Harmar Village Health & Rehab Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policies and clinical records, facility provided documents, as well as staff interviews, it was determined that the facility failed to update an individualized care plan to address the resident's specific nutritional concerns and preferences and failed to address discontinued resident specific interventions for one of three residents (Resident R13) reviewed.Findings include: Review of facility policy Diet Orders dated 8/15/25, indicated the facility will ensure residents are provided meals as ordered by their healthcare provider. Diet orders will follow the facility formulary or an individualized diet as written/approved by the Registered Dietitian Nutritionist. The Food and Nutrition Services Manager will utilize a tray card identification system to ensure that each resident receives his or her diet as ordered, and that the diet in the medical record reflects the diet in the tray card system. Review of facility policy Comprehensive Care Planning dated 8/15/25, indicated an…

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

Based on observations, clinical record review, and staff interviews, it was determined the facility failed to ensure a resident receiving enteral feeding received appropriate care and services for one of two resident reviewed (Resident 118).Findings include: Review of Resident 118's clinical record revealed an admission date of 3/16/26, with diagnoses that included encounter for attention to gastrostomy, adult failure to thrive, and malnutrition. Review of Resident R118's care plan dated 3/13/26, indicated to provide tube feed and flush per order. Review of Resident 118's physician order dated 3/16/26, revealed an order for Enteral: Pump Feed Set Up Special Instructions: Provide Isosource 1.5 at 60ml/hr x 22 hours. Hang at 11 AM. Take down at 9 AM or when 1320 ml total volume has been infused Review of Resident 118's physician order dated 3/16/26, indicated to give 150ml free water flush every four hours, six times a day. Observation on 3/30/26, at 10:30 a.m. Resident R118's 1.5 Isosource bottle and 1000 ml water flush bag were undated. Interview on 3/30/26, at 10:34 a.m. the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical records, observations and staff interviews, it was determined that the facility failed to provide appropriate respiratory care and maintain oxygen equipment for three of three residents (Residents R56, R65, and R101).Findings include: Review of facility policy Oxygen Administration Policy dated 8/15/25, indicated all residents who are receiving oxygen therapy shall have tubing, mask, cannula changed weekly. Clean concentrator external filters weekly. Review of the face sheet indicated Resident R56 admitted to the facility on [DATE]. Review of Resident R56's Minimum Data Set (MDS - a periodic assessment of care needs) dated 2/2/26, indicated diagnoses of chronic obstructive pulmonary disease (COPD- a group of diseases that block airflow and make it hard to breathe), muscle wasting, and abnormal finding of lung field. Review of Resident R56's physician order 1/12/26, indicated oxygen: clean oxygen concentrator and filter, change tubing weekly. Wipe down concentrator,…

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, staff interview, and observations, it was determined that the facility failed to ensure that it was free from a medication error rate of five percent or greater based on three medication errors out of 36 opportunities.Findings include: Observation of medication administration on 4/1/26, at 8:56 a.m., Licensed Practical Nurse (LPN), Employee E14 was observed preparing to administer Resident R61 40 milligram (mg) Ingreeza (a prescription medication used to treat involuntary movements caused by tardive dyskinesia and chorea associated with Huntington's disease) capsule softened in pudding. Resident R61 was ordered to have his medications crushed. LPN, Employee E14 failed to administer Resident R61's 50 MCG/ACTUAT fluticasone propionate (known as flonase, a nasal spray used to treat sneezing, itchy or runny nose, or other symptoms caused by hay fever) and 1 MG/ML olopatadine (used to treat eye itching caused by allergies) Ophthalmic Solution due to the medications not being available. During an interview on 4/1/26, at 9:23 a.m. LPN, Employee E14…

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 interviews with staff, it was determined that the facility failed to ensure that residents are free of significant medication errors for one of four residents reviewed (Resident R61).Findings include: Review of facility policy Medication Shortages/Unavailable Medications dated 1/12/25, indicated upon discovery that facility has an inadequate supply of a medication to administer to a resident, facility staff should immediately initiate action to obtain the medication from pharmacy. If the medication is unavailable from pharmacy or a third-party pharmacy, and cannot be supplied from the manufacturer, facility should obtain alternate physician/prescriber orders, as necessary. Review of the clinical record indicated Resident R61 was admitted to the facility on [DATE], with diagnoses of bipolar disorder, anxiety, and depression. Review of Resident R61's care plan dated 11/18/25, indicated to finely crush the resident's pills. Review of Resident R61'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 observations, and staff interviews, it was determined that the facility failed to store medications properly, for three of three treatment carts (Treatment cart outside room [ROOM NUMBER], Treatment cart outside room [ROOM NUMBER], and 2nd floor treatment cart) and one of three medication carts (East Medication Cart), and two of five residents with treatment medications at bedside (Resident R3, and R40).Findings include: Observation on 3/30/26, at 9:05 a.m. indicated a treatment cart unlocked and unattended outside room [ROOM NUMBER]. Interview with Registered Nurse (RN) Employee E2 on 3/30/26, at 9:08 a.m. confirmed a treatment cart unlocked and unattended outside room [ROOM NUMBER]. Observation on 3/30/26, at 12:02 p.m. indicated a treatment cart unlocked and unattended outside room [ROOM NUMBER]. Interview with Licensed Practical Nurse (LPN) Employee E4 on 3/30/26, at 12:04 p.m. confirmed a treatment cart unlocked and unattended outside room [ROOM NUMBER]. Observation on 4/1/26, at 8:57 a.m. the 2nd…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy and clinical records, and staff and resident interviews, it was determined that the facility failed to ensure that a resident was assessed by a dentist for one of three residents (Resident R14).Findings include: Review of the facility policy Dental Services Policy dated 8/15/25, indicated the facility will assist residents in obtaining routine and 24-hour emergency dental care/services to meet the needs of each resident. All dental services provided are recorded / scanned in the resident's medical record. Review of the admission record indicated Resident R14 was admitted to the facility on [DATE]. Review of Resident R14's Minimum Data Set (MDS - a periodic assessment of care needs) dated 3/9/26, indicated diagnoses of heart failure (heart doesn't pump blood as well as it should), stroke (damage to the brain from an interruption of blood supply), and diabetes (a long-term condition in which the body has trouble controlling blood sugar and using it for energy). Review of Resident…

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

Based on facility policy review, review of Quality Assurance attendance records, and staff interview, it was determined that the facility failed to conduct Quality Assessment and Assurance (QAA) meetings at least quarterly for two of four quarterly meetings (Quarter Two 2025, Quarter Three 2025).Findings Include: The facility Quality Assurance and Performance Improvement (QAPI) Program policy dated 8/15/25, indicated QAPI efforts are a component of the facility QAA (Quality Assessment and Assurance) Committee's responsibilities. The QAA Committee is responsible for both Quality Assessment and Assurance activities (QA) and ongoing, proactive, Performance Improvement (PI) activities. QAPI represents the merger of these two processes.The Committee will meet on a regular basis (at least quarterly, and as needed) to coordinate and evaluate activities of the QAPI program/plan. Review of Quality Assurance and Performance Improvement (QAPI) sign in sheets and attendance records, failed to reveal documentation that quarterly meetings were conducted during Quarter Two 2025 and Quarter Three…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy, clinical record review, observation, and staff interview, it was determined that the facility failed to ensure that Enhanced Barrier Precautions (EBP) were managed properly for one of three resident (Resident R12) and failed to properly monitor a resident's personal refrigerator temperature for one of two residents (Resident R44).Findings include: Review of the facility policy Enhanced Barrier Precautions Policy dated 8/15/25, indicated EBP are intended to prevent transmission of multi-drug-resistant organisms (MDROs) via contaminated hands and clothing of healthcare workers to high-risk residents during high contact activities. High-risk residents are those with chronic wounds and indwelling devices. Staff will put on both gloves and gown before initiating the activity and remove personal protective equipment before exiting the room. Review of the facility policy Freezers and Refrigerators Policy dated 8/15/25, indicated monthly tracking sheets for all refrigerators and freezers will…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy, clinical record review and staff interview, it was determined that the facility failed to make certain that pneumococcal vaccinations were tracked in the electronic health record (Residents R12, and R44).Findings include: Review of the facility policy Harmar Village Health and rehab Center Infection Prevention and Control Plan dated 8/15/25, indicated the Infection Preventionist (IP) ensures oversight of the infection prevention committee strategies and approaches to prevent and/or address, at a minimum vaccinations. Review of the face sheet indicated Resident R12 admitted to the facility on [DATE]. Review of Resident R12's Minimum Data Set (MDS - a periodic assessment of care needs) dated 2/9/26, indicated the diagnoses of diabetes (a long-term condition in which the body has trouble controlling blood sugar and using it for energy), stroke (damage to the brain from an interruption of blood supply), and seizure disorder (a person experiences abnormal behaviors, symptoms and sensations,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical records, and staff interview, it was determined that the facility failed to make certain that residents received proper treatment for pressure ulcers for one of three residents (Resident R1).Findings include: Review of facility policy Pressure Injury Prevention and Management dated January 2026, indicated residents admitted with existing pressure injuries will receive necessary treatment and services, consistent with professional standards of practice, to promote healing and prevent infection. Review of the clinical record indicated Resident R1 was admitted to the facility on [DATE]. Review of Resident R1's admission Minimum Data Set (MDS - a periodic assessment of care needs) dated 10/2/25, indicated diagnoses of high blood pressure, wound infection, and chronic pain syndrome. Section M - Skin Conditions, Question M0300C indicated the resident was admitted with one Stage 3 pressure ulcer (a skin injury involving full-thickness skin loss and exposure of the fatty…

