12: moderately impaired 0-7: severe impairment Review of the clinical record indicated Resident R62 was admitted to the facility on [DATE], and readmitted on [DATE]. 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.

Based on observations and resident and staff interviews it was determined that the facility failed to provide a clean and homelike environment on one of two nursing units (A/E Nursing Unit) and for five of fourteen residents (Residents R15, R52, R53, R62, and R66). Findings include: During an observation on 2/3/25, at approximately 11:00 a.m., Resident R52's was noted to have trash on the floor, a drawer of the bedside table pulled out of the table and on its side, soiled washcloth and resident clothing on the floor, disposable cups and used gloves under the bed, and screws and a metal bracket on the windowsill. The foot board was removed from the bed and was lying on the floor in front of the wardrobe. The floor food residue adhered to it and dust and crumbs all over it. During an observation on 2/4/25, at approximately 8:40 a.m., an Environmental Service (EVS) Worker was seen entering Resident R52's room and emptying the trash can. No other services were performed. Observation at this time revealed no significant change from the previous observation on 2/3/25. During an interview…

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 Resident Assessment Instrument (RAI) User's Manual, clinical records, and staff interviews, it was determined that the facility failed to ensure that MDS assessments accurately reflected the resident's status for eight of sixteen residents (Resident R30, R43, R54, R56, R64, R66, R69, and R70). Findings include: The Resident Assessment Instrument (RAI) User's Manual, which gives instructions for completing Minimum Data Set (MDS, mandated assessments of a resident's abilities and care needs), dated October 2024, indicated the following instructions: Coding Instructions O0300A, Is the Resident's Pneumococcal Vaccination Up to Date? -Code 0, no: if the resident's pneumococcal vaccination status is not up to date or cannot be determined. Proceed to item O0300B, If Pneumococcal vaccine not received, state reason. -Code 1, yes: if the resident's pneumococcal vaccination status is up to date. Skip to O0350, Resident's COVID-19 vaccination is up to date. If the resident has not received 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 policies and documents, clinical records, and staff interviews, it was determined that the facility failed to provide care and services to possibly prevent hospitalization and failed to provide care and services after hospitalization for one of four residents (Resident R22). Review of the clinical record indicated that Resident R22 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of the Minimum Data Set (MDS - periodic assessment of resident care needs) dated 1/16/25, included diagnoses of chronic obstructive pulmonary disease (COPD, a group of progressive lung disorders characterized by increasing breathlessness), 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 Resident R22's weight record revealed the following: 04/03/24: 335.0 lbs. (pounds) 050/1/24: 322.0 lbs. 06/11/24: 325.0 lbs. 07/10/24: 378.2…

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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and staff interview, it was determined that the facility failed to provide a safe environment for two of five residents ordered fall precautions (Resident R41 and R63) and on one of two nursing units (A/E Nursing Unit). Findings include: Review of the facility policy Falls - Clinical Protocol dated 10/23/24, indicated when a resident is found on the floor, the facility is obligated to investigate into how the resident got there and put into place an intervention to minimize it from recurring. This will be documented in the resident's care plan and progress notes. Review of the clinical record indicated Resident R41 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of the Minimum Data Set (MDS, periodic assessment of resident care needs) dated 12/9/24, included diagnoses of a seizure disorder and history of a stroke. Review of the fall assessment completed on 1/31/25, indicated Resident R41 was at medium risk for falls. Review of a physician order dated 7/10/23,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical record review, observations, and staff interview, it was determined that the facility failed to provide respiratory care/oxygen services consistent with professional standards of practice for one of four residents (Resident R22). Findings include: Review of facility policy, titled Oxygen Administration, with a review date of 10/23/24, purpose is to improve oxygenation in residents with respiratory insufficiency, obstructive sleep apnea, or restrictive/obstructive lung disease. This includes verification of a physician order for use of device, regulator checking equipment and periodic assessment. The Resident Assessment Instrument (RAI) User Manual, which gives instructions for completing Minimum Data Set assessments (mandated assessments of a resident's abilities and care needs), dated October 2024, indicated that Section O: Special Treatments, Procedures, and Programs, Non-invasive Mechanical Ventilator (BiPAP/CPAP) should be checked if the resident utilized a BiPAP…

