Forest Park Nursing And Rehabilitation

Based on facility policy review, observations, and staff interviews, it was determined that the facility failed to promote care for residents in a manner and environment that enhances each resident's dignity for six of 23 Residents reviewed (Residents 6, 7, 34, 42, 57, and 68). Findings Include: Review of facility policy, titled Dignity, with a last review date of February 3, 2025, revealed, in part, 5. When assisting with care, residents are supported in exercising their rights. For example, residents are e. provided with a dignified dining experience; 10. Staff protect confidential clinical information. Examples include the following: b. Signs indicating the resident's clinical status or care needs are not openly posted in the resident's room unless specifically requested by the resident or family member. Discreet posting of important clinical information for safety reasons is permissible (e.g., taped to the inside of the closet door); and 12. Demeaning practices and standards of care that compromise dignity are prohibited. Staff are expected to promote dignity and assist…

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

Based on clinical record reviews, observation, facility document review, and resident and staff interviews, it was determined that the facility failed to provide care and services in accordance with professional standards for four of 23 residents reviewed (Resident 5, 64, 68, and 88). Findings include: Review of Resident 5's clinical record revealed diagnoses that included vascular dementia (disease process in which damage to the blood vessels of the brain causes decreased contact with reality and decreased ability to perform activities of daily living) and congestive heart failure (decreased ability of the heart to pump blood through the body). Review of Resident 5's clinical record revealed that on April 30, 2024, Resident 5 had a consultative gastrointestinal appointment for signs of dysphagia (difficulty swallowing). Review of the consultation report revealed the recommendations stated, Call with update in [two] weeks if [swallowing] no better Barium swallow next. Continue soft diet, thin liquids. Recommends dentures - see dentist. Review of the consultation sheet revealed it…

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

Based on clinical record review and staff interviews, it was determined that the facility failed to monitor the resident's nutritional status for one of seven residents reviewed for nutrition (Resident 72). Findings include: Review of Resident 72's clinical record revealed diagnoses that included hypotension (low blood pressure) and atrial fibrillation (an irregular heartbeat). Review of Resident 72's clinical record revealed a full nutrition assessment/weight change completed by the dietitian on September 13, 2024, at 10:16 PM, which read, in part, that Resident 72 triggers for significant undesired weight loss of 25% in one month and will order weekly weights for four weeks for weight monitoring. Will monitor weight trends. Review of Resident 72's September 2024 MAR (Medication Administration Record) revealed an order for Weights; weekly weights for 4 weeks, for weight monitoring for four administrations, with a start date of September 14, 2024. Further review of Resident 72's September 2024 MAR revealed that no weights were obtained per the order above on September 14 and 28,…

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

Based on clinical record reviews and staff interviews, it was determined that the facility failed to adequately monitor possible side effects and target behaviors for two of five residents reviewed for unnecessary psychotropic medications (Residents 68 and 80). Findings include: Review of Resident 68's clinical record revealed diagnoses that included depression, anxiety, and cerebral infarction (a stroke-damage to the brain from interruption of its blood supply). Review of Resident 68's physician orders revealed an order for lorazepam tablet 0.5 milligrams give one tablet via PEG (percutaneous endoscopic gastrostomy-a flexible feeding tube placed through the abdominal wall and into the stomach which allows nutrition to be placed directly into the stomach) tube every 6 hours as needed for anxiety for 14 days, dated February 20, 2025. Review of Resident 68's Medication Administration Records (MARs) for February 2025 and March 2025 revealed that he had received four doses of his lorazepam: February 21, 2025, at 10:54 PM; March 3, 2025, at 11:53 AM and 9:21 PM; and March 6, 2025, 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 facility policy review, observations, and staff interviews, it was determined that the facility failed to store food items in accordance with professional standards for food service safety in the main kitchen and three of three nourishment areas. Findings include: Review of facility policy, titled Food Receiving and Storage, last revised October 2023, read, in part, Food shall be received and stored in a manner that complies with safe food handling practices. Dry foods that are stored in bins will be removed from original packaging, labeled and dated ('use by' date). All food items to be kept at 41 degrees Fahrenheit must be placed in the refrigerator located at the nurses station and labeled with a 'use by' date. Observation of the dry storage area on March 3, 2025, at 9:38 AM, revealed one bag of egg noodles open without an open date or use by date once opened; one bag of spiral pasta open without an open date or use by date once opened; 10 boxes of fudge round cookies not dated; and one box of potatoes that were all covered with sprouts and appeared to be old. 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.

Based on facility policy review and staff interview, it was determined that the facility failed to establish and implement an antibiotic stewardship program to monitor the use of antibiotics. Findings include: Review of the facility's policy, titled Antibiotic Stewardship, last revised December 2016, revealed the policy statement was, Antibiotics will be prescribed and administered to residents under the guidance of the facility's antibiotic stewardship program. The policy's interpretation and implementation included, The purpose of our antibiotic stewardship program is to monitor the use of antibiotics in [the] residents. As of March 6, 2025, at 11:45 AM, the facility was unable to provide evidence that antibiotic stewardship was implemented via providing documentation including, but not limited to, tracking antibiotics used, duration of use, and monitoring culture and sensitivity of identified organisms to ensure prescribed antibiotic effectiveness. During a staff interview on March 6, 2025, at approximately 11:45 AM, Nursing Home Administrator revealed it was the facility'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 facility policy review, clinical record reviews, and staff interviews, it was determined that the facility failed to notify the resident/resident representative of a resident's transfer, in writing, to include: the reason for the transfer or discharge, date of transfer, location of transfer, statement of the resident's appeal rights, name, and address (mailing and email) for two of four resident records reviewed for hospitalization (Residents 21 and 80). Findings include: Review of facility policy, titled Bed-Holds and Returns, last reviewed February 3, 2025, revealed, in part, 3. Prior to a transfer, written information will be given to the residents and the resident representative that explain in detail: d. the details of the transfer (per the notice of transfer). Review of Resident 21's clinical record revealed diagnoses that included hypertensive heart disease without heart failure (a long-term condition that develops over many years in people who have high blood pressure), chronic kidney disease…

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 record reviews, and staff interviews, it was determined that the facility failed to ensure the resident and/or the resident's representative were provided the bed-hold notice upon transfer for two of four residents reviewed for hospitalizations (Residents 21 and 80). Finding include: Review of the facility policy, titled Bed-Holds and Returns, last reviewed February 3, 2025, revealed, in part, 3. Prior to a transfer, written information will be given to the residents and the residents representatives that explains in detail: a. the rights and limitations of the resident regarding bed-holds; b. the reserve bed payment policy as indicated by the state plan (Medicaid resident); c. the facility per diem rate required to hold a bed (non-Medicaid resident), or to hold a bed beyond the state bed-hold period (Medicaid residents . Review of Resident 21's clinical record revealed diagnoses that included hypertensive heart disease without heart failure (a long-term condition that…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff interviews, it was determined that the facility failed to ensure that the resident assessment accurately reflected the resident's status for two of 26 residents reviewed (Residents 64 and 72). Findings include: Review of Resident 64's clinical record revealed diagnoses that included contracture of muscle (a condition where muscles, tendons, joints, or other tissues tighten or shorten, causing deformity and loss of movement in the joint), functional quadriplegia (complete immobility due to severe disability or frailty caused by another medical condition, without physical injury or damage to the brain or spinal cord), and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest in things). Review of Resident 64's clinical record revealed he has been on a turning and repositioning program since his admission on [DATE]; and the intervention has been noted to be a part of his pain management program since December 14, 2024. 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, clinical record review, and resident and staff interviews, it was determined that the facility failed to ensure the care plan was reviewed and revised for two of 26 residents reviewed (Residents 65 and 88). Findings Include: Review of Resident 65's clinical record revealed diagnoses that included congestive heart failure (a serious condition that occurs when the heart can't pump blood efficiently enough to meet the body's needs) and difficulty walking not elsewhere classified (a medical term used when someone has difficulty walking but the cause cannot be more precise). Observation of Resident 65 on March 3, 2025, at 11:22 AM, revealed Resident 65 lying in bed, and Resident 65's rolling walker was sitting beside the Resident's bed. Interview with Resident 65 at that time revealed that she is able to walk with the rolling walker. Review of Resident 65's care plan revealed a care plan with a focus area of, Requires assistance transferring from one position to anther related to unsteady gait, with a revision date of January 8, 2025. The care plan failed to…

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

Based on facility policy reviews, product information review, observations, clinical record reviews, and staff interviews, it was determined that the facility failed to ensure care and services were provided in accordance with professional standards for two of six residents observed during medication preparation and administration for (Residents 25 and 65) and for one of one resident observed for treatment administration (Resident 68). Findings include: Review of facility policy, titled Administering Medications, with a last review date of February 3, 2025, revealed,in part, 25. Staff follows established facility infection control procedures (e.g., handwashing, antiseptic technique, gloves, isolation precautions, etc.) for the administration of medications, as applicable. Review of facility policy, titled Insulin Administration, with a last review date of February 3, 2025, revealed, in part, 5. The nursing staff will have access to specific instructions (from the manufacturer if appropriate) on all forms of insulin delivery system(s) prior to their use. Review of facility policy,…