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 the facility failed to obtain laboratory services as ordered for two of five residents reviewed (Residents R2 and R3).Findings include: Review of the clinical record indicated Resident R2 was admitted to the facility on [DATE]. Review of Resident R2's Minimum Data Set (MDS - a periodic assessment of care needs) dated 11/2/25, indicated diagnoses of high blood pressure, dementia (a group of symptoms that affects memory, thinking and interferes with daily life), and diabetes mellitus (a metabolic disorder in which the body has high sugar levels for prolonged periods of time).Review of a physician order dated 11/4/25, indicated to obtain a CBC (Completed Blood Count - a test that measures red blood cell, hemoglobin, white blood cell, and platelet levels in the blood).Review of a physician order dated 11/4/25, indicated to obtain a CMP (Complete Metabolic Panel - a test that measures 14 different substances in blood and helps evaluate how well…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical records, and staff interviews, it was determined that the facility failed to notify a medical provider of a change in condition for two of seven residents (Resident R6 and R7).Findings include: Review of the facility, Resident Change in Condition Policy dated 10/23/25, indicated, The licensed nurse will recognize and intervene in the event of a change in resident condition. The Physician/ Provider and the Family/Responsible Party will be notified as soon as the nurse has identified the change in condition, and the resident is stable. Review of the facility policy, Resident Weight Policy dated 10/23/25, indicated each resident's weight will be determined upon admission/readmission to the facility, weekly for the first four weeks after admission/readmission, and monthly or more often if risk is identified, or as ordered. Review of the clinical record indicated Resident R6 was admitted to the facility on [DATE]. Review of Resident R6's Minimum Data Set (MDS, periodic…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy, clinical record review, and resident and staff interview, it was determined that the facility failed to procure physician's orders for the need to have crushed medications for 29 of 33 residents (Resident R8, R9, R10, R11, R12, R13, R14, R15, R16, R17, R18, R19, R20, R21, R22, R23, R24, R25, R26, R27, R28, R29, R30, R31, R32, R33, R34, R35, and R36). Findings include: Review of the Facility assessment dated [DATE], indicated the facility will provide speech therapy services. During an interview on 11/13/25, at 2:25 p.m. Speech Therapist Employee E7 stated that the speech department adjusts diet consistency orders but does not address the need for a physician's order for crushed medications. When asked how nursing staff are aware of the need for a resident to have medications crushed, Speech Therapist Employee E7 stated, I would assume the staff know. During a review of current residents on 11/14/25, it was noted that four residents (Residents R2, R3, R4, and R5) had physician orders for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility documents, clinical records, and staff interview, it was determined that the facility failed to make certain that medical records on each resident are complete and accurately documented for of 14 of 104 residents (R2, R8, R14, R16, R17, R21, R32, R33, R37, R39, R40, R41, R43, and R44).During an interview on [DATE], at approximately 12:30 p.m. when asked how they ascertain if a resident required their medications to be crushed, Licensed Practical Nurse (LPN) Employee E8 stated she reviews the physician's orders. LPN Employee E8 displayed the physician's order screen in the electronic charting system, and indicated an order that stated, May crush medications unless contraindicated. Additionally, LPN Employee E8 stated that there were report sheets at the nurse's station that indicate if residents required their medications crushed. LPN Employee E7 was unable to provide a report sheet for her unit. Review of additional resident charts on [DATE], at approximately 1:00 p.m. revealed 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 a review facility policy, clinical records, and staff interviews, it was determined that the facility failed to develop a person-centered care plan related to the need for crushed medications for one of five residents (Resident R1).Findings include: Review of the facility policy Comprehensive Care Plan dated 10/23/25, indicated an interdisciplinary plan of care will be established for every resident and updated in accordance with State, and Federal requirements and on an as needed basis. Review of the clinical record indicated Resident R1 was admitted to the facility on [DATE] Review of the Minimum Data Set (MDS, periodic assessment of resident care needs) dated 10/8/25, included diagnoses of dementia (a group of symptoms that affects memory, thinking and interferes with daily life), and chronic obstructive pulmonary disease (COPD, a group of progressive lung disorders characterized by increasing breathlessness). Review of the facility diagnosis list included dysphagia (difficulty swallowing) with a…

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

Based on review of facility policy, resident records and staff interviews it was determined that the facility failed to make certain that a controlled substance (drugs with the potential to be abused) was disposed of as per acceptable standards of practice for one of three closed resident records (Closed Resident Record CR1). Findings include: The facility Discontinued medication procedure policy last reviewed 1/10/25, indicated that controlled medications are to remain in the facility under double lock and be destroyed following the controlled medication destruction policy and procedure. The nurse discontinuing the medication will remove the medication from the cart and store in a secure area. Facility documentation of controlled substance list dated 7/2025, indicated that Clonazepam (Klonopin) is a schedule four controlled substance. Review of Closed Resident Record CR1's admission record indicated 6/30/25, indicated she had diagnoses that included diabetes (metabolic disorder impacting organ function related to glucose levels in the human body), chronic obstructive pulmonary…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of clinical records, and staff interview it was determined that the facility failed to provide appropriate treatment and care for one of four residents (Resident R1) Findings include: Resident R1 was admitted to the facility on [DATE]. Review of Resident R1 clinical record indicated the following diagnosis of dementia (loss of cognitive functioning- thinking remembering, and reasoning, to such an extent that it interferes with a person's daily life and activities), anxiety, and bipolar (mental health condition that affects a person's mood, energy, activity, and thought and is characterized by manic (or hypomanic) and depressive episodes). Review of the clinical record physician orders indicated Resident R1 was prescribed: ziprasidone HCl - (Geodon - an antipsychotic to treat bipolar disorder) capsule; 80 mg; Amount to Administer: 80 MG; oral Further review of the clinical record indicated Resident R1 missed five doses of ziprasidone for AM and PM doses. Review of clinical progress notes did 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy and facility documents it was determined that the facility failed to make certain controlled substances were accounted for accurately and destroyed approiately for one of four residents. Findings include: Review of facility policy Inventory Control of Controlled Substances dated 01/10/25, indicated: Facility should maintain separate individual controlled substance records on all Schedule II medications and any medication with a potential for abuse or diversion in the form of a declining inventory using the Controlled Substances Declining inventory Record Facility should insure the incoming and outgoing nurses count all Schedule II controlled substances and other medications with a risk of abuse or diversion at the change of each shift. Resident R2 was admitted to the facility on [DATE]. Review of Resident R2 MDS (minimum data set - a periodic assessment of needs) dated 2/13/25, indicated a diagnosis of PVD ( a slow and progressive disorder of the blood vessels), osteoporosis…

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

Based on review of facility policies, observations, and staff interviews, it was determined the facility failed to maintain clean equipment in a manner to prevent foodborne illness in the Main Kitchen. Findings include: Review of facility policy Kitchen Sanitation and Cleaning Schedules dated 1/10/25, indicated that food and nutrition services staff will maintain the sanitation of the kitchen through compliance with a written, comprehensive cleaning schedule During an observation and interview on 3/11/25, at 1:15 p.m. Certified Dietary Manager Employee E21 confirmed that a fan that was pointed towards the clean dishes coming out of the dish machine, was covered in a gray, fuzzy substance, and that the facility failed to maintain clean equipment to prevent foodborne illness. 28 Pa. Code: 201.14(a) Responsibility of licensee 28 Pa. Code: 201.18(b)(1) Management. 28 Pa. Code: 211.6(f) Dietary services.

Based on observation, and staff interview it was determined that the facility failed to properly contain and dispose of garbage in one of two outside dumpsters to prevent the potential for rodent and insect infestation (dumpster one). Findings include: During an observation and interview of the facility's outdoor trash receptacles on 3/11/25, at 12:45 p.m. Certified Dietary Manager Employee E21 confirmed that the lid/cover was not closed on dumpster one. During an observation on 3/13/25, at 8:29 a.m. the lid/cover of dumpster one was noted to be open. During an interview on 3/13/25, at 8:30 a.m. the Nursing Home Administrator confirmed that the facility failed to properly contain and dispose of garbage in the outside trash receptacles to prevent the potential for rodent and insect infestation. 28 Pa. Code 201.18(b)(3) Management.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy, observation and staff interview, it was determined that the facility failed to ensure that care was provided in a manner which maintained resident dignity on three of three units (Second Floor Resident R81, Third Floor Resident R31, and Memory Impaired Unit (MIU) Resident R65). Findings include: Review of facility policy Resident Rights and Facility Responsibilities dated 1/10/25, indicated it is the facility's policy to comply with all Residents Rights, and to communicate these rights to residents and their designated representatives in a language that they can understand. Review of the facility's Resident Handbook indicated residents have the right to be treated at all times with courtesy, respect, and full recognition of dignity and individuality. Review of Resident R31's clinical record indicated the resident was admitted to the facility on [DATE]. Review of Resident R31's Minimum Data Set (MDS - a periodic assessment of care needs) dated 2/24/25, indicated diagnoses of high blood…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical records, and staff interview, it was determined that the facility failed to provide documentation of advanced directives or was given the opportunity to formulate an advance directive (a written instruction such as a living will or durable power of attorney for health care for when the individual is incapacitated) for two of four residents reviewed (Resident R31, and R42). Findings include: A review of the facility policy Advanced Directives Information last reviewed 1/10/25, indicated that advanced directives are written instructions about future medical care if or when you become unable to make decisions for yourself. Advanced directives will be discussed with you or your representative to determine if any advanced directives have been chosen or if you have any questions. Your medical record will identify any chosen advanced directives. Review of Resident R31's clinical record indicated the resident was admitted to the facility on [DATE]. Review of Resident R31's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to make certain that the necessary resident information was communicated to the receiving health care provider for four of five residents sampled with facility-initiated transfers (Residents R26, R31, R44, and R95). Review of facility policy Transfers dated 1/10/25, indicated forms that need to be sent out with facility-initiated transfers to hospital: Discharge/Transfer Form, copy of care plan goals, and Bed Hold Notice. Review of the clinical record revealed that Resident R26 was admitted to the facility on [DATE]. Review of Resident 26's MDS (Minimum Data Set, periodic assessment of resident care needs) dated 2/11/25, indicated diagnoses of anxiety disorder (mental illnesses that involve persistent and uncontrollable feelings of fear), hyperlipidemia (abnormally high levels of fats are in the bloodstream), and dementia (neuro-cognitive disorder impacting reasoning, judgment, and memory).…

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 interviews, it was determined that the facility failed to notify the resident or resident's representative of the facility bed-hold policy (an agreement for the facility to hold a bed for an agreed upon rate during a hospitalization) for four of four resident hospital transfers (Residents R31, R44, R74, and R95). Review of facility policy Transfers dated 1/10/25, indicated forms that need to be sent out with facility-initiated transfers to hospital: Discharge/Transfer Form, copy of care plan goals, and Bed Hold Notice. Review of Resident R31's clinical record indicated the resident was admitted to the facility on [DATE]. Review of Resident R31's Minimum Data Set (MDS - a periodic assessment of care needs) dated 2/24/25, indicated diagnoses of high blood pressure, diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time), and aphasia (a language disorder that affects a person's ability to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical record review, and staff interviews, it was determined that the facility failed to make certain that residents were provided appropriate treatment and care for eight of 24 residents (Residents R1, R19, R47, R62, R81, R90, R203, and R253). Findings include: Review of facility policy Resident Weight dated 1/10/25, indicated weights will be obtained routinely in order to monitor nutritional health over time. Each resident's weight will be determined upon admission/readmission to the facility, weekly for the first four weeks after admission/readmission, and monthly or more often if risk is identified, or as ordered. Nursing is responsible for obtaining weights. Weights will be recorded in the electronic health record. Review of the facility policy Diabetic Protocol dated 1/10/25, indicated the provider and staff will work together to give appropriate treatment to manage diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time).…

