Mountain View Rehabilitation And Senior Living Ctr

Based on review of facility documentation and staff interview it was determined that the facility failed to maintain documentation of staff COVID-19 vaccination status, for two of two staff reviewed (Employees 27 and 28). Findings include: Interview with Employee 27 (nurse aide) on April 29, 2026, at 9:29 AM revealed that she declined the COVID vaccination that the facility offered last year. Interview with Employee 28 (nurse aide) on April 29, 2026, at 9:31 AM revealed that she received COVID vaccinations in the past but declined the COVID vaccination the facility offered last year. Interview with Employee 26, (infection preventionist) on May 1, 2026, at 11:23 AM revealed that she was unable to provide evidence that she maintained staff documentation of their current COVID-19 vaccination status. Review of Employees 27 and 28's employee health files also revealed no evidence of their vaccination status. The surveyor reviewed the above noted findings with the Nursing Home Administrator on May 1, 2026, at 11:51 AM. 483.80 Infection controlPreviously cited 5/2/2025 28 Pa. Code…

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

Based on observation and resident and staff interview, it was determined that the facility failed to ensure a clean, comfortable, and homelike environment on two of four open nursing units (G unit emergency exit doorway, and F unit, Residents 4, 95, and 127). Findings include: Interview with Resident 4 on the F unit hallway on April 28, 2026, at 12:50 PM revealed that she requested the surveyor observe her room. Observation of Resident 4's room on April 28, 2026, at 12:52 PM revealed personal possessions that blocked the door to the bathroom, blocked access to the handwashing sink, blocked access to her and her roommate's closet, covered the majority of dresser and furniture surfaces, and covered a large portion of the floor space. Resident 4 stated on the date and time of the observation that she required staff assistance to organize her room and remove two of the storage totes that were present in the room. Resident 4's manual wheelchair (not in use while she sat in a motorized wheelchair) was stored on her roommate's side of the room (in front of the closets). Resident 4'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.

Based on clinical record review and staff interview, it was determined that the facility failed to monitor the use of psychotropic medications for one of five residents reviewed for potentially unnecessary medications (Resident 2).Findings include: Clinical record review for Resident 2 revealed active physician orders for staff to administer the following psychotropic medications: Lexapro (an antidepressant medication) 10 milligrams (mg), two tablets in the morning for depression.Trazadone (an antidepressant medication) 50 mg, half a tablet in the morning and one tablet at bedtime for depression.Seroquel (an antipsychotic medication) 25 mg, one tablet two times a day for psychosis. A physician order dated January 9, 2026, instructed staff to monitor Resident 2's behavior related to agitation and anxiety. There was no documentation in Resident 2's clinical record that staff monitored Resident 2's behaviors related to his psychosis and depression. Resident 2's clinical record failed to provide evidence that the facility was monitoring for potential side effects from Resident 2's use…

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

Based on observation, clinical record review, review of select facility documents, and staff and resident interview, it was determined that the facility failed to provide resident assistance to attend activities of interest for one of two residents reviewed for activities (Resident 140).Findings include: Interview with Resident 140 on April 28, 2026, at 12:55 PM, revealed that they enjoyed some of the activities, especially bingo which was scheduled for that day at 2:00 PM. Resident 140 stated that they are dependent on staff to take them to the activities, and often they do not come to get them. Observation on April 28, 2026, at 3:15 PM, revealed that bingo was ongoing, but Resident 140 was not present. Concurrent interview with Resident 140 revealed that they did not change their mind and they still wanted to attend Bingo today, but staff did not come to take them. Review of Resident 140's clinical record reveals they have a care plan (outline of an individual's health needs, specific care requirements, and the actions necessary to achieve desired health outcomes) Focus that was…