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, clinical record review, observation, and staff interview, it was determined that the facility failed to ensure that residents receive necessary treatment and services, consistent with professional standards of practice, to identify pressure ulcers and to promote healing and prevent infection of a pressure ulcer for one of three residents reviewed for pressure ulcers (Resident 68). Findings include: Review of facility policy, titled Dressings, Dry/Clean, with a last review date of February 3, 2025, revealed, in part, 15. Cleanse the wound with ordered cleanser. If using gauze, use clean gauze for each cleansing stroke. Clean from the least contaminated area to the most contaminated area (usually, from the center outward); 16. Use dry gauze to pat the wound dry; and 17. Apply the ordered dressing and secure with tape or bordered dressing per order. Review of Resident 68's clinical record revealed diagnoses that included cerebral infarction (a stroke-damage to the brain from interruption of its blood supply), type 2 diabetes mellitus (disease that…

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, 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 one resident reviewed for oxygen use (Resident 57). Findings include: Review of the facility policy, titled Oxygen Administration, with a last review date of February 3, 2025, revealed, in part, Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration. Review of Resident 57's clinical record revealed diagnoses that included hypertension (high blood pressure), atrial fibrillation (abnormal heart rhythm characterized by rapid and irregular beating of the upper chamber of the heart), and cerebral infarction (a stroke-damage to the brain from interruption of its blood supply). Observations of Resident 57 on March 3, 2025, at 11:01 AM, and March 4, 2025, at 11:00 AM, revealed that the Resident was receiving oxygen at 1 liter per minute via a nasal cannula. Review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy review, clinical record review, and resident and staff interviews, it was determined that the facility failed to ensure that pain management is provided to residents who require such services consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for one of three residents reviewed for pain management (Resident 64). Findings include: Review of facility policy, titled Pain Assessment and Management, last reviewed February 3, 2025, read, in part, The purposes of this procedure are to help the staff identify pain in the resident, and to develop interventions that are consistent with the resident's goals and needs and that address the underlying causes of pain. Pain management is a multidisciplinary care process that includes the following: Developing and implementing approaches to pain management; identifying and using specific strategies for different levels and sources of pain; monitoring for the…

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

Based on policy review, observation, record review, and staff interviews, it was determined that the facility failed to complete a risk benefit analysis and obtain consent for enabler bar use for one of 23 residents reviewed (Resident 56). Findings include: Review of the facility policy, titled Bed Safety last reviewed February 3, 2025, revealed, 5. If side rails are used, there shall be an interdisciplinary assessment of the resident, consultation with the attending physician, and input form the resident and/or legal representative. 6. The staff shall obtain consent for the use of side rails from the resident or the resident's legal representative prior to their use. Review of Resident 56's clinical record revealed the diagnoses that included dementia (a chronic disorder of the mental processes caused by brain disease, marked by memory disorders, personality changes, and impaired reasoning) and acquired absence of the right and left leg above the knee (absence of a limb that has been removed due to trauma, medical condition, or surgery). Observation of Resident 56's room on March…

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

Based on clinical record review, policy review, and staff interviews, it was determined that the facility failed to act upon the licensed pharmacist's report of a medication recommendation, and failed to provide a monthly medication regimen review for one of five residents reviewed for unnecessary medications, psychotropic medications, and medication regimen review (Resident 23). Findings include: Review of the facility policy, titled Consultant Pharmacist Reports: Medication Regimen Review (Monthly Report), with a last review date of February 3, 2025, revealed, The consultant pharmacist reviews the medication regimen of each resident at least monthly; and Physician accepts and acts upon suggestion or rejects and provides and explanation for disagreeing. Review of Resident 23's clinical record revealed diagnoses that included anxiety disorder (a group of mental health conditions characterized by excessive and persistent worry, fear, and nervousness that can significantly interfere with daily life) and hypertension (high blood pressure). Review of Resident 23's pharmacy…

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, observation, and staff interview, it was determined that the facility failed to properly label and store prescribed medication or preventative creams in one of two treatment carts observed (Evergreen Way/Stepping Stones). Findings include: Review of facility policy, titled Storage of Medications, with a last review date of February 3, 2025, revealed, in part, 2. Drugs and biologicals are stored in the packaging, containers or other dispensing systems in which they are received. Only the issuing pharmacy is authorized to transfer medications between containers; 3. The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. Review of facility policy, titled Pharmacy Services Policy and Procedure, with a last review dated of February 3, 2025, revealed, in part, Drugs and biologicals used in the facility shall be labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when…

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

Based on clinical record review, facility document review, and resident and staff interviews, it was determined that the facility failed to provide assistance with activities of daily living for three of six residents reviewed (Residents 4, 12, and 13). Findings include: During a resident interview on February 24, 2025, Resident 4 stated that he had not been receiving showers or baths twice a week as he is supposed to receive. Review of Resident 4's comprehensive plan of care revealed Resident 4 was care planned to receive limited assistance with bathing from staff. Review of Resident 4's Nurse Aide task documentation revealed that no shower/bathing documentation for January 29, 2025; February 12, 15, and 22, 2025. Review of the document revealed that the shower/bathing task for February 1, 2025, was marked as, Not applicable. During a resident interview on February 24, 2025, Resident 12 stated, No, when asked if she was receiving a shower or bath twice a week. Review of Resident 12's comprehensive plan of care revealed that Resident 12 required extensive assistance from staff 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 clinical record review and staff interviews, it was determined that the facility failed to provide pharmaceutical services to accurately acquire, receive, dispense, and administer drugs to meet the needs of each resident for four of four residents reviewed (Residents 1, 6, 7, and 8). Findings include: Review of Resident 1's clinical record revealed diagnoses that included cerebral infarction (a stroke-damage to the brain from interruption of its blood supply), history of liver transplant, and respiratory failure (long term condition in which the respiratory system is unable to adequately exchange oxygen and carbon dioxide in the body). Review of Resident 1's January 2025 Medication Administration Record (MAR) revealed that on January 31st, day shift, 15 medications (a total of 18 doses) were coded 9- see progress notes. Review of Resident 1's progress notes revealed two notes dated January 31, 2025, which indicated that the medications were unavailable and awaiting delivery from pharmacy. 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, facility document review, policy review, and staff interviews, it was determined that the facility failed to establish and maintain an infection prevention and control program for two of four unit hallways observed (Evergreen Way and Laurel Lane). Findings include: Upon entrance to the facility on February 24, 2025, at approximately 9:00 AM, it was observed that the facility had a posted sign that the facility was under infectious disease outbreak procedure and that masks were required within the facility. During an interview directly after entering the building, Nursing Home Administrator confirmed that visitors and staff should be wearing masks while in the building. During observations of the Laurel Lane unit on February 24, 2025, between approximately 9:30 AM, and 10:30 AM, it was observed that Employee 1 was not wearing a mask. During the observations, Employee 1 was observed entering multiple resident rooms providing medications to residents. During multiple observations on February 24, 2025, between approximately 9:30 AM and 2:20 PM, Employee 6 was…

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

Based on policy review, clinical record review, observations, and staff interview, it was determined that the facility failed to ensure appropriate care and services were provided for an indwelling urinary catheter for one of two residents reviewed for urinary catheter (Resident 1). Findings include: Review of facility policy, titled Catheter Care, Urinary, last revised September, 2014, revealed that subsection, Infection Control, stated, b. Be sure the catheter tubing and drainage bag are kept off the floor. Review of Resident 1's clinical record revealed diagnoses that included type two diabetes mellitus (decreased ability of the body to utilize insulin for the transport of glucose into the cells for nourishment) and cerebral infarct (commonly known was stroke, sudden interruption of the blood flow to the brain leading to cell death). During multiple observations on February 24, 2025, between 10:13 AM and approximately 2:15 PM, it was observed, from the hallway, that Resident 1's foley catheter (tube inserted into the bladder to facilitate the removal of urine into a container)…

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, clinical record review, facility document and policy review, and resident and staff interviews, it was determined that the facility failed to provide a sufficient number of staff for the administration of medications for one of four units observed, which resulted in the missed or late administration of medications for four of 12 residents reviewed for medication administration (Residents 4, 5, 9, and 10). Findings include: Review of the facility policy, titled Administering Medications, last revised April, 2019, revealed the policy statement was, Medications are administered in a safe and timely manner, and as prescribed. Review of the policy revealed it included, 3. Staffing schedules are arranged to ensure that medications are administered without unnecessary interruptions .4. Medications are administered in accordance with prescriber orders, including any required time frame .5. Medication administration times are determined by resident need and benefit, not staff convenience. Factors include: a. enhancing optimal therapeutic effect of the medication; b.…

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

Based on clinical record review, facility document review, facility policy review, and staff interviews, it was determined that the facility failed to ensure the resident record was complete and accurately documented for one of three residents reviewed for change in medical condition (Resident 14). Findings include: Review of facility policy, titled Change in Resident's Condition or Status, last revised February 2021, revealed subsection 8 stated, The nurse will record in the resident's medical record information relative to a change in the resident's medical/mental condition or status. Review of facility education provided to staff, dated December 5, 2024, with the topic of, Change in Residents Condition or Status, revealed the education included, Any changes in condition must be reported to [Registered Nurse] supervisor/Unit manager immediately so an assessment can be completed. When a change in condition has been identified a [user defined assessment form] must be completed. Review of Resident 14's clinical record revealed diagnoses that included congestive heart failure (disease…

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 sufficient space for residents to participate and observe an activity for one of one activity observed in the Florida Room lounge. Findings include: Observation on February 24, 2025, at approximately 10:35 AM, revealed that the morning activity of Bean Bag Toss was being held in the lounge outside of the Florida Room. There were 14 residents seated near one another at one end of room, and Resident 3 was noted to be sitting in the doorway to the room. There was also two activity staff present assisting with the activity. In addition to the activity that was occurring, there was a resident-use computer sitting on an overbed table where Resident 4 was observed sitting in his wheelchair using the computer. Subsequent observation of Resident 3 at approximately 10:54 AM, revealed Resident 3 was sitting in the hallway, and a separate resident was sitting in the door frame participating in the activity. During an interview with Resident 3, Resident 3 stated that she was…