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 interviews, it was determined that the facility failed to properly monitor weight and nutrition status by failing to obtain weights for two of four residents (Residents R65 and R81). Findings include: Review of facility policy Resident Weight dated 1/10/25, indicated weights will be obtained routinely in order to monitor nutritional health over time. Each resident's weight will be determined upon admission/readmission to the facility, weekly for the first four weeks after admission/readmission, and monthly or more often if risk is identified, or as ordered. Nursing is responsible for obtaining weights. Weights will be recorded in the electronic health record. Review of the clinical record indicated Resident R65 was admitted to the facility on [DATE]. Review of Resident R65's Minimum Data Set (MDS - a periodic assessment of care needs) dated 2/5/25, indicated diagnoses of high blood pressure, hyperlipidemia (high levels of fat in the blood),…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical record review, observation, and staff interview, it was determined that the facility failed to ensure that residents with an enteral feeding tube (a tube inserted in the stomach through the abdomen) received appropriate treatment and services to prevent potential complications for two of three residents (Residents R31, and R95). Findings include: Review of facility policy Enteral Feeding Tube dated [DATE], indicated enteral nutrition tubes will be utilized only after assessment determines that the clinical condition of the resident makes use of the feeding tube medically necessary and consent of the resident, or representative is given. Services will be provided to restore normal eating skills to the extent possible. Licensed clinicians with demonstrated competence may administer enteral feeding. If irrigation sets are used, they should be rinsed with warm water after each use and replaced every 24 hours. Review of Resident R31's clinical record indicated the resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, observations, staff interviews, and clinical record review, it was determined that the facility failed to provide appropriate respiratory care for six of six residents (Residents R31, R42, R74, R81, R203, and R253). Findings include: Review of facility policy Oxygen Administration dated 1/10/25, indicated licensed clinicians will administer oxygen via the specified route as ordered by the provider. Change tubing, mask, cannula (a thin, flexible tube that is inserted into the nose to deliver oxygen) weekly and document. Change prefilled humidifier bottle when empty. Humidifcation should be added if flow rate is more than four liters per minute of oxygen. Review of facility policy Nebulizer (a machine that turns liquid medicine into a mist that can be inhaled into the lungs) Administration dated 1/10/25, indicated licensed clinicians may deliver medication via a nebulizer machine. Review of Resident R31's clinical record indicated the resident was admitted to the facility on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to obtain a physician order and conduct ongoing accurate assessments to ensure that bedrails were used to meet residents' needs, and the risks associated with bedrail usage for three of five residents (Residents R47, R65, and R253). Findings include: Review of facility policy Bed Rail dated 1/10/25, indicated if a bed or side rail or bar is used, the facility will evaluate the potential risks associated with the use of bed rails including entrapment, prior to bed rail installation using the Bed and Bed Rail Safety Inspection Checklist. Review of the clinical record indicated Resident R47 was admitted to the facility on [DATE]. Review of Resident R47's Minimum Data Set (MDS - a periodic assessment of care needs) dated 2/3/25, indicated diagnoses of high blood pressure, hyperlipidemia (high levels of fat in the blood), and dementia (a group of symptoms that affects memory,…

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, resident observations, resident and staff interviews, it was determined that the facility failed to have sufficient nursing staff to provide nursing and related services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of six of ten residents (Residents R1, R8, R22, R60, R81, and R90). Findings include: Review of the facility's Registered Nurse (RN) job description indicated staff will accurately administer medication and treatment to residents per physician orders and maintain comprehensive documentation on required charting, medication/treatment administration, incidents/accidents, physician orders, admission/transfer/discharge, weights/vitals, etc. Review of the facility's Licensed Practical Nurse (LPN) job description indicated staff will accurately administer medication and treatment to residents per physician orders and maintain comprehensive documentation on required charting, medication/treatment administration, incidents/accidents, physician orders, admission/transfer/discharge, weights/vitals,…

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

Based on review of personnel records and staff interview it was determined that the facility failed to complete annual performance evaluations for five of five nurse aide (NA) personnel records (NA Employee E11, E12, E13, E14, and E15). Findings include: Review of personnel records indicated that NA Employees E11, E12, E13, E14, and E15 had a hire date at the facility of 7/1/23. Review of personnel records did not include annual performance evaluations based on the date of hire for NA Employee E11, E12, E13, E14, and E15. During an interview on 3/13/25, at 12:16 p.m. the Nursing Home Administrator confirmed that the facility failed to complete annual performance evaluations for five of five nurse aides as required. 28 Pa Code: 201.20 (a)(b)(d) Staff development.

Based on review of facility policy, observation and staff interview it was determined the facility failed to dispose or reconcile discontinued medication in a timely manner for one of three nursing units (Second Floor) and one of two medication rooms (Third Floor Medication Room). Findings include: Review of facility policy Discontinued Medication Procedure dated 1/10/25, indicated when a medication is discontinued, the medication will be sent home with the patient on discharge, returned to pharmacy, or destroyed according to policy. The nurse discontinuing the medication will remove the medication from the cart and store in a secure area. Items eligible for return will be returned to the pharmacy within 48 hours or as soon as practicably possible. During an observation of the Second Floor nursing unit on 3/11/25, at 10:15 a.m. revealed a cardboard box stored under a desk at the nurse's station. The cardboard box contained the following medications and biologicals: - Six bags of TPN (total parental nutrition, a nutrition solution administered intravenously via a vein) - One opened…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff interview, it was determined that the facility failed to maintain complete and accurate documentation for three of three residents (Residents R44, R62, and R65). Findings include: Review of facility policy Comprehensive Care Planning dated /10/25, indicated a facility designee, appointed and directed by the Administrator is responsible for developing and maintaining an accurate record of residents scheduled for the Resident Care Plan Conference. The presence of all Resident Care Conferences staff/attendees and their relationship to the resident will be documented. Review of the clinical record indicated Resident R44 was admitted to the facility on [DATE]. Review of Resident R44's Minimum Data Set (MDS - a periodic assessment of care needs) dated 2/6/25, indicated diagnoses of anemia (too little iron in the blood), hyperlipidemia (high levels of fat in the blood), and dementia (a group of symptoms that affects memory, thinking and interferes with daily life). Review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policies, observations, resident and staff interviews, it was determined that the facility failed to determine the ability to self-administer medications for four of 21 residents (Residents R14, R42, R74, and R80). Findings include: Review of facility policy General Dose Preparation and Medication Administration dated 1/10/25, indicated that this policy is related to medication administration. Facility should take all measures required by facility policy including but not limited to the following: Facility staff should no leave medications or chemicals unattended. Review of Resident R14's clinical record indicated the resident was admitted to the facility on [DATE]. Review of Resident R14's Minimum Data Set (MDS - a periodic assessment of care needs) dated 2/4/25, indicated diagnoses of asthma (condition where the airways narrow and swell), osteoporosis (condition when the bones become brittle and fragile), and dysphagia (difficulty swallowing). Review of Resident R14's physician'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 clinical record and interview, it was determined that the facility failed to notify the resident's responsible party of changes in condition for one of six sampled residents (Resident R71). Findings include: Review of the Resident R71 admission record indicates he was admitted on [DATE]. Review of Resident R71 5 day MDS assessment (MDS-Minimum Data Set Assessment. Periodic assessment of resident care needs) dated 2/17/25, indicated that the resident current diagnoses were pneumonia, major depressive disorder and sepsis. Review of Resident R71 nurse progress dated 1/17/25 indicated family was concerned with Seroquel making the resident tired. Review of Resident R71 nurse progress dated 1/31/25, physician saw resident indicating dose was appropriate. Review of Resident R71 nurse progress dated 2/1/25 pharmacy indicated Seroquel was at appropiate dose. Review of Resident R71 nurse progress dated 1/17/25- 2/9/25 revealed no notification to guardian regarding Seroquel dose. During an interview on 3/12/25 at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of resident records, admission documentation and staff interview, it was determined that the facility failed to maintain admission documentation for one of two residents (Resident R100). Findings include: Review of Resident R100 was admitted [DATE] with diagnoses that include dementia(progressive decline in cognitive abilities, including memory, thinking, reasoning, and problem-solving), acute kidney failure and hypertension. Review of the Resident Assessment Instrument 3.0 User's Manual effective October 2019, indicated that a Brief Interview for Mental Status (BIMS) is a screening test that aides in detecting cognitive impairment. The BIMS total score suggests the following distributions: 13-15: cognitively intact 8-12: moderately impaired 0-7: severe impairment Review of Resident R100's admission MDS assessment (Minimum Data Set assessment MDS- a periodic assessment of resident care needs) dated 10/29/24 indicated the resident was assessed as having a BIMS score of 4, which indicates severe…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of facility policy, clinical records, and staff interview, it was determined that the facility failed to develop a baseline care plan for two of five residents (Resident R90, and R203). Findings include: Review of facility policy Interim/Baseline Care Plan dated 1/10/25, indicated that within 48 hours of admission, the facility will develop and implement an interim/baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident until a comprehensive assessment can be completed, leading to a comprehensive care plan. The baseline care plan will be sued until the comprehensive assessment and care plan is developed by the interdisciplinary team. Review of the clinical record indicated Resident R90 was admitted to the facility on [DATE]. Review of Resident R90's Minimum Data Set (MDS - a periodic assessment of care needs) dated 1/30/25, indicated diagnoses of high blood pressure, hyperlipidemia (high levels of fat in the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical records, and staff interview, it was determined the facility failed to update a care plan for one of three residents (Resident R50) to accurately reflect the current status of the resident and care needs. Findings include: Review of the facility policy Comprehensive Care Plan dated 1/10/25, indicated an interdisciplinary plan of care will be established for every resident and updated in accordance with State, and Federal requirements and on an as needed basis. Review of the admission record indicated Resident R50 was admitted to the facility on [DATE]. Review of Resident R50's Minimum Data Set (MDS - a periodic assessment of care needs) dated 2/5/25, indicated the diagnoses of anemia (the blood doesn't have enough healthy red blood cells), high blood pressure, and heart failure (heart doesn't pump blood as well as it should). Review of medical records revealed that Resident R50 had a hospital stay from 12/23/24, through 12/31/24, with diagnoses of a fecal impaction…