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 and biologicals were properly disposed of in one of two medication rooms (Units B/C medication room). Findings include: Review of the facility policy Storage of Medications dated 10/23/24, indicated that discontinued, outdated, or deteriorated drugs are returned to the dispensing pharmacy or destroyed. During an observation of the Units B/C medication room medication room on 2/3/25, at approximately 11:30 a.m. four opened, partially used bottles of acetic acid solution (a type of antiseptic), with open dates of 1/22/25, 1/25/25, 1/31/25, and 2/1/25 were observed. On each of the bottles was a pre-printed pharmacy label that read: BOTTLE EXPIRES 24 HOURS AFTER OPENING. During an interview on 2/3/25, at 2:36 p.m. Registered Nurse Employee E2 confirmed the above observations. During an interview on 2/6/25, at approximately 3:30 p.m. the Nursing Home Administrator and the Director of Nursing confirmed that the facility failed to make…

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 staff interview, it was determined that the facility failed to make certain residents who requested the pneumococcal vaccine were provided the vaccination for six of seven residents (Resident R43, R54, R56, R64, R69, and R70). Findings include: Review of the facility policy Pneumococcal Vaccination dated 10/23/24, previously reviewed 1/18/24, indicated all residents are offered the pneumococcal vaccines to aid in preventing pneumonia/pneumococcal infections. Review of the admission Record indicated that Resident R43 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident R43's Pneumococcal Vaccine Informed Consent/Declination form, dated 8/9/24, revealed Resident R43 consented to receive the pneumococcal vaccination. Review of Resident R43's clinical record failed to reveal the pneumococcal vaccine was provided. Review of the admission Record indicated that Resident R54 was admitted to the facility on [DATE]. Review of Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, documents, clinical records, and staff interviews, it was determined that the facility failed to ensure that residents were free from significant medication errors for one of three residents (Resident R1). Findings include: Review of facility policy Administering Medications 1/18/24, indicated medications are administered in a safe and timely manner, and as prescribed. The policy further stated that the individual administering the medication records in the resident's medical record: -the date and time the medication was administered; -the dosage; -the route of administration; -the injection site (if applicable); -any complaints or symptoms for which the drug was administered; -any results achieved and when those results were observed; and -the signature and title of the person administering the drug. Review of Resident R1's admission record indicated he was originally admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident R1's Minimum Data Set (MDS -…

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

Based on review of facility policy and documentation, resident and staff interviews, it was determined that the facility failed to demonstrate response to grievances from resident council for six of six months ( January 2024, February 2024, March 2024, April 2024, May 2024, June 2024). Findings include: Review of the facility policy Grievance/Concern Resolution dated 1/18/24, indicated to resolve resident concerns in a timely manner, facility utilizes a grievance form to identify concerns and track via a monthly log. Unable to review resident council meeting minutes for indication of any concerns. During an interview on 7/18/2024, at 10:30 a.m. and 1:38 p m. Residents indicated that residents' concerns are not being addressed and are on-going. During an interview on 7/18/24 at 1:34 p.m., with the previous Resident Council president it was discussed that the resident was relieved of their duties while unavailable and a new president was named in their place with no vote occurring. During an interview on 7/18/2024, at 2:48 p.m. Nursing Home Administrator and Regional Nursing Home…

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

Based on a resident group interview and staff interview, it was determined that the facility failed to provide an ongoing program of activities based on the identified preferences/interests for seven of seven residents to enhance the resident's quality of life (Residents R100, R101, R102, R103, R104, R105 and R106). Findings include: During an attempted review of facility activity calendars, there were no Activities Calendars for the dates May 2024- June 2024. There is a calendar in all residents rooms listing one activity each day with no time associated for these activities. During an interview on 7/18/24 at 9: 23 a.m., the Ombudsman indicated that they had been contacted by residents that were complaining that there were no activities occurring. The Ombudsman had contacted the previous Nursing Home Administrator that stated they would take care of the situation. During an interview on 7/18/24, at 1:30 p.m.,Resident Council president indicated that activities were occurring until the Activities Director was terminated April 3, 2024. During an interview on 7/18/24, at 2:30 p.m. the…

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

Based on review of the facility policy, Resident Council Meeting minutes, facility documentation and staff interview, it was determined that the facility failed to ensure that the Activities Department had a qualified director to oversee the activities program for three out of six months (April, May, June). The findings include: Review of Activities Director job description/competency/evaluation last reviewed on 1/18/24, indicated the education and qualifications for the job of Activities Director included post-secondary education in a related field is desired, and two years experience as a supervisor or long-term care Activity Director or previous work experience under a Certified Activity Consultant. Review of the previous Activity Director Employee personnel file indicated they became the activities director on 6/23/23 and then was terminated 4/3/24. Further review did not include information regarding a replacement being hired. During interviews and observations on 7/18/24 at 11:30 a.m., residents that stated there have been no activites since the previous Activities Director…