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

Based on policy review, facility document review, observations, and staff interviews, it was determined that the facility failed to implement infection control policies and procedures to help prevent the development and spread of a communicable disease for four of four units observed (Laurel Lane, Evergreen, Stepping Stone, and Dementia units). Findings include: Review of facility policy, titled Isolation - Categories of Transmission-Based Precautions, with a revision date of October 2018, revealed the policy statement was, Transmission-based precautions are initiated when a resident develops signs and symptoms of a transmissible infection; arrives for admission with symptoms of an infection; or has a laboratory confirmed infection; and is at risk of transmitting the infection to other residents. Review of the Policy Interpretation and Implementation subsection revealed it stated, .2. Transmission-based precautions are additional measures that protect staff, visitors and other residents from becoming infected. These measures are determined by the specific pathogen and how it is…

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

Based on observations and staff interviews, it was determined that the facility failed to ensure the resident's right to a clean, comfortable, and homelike environment in the multi-purpose room and four of four nursing units observed (Evergreen, Laurel Lane, Stepping Stones, and Chapelwood). Findings Include: Observation in the hallways on Laurel Lane, Evergreen, and Stepping Stones, on October 8, 2024, at 9:20 AM, revealed dried, dark spills on the floors throughout the hallways as well as miscellaneous debris on the floors. Observation of the hallway to the multi-purpose room on October 8, 2024, at 10:30 AM, revealed dark spots of dried liquid on the floor and a dead bug near the door to the courtyard. Observation of the multi-purpose room at this time revealed miscellaneous debris, including paper, food and dead bugs, on multiple places on the floor of the room. Observation of the Chapelwood unit on October 8, 2024, at 10:31 AM, revealed dark, dried spills on the hallway floor as well as miscellaneous debris on the floor. Additional observations of Evergreen, Laurel Lane,…

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, clinical record review, and staff interview, it was determined that the facility failed to ensure care and services were provided in accordance with professional standards of practice for one of five residents reviewed (Resident 4). Findings include: Review of Resident 4's clinical record revealed diagnoses that included normal pressure hydrocephalus (rare condition that causes excess fluid in the brain and affects gait, cognition, and bladder control) and dementia (loss of memory, language, problem-solving, and other thinking abilities that are severe enough to interfere with daily life). Review of nursing progress notes dated July 3, 2024, revealed Resident 4 returned from her neurology appointment at 1230 PM, with recommendations that included starting Rytary (used to treat symptoms of Parkinson's Disease such as muscle stiffness, tremors, spasms, and poor muscle control) three times per day, and starting Gabapentin (used to treat seizures, nerve pain and restless leg syndrome) three times per day. Further review revealed that the physician was notified 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 clinical record review and resident and staff interviews, it was determined that the facility failed to maintain adequate personal hygiene and grooming of residents dependent on staff for assistance with these activities of daily living for two of three residents reviewed (Residents 1 and 3). Findings include: Review of Resident 1's clinical record revealed diagnoses that included muscle weakness and history of falling. Review of Resident 1's current care plan revealed that he had a self-care deficit related to weakness and impaired mobility, and that he required assistance with bathing. During an interview with Resident 1 on July 29, 2024, at 10:30 AM, he revealed that he was supposed to receive two showers per week, but he was lucky if he received one per week. Review of shower documentation revealed that it was not documented that Resident 1 received a shower on July 1, 15 and 22, 2024. No refusals were noted on these dates. Review of Resident 3's clinical record revealed diagnoses that included muscle weakness and hemiplegia and hemiparesis following cerebrovascular…

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

Based on clinical record review, facility document review, and staff interviews, it was determined that the facility failed to provide transportation services to maintain highest practical level of health and well-being for one of 10 residents reviewed (Resident 5). Findings include: Review of Resident 5's clinical record revealed diagnoses that included peripheral vascular disease (disease process which results in decreased blood circulation to the extremities) and stage three chronic kidney disease (moderately impaired ability of the kidneys to filter toxins from the blood). Review of facility grievance form completed by Resident 5, dated July 8, 2024, revealed that Resident 5 submitted a grievance after the facility was unable to transport the Resident to a scheduled doctor appointment on July 2, 2024, and a scheduled surgical appointment on July 8, 2024. During a an interview with the DON on July 8, 2024, at approximately 11:10 AM, Resident 5 was scheduled to have pre-surgical vein mapping (non-invasive procedure in which ultra sound imaging is used to size, depth, and location…

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 ensure the posting of nursing staffing data on a daily basis for two days reviewed (June 16 and 17, 2024). Findings include: During observation on June 17, 2024, at approximately 12:00 PM, it was revealed that the daily nurse staffing information posted was dated June 15, 2024. During a staff interview on June 17, 2024, at approximately 1:10 PM, the Director of Nursing revealed that the night shift Registered Nurse or the Human Resources employee is responsible for posting the daily nurse staffing information each day. At approximately 1:15 PM, Nursing Home Administrator confirmed that the nurse staffing information that was posted was dated for June 15, 2024. 28 Pa code 201.18(b)(3) Management

Based on observations, policy review, select document review, and staff interviews, it was determined that the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety in the kitchen, in three of three nursing unit refrigerators, and one of two ice machines (Evergreen Way/Stepping Stones unit). Findings include: Review of facility policy, titled Food Receiving and Storage, with a last revised date of October 2017, revealed, in part: 1. Food services, or other designated staff, will maintain clean food storage areas at all times. 8. All foods stored in the refrigerator or freezer will be covered, labeled, and dated ('use by' date). 14. Food items and snacks kept on the nursing units must be maintained as indicated below: a. All food items .must be labeled with a 'use by' date. b. All foods belonging to a residents must be labeled with the resident's name, the item and the 'use by' date. e. Other opened containers must be dated and sealed or covered during storage. g. Medications .may not be stored in the same refrigerator…

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 ensure the resident's right to a clean, comfortable, and homelike environment for one of three shower rooms observed (Laurel Lane) and two of four nursing units observed (Evergreen and Chapelwood). Findings Include: Observations of Resident 9's wheelchair on the Chapelwood unit on April 15, 2024, at 9:29 AM; April 17, 2024, at 8:12 AM; and April 17, 2024, at 10:02 AM, revealed that the base of her wheelchair had a moderate amount of dry dusty appearing debris, and the seat cushion had a small amount of dried food debris. Observation of Resident 15's room on the Chapelwood unit on April 15, 2024, at 9:03 AM, revealed the following: one of the closet doors was off track, leaning into closet and causing the other closet door to be pushed outward at the floor; there were missing slats from the window blinds lying on the floor; the Resident's wheelchair had food debris noted on the seat surface; the clear plastic chair rail along the wall, near the head of the bed, had a brown sticky…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff interviews, it was determined that the facility failed to provide notice of transfer to the resident and/or resident representative, as well as a notice to the Office of the State Long-Term Care Ombudsman, after a transfer out of the facility for seven of 10 residents reviewed for hospitalization (Residents 4, 32, 35, 63, 71, 72, and 89). Findings include: Review of Resident 4's clinical record on April 16, 2024, at approximately 10:30 AM, revealed diagnoses that included hypothyroidism (condition of the thyroid gland that results in decreased production of thyroid hormones) and vascular dementia (progressive, irreversible degenerative disease of the brain that results in decreased reality awareness and decrease in capacity to perform activities of daily living). Review of Resident 4's clinical record revealed that on October 1, 2023, Resident 4 was transferred to a hospital emergency room for concerns of chest pain. The Resident subsequently returned from the hospital…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, facility policy review, and staff interviews, it was determined that the facility failed to provide residents with a copy of the facility's bed-hold policy as a result of a transfer out of the facility for seven of 10 residents reviewed for hospitalization (Residents 4, 32, 35, 63, 71, 72, and 89). Findings include: Review of facility policy, titled Bed-Holds and Returns, last revised March 2022, read, in part, 1. All residents/representatives are provided written information regarding the facility bed-hold policies, which address holding or reserving a resident' bed during period of absence (hospitalization or therapeutic leave). b. at the time of transfer (or, if the transfer was an emergency, within 24 hours). Review of Resident 4's clinical record on April 16, 2024, at approximately 10:30 AM, revealed diagnoses that included hypothyroidism (condition of the thyroid gland that results in decreased production of thyroid hormones) and vascular dementia (progressive, irreversible…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff interviews, it was determined that the facility failed to submit Minimum Data Set (MDS) assessments within the required timeframe (14 days following completion) for 13 of 103 residents reviewed (Residents 2, 3, 8, 14, 32, 33, 36, 56, 61, 66, 68, 86, and 97). Findings include: Review of Resident 2's clinical record revealed diagnoses that included Alzheimer's Disease and epilepsy (seizure disorder). Review of Resident 2's MDS assessments (Minimum Data Set - an assessment tool to review all care areas specific to the resident such as a resident's physical, mental, or psychosocial needs), revealed her quarterly MDS assessment dated [DATE], was not completed until April 9, 2024, and was accepted on April 12, 2024. Review of Resident 3's annual assessment dated [DATE], revealed it was not completed until January 20, 2024, and was not accepted until January 23, 2024. Review of Resident 3's quarterly MDS assessment dated [DATE], revealed it was completed, but had not yet been…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, clinical record review, and resident and staff interviews, it was determined that the facility failed to ensure the care plan was reviewed and revised for four of 29 residents reviewed (Residents 32, 72, 89, and 407). Findings include: Review of Resident 32's clinical record revealed diagnoses that included malignant neoplasm of colon (colon cancer) and chronic obstructive pulmonary disease (COPD - chronic inflammatory lung disease that causes obstructed airflow from the lungs). Review of nursing progress note dated April 1, 2024, revealed that Resident 32 was admitted to hospice (medical services, emotional support, and spiritual resources for people who are in the last stages of a terminal illness) on that date for malignant neoplasm of colon. Review of Resident 32's active care plan on April 17, 2024, failed to reveal any notation of hospice services. During an interview with the Director of Nursing (DON) on April 18, 2024, at 11:47 AM, she confirmed that Resident 32's care plan 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff interviews, it was determined that the facility failed to ensure care and services are provided in accordance with professional standards of practice that will meet each resident's physical, mental, and psychosocial needs for three of 29 residents reviewed (Residents 31, 32, and 73). Findings include: Review of Resident 31's clinical record revealed diagnoses that included hypertension (elevated blood pressure) and chronic kidney disease (CKD - longstanding disease of the kidneys leading to renal failure). Further review of Resident 31's clinical record revealed a POLST form (Pennsylvania Orders for Life Sustaining Treatment), dated [DATE], stating that if Resident 31 was found with no pulse and not breathing, Resident 31 wishes to have CPR/Full Treatment (full resuscitative measures). Review of Resident 31's physician orders revealed an order dated [DATE], for DNR (Do Not Resuscitate), meaning no CPR would be provided if Resident 31 was found without a pulse and not…