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, job descriptions, clinical record review, and staff interviews, it was determined that the facility failed to provide care and services to meet the accepted standards of practice by failing to complete an admission assessment for two of four residents (Residents R90 and R203). Findings include: Review of the facility's Licensed Practical Nurse (LPN) job description indicated staff will maintain comprehensive documentation on required charting, medication/treatment administration, incidents/accidents, physician orders, admission/transfer/discharge, weights/vitals, etc. Review of the facility's Registered Nurse (RN) job description indicated staff will maintain comprehensive documentation on required charting, medication/treatment administration, incidents/accidents, physician orders, admission/transfer/discharge, weights/vitals, etc. Review of the clinical record indicated Resident R90 was admitted to the facility on [DATE]. Review of Resident R90's Minimum Data Set (MDS - a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of clinical record review and interview with staff, it was determined that the facility failed to provide discharge planning that focuses on the resident's discharge goals and preparation of resident to be active partners in the discharge planning process that focuses on the resident's discharge planning and process for one of three residents (R46). Findings include: Review of Resident R46's admission record indicated R46 was admitted [DATE]. Review of R46's Minimum Data Set (MDS-a periodic assessment of care needs) dated 2/13/25, indicated diagnoses of muscle wasting, anemia and failure to thrive. Review of R46s physician orders dated 3/9/25, indicated resident to discharge to home with home health. Review of Resident R46's progress notes dated March 2025 indicated no discharge instruction, no inventory or medication reconciliation, no indication that the R46 had been discharged . During an interview on 3/13/25, at 2:45 p.m. the Director of Nursing confirmed that the facility failed complete…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical records, and staff interview, it was determined that the facility failed to make certain that residents received proper treatment and monitoring for pressure ulcers and failed to develop a plan of care timely for two of three residents (Residents R47 and R60). Findings include: Review of facility policy Pressure Injury Prevention and Treatment dated 1/10/25, indicated pressure injuries identified will be assessed initially an at least weekly thereafter, until closed. Review of the facility's Registered Nurse (RN) job description indicated staff will accurately administer medication and treatment to residents per physician orders and maintain comprehensive documentation on required charting, medication/treatment administration, incidents/accidents, physician orders, admission/transfer/discharge, weights/vitals, etc. Review of the facility's Licensed Practical Nurse (LPN) job description indicated staff will accurately administer medication and treatment to residents…

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 reviews of facility policy, observations, and staff interviews, it was determined that the facility failed to implement effective safety measures by not supervising residents during mealtime for one of three floors (Third Floor), and failed to make certain that each resident received adequate monitoring of elopement (leaving an area without permission) devices for one of two residents (Resident R82). Findings include: Review of facility policy Resident Rights and Facility Responsibilities dated 1/10/25, indicated it is the facility's policy to comply with all Residents Rights, and to communicate these rights to residents and their designated representatives in a language that they can understand. During a dining room observation on 3/10/25, at 11:32 a.m. eight residents were sitting in the main dining room on the Third floor waiting for lunch. During a dining room observation on 3/10/25, at 11:42 a.m. staff members served residents their lunch in the main dining room and left the room. During an…

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

Based on review of resident clinical records and staff interview, it was determined the facility failed to provide consistent and complete communication with the dialysis (treatment that helps body remove extra fluid and waste products) center for one of one resident receiving hemodialysis (Resident R66) for two of four days. Findings include: A review of Resident R66's MDS (MDS-a periodic assessment of resident care needs) dated 2/10/25, with the diagnosis of end stage renal disease (permanent condition in which the kidneys can no longer filter the blood), diabetes mellitus and hypertension. A review of Resident R66 physician orders last revised on 10/27/24, indicate dialysis Mondays, Wednesdays and Fridays. A review of Resident R66's dialysis binder indicated dialysis sheets completed on 1/3/25, 1/6/25, 1/8/25, 1/13/25, 1/15/25 and 1/17/25, incomplete 1/10/25, 1/20/25, 1/22/25, 1/27/25, 1/29/25, 2/12/25, 2/14/25, 2/17/25, 2/19/25, 2/21/25 and 2/24/25. During an interview on 3/13/25 Director of Nursing at 11:45 a.m., confirmed the dialysis communication forms for Resident R66 were…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policies, clinical record review, and staff interview, it was determined that the facility failed to identify a diagnosed specific condition for treatment for one of three residents receiving psychotropic medications (Resident R62). Review of facility policy Psychoactive Medication Policy dated 1/10/25, indicated diagnoses supporting the use of psychoactive medication will be documented in the medical record. Review of the clinical record revealed Resident R62 was admitted to the facility on [DATE]. Review of Resident R62's Minimum Data Set (MDS - a periodic assessment of care needs) dated 2/25/25, indicated diagnoses of high blood pressure, hyperlipidemia (high levels of fat in the blood), and dementia (a group of symptoms that affects memory, thinking and interferes with daily life). Review of a physician order dated 11/14/24, indicated to administer Seroquel (an antipsychotic) 25 mg (milligrams) twice a day. The physician order failed to identify a specific condition for treatment. 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 review of facility policies, observations, and staff interviews, it was determined that the facility failed to properly store medications on one of three nursing units (Second Floor), one of two medication rooms (Third Floor Medication Room), and two of three medication carts (Three South Medication Cart and Three East Medication Cart). Findings include: Review of facility policy Storage and Expiration Dating of Medications and Biologicals dated 1/10/25, indicated the facility should ensure medications and biologicals, including treatment items, are securely stored in a locked cabinet/cart or locked medication room that is inaccessible by residents and visitors. Once any medication or biological package is opened, facility should follow manufacturer/supplier guidelines with respect to expiration dates for opened medications. Facillity staff should record the date opened on the primary medication container (i.e., vial, bottle, inhaler) when the medication has a shortened expiration date once opened. If a multi-dose vial of an injectable medication has been opened or accessed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of facility policy, resident clinical records, and staff interview, it was determined the facility failed to obtain a diagnosis, and order for hospice services and to ensure the coordination of hospice services with facility services to meet the needs of each resident for end-of-life care for three of four residents (Resident R39, R62, and R81). Findings include: Review of the facility policy Hospice Care dated 1/10/25, indicated that the facility will ensure that the resident's plan of care and a description of the services furnished by the facility to attain or maintain the residents highest practicable physical, mental, and psychological wellbeing. The facility will also obtain from hospice the instructions on how to access the hospice's 24 hour on-call system Review of the clinical record revealed that Resident R39 was admitted to the facility on [DATE]. Review of Resident R39's MDS (Minimum Data Set- periodic assessment of resident care needs) dated 2/28/25, indicated diagnoses of high…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, observations, and staff interviews, it was determined that the facility failed to implement infection control practices to prevent cross contamination during a dressing change for one of three residents (Resident R81). Findings include: Review of facility policy Clean Dry Dressing Change dated 1/10/25, indicated where sterile technique is not ordered or indicated, wounds will be dressed using clean technique which avoids direct contamination of material and supplies. Procedure: - Perform hand hygiene - Introduce self to patient/resident - Confirm patient/resident ID - Explain procedure to patient/resident, offer bathroom, analgesia - Ensure privacy - Set up clean field using a barrier, towel, chux, etc - Position patient to visualize area to be dressed - Perform hand hygiene - [NAME] clean gloves - Check any dressing present, remove and wrap in gloves as you take gloves off, discard in trash bag - Assess wound (if you need to touch the area perform hand hygiene and don new…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy, clinical record review and staff interview, it was determined that the facility failed to provide accurate and timely documentation related to the Influenza and Pneumonia vaccine for one of six residents (Resident R63). Findings include: Review of facility policy Resident Vaccination dated 1/10/25, indicated that residents or their responsible party will be asked about prior vaccinations at admission. Prior doses of influenza, pneumococcal, COVID-19, and other vaccines will be documented in the immunization portal in the electronic health record. Consents, refusals, or medical ineligibility will be documented. Review of Resident R63's clinical record indicated the resident was admitted to the facility on [DATE]. Review of Resident R63's Minimum Data Set (MDS - a periodic assessment of care needs) dated 1/29/25, indicated diagnoses of multiple sclerosis (a disease that affects central nervous system), seizures (a disruption of brain electrical activity that can cause changes in behavior,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy, clinical record review and staff interview, it was determined that the facility failed to provide accurate and timely documentation related to the COVID-19 (a respiratory disease) vaccine for two of six residents (Resident R6, and R63). Findings include: Review of facility policy Resident Vaccination dated 1/10/25, indicated that residents or their responsible party will be asked about prior vaccinations at admission. Prior doses of influenza, pneumococcal, COVID-19, and other vaccines will be documented in the immunization portal in the electronic health record. Consents, refusals, or medical ineligibility will be documented. Review of Resident R6's clinical record indicated the resident was admitted to the facility on [DATE]. Review of Resident R6's Minimum Data Set (MDS - a periodic assessment of care needs) dated 2/5/25, indicated diagnoses of hypertension, coronary artery disease (damage or disease in the heart's major blood vessels), and cancer (uncontrolled cell growth and the…

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

Based on review of facility documents and staff interview, it was determined that the facility failed to provide training on effective communication for four of five staff members (Employee E11, E12, E13, and E14). Findings include: Review of the Facility Assessment dated 1/26/25, indicated that new staff are trained during orientation and existing staff are trained monthly on specific topics to ensure educational requirements are met. Review of facility provided documents and training records revealed the following staff members did not have documented training on effective communication. Nurse Aide (NA) Employee E11 had a hire date of 7/1/23, failed to have effective communication in-service education between 7/1/23, and 7/1/24. NA Employee E12 had a hire date of 7/1/23, failed to have effective communication in-service education between 7/1/23, and 7/1/24. NA Employee E13 had a hire date of 7/1/23, failed to have effective communication in-service education between 7/1/23, and 7/1/24. NA Employee E14 had a hire date of 7/1/23, failed to have effective communication in-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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical record, and staff interview it was determined that the facility failed to make certain residents are free from significant medication errors for one of three ( Resident R1). Findings include: Review of facility policy Medication Administration Times dated 1/10/25, indicated: Facility should insure that authorized personnel, as determined by applicable law, administer medications according to times of administration as determined by Facility's pharmacy committee and/or Physician/Prescriber. Review of Resident R1 admission record indicated they were admitted on [DATE]. Review of Resident R1 clinical record admission record indicated a diagnosis of osteoarthritis (degenerative joint disease, in which the tissues in the joint break down over time, diabetes mellitus (group of diseases that affect how the body uses bloods sugar), and hypertension (is when the pressure in your blood vessels is too high). Review of physician orders for 1/26/25, indicated the following:…