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 six residents (Resident R1). Review of the facility policy Resident Elopement dated 1/17/24, indicated cognitively impaired residents at risk for elopement will be appropriately monitored to reduce the potential for injury. Elopement is defined as a resident leaving the physical structure of the facility without knowledge of facility staff. Review of the clinical record revealed Resident R1 was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS - periodic assessment of resident care needs) dated 4/1/24, included diagnoses of diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time), arthritis (inflammation of one or more joints, causing pain and stiffness), and dementia (a group of symptoms that affects memory, thinking and…

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

Based on review of facility policy, observations, and staff interview, it was determined that the facility failed to maintain a safe, comfortable, home-like environment for one of two resident shower rooms (C-Wing shower room). Findings include: Review of facility policy Clean, Safe and Orderly Environment, last reviewed 1/17/23, indicated the facility will be maintained in clean, safe, and orderly manner. Housekeeping, Laundry, and Maintenance services will be provided properly with precautions taken to prevent infection and cross contamination. During an observation on 3/1/24, at 1:00 p.m. the following was noted in the C-Wing shower room: -First shower area: Numerous partially used, resident specific hygiene items (shampoo, body wash, deodorant) on the shower floor, nail clippers on the floor, and a plastic caddy with hygiene items in it. A plastic cover for a curtain rod was on the floor of the shower. Numerous adhesive stickers from the tops of baby powder containers adhered to the shower wall. A brown substance that appeared to be feces was on the shower floor. -Second shower…

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 vendor invoices, facility financial documents, and interviews with vendors and staff, it was determined that facility failed to pay bills in a timely manner. Findings include: Review of 28 PA Code Commonwealth of Pennsylvania Long Term Care Licensure Regulations, subsection §201.14(g), dated 7/1/23, indicated that a facility owner shall pay in a timely manner bills incurred in the operation of a facility that are not in dispute and that are for services without which the residents' health and safety are jeopardized. Review of vendor submitted communication dated 2/27/24, indicated that the Ambulance Vendor was no longer providing services to the company, and was owed $20,534.10. During an interview on 3/1/24, at approximately 12:30 p.m. the Nursing Home Administrator confirmed that the facility no longer utilizes the services of the Ambulance Vendor, and provided alternative transportation with another vendor and the use of the facility transport van. Review of the facility provided contractor report on 3/1/24, at approximately 2:00 p.m. revealed a balance 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 financial documents, interview with vendors and staff, it was determined that Corporate failed to pay bills in a timely manner for services without which the residents' health and safety are impacted for 20 of 71 residents (Residents R1, R2, R3, R4, R5, R6, R7, R8, R9, R10, R11, R12, R13, R14, R15, R16, R17, R18, R19, and R20). Findings include: 28 PA Code Commonwealth of Pennsylvania Long Term Care Licensure Regulations subsection 201.14(g), dated July 1, 2023, revealed that a facility owner shall pay in a timely manner bills incurred in the operation of a facility that are not in dispute and that are for services without which the residents' health and safety are impacted. Request on 12/28/23, at 8:35 a.m. the Nursing Home Administrator (NHA) could not produce the facility's Accounts Payable log as all billing is handled by Corporate. The NHA reached out to corporate for the information. Review of facility's Aging Schedule as of 12/27/23, indicated Oxygen Supply Vendor V1 was owed…

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, grievances from July 2023, through November 2023, and staff interviews, it was determined that the facility failed to provide residents with access to their personal funds/petty cash for two of three residents (Residents R10 and R11). Findings include: Review of the facility policy Resident Trust Distribution of Funds last reviewed on 1/17/23, indicated that the facility will ensure timely distribution of petty cash and the amount available will be $45.00 per Medicaid resident, unless other funds are available. Unused funds will accumulate accordingly for resident use. During a review of two Grievances for Residents R10 and R11 documented by the Social Worker Employee E3 after the July 26, 2023, Resident Council meeting indicated that both residents had requested monies from the Business Office Manager (BOM) and were told they would have to wait and the amounts had to be requested and it was not available in the petty cash fund at the time. During an interview on 12/6/23, at 10:15 a.m., the Nursing Home Administrator and the Regional Contracted…

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.