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, clinical record review, and staff interviews, it was determined that the facility failed to implement fall interventions for three of 29 residents reviewed (Residents 31, 35, and 72). Findings Include: Review of Resident 31's clinical record revealed diagnoses that included hypertension (elevated blood pressure), muscle weakness, lack of coordination, and repeated falls. Review of Resident 31's current fall care plan revealed an intervention, in part, dated November 20, 2023, for a scoop mattress (a mattress with edges that are built higher than the center to help keep a resident from rolling off) to be placed on bed for fall safety. Observations of Resident 31 in their bed on April 15, 2024, at 9:16 AM; April 16, 2024, at 9:52 AM; and April 17, 2024, at 8:25 AM; all failed to reveal the presence of scoop mattress on their bed. Observation was shared with Employee 2 on April 17, 2024, at 8:30 AM. She indicated that she would follow-up on the noted concern. Observation on Resident 31's room on April 17, 2024, at 12:10 PM, revealed that they were out of bed, 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 facility policy review, observations, clinical record review, and staff interviews, it was determined that the facility failed to ensure residents receive appropriate treatment and services to prevent urinary tract infections in residents with a foley catheter for one of one Residents reviewed (Resident 31). Findings include: Review of facility policy, titled Catheter Care, Urinary, with a last revision date of September 14, 2014, revealed, in part: The urinary drainage bag must be held or positioned lower than the bladder at all times to prevent the urine in the tubing and drainage bag from flowing back into the urinary bladder . be sure the tubing and catheter bag are kept off of the floor. The policy indicated step-by-step procedural instructions on how to perform catheter care, which included the following: cleansing of the genital and perineum with soap and water and rinsing well; using a clean washcloth with warm water and soap to cleanse and rinse the catheter from insertion site to approximately four inches outward; and that the following information should be…

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

Based on review of facility policy, clinical record review, and resident and staff interviews, it was determined that the facility failed to ensure that the residents who are trauma survivors receive culturally competent, trauma-informed care in accordance with professional standards of practice in order to eliminate or mitigate triggers that may cause re-traumatization of the resident for one of 30 residents reviewed (Resident 80). Findings include: Review of facility policy, titled Trauma Informed Care, revised March 2019, revealed, Purpose: To guide staff in appropriate and compassion care specific to individuals who have experienced trauma. Review of Resident 80's clinical record revealed diagnoses that included Post Traumatic Stress Disorder (PTSD - a disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event. The condition may last months or years, with triggers that can bring back memories of the trauma, accompanied by intense emotional and physical reactions) and depression (a group of conditions associated with the elevation or…

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 select facility documentation and staff interview, it was determined that the facility failed to ensure that nurse aide performance evaluations were completed at least annually and that in-service education was provided based on the outcome of these reviews for five of five nurse aides reviewed (Employees 5, 6, 7, 8, and 9). Findings Include: Review of select facility documentation revealed that Employee 5 was hired in 2015; Employee 6 was hired in 2022; Employee 7 was hired in 2018; Employee 8 was hired in 2009; and Employee 9 was hired in 2008. Review of facility-provided employee performance evaluations for Employees 5, 7, 8, and 9 revealed: one was completed on February 20, 2019, for Employee 5; one was completed on July 28, 2019, for Employee 7; one was completed in December 2021 for Employee 8; and one was completed on March 23, 2023, for Employee 9. No performance evaluation was provided for Employee 6. During an interview with the Nursing Home Administrator on April 19, 2024, at 11:59 AM, she acknowledged that the nurse aide performance evaluations were…

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

Based on clinical record review, facility policy review, and staff interviews, it was determined that the facility failed to ensure Medication Regimen Reviews were completed by a consultant pharmacist, responded to in a timely manner by the attending physician or prescriber, and that a rationale was provided for any declined recommendations for five of five residents reviewed for unnecessary medications (Residents 27, 32, 86, 89, and 407). Findings include: Review of facility policy, titled Medication Regimen Reviews, revised May 2019, revealed, The consultant pharmacist reviews the medication regimen of each resident at least monthly .The attending physician documents in the medical record that the irregularity has been reviewed and what (if any) action was taken to address it. Review of Resident 27's clinical record revealed diagnoses that included diabetes (a group of endocrine diseases that cause high blood sugar levels) and major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant…

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

Based on clinical record review and staff interview, it was determined that the facility failed to ensure as needed antipsychotic drugs were evaluated and renewed every 14 days for one of five residents reviewed for unnecessary medications (Resident 86). Findings include: Review of Resident 86's clinical record revealed diagnoses that included dementia (loss of memory, language, problem-solving, and other thinking abilities that are severe enough to interfere with daily life) with psychotic disturbance (loss of contact with reality) and depression (mood disorder that causes persistent feelings of sadness and loss of interest). Review of Resident 86's current active physician orders revealed an order for ABH gel (combination medication consisting of Ativan [antianxiety medication], Benadryl [antihistamine], and Haldol [antipsychotic medication]) every four hours as needed for agitation, effective April 21, 2023, and no documented end date. Review of Resident 86's clinical record failed to reveal evidence that the order for ABH gel was reviewed for appropriateness after 14 days.…

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, test tray completion, review Resident Council Meeting minutes, and resident and staff interviews, it was determined that the facility failed to provide beverages that are palatable and at a safe and appetizing temperature for one of one meal observed on the Evergreen Way hall. Findings include: Review of facility policy, titled Food Preparation and Service, with a last revised date of April 2019, revealed, in part, the following: Food and nutrition services employees prepare and serve food in a manner that complies with safe food handling practices. In section titled Food Preparation, Cooking and Holding Time/Temperatures, revealed 1. The 'danger zone' for food temperatures is between 41 degrees Fahrenheit and 135 degrees Fahrenheit. This temperature range promotes rapid growth of pathogenic microorganisms that cause foodborne illness. 2. Potentially hazardous foods include meats, poultry, seafood, cut melon, eggs, milk, yogurt, and cottage cheese. 3. The longer foods remain in the 'danger zone' the greater the risk for growth of harmful…

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 document review and staff interview, it was determined that the facility failed to maintain an accurate data collection system of infection surveillance from June 2023 through September 2023. Findings Include: Review of facility form, titled Monthly Infection Control Log (Line List), revealed data to be collected and documented each month include resident's name, room number, unit, type of infection, date of infection, culture, antibiotic resistant, classification, and isolation precautions. Review of the facility's completed Monthly Infection Control Log (Line List) failed to reveal that any documentation of infections occurred for June, July, August or September in 2023. On April 18, 2024, at 8:36 AM, the Nursing Home Administrator stated the facility was unable to locate any infection tracking for June, July, August or September in 2023. 28 Pa. Code 201.14(a)(c) Responsibility of licensee 28 Pa. Code 201.18(b)(1) Management 28 Pa code 211.10(a) Resident care policies

Based on personnel file review and staff interview, it was determined that the facility failed to ensure each nurse aide was provided required in-service training consisting of no less than 12 hours per year for five of five nurse aide employee records reviewed (Employees 5, 6, 7, 8, and 9). Findings Include: Review of select facility documentation revealed that Employee 5 was hired in 2015; Employee 6 was hired in 2022; Employee 7 was hired in 2018; Employee 8 was hired in 2009; and Employee 9 was hired in 2008. Review of training records provided by the facility failed to reveal evidence that Employees 5, 6, 7, 8, and 9 received at least 12 hours of annual in-service training. During an interview with the Nursing Home Administrator on April 18, 2024, at 11:59 AM, she acknowledged the concern with the aforementioned nurse aides not completing 12 hours of in-service training annually. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 201.20(a)(d) Staff development

Based on facility policy review, observations, and staff interviews, it was determined that the facility failed to promote care for residents in a manner and environment that enhances each resident's dignity for two of 23 Residents reviewed (Residents 9 and 31). Findings Include: Review of facility policy, titled Dignity, with a last revised date of February 2021, revealed, in part: 11. Staff promote, maintain, and protect resident privacy, including bodily privacy .; and 12. Demeaning practices and standards of care that compromise dignity are prohibited. Staff are expected to promote dignity and assist residents; for example: a) helping the resident to keep urinary bags covered. Review of Resident 9's clinical record revealed diagnoses that included cerebral infarction (a stroke - damage to the brain from interruption of its blood supply), abnormal posture, and stiffness of left hand. Observation of Resident 9 on April 16, 2024, at 9:39 AM, revealed that she was sitting in her wheelchair in the unit common area at a table. Her shirt was slightly raised up, her pants were slightly…