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, controlled medication shift reconciliation records and staff interviews, it was determined that the facility failed to implement procedures to promote accurate accounting of controlled medications on five of five medication carts reviewed (2 North, 2 South, 3 East, Memory Impaired Unit (MIU), and 3 South). Findings include: Review of facility policy Inventory Control of Controlled Substances dated 8/28/24, indicated facility should ensure that the incoming and outgoing nurses count all Schedule II controlled substances and other medications with a risk of abuse or diversion at the change of each shift or at least once daily and document the results on a Controlled Substance Count Verification/Shift Count Sheet. During a review of the Controlled Medication Shift Reconciliation log for the 3 East Medication Cart on 1/22/25, at 1:11 p.m. revealed the oncoming nurse and/or outgoing nurse failed to sign the sheet during shift change to verify counts of controlled drugs on the following dates: - 1/1/25, oncoming nurse for 11 p.m. shift - 1/2/25,…

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

Based on review of facility policy, observation, and staff interview it was determined that the facility failed to maintain the confidentiality of residents' medical information on one of five medication carts (3 East Medication Cart). Findings include: During an observation on 1/22/25, at 1:09 p.m. the 3 East Medication Cart at the nurses station was left unattended with the computer screen open with identifiable information any passerby could see resident personal and confidential information. During an interview on 1/22/25, at 1:10 p.m. Licensed Practical Nurse Employee E2 confirmed the above observation. During an interview on 1/22/25, at 1:46 p.m. the Nursing Home Administrator confirmed that the facility failed to maintain the confidentiality of residents' medical information as required. 28 Pa. code: 211.5(b) Clinical records. 28 Pa. Code: 201.29(i) Resident Rights. 28 Pa. Code: 211.12(d)(3) Nursing Services.

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 complete admission activites evaluation for three of three residents as required. (Residents R1, R2 and R3) Findings include: During a review of clinical record indicated that Resident R3 was admitted [DATE]. During a review of clinical record clinical assessment summary indicated Resident R3 admission Activities Evaluation due date was 11/16/24, and it was not completed and overdue. During a review of clinical record indicated that Resident R1 was admitted [DATE]. During a review of clinical record clinical assessment summary indicated Resident R1 admission Activities Evaluation due date was 11/31/24, and it was not completed and overdue. During a review of clinical record indicated that Resident R2 was admitted [DATE]. During a review of clinical record clinical assessment summary indicated Resident R2 admission Activities Evaluation due date was 12/2/24, and it was not completed and overdue. During an interview…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical records and staff interview, it was determined that the facility failed to revise a care plan for one of three residents (Resident R3) to accurately reflect the current status of the resident. Findings include: Review of clinical record indicated Resident R3 was admitted to the facility on [DATE], with diagnoses that included encephalopathy(disease in which the functioning of the brain is affected by some agent or condition), hypothyroidism and anemia. Review of Resident R3's Minimum Data Set (MDS-a mandated assessment of a resident's abilities and care needs) assessment, dated 11/18/24, indicated the diagnoses remain current. Review of Resident R3's Resident Care Plan Summary Report (report nurse aides used to know what kind of care to provide) dated 11/18/24, indicated equip resident with a device that alarms when wanders. Check for proper functioning of device every day and placement q shift. Review of Resident R3's physician orders dated 11/13/24 indicated no order for device. During an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, resident grievances for 60 days, resident counsel meetings for 60 days, and staff interviews, it was determined that the facility failed to effectively resolve and provide responses to a resident in a timely manner in relation to a concern documented via resident council minutes and complete the reports in their entirety for one of three concerns reviewed. Findings include: Review of facility Resident Grievances and Concerns policy dated 8/8/24, indicated that facility recognizes that residents have the right to voice grievances at the facility, or other agencies or entities that hear grievances, without discrimination. Such grievances include those with respect to care and treatment that has been furnished, the behavior of staff and other residents and any other concern regarding the resident's stay. Review of the facility's Resident Council Agenda Minutes for October of 2024, indicated the following nursing concern had not been responded to in a timely manner: -10/9/24:…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility documents, facility policy, clinical records, and staff interviews, it was determined that the facility failed to implement written policies and procedures to ensure a complete and thorough investigation of an allegation of neglect for one of three residents (Resident R1). Findings include: Review of facility policy Abuse, Neglect, and Exploitation dated 8/28/24, indicated it is the facility's policy to investigate all allegations, suspicions and incidents of abuse, neglect, involuntary seclusion, intimidation, exploitation or residents, misappropriation of resident property and injuries of unknown source. Facility staff must immediately report all such allegations to the Administrator or Abuse Coordinator. The Administrator or Abuse Coordinator will immediately begin an investigation and notify the applicable local and state agencies. If a staff member is accused or suspected of abuse the facility immediately remove staff member from resident care area and request a written statement…

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, reports submitted to the State, and staff interview, it was determined that the facility failed to report an allegation of neglect in the required time frame for one of three residents (Resident R1). Findings include: Review of facility policy Abuse, Neglect, and Exploitation dated 8/28/24, indicated neglect is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. All allegations of abuse, neglect, involuntary seclusion, injuries of unknown source, and misappropriation of resident property must be reported immediately to the Administrator, Director of Nursing, and to the applicable State Agency. All serious incidents involving a resident will be reported to the Department of Health (State Agency) field office within 24 hours. Review of the clinical record indicated Resident R1 was admitted to the facility on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility documents, facility policy, clinical records, and staff interview, it was determined that the facility failed to conduct a thorough investigation of an allegation of neglect for one of three residents (Resident R1). Findings include: Review of facility policy Abuse, Neglect, and Exploitation dated 8/28/24, indicated it is the facility's policy to investigate all allegations, suspicions and incidents of abuse, neglect, involuntary seclusion, intimidation, exploitation or residents, misappropriation of resident property and injuries of unknown source. If a staff member is accused or suspected of abuse the facility immediately remove staff member from resident care area and request a written statement from accused staff member. The person investigating the incident should interview the resident, the accused, and all witnesses and obtain written statements from the resident, if possible, the accused, and each witness. Evidence of the investigation should be documented. Review of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility documents, facility policy, and staff interviews, it was determined that the facility failed to implement written policies and procedures to conduct a thorough investigation of an incident to rule out neglect for one of two residents (Resident R2). Findings include: Review of facility Pennsylvania Resident Abuse policy dated 7/11/24, last reviewed 8/28/24, indicated the facility will not tolerate abuse, neglect, or mistreatment of residents by anyone. Staff must immediately report all such allegations to the administrator/abuse coordinator. The administrator/abuse coordinator will immediately begin an investigation and notify the applicable local and state agencies. The investigation must be completed within five working days from the alleged occurrence. Evidence of the investigation should be documented. Review of the facility's undated Nurse Aide job description indicated the purpose of your job is to provide a safe environment, give emotional and social support and attend 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical records, observation, and interviews with staff, it was determined that the facility failed to make certain that residents were assessed and received the necessary services to prevent pressure ulcers/wounds from developing for one of three residents (Residents R1). Findings include: Review of the facility Pressure Injury Prevention and Treatment Policy dated 9/18/23, last reviewed 8/28/24, indicated new pressure injuries will not develop unless the individual's clinical condition demonstrates that they were unavoidable. It was indicated residents are assessed for pressure injury risk on admission. It was indicated pressures injuries identified will be assessed initially and include location and stage, size, exudate, pain, wound bed description, appearance of surrounding tissues, and any evidence of infection. Review of the facility Comprehensive Care Planning Policy dated 3/2/21, last reviewed 8/28/24, indicated a baseline care plan must be developed within 48 hours…

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, resident observations, resident and staff interviews, and grievance review, it was determined that the facility failed to have sufficient nursing staff to provide nursing and related services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of four of eight residents (Residents R3, R4, R5, and R6). Findings Include: Review of the facility's undated Nurse Aide job description indicated the purpose of your job is to provide a safe environment, give emotional and social support and attend to the resident's physical needs and comfort. Performs direct care to the residents as assigned, in accordance with the resident's care plan, and as directed by your supervisor. Follows all health, sanitary and infection control policies and maintains established standards of practice set forth by community's administration and Nursing Policies and Procedures. During an interview on 9/25/24, at 11:19 a.m. Registered Nurse (RN), Employee E1 stated there always is a concern with staffing due to staff calling off. It 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 review of facility policy, observation, and staff interviews, it was determined that the facility failed to implement infection control measures during a COVID-19 outbreak for one of two nursing floors (2nd floor). Finding include: Review of the facility's undated Nurse Aide job description indicated the purpose of your job is to provide a safe environment, give emotional and social support and attend to the resident's physical needs and comfort. Performs direct care to the residents as assigned, in accordance with the resident's care plan, and as directed by your supervisor. Follows all health, sanitary and infection control policies and maintains established standards of practice set forth by community's administration and Nursing Policies and Procedures. Review of the facility's Monthly Isolation Precaution Tracking dated 2024, indicated Resident R3 tested positive for COVID-19 on 9/23/24. It was indicated the resident was in isolation until 10/4/24. During an observation on 9/25/24, at 11:47 a.m. droplet isolation precautions signage was observed outside Resident R3'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 and facility record review, facility submitted documents it was determined that the facility failed to provide adequate supervision to prevent elopement for one of twenty Residents (Resident R1). Findings include: Review of the facility policy Elopement/Unauthorized Absence Policy dated 8/28/24, indicated The facility will identify residents with potential and/or actual risk factors for elopement and protect the resident through development and implementation of safety interventions. In the event of a resident elopement the facility will implement its policies and procedures promptly to locate the resident in a timely manner. Review of the Resident Assessment Instrument 3.0 User's Manual effective October 2023, indicated that a brief Interview of Mental Status (BIMS) is a screening test that aides in detecting cognitive impairment. The BIMS total score suggest the following distributions: 13-15: cognitively intact 8-12: moderately impaired 0-7: severe impairment Review…

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

Based on review of facility documentation, and interviews with staff it was determined that the facility failed to maintain and implement an effective, quality assurance and performance improvement program that focuses on outcome as required by failing to implement a QAPI for an elopement for one of 15 Residents (Resident R1). Findings include: Facility policy Quality Assurance and Performance Improvement (QAPI) Policy dated 8/28/24, indicated: The purpose of QAPI in the facility is to take a proactive approach to continually improving delivery of care and serviced and to engage residents, caregivers, and other clinical/ operational partners in maximizing quality of life and quality of care. The QAPI program will establish system[s] for monitoring care and services, drawing data from multiple sources, including the Facility Assessment. The program should actively incorporate feedback from residents, staff, families, and others as appropriate. This includes investigating, tracking, and monitoring adverse events and allegations of abuse of all types, as well as implementing action…

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, and staff interview it was determined that the facility failed to implement a care plan for a behavior for one of three residents (Resident R1). Findings include: Review of facility policy Comprehensive Care Planning Policy dated 8/28/24, indicated The facility must develop a Person Centered Comprehensive Care Plan for each resident that include measurable objectives and time tables to meet the resident's medical, nursing, and mental and psychosocial needs. A review of the clinical record revealed Resident R1 was admitted to the facility on [DATE], with diagnosis of dementia (a loss of cognitive function that affects a person ability to think, remember, and reason) . Review of the progress notes indicates Resident R1 had behaviors of toileting in trash cans on the following days: 8/24/24: went to bathroom in trash can. 9/7/24: housekeeping found trash can were Resident R1 had urinated in another residents trash can. Review of care plans failed to include 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 an observation and staff interviews, it was determined that the facility failed to prominently display Nurse Staffing Information on 7/30/24, as required, Findings include: During an observation on 7/30/24, at 10:39 am Employee E1 failed to locate the Nurse Staffing Information at the facility's receptionist desk. During an interview on 7/30/24, at 10:39 am Employee E1 confirmed that the facility failed to display the Nurse Staffing Information at the facility's receptionist desk. During an interview on 7/30/24 at 10:40 am the Nursing Home Administrator confirmed that the facility failed to display the Nurse Staffing Information in a prominent place as failed to be readily accessible to residents and visitors as required.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical records, observations and staff interviews it was determined that the facility failed to provide an environment that was free of accident hazards, failed to ensure that residents received neurological assessments after a fall, consistently document incident report and post-fall investigation in the (Electronic Health Record -E.H.R.), failed to complete a new nursing fall risk evaluation (E.H.R.) after a fall, and failed to consistently document regarding post-incident response/symptoms for seventy two hours after a fall, for one of three residents (Resident R1). Findings include: The facility Incident and accident policy dated 11/7/22, indicated that an accident is any occurrence which is not consistent with routine care. The incident/accident will be recorded in the health record. Documentation regarding post-incident response and symptoms will be completed every shift for 72 hours post-occurrence. Review of the Facility provided undated, Fall Prevention and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policies, documents and clinical records and staff interviews, it was determined that the facility failed to make certain a resident was free from abuse and neglect for one of two residents reviewed (Resident R3). Findings include: Review of facility policy Pennsylvania Resident Abuse last reviewed 1/15/24, indicated that the facility will not tolerate abuse, neglect, mistreatment, exploitation of residents, and misappropriation of resident property by anyone. It is the facility's policy to investigate all allegations, suspicions and incidents of abuse, neglect, involuntary seclusion, intimidation, exploitation of residents, misappropriation of resident property and injuries on unknown source. Review of facilities current Nurse Aide (NA) job description indicated the primary purpose of you (NA) job is to provide a safe environment, give emotional and social support and attend to the resident's physical needs and comfort. Performs direct care to the resident as assigned, in accordance…

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 make certain that the necessary resident information was communicated to the receiving health care provider for five out of five residents sampled with facility initiated transfers (Residents R35, R52, R54, R77 and Closed Record(CR) CR86). The findings include: Review of the clinical record indicated Resident R35 was admitted to the facility on [DATE]. Review of Resident R35's Minimum Data Set (MDS - a periodic assessment of care needs) dated 2/7/24, indicated diagnoses of diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time), hypertension (high blood pressure in the arteries) and, anemia (too little iron in the body causing fatigue). Review of Resident 35's clinical record revealed that the resident was transferred to the hospital on [DATE] and returned to the facility on [DATE]. Review of Resident R35's clinical record revealed no documented evidence that the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical records, and staff interviews, it was determined that the facility failed to notify the resident or resident's representative of the facility bed-hold policy (an agreement for the facility to hold a bed for an agreed upon rate during a hospitalization) for five of five resident hospital transfers (Residents R35, R52, R54, R77 and Closed Record (CR) R86). Findings Include: Review of the facility policy Bed Hold Letter Policy, dated 1/15/24, indicated it is the policy of the facility to track Medicaid bed hold days and notify appropriate parties via Medicaid Bed Hold Letter. Business office or designee will complete the Medicaid Bed Hold Letter and send to the appropriate parties' certified/return receipt requested. The Medicaid Bed Hold Letter can be given directly to the responsible party if they are present. Medicaid copy will be retained in resident's financial file. Review of the clinical record indicated Resident R35 was admitted to the facility on [DATE]. Review…

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

Based on a review of facility policies, observations, and staff interviews, it was determined that the facility failed to properly label and date food products, monitor food expiration dates, properly restrain facial hair, and properly maintain kitchen equipment in a sanitary condition in the Main Kitchen creating the potential for food-borne illness. Findings include: Review of facility policy Storage of Refrigerated Foods, dated 1/15/24, indicated that staff should label and note pull date on all food items when removing from the freezer. Refrigerated foods should be stored upon delivery and rotated so all new deliveries are placed behind existing stock. Refrigerated foods prepared and held for more than 24 hours will be marked to indicate the date the food will be consumed or discarded, Prepared foods will be held maximum of 7 days with day of preparation counted as day 1. Review of facility policy Storage of dry Food, dated 1/15/24. indicated that staff should rotate stock on first in/first out system. New stock is placed in back of previously delivered items of the same food so…

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

Based on review of facility policy, observations, and staff interview it was determined that the facility failed to maintain the confidentiality of residents' medical information for seven out of ten resident rooms (Resident R47, Resident R10, Resident R9, Resident R61, Resident R70, Residents R3, and Resident R63). Findings include: The facility Notice of privacy practices-your information, your rights, our responsibilities policy dated 1/15/24, indicated that the facility is required by law to maintain the privacy and security of your protected health information. During a tour on 4/15/24, at 9:15 a.m. the following was observed At 9:15 a.m. Resident R47 room was observed with a sign above Resident R47 bed which stated : keep O2 on and cut food in small pieces. At 9:24 a.m. Resident R10 room was observed with a sign above her bed which stated: no blood pressure to right arm. Resident R10 bed frame was observed with a sign which stated: Assist x 2. During a tour on 4/15/24, at 10:10 a.m. with Registered Nurse (RN) Employee E12 the following was observed: At 10:10 a.m. tour Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of clinical records, and staff interviews, it was determined that the facility failed to ensure that the facility develop and implement a plan of care to include a focus and interventions to maintain a resident's highest practicable physical well-being as required for three of nine residents (Residents R11, R32, R51), and failed to ensure the comprehensive care plan for a seat belt release was implemented for one of three residents (Resident R54). Findings include: Review of Title 42 Code of Federal Regulations (CFR) §483.21 - Comprehensive Care Plans, the facility must develop and implement a comprehensive care plan for each resident that includes measurable objectives, and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment, and must be culturally competent and trauma informed. Review of the clinical record indicated Resident R11 was admitted to the facility on [DATE]. Review of Resident R11's Minimum Data Set…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the pharmacy recommendations, clinical record, and staff interview, it was determined that the facility failed to act on the pharmacy recommendations in a timely manner for three of four residents (Resident R3, R41, and R60). Findings include: The facility Medication regimen review policy dated 8/17/23, indicated that the facility and the consultant pharmacist will follow guidance outlined in the CMS State operations manual. If an irregularity does not require urgent action but should be addressed before the consultant pharmacists next monthly MRR, the facility staff and the consultant pharmacist will confer on the timeliness of attending physician responses. The attending physician should address the consultant pharmacist's recommendation no later than their next scheduled visit to the facility to assess the resident, either 30 or 60 days per applicable regulation. Review of Resident R3's admission record indicated she was originally admitted on [DATE], and readmitted on [DATE]. Review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, resident records, and staff interviews it was determined that the facility failed to provide evidence that non-pharmacological interventions (interventions attempted to calm a resident other than medication) were attempted prior to the administration for one of four residents and the facility failed to ensure a resident's medication regimen was free from potentially unnecessary medications for three out of four residents (Residents R41, R60, and R61). Findings include: The facility Dementia care services policy dated 1/15/24, indicated that the use of pharmacological approaches will be limited to situations where non-pharmacological approaches have been tried and failed. The facility Psychoactive medication policy dated 1/15/24, indicated that all residents receiving psychoactive mediication will have their behaviors, effectiveness of interventions (pharmacological and non-pharmacological) and potential for gradual dose reduction of psychoactive medications monitored and…