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 select facility documentation and staff interview, it was determined that the facility failed to provide the required notice to the resident or the resident's representative following the end of their Medicare coverage for one of two residents reviewed (Resident 60). Findings include: A Skilled Nursing Facility (SNF) Beneficiary Protection Notification Review form completed by the facility on April 18, 2024, revealed that Medicare coverage for Resident 60 began on November 1, 2023, and that her last covered day was November 16, 2023. The form indicated that the facility-initiated discontinuation from Medicare Part A coverage and that the Resident's benefit days were not exhausted. Further review of the form revealed that an Advanced Beneficiary Notice of Non-coverage (ABN - a notice given to Medicare beneficiaries to convey that Medicare is not likely to provide coverage for a skilled service) was not provided to the Resident or her Representative at the time that Medicare Part A was discontinued. During an interview with the Nursing Home Administrator on April…

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, facility policy review, clinical record review, and resident and staff interviews, it was determined that the facility failed to investigate an injury of unknown origin to rule out abuse, neglect, or mistreatment for one of 29 residents reviewed (Resident 72). Findings Include: Review of facility policy, titled Forest Park Abuse Policy, with a review/revise date of April 24, 2018, revealed Injury of unknown source is defined as an injury that meets both of the following conditions: (1) The source of the injury was not observed by any person or the source of the injury could not be explained by the resident; and (2) The injury is suspicious because of: (a) the extent of the injury; or (b) the location of the injury (e.g., the injury is located in an area not generally vulnerable to trauma); or (c) the number of injuries observed at one particular point in time; or (d) the incidence of injuries over time. Review of Resident 72's clinical record revealed diagnoses that included Type 2 Diabetes Mellitus and unstageable left heel pressure ulcer (injury to skin 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 clinical record review and staff interview, it was determined that the facility failed to ensure that a comprehensive assessment was completed every 12 months, as required, for one of 103 residents (Resident 73). Findings include: Review of Resident 73's clinical record revealed diagnoses that included hypertension (elevated blood pressure) and gout (a form of arthritis that causes severe pain, swelling, redness and tenderness in joints). Further review of Resident 73's clinical record revealed he had a comprehensive MDS assessment (Minimum Data Set - an assessment tool to review all care areas specific to the resident such as a resident's physical, mental, or psychosocial needs) completed on March 9, 2023. Review of Resident 73's MDS assessments revealed that Resident 73's comprehensive MDS assessment dated [DATE], has not yet been completed and was still in progress. Resident 73 has had no other comprehensive MDS assessments completed since March 9, 2023. On April 17, 2024, at 2:36 PM, 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff interviews, it was determined that the facility failed to ensure that quarterly Minimum Data Set assessments were completed within the required timeframe for two of 103 residents (Residents 31 and 45). Findings include: Review of Resident 31's clinical record revealed diagnoses that included hypertension (elevated blood pressure) and chronic kidney disease (CKD - longstanding disease of the kidneys leading to renal failure). Review of Resident 31's MDS assessments (Minimum Data Set - an assessment tool to review all care areas specific to the resident such as a resident's physical, mental, or psychosocial needs), revealed that Resident 31 had a quarterly MDS scheduled for March 15, 2024. Further review of Resident 31's MDS assessments revealed that Resident 31's quarterly MDS assessment dated [DATE], had four sections that had not yet been completed and was still in progress. During an interview with the Nursing Home Administrator (NHA) and Director of Nursing (DON) 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.

Based on clinical record review and staff interviews, it was determined that the facility failed to ensure that the resident assessment accurately reflected the resident's status for one of four residents reviewed for pressure injuries (Resident 60) and one of four residents reviewed for dementia care (Resident 86). Findings include: Review of Resident 60's clinical record on April 16, 2024, at approximately 10:20 AM, revealed diagnoses that included diabetes mellitus type 2 (decreased ability of the body to utilize insulin for the transport of glucose from the blood stream into the cells for nourishment) and stage III pressure injury (wound of the skin that extends through the layers of skin) of the sacral region. Review of Resident 60's clinical record revealed Resident 60 developed an unstageable pressure injury of the sacral region while a resident at the facility on November 16, 2023. Review of consultant wound physician's progress notes revealed the pressure ulcer remained unstageable until January 17, 2024, at which time the consultant wound physician assessed the pressure…

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, observations, clinical record review, and staff interviews, it was determined that the facility failed to maintain adequate personal hygiene and grooming of residents dependent on staff for assistance with these activities of daily living for one of 23 residents reviewed (Resident 9). Findings include: Review of facility policy, titled Activities of Daily Living, Supporting, with a last revised date of March 2018, revealed, in part: Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene. Review of Resident 9's clinical record revealed diagnoses that included cerebral infarction (a stroke - damage to the brain from interruption of its blood supply), abnormal posture, and stiffness of left hand. Review of Resident 9's care plan revealed a focus for ADL (Activities of Daily Living - washing face, brushing teeth, personal hygiene) Self-care deficit related to CVA (stroke), weakness, impaired gait and mobility, with a 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.

Based on observation, clinical record review, and staff interviews, it was determined that the facility failed to ensure that respiratory care and services provided were consistent with professional standards of care for one of two residents reviewed for respiratory care (Resident 407). Findings include: Review of facility policy, titled Oxygen Administration, with a revision date of October 2010, revealed 1. Verify that there is a physician's order for this procedure. Review of Resident 407's clinical record on April 18, 2024, at 10:57 AM, revealed diagnoses of metabolic encephalopathy (an alteration in consciousness caused due to brain dysfunction) and chronic diastolic (congestive) heart failure (a condition in which the heart's left ventricle becomes stiff and unable to fill properly). During an interview on April 15, 2024, at 9:35 AM, with Resident 407, an observation was made of Resident 407 receiving supplemental oxygen via nasal canula at 2.5 liters (of oxygen) per minute. An additional observation was made on April 16, 2024, at 11:13 AM, of the oxygen tubing and nasal…

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 and staff interviews, it was determined that the facility failed to provided food per resident preference for two of 24 residents observed (Residents 96 and 358). Findings include: During an interview with Resident 96 on April 15, 2024, at 10:44 AM, the Resident indicated that they only receive 1% milk and would prefer to have 2% or whole milk. The Resident further indicated that they had spoken to Employee 1 (Certified Dietary Manager) regarding their preference, and was told by Employee 1 that the facility can only get 1% from their supplier. During an interview with Resident 358 on April 15, 2024, at 10:46 AM, the Resident indicated that they only receive 1% milk and would prefer to have 2% or whole milk. The Resident also indicated that they had spoken to Employee 1 regarding their preference, and was told by Employee 1 that the facility can only get 1% from their supplier. During an interview with Employee 1 on April 18, 2024, at 9:47 AM, they indicated that there was a national shortage on paper milk cartons and that they can only get 1% in the individual…

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, clinical record review, and staff interviews, it was determined that the facility failed to provide adaptive feeding devices for two of 29 residents reviewed (Residents 9 and 35). Findings Include: Review of Resident 9's clinical record revealed diagnoses that included cerebral infarction (a stroke - damage to the brain from interruption of its blood supply), abnormal posture, and stiffness of left hand. Review of Resident 9's physician orders revealed a diet order that included a Kennedy cup with meals, dated February 4, 2024. Review of Resident 9's current care plan revealed a care plan focus for being at risk for altered nutrition with an intervention for Kennedy cup, with a revision date of May 27, 2021. Observation of Resident 9 at lunch on April 15, 2024, at 11:55 AM, revealed that a Kennedy cup was present on her meal tray, but was turned upside down with no beverage ever poured into the cup. She had three small plastic beverage cups, each containing a beverage. Observation of Resident 9 at breakfast on April 16, 2024, at 8:03 AM, revealed that a…

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

Based on review of facility documents and staff interview, it was determined that the facility failed to ensure that all required staff persons were in attendance at quarterly Quality Assurance Process Improvement (QAPI) Committee meetings for one of four quarters reviewed (fourth quarter, October - December 2023). Findings include: A review of Quality Assurance/Performance Improvement (QAPI) Committee meeting sign-in sheets for the period of April 2023 through March 2024, failed to reveal that the Nursing Home Administrator (NHA), owner, board member, or other person in a leadership role was present at any of the meetings held in the fourth quarter of 2023. During an interview with the NHA on April 18, 2024, at 12:00 PM, she revealed that she was not able to locate any sign-in sheets that had all required members for that time period. 28 Pa. Code §201.18(e)(1)(2)(3) Management

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record reviews and staff interviews, it was determined that the facility failed to reevaluate and update the discharge plan for two of four residents reviewed (Residents 1 and 4); and failed to develop an effective discharge plan for one of four residents reviewed (Resident 3). Findings include: Review of Resident 1's clinical record revealed diagnoses that included prostate cancer, legal blindness, abnormalities of gait (walking) and mobility (the ability to move or be moved freely and easily), aftercare of a fracture (a break) of the right femur (large bone located in the thigh area of the leg), and unspecified fall encounter. Resident 1 was admitted to the facility on [DATE], and discharged home on March 7, 2024. Review of Resident 1's progress notes revealed a note dated March 3, 2024, at 4:50 PM, written by the Social Worker that indicated Resident 1's Representative was contacted to discuss the discharge plan, and that they would work on HH [home health] nursing, PT [Physical Therapy]/OT…