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

Based on review of facility policies, observations and staff interview it was determined that the facility failed to store all drugs and biologicals in a safe, secure, and orderly manner for one of two nursing floors (second floor). Findings include: During an observation and interview on 4/15/24, at 11:01 a.m. a 1.5 ounce bottle of 1% Tolnaftate Antifungal powder (medication applied to the skin used to treat fungal infections) was observed on Resident R56's nightstand. LPN, Employee E17 confirmed the facility failed to properly store and secure medications. During an interview with on 4/15/23, at 1:40 p.m. the Director of Nursing confirmed the facility failed to store all drugs and biologicals in a safe, secure, and orderly manner for one of two nursing units (second floor). 28 Pa Code: 211.9 (a) Pharmacy services. 28 Pa code: 211.12 (d) (1) (5) Nursing services.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical records and staff interview, it was determined that the facility failed to ensure a resident representative was notified in advance of care conference meetings for one of two residents (Resident R3). Findings include: The facility Comprehensive care planning policy dated 3/2/21 and last reviewed 1/15/24, indicated that a comprehensive care plan must be developed by the interdisciplinary Care Planning Team within seven days after completion of the comprehensive Minimum Date Set assessment (MDS). The facility designee is responsible for mailing an original letter of requested participation to an appropriate family member or legal representative for all residents scheduled for review who have been deemed legally incompetent or have been charted as being medically incompetent by their attending physician. A review of the Resident Assessment Instrument 3.0 User's Manual effective October 2019, indicated that a Brief Interview for Mental Status (BIMS, a screening test 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 review of facility policy, clinical records, and staff interviews it was determined that the facility failed to notify a family representative of a change in condition for two of ten residents (Resident R41 and CR85). Findings include: Review of the facility Resident Change in Condition Policy last reviewed 1/15/24, indicated the provider and family/responsible party will be notified as soon as the nurse identified a change in condition and the resident is stable. The provider, family, or responsible party will be notified when there has been a reaction to a medication or treatment, a significant change in the resident's physical, emotional, or mental condition, and a need to alter the resident's medical treatment, including a change in the provider orders. Review of the clinical record indicated that Resident CR85 was admitted to the facility on [DATE], with diagnoses of anxiety, depression, and dementia (loss of cognitive functioning, thinking, remembering, and reasoning to such an extent that 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, resident records, resident group, and staff interview it was determined that the facility failed to provide a comprehensive review of resident admission rights and maintain admission documentation for two of three residents (Resident R7 and R89). Findings include: The facility New admission/ readmission process policy dated 7/1/23, indicated that new admissions will be promptly introduced to key personnel and oriented to the facility. The facility Admissions packet last reviewed , indicated that a resident or a resident representative acknowledge that the following information was provided prior to or at the time of admission: a resident handbook, plan of care scheduling, grievance procedure and an explanation of resident rights. Review of Resident R7's admission record indicated she was admitted on [DATE]. Review of Resident R7's MDS assessment (Minimum Data Set assessment: MDS -a periodic assessment of resident care needs) dated 3/28/24, indicated that she had 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the Resident Assessment Instrument (RAI) User's Manual, clinical records, and staff interviews, it was determined that the facility failed to ensure that MDS assessments accurately reflected the resident's status for one of five residents (Resident R11). Findings include: The Resident Assessment Instrument (RAI) User's Manual, which gives instructions for completing Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2023, indicated the following instructions: -Section I: Active Diagnoses, that a diagnosis should be checked if they had had an active diagnosis for a disease or condition in the last seven days. Review of the clinical record indicated Resident R11 was admitted to the facility on [DATE]. Review of Resident R11's MDS dated [DATE], indicated diagnoses of bipolar disorder (a mental condition marked by alternating periods of elation and depression), osteoporosis (a condition when the bones become brittle and fragile), and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of clinical record, facility policy, and staff interview, it was determined that the facility failed to develop a baseline care plan that included interventions needed to provide effective and person-centered care for two of six residents (Resident R32 and R77). Findings include: The facility policy Interim/Baseline Care Planning Policy last reviewed 1/15/24, indicated within 48 hours of admission, the facility will develop and implement an interim/baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident. Review of the admission record indicated Resident R32 was admitted to the facility on [DATE], with diagnoses of chronic obstructive pulmonary disease (a chronic inflammatory lung disease that causes obstructed airflow from the lung), anxiety, and cancer Review of Resident R32's physician order dated 2/7/24, indicated to administer oxygen via nasal cannula continuously at 2 liters/minutes. It was indicated to check…

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, job description review, observation, and staff interviews, it was determined that the facility failed to provide care and services to meet the accepted standards of practice for one of six residents (Resident R2). Findings include: Review of the facility Licensed Practical Nurse job description indicated that the Licensed Practical Nurse (LPN) will cooperate with other resident services when coordinating nursing services to ensure that the resident ' s total regimen of care is maintained. Prepare and administer medications as ordered by the physician. Must demonstrate knowledge and skills necessary to provide care appropriate to the age-related needs of the residents served. Review of the clinical record indicated that Resident R2 was admitted to the facility on [DATE]. Review of Resident R2's Minimum Data Set (MDS - a periodic assessment of care needs) dated 3/16/24, indicated diagnoses of hypertension (high blood pressure), dementia (a group of symptoms that affects memory,…

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, a resident council group interview, resident and staff interviews, it was determined that the facility failed to make certain that showers were consistently provided for one of two residents (Resident R14). Findings include: Review of the facility Resident Bath/Showering/Scheduling Policy dated 1/15/24, indicated each resident will be asked about their bathing preference and will be scheduled to receive bathing a minimum of two times per week unless they prefer less frequent baths. The facility will maintain a bathing/showering schedule for each unit. Review of the facility ADL Documentation Policy dated 1/15/24, indicated activities of daily living care will be documented each shift by staff providing the care. This shall include, but not limited to, documentation of bathing, dressing, and transferring. Review of Resident R14's admission record indicated that Resident R14 was admitted to the facility on [DATE], with diagnoses that included stroke…

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 wound tracking documentation, resident clinical records and staff interview it was determined that the facility failed to provide a weekly wound assessment for one of two resident records with a non-pressure skin concern (Resident R67). Findings include: Review of Resident R67's admission record indicated she was admitted on [DATE], and readmitted on [DATE]. Review of Resident R67's Minimum Data Set assessment (MDS -a periodic assessment of resident care needs) dated 2/6/24, indicated she had diagnoses that included anxiety disorder (a medical condition creating a sense of acute fear, restlessness, and worry), hypertension (a condition impacting blood circulation through the heart related to poor pressure), and peripheral vascular disease (PVD- a narrowing of the blood vessels in the legs). The MDS assessment indicated that these were the most recent diagnoses upon review. Review of Resident R67's care plan dated 10/11/23, indicated that she had an arterial ulcer (a break in the skin due 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 review of facility policy, clinical record review, observation, and staff interview, it was determined that the facility failed to accurately monitor and assess for changes in skin condition for one of six residents (Resident R2). Findings include: Review of the facility policy Clean Dressing Change Policy, dated 1/15/24, indicated the facility, where sterile technique is not ordered or indicated, wound will be dressed using clean technique which avoids direct contamination of material and supplies. The facility will check any dressing present, assess wound, cleanse and apply new dressing as ordered and, document procedure and update findings. Review of Resident R2's admission record indicated admission to the facility on 3/10/20. Review of Resident R2's Minimum Data Set (MDS - a periodic assessment of care needs) dated 3/16/24, indicated diagnoses of hypertension (high blood pressure), dementia (a group of symptoms that affects memory, thinking and interferes with daily life), diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical records, observations and staff interviews it was determined that the facility failed to provide an environment that was free of accident hazards and the facility failed to ensure that residents received neurological assessments after an incident involving a fall for four of six residents (Residents R3, Resident R61, Resident R60, and Resident R88). Findings include: The facility Incident and accident policy dated 11/7/22, indicated that an accident is any occurrence which is not consistent with routine care. Following all unusual occurrences, a complete set of vitals will be taken every shift for 72 hours. Documentation regarding post-incident response and symptoms will be completed every shift for 72 hours post-occurrence. Review of Resident R3's admission record indicated she was originally admitted on [DATE], and readmitted on [DATE]. Review of Resident R3's MDS assessment (Minimum Data Set assessment: MDS -a periodic assessment of resident care needs) 2/1/24,…

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 a review of facility policy, clinical record review and staff interview, it was determined that the facility failed to make certain that weights were monitored, and a resident was timely assess for nutritional status for one of three residents (Resident R11). Findings include: Review of facility policy Resident Weight, dated 1/15/24, indicated that weights will be obtained routinely in order to monitor nutritional health over time. Each resident's weight will be determined upon admission/readmission to the facility, weekly for the first four weeks after admission/readmission, and monthly or more often if risks is identified, or as ordered. Upon admission/readmission, the resident will be weighed as soon as practically possible, but no later than 24 hours after admission/readmission. Review of the clinical record indicated Resident R11 was admitted to the facility on [DATE]. Review of Resident R11's Minimum Data Set (MDS - a periodic assessment of care needs) dated 2/6/24, indicated diagnoses of bipolar…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, observations, staff interviews, and clinical record review, it was determined that the facility failed to provide oxygen as ordered for one of four residents (Resident R32). Findings include: Review of the facility's Oxygen Administration (all routes) Policy dated 1/15/24, indicated oxygen will be administered via the specific route as ordered by a provider. Review of the clinical record revealed that Resident R32 was admitted to the facility on [DATE]. Review of the admission record indicated Resident R32 was admitted to the facility on [DATE], with diagnoses of chronic obstructive pulmonary disease (a chronic inflammatory lung disease that causes obstructed airflow from the lung), anxiety, and cancer. Review of Resident R32's Minimum Data Set (MDS - a periodic assessment of care needs) dated 2/10/24, indicated the diagnoses were current. Section O- Special Treatments Procedures and Programs indicated the resident received oxygen therapy while a resident. Review of Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, resident record review, and staff interviews, it was determined that the facility failed to provide a trauma survivor with trauma informed care to eliminate or mitigate triggers that may cause re-traumatization of the resident for one of two residents (Resident R11). Findings include: Review of facility policy Social Services dated 1/15/24, indicated that Social Services will assist in implementing interventions for the resident's needs by developing and maintaining care plans which are individualized, realistic, with measurable goals, including, but limited to trauma, PTSD (Post Traumatic Stress Disorder- a disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event and may have triggers that can bring back memories of trauma accompanied by intense emotional and physical reactions). Social Services is responsible for assessing and ensuring residents who are trauma survivors received culturally competent, trauma informed…