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 record reviews, and staff interviews, it was determined the facility failed to develop a discharge summary that included a recapitulation of the resident's stay, reconciliation of medications, and post-discharge plan of care that indicated where the individual plans to reside, any arrangements that have been made for the resident's follow-up care, and any post-discharge medical and non-medical services for four of four residents reviewed (Residents 1, 2, 3, and 4). Findings Include: Review of facility policy, titled Discharging the Resident, revealed the following, in part: 5. If the resident is being discharged home, ensure that resident and/or responsible party receive teaching and discharge instructions; and in section titled Documentation that The following information should be recorded in the resident's medical record: 1. The date and time the discharge was made. 2. The name and title of the individual(s) who assisted in the discharge. 3. All assessment data…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record reviews and staff interviews, it was determined that the facility failed to provide medically-related social services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for residents transitioning to home by not making appropriate referrals for home care services for two of four residents reviewed (Residents 1 and 3); and failing to inform a resident of a change in their discharge plan for one of four residents reviewed (Resident 4). Findings Include: Review of Resident 1's clinical record revealed diagnoses that included prostate cancer, legal blindness, abnormalities of gait (walking) and mobility (the ability to move or be moved freely and easily), aftercare of a fracture (a break) of the right femur (large bone located in the thigh area of the leg), and unspecified fall encounter. Resident 1 was admitted to the facility on [DATE] and was discharged home on March 7, 2024. Review of Resident 1's progress notes revealed a note dated March 3,…

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 record review, and staff interviews, it was determined that the facility failed to ensure pharmaceutical services provide an accurate account for the obtaining of medications and disposition of medications during the discharge process for four of four residents reviewed (Residents 1, 2, 3, and 4). Findings include: Review of facility policy, titled Discarding and Destroying Medications, with a last revised date of April 2019, revealed 11. The medication disposition record will contain the following information: a. The resident's name; b. Date medication disposed; c. The name and strength of the medication; d. The name of the dispensing pharmacy; e. The quantity disposed; f. Method of disposition; g. Reason for disposition; and h. Signature of witnesses. 12. Completed medication disposition records shall be kept on file in the facility for at least two (2) years, or as mandated by state law governing the retention and storage of such records. Review of Resident 1's closed…

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

Based on clinical record review and staff interview, it was determined that the facility failed to ensure timely notification of the listed emergency contact person following a fall for one of six residents reviewed (Resident 1). Findings include: Review of Resident 1's closed clinical record revealed that diagnoses that included dementia (irreversible, progressive degenerative disease of the brain, resulting in loss of reality contact and functioning ability), hypertension (elevated blood pressure), and a history of repeated falls. A review of the nursing notes dated February 10, 2024, revealed that Resident 1 had an unwitnessed fall on February 10, 2024, at 5:00 AM, without injury. The staff documented they would notify the emergency contact later on the morning of February 10, 2024. Review of the fall investigation revealed that the Emergency Contact person was never notified until February 12, 2024, at 9:26 AM. During an interview with the Director of Nursing (DON) on March 25, 2024, at approximately 1:00 PM, the DON confirmed the delay in notification of the Emergency Contact…

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 record review, staff interview, and policy review, it was determined that the facility failed to accurately document information in the clinical record for one of three residents reviewed (Resident 1). Findings include: A review of the facility policy, titled Charting and Documentation, last revised July 2017, stated under #3, Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate. A review of the closed clinical record for Resident 1 revealed diagnoses that included percutaneous endoscopic gastrostomy (PEG- medical procedure in which a tube is passed into a person's stomach through the abdominal wall) and dysphagia (difficulty swallowing foods or liquids). A review of Resident 1's physician orders dated February 2024, revealed Resident 1 was NPO (nothing by mouth). A review of nursing notes dated February 8, 9, 13, 16, and 17, 2024, revealed staff documented Resident 1 received a regular texture diet and PEG tube feedings. The NPO status was verified by the facility on March 25, 2024, with a review of a dietary system…

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

Based on clinical record review, observation, and staff interviews, it was determined the facility failed to ensure each resident received proper treatment and assistive devices to maintain hearing abilities for one of nine residents reviewed (Resident 2). Findings include: Review of Resident 2's clinical record revealed diagnoses that included hypertension (elevated blood pressure) and chronic kidney disease (CKD - when the kidneys have become damaged over time [for at least 3 months] and have a hard time doing all of their important jobs). Review of Resident 2's clinical record revealed a nurse's progress note dated May 10, 2023, at 4:41 PM, with the following note text: Dayshift nurse reports unable to locate resident's hearing aid. Asked staff to look for hearing aids. Social Services made aware. An observation of Resident 2 on March 6, 2024, at 10:53 AM, revealed Resident 2 was not wearing hearing aids at that time. During an interview with Employee 3 (Licensed Practical Nurse [LPN]) on March 6, 2024, at 10:55 AM, Employee 3 confirmed Resident 2 did not currently have hearing…

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

Based on clinical record review and staff interview, it was determined that the facility failed to ensure that residents receive necessary treatment and services consistent with professional standards of practice to promote healing and prevent infection for one of 10 residents reviewed (Resident 9). Findings include: Review of Resident 9's clinical record reveals diagnoses that included chronic kidney disease (CKD - a gradual loss of kidney function occurs over a period of months to years) and hypertension (high blood pressure). Review of Resident 9's clinical record revealed the following treatment orders: Treatment 1: Pressure ulcer sacrum, cleanse with NSS (normal sterile saline), apply Santyl and cover with alginate and bordered foam dressing once a day and as needed every evening shift for wound, with a start date of December 1, 2023, and a discharge date of January 6, 2024; Treatment 2: Pressure ulcer sacrum, apply ¼ strength Dakins wet to dry and cover with bordered foam dressing every evening shift for wound, with a start date of January 6, 2024, and a discharge date of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, facility policy review, clinical record review, and resident and staff interviews, it was determined that the facility failed to inspect Resident's personal medical equipment brought into the facility to ensure a safe and functional environment for one resident reviewed (Residents 1). Findings include: Review of facility policy, titled Electrical Appliances, with a last revised date of January 2019, revealed, in part, the following: 1. Residents may not maintain any electrical appliances (i.e., heating irons, cooking utensils, etc.,) within their living area, unless approved, in writing, by the administrator, or his/her designee; 3. Should electrical appliances be permitted, each must be in good working order, free of frayed cords, and UL approved. Review of facility policy, titled Electrical Safety for Residents, with a last revised date of January 2011, revealed, in part, 2. Inspect electrical outlets, extension cords, power strips, and electrical devices as part of routine fire safety…

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 clinical records and staff interviews, it was determined that the facility failed to ensure care and services were provided in accordance with professional standards that met the resident need for one of four residents reviewed (Resident 4). Findings include: Review of Resident 4's clinical record on January 3, 2024, at 1:00 PM, revealed a diagnosis of hydronephrosis with renal and ureteral calculous obstruction (swelling of one or both kidneys because of excess fluid due to a backup of urine caused by a blockage of the urinary tract). Review of Resident 4's clinical record revealed that Resident 4 had been scheduled for a surgical procedure on December 21, 2023. During an electronic communication on January 3, 2024, at 12:19 PM, Director of Nursing (DON) revealed that Resident 4's December 21, 2023, surgery was canceled on December 20, 2023, and rescheduled to January 11, 2024, due to the facility not receiving instruction nor a physician order to hold Resident 4's coumadin (anticoagulant/blood thinner) prior to the procedure. Review of Resident 4's clinical…

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, observations, and staff interviews, it was determined that the facility failed to maintain a safe, clean, and home-like environment for six of 11 Residents reviewed (Residents 3, 4, 5, 6, 7, and 9) and on three of three nursing units observed. Findings include: Review of facility policy, titled Cleaning and Disinfection of Resident-Care Items and Equipment, with a last revised date of October 2018, indicated: 3. Durable medical equipment (DME) must be cleaned and disinfected before reuse by another resident; and 4. Reusable resident-care equipment will be decontaminated and/or sterilized between residents according to manufacturer's instructions. Observation of Resident 3 on November 29, 2023, at 12:57 PM, revealed the presence of a visible dust build-up on the frame and wheel spokes of their wheelchair. Observation of Resident 4 on November 29, 2023, at 12:58 PM, revealed the presence of a visible dust build-up on the frame of their chair. Observation of Resident 5 on November 29, 2023, at 1:02 PM, revealed the presence of a visible dust build-up 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.

Based on clinical record reviews, policy review, observations, and staff interviews, it was determined that the facility failed to develop and/or implement a comprehensive person-centered care plan for four of 11 records reviewed (Residents 2, 6, 7, and 9). Findings include: Review of facility policy, titled Care Plans, Comprehensive Person-Centered, with a last revised date of December 2016, revealed 13. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. Review of facility policy, titled Goals and Objectives, Care Plans, with a last revised date of April 2009, revealed the following: 1. Care plan goals and objectives are defined as the desired outcome for a specific resident problem; 2. When goals and objectives are not achieved, the resident's clinical record will be documented as to why the results were not achieved and what new goals and objectives have been established. Care plans will be modified accordingly; and 4. Goals and objectives are entered on the resident's care plan so that all…

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

Based on clinical record review, observation, facility policy review, and staff interviews, it was determined that the facility failed to ensure dental services were provided to meet resident need for one of one residents reviewed (Resident 9). Findings include: Review of facility policy, titled Dental Services, with a last revised date of December 2016, indicated the following: 10. If dentures are damaged or lost, residents will be referred for dental services within 3 days. If the referral is not made within 3 days, documentation will be provided regarding what is being done to ensure that the resident is able to eat and drink adequately while awaiting the dental services; and the reason for the delay. 11. All dental services provided are recorded in the resident's medical record. A copy of the resident's dental record is provided to any facility to which the resident is transferred. Review of Resident 9's clinical record revealed diagnoses that included dementia (a chronic disorder of the mental processes caused by brain disease, and marked by memory disorders, personality…

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

Based on clinical record review, policy review, and staff interview, it was determined that the facility failed to notify the listed emergency contact person (Resident's Representative) of the transfer to the hospital for one of nine residents reviewed (Resident 1). Findings include: A review of the facility policy, titled Change in Resident's Condition or Status last revised February 2021, stated, A nurse will notify the residents representative when it is necessary to transfer a resident to the hospital. Clinical record review revealed that Resident 1 had diagnoses that included urinary tract infection (an infection in any part of the urinary system, the kidneys bladder or urethra) and Type 2 Diabetes Mellitus (a form of diabetes that is characterized by high blood sugar, insulin resistance, and relative lack of insulin). Review of a nurse's note dated June 22, 2023, revealed that Resident 1 was transferred to the hospital due to shortness of breath. There was no documentation in the clinical record that the Resident's Representative was notified of the transfer. During an 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy review, clinical record review, and staff interview, it was determined that the facility failed to ensure each resident the right to formulate an advance directive and facilitate follow-up procedures to provide information to the resident or resident representative at an appropriate time for six of 35 residents reviewed (Residents 34, 38, 54, 97, 207, and 209). Findings Include: Review of facility policy, titled Advance Directives, revised September 2022, revealed The resident has the right to formulate an advance directive, including the right to accept or refuse medical or surgical treatment. 1. Prior to or upon admission of a resident, the social services director or designee inquires of the resident, his/her family members and/or his or he legal representative, about the existence of any written advance directives. 2. The resident or representative is provided with written information concerning the right to refuse or accept medical or surgical treatment and to formulate an advance…

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

Based on clinical record review, observation, as well staff and resident interviews, it was determined that the facility failed to ensure the care plan was reviewed and revised for four of 29 residents reviewed (Resident 38, 71, 73, and 99). Findings include: Review of Resident 38's clinical record revealed diagnoses that included gangrene (dead tissue caused by an infection or lack of blood flow), peripheral vascular disease (a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs), and hypertension (elevated blood pressure). Review of Resident 38's current care plan revealed a care plan in place for pain related to left foot amputation site, sacral pressure areas, and MASD (moisture associated skin damage), with a revision date of May 5, 2022. Further review revealed a care plan, revised on March 16, 2023, for nutritional status related to recent surgery, pressure area on foot. Review of Resident 38's clinical record revealed no evidence that Resident 38 currently had any pressure areas. In an email correspondence from the Nursing Home Administrator…

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, facility policy review, clinical record review, and resident and staff interviews, it was determined that the facility failed to ensure care and services were provided in accordance with professional standards of practice for five of 29 residents reviewed (Residents 1, 23, 68, 94, and 209). Findings Include: Review of facility policy, titled Administering Medications, revised April 2019, revealed Medications are administered in a safe and timely manner, and as prescribed. Residents may self-administer their own medications only if the attending physician, in conjunction with the interdisciplinary care planning team, has determined that they have the decision-making capacity to do so safely. Review of Resident 1's clinical record revealed diagnoses that included Schizoaffective disorder (a mental health condition including schizophrenia and mood disorder symptoms) and Bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs). Observation of Resident 1, on April 24, 2023, at 10:14 AM, revealed that Resident…

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

Based on facility policy reviews, observations, clinical record reviews, and resident and staff interviews, it was determined that the facility failed to provide respiratory care/oxygen services consistent with professional standards of practice for four of 26 residents reviewed (Residents 20, 49, 58, and 359). Findings include: Review of facility policy, titled CPAP (Continuous Positive Airway Pressure - a machine that uses mild air pressure to keep breathing airways open while one sleeps) -BiPAP (bilevel positive airway pressure which is a type of ventilator used to treat sleep apnea) Support with revision date of March 2015 under section titled General Guidelines for Cleaning identified the following guidelines for routine cleaning: 5 Humidifier b. Clean humidifier weekly and air dry; and #7 Masks, Nasal pillows, and tubing should be clean daily by placing in warm soapy water and soaking/agitating for 5 minutes. Mild dish detergent should be used. Rinse with warm water and allow it to air dry between uses. Review of Resident 20's clinical record documented diagnoses that…

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, clinical record review, observations, and interviews with staff, it was determined that the facility failed to ensure that residents who require dialysis receive such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for three of three residents reviewed (Residents 23, 99, and 359). Findings include: Review of facility policy, titled End-Stage Renal Disease (ESRD), Care of a Resident with with a revision date of September 2010, revealed: 2. Education and training of staff includes, specifically: a. the nature and clinical management of ESRD (including infection prevention and nutritional needs) and b. the type of assessment data that is to be gathered about the resident's condition on a daily or per shift basis; and 4. Agreements between this facility and the contracted ESRD facility include all aspects of how the resident ' s care will be managed, including: b. how information will be exchanged between the facilities. Review of Resident 23's clinical…

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, observations, record reviews, and interviews, the facility failed to complete a risk-benefit analysis and obtain consent for enabler bar use for three of 29 residents reviewed (Residents 30, 36, and 54). Findings include: Review of facility policy, titled Bed Rails with a last reviewed/revised date of October 24, 2022, revealed: Each resident will not have bed rails in use at the facility unless the IDT (interdisciplinary team) has completed a comprehensive assessment, use of alternative approaches have been unsuccessful, and informed consent is obtained. The facility must: 1. Have attempted with documentation of alternatives to bed rails and determined that these alternatives do not meet the resident's needs, the facility must assess the resident for the risks of entrapment and possible benefits of bed rails. 2. In addition, the resident assessment must include an evaluation of the alternatives to the use of a bed rail that were attempted and how these alternatives failed to meet the resident's assessed needs. 3. The facility must also assess 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 facility policy review, clinical record review, and staff interviews, it was determined that the facility failed to ensure that the physician reviewed and responded to pharmacy review recommendations in a timely manner for four of five residents reviewed for unnecessary medications (Residents 53, 54, 79, and 94). Findings include: Review of facility policy, titled Medication Regimen Reviews with last revised date of January 31, 2023, revealed the following: 1) The Consultant Pharmacist will perform a medication regimen review (MRR) for every resident in the facility. 2) Routine reviews will be done monthly. 5) The primary purpose of this review is to help the facility maintain each resident's highest practicable level of functioning by helping them utilize medications appropriately and prevent or minimize adverse consequences related to medication therapy to the extent possible. 8. The Consultant Pharmacist will provide a written report to physicians for each resident with an identified irregularity. If…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to ensure that residents were free from unnecessary psychotropic medications for five of five residents reviewed for unnecessary medications (Residents 53, 54, 79, 94, and 209). Findings include: Review of facility policy, titled Antipsychotic Medication Use, revised July 2022, revealed, Residents will not receive medications that are not clinically indicated to treat a specific condition. Antipsychotic medications will be prescribed at the lowest possible dosage for the shortest period of time and are subject to gradual dose reduction and re-review .The attending physician and other staff will gather and document information to clarify a resident's behavior, mood, function, medical condition, specific symptoms, and risks to the resident and others .The attending physician will identify, evaluate and document, with input from other disciplines and consultants as needed, symptoms that may…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, policy review, product manufacturer label, and interviews, it was determined that the facility failed to store and serve food/beverages in accordance with professional standards for food safety in the kitchen, in two of three nourishment rooms, one of two ice rooms/areas, and the activity room. Findings include: Review of facility policy, titled Labeling and Dating, undated, indicated the following: 1) Receiving and Storing Food: When contents are removed from the master container (cardboard box), they must be dated (and labeled if needed) to ensure that items are used by the expiration date; Some frozen vegetables and pasta products are packed in unlabeled plastic bags, and must be labeled and dated; dating examples: using the year is desirable for dry goods (spices) and frozen foods that have a longer shelf life; 2) Storing Prepared Food: All prepared foods must be labeled and dated to ensure that all staff are aware of the contents of the package and when it must be used by; foods may…