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, resident council group interview, resident and staff interviews, it was determined that the facility failed to have sufficient nursing staff to provide nursing and related services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of two of ten residents (Resident R62 and R14). Findings Include: Review of the Facility assessment dated [DATE], indicated staff assignments are determined by acuity, interpersonal needs, and census to adequately provide person centered care. Within each assignment, the individual needs of the resident are acknowledged by the care nurse. It stated it is the facility's goal to ensure the health, safety, comfort, and well-being of the resident. Review of the facility ADL Documentation Policy dated 1/15/24, indicated activities of daily living care will be documented each shift by staff providing the care. This shall include, but not limited to, documentation of food intake, toileting, ambulation,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of clinical records and staff interview, it was determined that the facility failed to ensure a resident with dementia receives the appropriate treatment and services to attain or maintain his highest practicable physical, mental, and psychosocial well-being for one of four residents reviewed (Resident R62). Findings include: Review of the facility Dementia Care Services Policy policy last reviewed 1/15/24, stated staff residents who are diagnoses with dementia will receive the appropriate treatment and services to attain or maintain his/her highest practicable physical, mental, psychosocial wellbeing. Staff must be familiar with dementia care approaches and each resident's person-centered care plan. Review of Resident R62's clinical record indicated the resident was admitted to the facility on [DATE], with diagnoses that included high blood pressure, depression, dementia (loss of cognitive function, thinking, remembering, and reasoning). A Minimum Data Set Assessment (MDS, a form completed at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of clinical records, and staff interview it was determined that the facility failed to ensure that a resident's physician was notified about abnormal laboratory test results for one of two residents (Resident R3) Findings include: The facility Resident change in condition policy dated 2/9/24, indicated that a licensed nurse will recognize and intervene in the event of a change in resident condition. The Physician/Provider will be notified as soon as the nurse has identified the change in condition. Review of Resident R3's admission record indicated she was originally admitted on [DATE], and readmitted on [DATE]. Review of Resident R3's MDS assessment (Minimum Data Set assessment: MDS -a periodic assessment of resident care needs) 2/1/24, indicated she had diagnoses that included neurocognitive disorder with Lewy bodies (a progressive form of dementia characterized by memory loss and progressive or persistent loss of intellectual functioning associated with protein deposits in nerve cells in 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 a review of facility policies, facility documents, a resident group interview, resident representative interviews, and staff interviews, it was determined that the facility failed to serve food products that appeared palatable for the supper meal on 4/10/24. (supper meal 4/10/24) Findings include: Review of facility policy Dining Experience at Mealtimes, dated 1/15/24, indicated that the facility will provide attractive, nourishing, and palatable meals. Review of facility document Concern Form , dated 4/11/24, indicated that Resident R14 had received burnt ravioli on 4/10/24. During an interview on 4/15/24, at 12:14 p.m. a resident representative stated that Resident R44 was served burnt ravioli that came up from the Main Kitchen last week. She stated that she brought in her mother's supper from home but was upset with the meal that was provided. During a resident group interview on 4/16/24, at 1:27 p.m. three out of seven residents voiced concerns with how the food in the facility taste. During an interview on 4/17/24, at 1:06 p.m. a resident representative stated 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 review of facility documents, resident clinical record, and staff interview it was determined that the facility failed to ensure a representative signed a binding arbitration agreement on the behalf of a resident lacking capacity to understand the agreement terms for one of three residents (Resident R50). Findings include: The facility Arbitration agreement last reviewed 1/15/24, indicated that arbitration is a cost effective method to resolve disputes. Arbitration is the exclusive resolution for all legal claims or disputes of any kind. A review of the Resident Assessment Instrument 3.0 User's Manual effective October 2019, indicated that a Brief Interview for Mental Status (BIMS, a screening test that aides in detecting cognitive impairment). The BIMS total score suggests the following distributions: 13-15: cognitively intact 8-12: moderately impaired 0-7: severe impairment Review of Resident R50's admission record indicated he was originally admitted [DATE], and readmitted on [DATE]. Review of…

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

Based on a review of facility policy, plans of correction, and the results of the current and former surveys, it was determined that the facility's Quality Assurance Performance Improvement (QAPI) committee failed to correct quality deficiencies and make certain that plans to improve the delivery of care and services effectively addressed recurring deficiencies. Findings include: Review of the facility policy QAPI (quality Assessment/Performance Improvement) Program, dated 1/15/24, indicated that the facility's QAPI program will establish systems for monitoring care and services, drawing data from multiple sources, including the Facility Assessment. The program should actively incorporate feedback from residents, staff, families, and others as appropriate. This includes investigating, tracking, and monitoring adverse events and allegations of abuse of all types, as well as implementing action plans to prevent recurrence. The focus will be on high-risk, high volume, and problem-prone areas. The facility's deficiencies and plans of correction for State Survey and Certification…

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, observation, and staff interviews, it was determined that the facility failed to dispose of PPE (Personal Protective Equipment) appropriately and perform hand hygiene practices consistent with accepted stands of practice, which created the potential for the cross-contamination and the spread of diseases and infections on one of two nursing floors (Third floor). Findings include: Review of facility policy Hand Hygiene/Handwashing Policy, last reviewed 1/15/24, indicated hand hygiene is the most important component for preventing the spread of infection. It was indicated hand hygiene should be performed immediately before touching a resident and before handling invasive medical devices. During an observation on 4/15/24, at 9:30 a.m. Physical Therapist Assistant (PTA) Employee E15 was observed exiting a resident's room while pushing a resident in a wheelchair who was on enhanced barrier precautions (requires wearing gloves and gowns). During an observation on 4/15/24, at 9:31 a.m. Employee E15 was holding a rolled up, used isolation gown in his hand.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy, clinical records, facility documents and staff interviews, it was determined that the facility failed to make certain residents were free from neglect for one of six residents (Resident R1). Findings include: Review of facility Resident Abuse Policy dated 3/17/23, indicates the facility will not tolerate abuse, neglect, mistreatment, exploitation of residents, and misappropriation of residents property by anyone. It is the facility's policy to investigate all allegations. Review of the clinical record indicated Resident R1 was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS-periodic assessment assessment of resident's care needs) dated 11/22/23, revelaed diagnoses of anemia, heart failure and coronary artery disease (caused by plaque buildup in the wall of the arteries that supply blood to the heart). Review of Resident R1 progress notes dated 12/3/23 at 5:45 p.m. indicated the following Resident found to have urine soaked brief, resulting in excoriation. Family…

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

Based on review of facility policy, facility documents, and staff interviews, it was determined that the facility failed to provide access to medical records to a resident or representative within a 24 hour period and/or to provide copies of medical records to the resident or representative within 48 hours for one of seven residents (Resident R1). Findings include: Review of facility policy Medical Records Requests Policy last revised 12/18/17, indicated that a resident or his/her legal representative may have access to the resident's own clinical records for review within 24 hours (excluding weekends and holidays) following the request, provided there is a valid authorization. Photocopies of the clinical record will be provided when requested by the resident or his/her legal representative (within two (2) working days of the request), with a valid written or verbal authorization. Review of facility documents indicated that a request for a copy of medical records by a representative of Resident R1 was received on 8/31/23, and was never sent. During an interview on 9/19/23, at 3:08…

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 policies and clinical records, as well as staff interviews, it was determined that the facility failed to maintain accountability for controlled medications (drugs with the potential to be abused) for four of four medication carts reviewed (3 South-1, 3 South-2, 3 East, and MIU). Findings include: A review of the facility's Controlled Medication Shift Reconciliation sign-off sheets for July, 2023, indicated controlled medications must be counted (reconciled) at the end of each shift by the off-going nurse and on-coming nurse. For 12 hour shift counts, the nurses are to sign the 7:00 a.m.- 7:00 p.m. and 7:00 p.m. -7:00 a.m. spaces and place an x in the 3:00 a.m. -11:00 p.m. space. Observations of the July, 2023 controlled medication count sheets on the 3-South-1 cart revealed no documented evidence that a controlled medication count was completed on July 6 at 7:00 a.m. and 7:00 p.m.; July 7 at 7:00 a.m.; July 12 at 3:00 p.m.; July 13 at 3:00 p.m.; July 19 at 7:00 p.m.; July 20 at 7:00 p.m.; July 30 at 7:00 a.m.; and July 31 at 7:00 a.m. and 7:00 p.m. Observations…

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, incident reports, reports submitted to the State, and a staff interview, it was determined that the facility failed to report an incident/allegation of abuse for one of three residents reviewed (Resident R4). Findings include: The facility policy Pennsylvania Resident Abuse, dated 3/17/23, indicated the facility staff must immediately report all such allegation to the Administrator/Abuse Coordinator. The Administrator/Abuse Coordinator must immediately begin an investigation and notify the applicable local and state agencies. Once the Administrator and Department of Health are notified an investigation must be conducted within five working days from the incident. The investigation must include any interviews and written statements from the resident, accused, and all witnesses. Witnesses include anyone who witnessed or heard the incident; came in close contact with the resident the day of the incident (including other residents, family member); and employees…

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 policies, clinical record reviews and staff interviews, it was determined that the facility failed to initiate a thorough investigation that included statements from the witnesses and/or statements from the residents for allegations of abuse and injuries of unknown origin for two of two residents (Residents R1 and R4). Findings include: The facility policy Pennsylvania Resident Abuse dated 3/17/23, indicated the facility staff must immediately report all such allegation to the Administrator/Abuse Coordinator. The Administrator/Abuse Coordinator must immediately begin an investigation and notify the applicable local and state agencies. It is indicated once the Administrator and Department of Health are notified an investigation must be conducted within five working days from the incident. The investigation must include an interviews and written statements from the resident, accused, and all witnesses. Witnesses include anyone who witnessed or heard the incident; came in close contact with the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of clinical record and staff interviews, it was determined that the facility failed to provide prescribed treatment necessary to manage constipation and promote normal bowel activity by implementing the bowel regimen protocol for two of three residents (Resident R3 and R7). Findings included: The facility's Bowel Tracking Policy last revised 2/26/20, indicated that the facility must record and monitor bowel activity of residents each shift and address issues identified. The DON is responsible for ensuring that a daily auditing process is in place to identify residents who had no bowel movement in three days (72 hours). If a resident has not had a bowel movement for three full days (72 hours), the nurse will initiate the facility bowel protocol. A review of the facility's Bowel Medication Monitor procedure, undated, indicated that residents should be given a laxative on the 3 p.m. to 11 p.m. shift, at bedtime, if a resident failed to have a bowel movement after three days. If no bowel movement on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical records and staff interviews, it was determined that the facility failed to make certain each resident received adequate supervision and assistance to prevent accidents for one of five residents (Resident R2). Findings include: The facility's Mechanical Lift policy, dated 1/7/22, indicated a mechanical lift may be used for transferring residents that cannot be safely transferred by themselves or with staff assistance. It was indicated a two person assist/oversight is required for total body lifts. Review of Resident R2's clinical record indicated she was admitted on [DATE], and readmitted on [DATE], with diagnoses that included stroke, traumatic brain injury, and seizures. Review of Resident R2's MDS assessment (MDS-Minimum Data Set assessment: a mandated assessment of resident's abilities and care needs) dated 7/11/23, indicated that the diagnoses were current. Review of Resident R2's care plan, dated 4/20/22, indicated the resident was totally dependent for 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of policies and clinical records, observations, and staff interviews it was determined that the facility failed to ensure that licensed nurses demonstrated the competencies and skills necessary to ensure medications were reordered and available for one of two residents (Resident R5). Findings include: The facility's current Flexible Medication Times policy, indicated that medications are administered in accordance with Pennsylvania State Regulations. Review of Resident R5's clinical records indicated an admission date of 3/30/18, with diagnoses of adjustment disorder mixed with anxiety, depressed mood, mild cognitive impairment, and low back pain. Review of R5's MDS dated [DATE], indicated the diagnoses were current. Physician's orders for Resident 5, dated 6/29/23 through 7/17/23, included orders to administer one milligram of clonazepam twice daily, 600 mg of Guaifenesin twice daily for cough, one drop of 0.1% olopatadine twice daily for allergic conjunctivitis/eczematous dermatitis, one daily…

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.