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

Based on clinical record review and staff interview, it was determined that the facility failed to ensure that clinical records were complete and accurately documented for two of 29 residents reviewed (Residents 29 and 38). Findings Include: Review of Resident 26's clinical record revealed diagnoses that included Type 2 Diabetes Mellitus, stroke, amputation of left leg below the knee (BKA), and amputation of right leg above the knee (AKA). Observation of Resident 26 on April 24, 2023, at 2:03 PM, revealed Resident 26 in the hallway, in his motorized wheelchair. Resident 26 was observed to have a seatbelt in place. Resident 26 was asked about the seatbelt and if he was able to release it. Resident 26 stated yes. Observation of Resident 26 on April 25, 2023, at 11:19 AM, revealed Resident 26 in the hallway, in his motorized wheelchair, with a seatbelt in place. Review of Resident 26's clinical record revealed no physician order for the seatbelt and no documentation of an assessment for the use of the seat belt to indicate whether Resident 26 could release the seat belt or 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 observation, facility policy review, clinical record review, and staff interview, it was determined that the facility failed to ensure the implementation of infection control processes and procedures regarding posted transmission-based precautions signage for a COVID-19 positive individual (Resident 207) and failed to maintain an accurate data collection system of infection surveillance from July 2022 through March 2023. Findings Include: Review of facility policy, titled Isolation - Categories of Transmission-Based Precautions, revised January 2012, revealed, Signs - the facility will implement a system to alert staff and visitors to the type of precaution the resident requires. Review of Resident 207's clinical record revealed diagnoses including COVID-19 (contagious viral infection) and congestive heart failure (weakness of the heart that leads to buildup of fluid in the lungs and surrounding body tissues). Review of Resident 207's current physician orders revealed an order for contact and droplet precautions: masks (N95), gloves, gown, and eye shield every shift,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility provided documentation, review of facility policy, and review of clinical records, as well as staff interviews, it was determined that the facility failed to provide accurate and timely documentation related to offering the COVID-19 vaccine and provide education regarding the benefits, risks, and potential side effects of the COVID-19 vaccine for five of five residents reviewed for immunizations (Residents 28, 59, 91, 93, and 97). Findings Include: Review of facility policy, titled Coronavirus Disease (COVID-19) - Vaccination of Residents, revised June 2022, revealed Each resident is offered the COVID-19 vaccine unless the immunization is medically contraindicated or the resident has already been immunized. Review of facility provided document, which lists Residents and their COVID-19 vaccination status, revealed that for Residents 28, 59, 91, 93, and 97, it was documented as no documentation/no history. Review of Resident 28's clinical record revealed Resident 28 was admitted to 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 facility policy review, observations, clinical record review, and staff interviews, it was determined that the facility failed to promote care for residents in a manner and environment that enhances each resident's dignity for two of 26 residents reviewed (Residents 71 and 79). Findings include: Review of facility policy, titled Dignity with a last revised dated of February 2021, revealed 12. Demeaning practices and standards of care that compromise dignity are prohibited. Staff are expected to promote dignity and assist residents: for example: a. helping the resident to keep urinary catheter bags covered. Review of Resident 71's clinical record revealed diagnoses that included benign prostatic hyperplasia (age associated prostate gland enlargement that can cause difficulty with urinating) and cerebral palsy (a congenital disorder of movement, muscle tone, or posture). Review of Resident 71's current physician orders revealed an order for foley catheter 16 French with 30 cubic centimeter balloon (a flexible tube placed through the urethra to the bladder to drain urine) to…

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

Based on observations and staff interview, it was determined that the facility failed to ensure that informational postings located throughout the facility contained all pertinent state agency and resident advocacy contact information. Findings include: Observation of the informational postings on April 25 2023, at 11:06 AM, revealed the informational postings present throughout the facility did not contain the mailing and email addresses of the State Survey Agency, mailing and email addresses of the State Long-Term Care Ombudsman program, contact information (name, phone number, mailing and email addresses) for home and community-based service programs and for the protection and advocacy network agency, as well as contact information (name, phone number, mailing and email addresses) for the Medicaid Fraud Control unit. During an interview with the Nursing Home Administrator on April 27, 2023, at 11:03 AM, she revealed that she was in the process of revising the postings. 28 Pa. Code 201.29(i) Resident rights

Based on observations and resident and staff interviews, it was determined that the facility failed to maintain a safe, clean, and home-like environment for one of three shower rooms (Evergreen Way/ Stepping Stones). Findings include: During an interview with Resident 84, on April 24, 2023, at 11:16 AM, they voiced a concern that there was a black substance that oozes out of the drain when using the shower in the shower room. Observations of the Evergreen Way/ Stepping Stones shower room on April 25, 2023, at 10:53 AM, and April 26, 2023, at 1:14 PM, revealed a black liquid, sticky appearing substance at the drain in the shower room. The flooring directly near the drain felt soft and sunken when stepping on the area, which also increased the oozing of the black substance. On April 27, 2023, at 11:22 AM, the Nursing Home Administrator (NHA) and Director of Nursing were made aware of the identified concern. Observation and interview with the NHA and Employee 8 (Housekeeping/Laundry Supervisor) on April 27, 2023, at 1:15 PM, revealed that they believe it is the glue oozing from 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 clinical record review, review of facility incident reports, review of facility policy, and interviews with staff, it was determined that the facility failed to conduct a timely and thorough investigation to rule out abuse, neglect, or mistreatment following unwitnessed falls for two of two residents reviewed for falls (Residents 78 and 209). Findings Include: Review of facility policy, titled Accidents and Incidents - Investigating and Reporting, revised July 2017, revealed, All accidents and incidents involving residents .occuring on our premises shall be investigated and reported to the Administrator. 1. The Nurse Supervisor/Charge Nurse and/or the department director or supervisor shall promptly initiate and document investigation of the accident or incident. 2. The following data, as applicable, shall be included on the Report of Incident /Accident form: .The circumstances surrounding the accident or incident .The name(s) of witnesses and their accounts of the accident or incident. Review of Resident 78's clinical record revealed diagnoses that included…

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 ensure that the resident assessment accurately reflected the resident's status for two of 29 residents reviewed (Residents 38 and 78). Findings Include: Review of Resident 38's clinical record revealed diagnoses that included gangrene (dead tissue caused by an infection or lack of blood flow), peripheral vascular disease (a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs), and hypertension (elevated blood pressure). Review of Resident 38's quarterly MDS assessment (Minimum Data Set - an assessment tool to review all care areas specific to the resident such as a resident's physical, mental, or psychosocial needs), dated March 16, 2023, revealed that in Section M, Resident 38 was coded as having one unstageable pressure ulcer. During an interview with the Nursing Home Administrator (NHA) on April 27, 2023, at 10:55 AM, she stated that Resident 38 had an a surgical site that was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy review, observation, clinical record review, and staff interviews, it was determined that the facility failed to ensure that a comprehensive, person-centered care plan was developed for three of 29 residents reviewed (Residents 26, 54, and 79). Findings Include: Review of facility policy, titled Care Plans, Comprehensive Person-Centered, with a last revised date of December 2016, revealed the following: 1) The interdisciplinary team, in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person centered care plan for each resident; 8) g. incorporate identified problem areas; and 10) identifying problem areas and their causes, and developing interventions that are targeted and meaningful to the resident, are the endpoint of an interdisciplinary process. Review of Resident 26's clinical record revealed diagnoses that included Type 2 Diabetes Mellitus, stroke, amputation of left leg below the knee (BKA), and amputation of right…

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 and resident interviews and clinical record review, it was determined that the facility failed to update a resident's discharge plan in the clinical record for one of 29 clinical records reviewed (Resident 23). Findings include: Review of Resident 23's clinical record revealed diagnoses that included: end stage renal disease (a condition in which a person's kidneys cease functioning on a permanent basis, leading to the need for long-term dialysis or a kidney transplant), atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow), high blood pressure (the force of the blood against the artery walls is too high), and congestive heart failure (a chronic condition in which the heart doesn't pump blood as well as it should). Interview with Resident 23 on April 25, 2023, at 9:30 AM, revealed he has been in the Nursing Home Transitions program (NHT- program was created to help re-balance the long-term care system in Pennsylvania so that people in need of long-term services could receive them in the setting of their choice, including 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.

Based on observation, test tray, and interviews, it was determined that the facility failed to provide food and beverage that are palatable and at a safe and appetizing temperature for one of one meal observed on the Stepping Stones hallway. Findings include: Observation on April 27, 2023, at approximately 11:05 AM, revealed the tray cart was delivered to Stepping Stones hallway. A test tray was completed on April 27, 2023, on the Stepping Stones hallway utilizing the last tray waiting to be served. Test tray temperatures were taken by Employee 9 (Dietary Manager) at approximately 11:30 AM and revealed the following: Milk 52 degrees Fahrenheit, not palatable temperature (point of service temperature should be less than 41 degrees Fahrenheit; Coffee 121 degrees Fahrenheit, not palatable temperature (point of service temperature should be greater than 135 degrees Fahrenheit); Juice 56 degrees Fahrenheit, not palatable temperature (point of service temperature should be less than 41 degrees Fahrenheit); Chocolate Mousse 59 degrees Fahrenheit, not palatable temperature (point of service…

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 regulations and staff interviews, it was determined that the facility failed to have an Infection Preventionist (IP) that completed an approved program for specialized training in infection prevention and control, prior to assuming the role of the IP. Findings include: The Centers for Medicare and Medicaid Services regulation §483.80(b)(4) states, The facility must designate one or more individual(s) as the Infection Preventionist(s) (IP)(s) who are responsible for the facility's IPCP (Infection Prevention Control Program) that have completed specialized training in infection prevention and control. Review of the facility's IPCP revealed that the facility did not have an Infection Preventionist who completed specialized training in infection prevention and control. During an interview with the Nursing Home Administrator (NHA), Director of Nursing (DON), and Assistant Director of Nursing (ADON) on April 27, 2023, at 12:15 PM, the DON stated that she just completed the post-test for the required training this past weekend. She stated she was having difficulty…

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 record review, and staff interview, it was determined that the facility failed to assess for eligibility and offer the pneumococcal and/or influenza vaccines to three of five residents reviewed (Residents 28, 91, and 93). Findings Include: Review of facility policy, titled Influenza Vaccine, revised August 2016, revealed All residents and employees who have no medical contraindications to the vaccine will be offered the influenza vaccine annually to encourage and promote the benefits associated with vaccinations against influenza. The facility shall provide pertinent information about the significant risks and benefits of vaccines to staff and residents (or residents' legal representatives). A resident's refusal of the vaccine and reason for refusal shall be documented on the Informed Consent for Influenza Vaccine and documented in the electronic health record. Review of facility polity, titled Pneumococcal Vaccine, revised October 2019, revealed All residents will be…

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