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

Based on clinical record review, review of facility documentation, and staff and resident interview, it was determined that the facility failed to provide the highest practical care regarding physician ordered medications, allergies, and devices for three of 35 residents reviewed (Residents 53, 116, and 140).Findings include: During an interview with Resident 140 on April 28, 2026, at 12:55 PM, they stated that they had increased pain in their right shoulder because the nurse had not applied their pain patch. The resident allowed the surveyor to assess the resident's shoulders, and no patch could be located on either shoulder. Clinical record review for Resident 140 revealed that the resident had an active physician order for a topical pain patch written April 10, 2026, that stated, Aspercreme Lidocaine External Patch 4 % (Lidocaine) apply to right shoulder topically one time a day for right shoulder pain and remove per schedule. Further review revealed that the patch was signed in the MAR (Medication Administration Record) as completed for April 28, 2026, indicating that the patch…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 select facility policy and procedure, clinical record review, and staff interview, it was determined that the facility failed to provide care consistent with professional standards of practice, for a resident who required dialysis services for one of two residents reviewed for dialysis concerns (Resident 7).Findings include: Review of the facility policy titled, Dialysis - Renal Dialysis Policy, last reviewed on January 30, 2026, noted (in part) a section titled, Post-Dialysis Care. This section of the policy noted that staff are to evaluate the dialysis access site for bleeding, signs/symptoms of infection, intact placement, etc. Document the observation of the access site. The policy also noted that if a shunt is present, assess the presence or absence of a bruit (a sound produced by blood flow) and thrill (a palpable vibration). Clinical record review for Resident 7 revealed a diagnoses list that included chronic kidney disease stage four (an advanced stage of kidney disease indicating severe damage to the kidneys which filter waste and excess fluid from the…

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

Based on clinical record review and staff interview, it was determined that the facility failed to identify triggers related to a resident's diagnosis of Post-Traumatic Stress Disorder, to provide culturally, competent, trauma-informed care, and to eliminate or mitigate re-traumatization for one of one resident reviewed for mood and behaviors (Resident 9).Findings include: Clinical record review revealed the facility admitted Resident 9 on October 14, 2024, with diagnoses including, Alzheimer's Dementia (disease that affects memory, thinking and behavior) and Post Traumatic Stress Disorder (PTSD, a mental and behavioral disorder that develops related to a terrifying event). Review of Resident 9's care plan-initiated April 30, 2025, revealed a mood problem related to chronic PTSD, noting Resident 9 has a history of unspecified childhood trauma, exposed to multiple childhood events that she does not like to discuss, or provide details, including her triggers noting she also has Alzheimer's and vascular dementia. A MDS (Minimum Data Set, an assessment completed at specific intervals 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 documentation, and staff interview, it was determined that the facility failed to ensure that nursing staff possessed the appropriate competencies and skill sets related to the care and assessment of residents with indwelling catheters and assessments for two of four employees reviewed (Employees 31 and 32).Findings include: A review of the facility Resident Matrix (CMS-802, form used to identify pertinent care categories for residents who reside in the facility) revealed that the facility had a total of 15 residents with indwelling urinary catheters and six residents with tube feedings. Facility documentation titled, Competency Check Off, revealed a list of competencies for licensed practical nurses that included (in part) foley catheter care and PEG (percutaneous endoscopic gastrostomy tube; a feeding tube placed through the abdomen and into the stomach) / G-tube (gastrostomy tube; a feeding tube placed through the abdominal wall and into the stomach) care. Facility documentation titled, Competency Check Off, revealed a list of competencies 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.

Based on employee personnel review and staff interview, it was determined that the facility failed to complete a performance evaluation of each nurse aide at least once every 12 months for two of three nurse aides reviewed (Employees 29 and 30).Findings Include: The facility noted the following hire dates for two current employees reviewed for performance evaluations: Employee 29's (nurse aide) hire date of May 20, 2018; and Employee 30's (nurse aide) hire date of April 28, 2025. A request to review the annual performance evaluations during a meeting with the Nursing Home Administrator and Employee 1 (registered nurse regional consultant), on April 30, 2026, at 2:30 PM and during a meeting on May 1, 2026 at 9:46 AM during a meeting with the Nursing Home Administrator and Director of Nursing, revealed no documented evidence that the facility is completing the evaluations at least once every 12 months. Interview with the Employee 1 on May 1, 2026, at 12:52 PM confirmed that the facility could provide no documentation that performance evaluations were completed on the above staff…

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

Based on clinical record review and staff interview, it was determined that the facility failed to develop and implement an individualized person-centered care plan to address dementia and cognitive loss displayed by one of three residents reviewed (Resident 2).Findings include: Clinical record review for Resident 2 revealed the facility admitted him on December 3, 2025, with diagnoses including dementia (loss of memory, language, problem-solving, and other thinking abilities that interfere with daily life) added August 5, 2025. A review of Resident 2's admission Minimum Data Set Assessment (MDS, a form completed at specific intervals to determine care needs) dated December 10, 2025, indicated that the facility assessed Resident 2 as having a diagnosis of dementia, or cognitive loss. The facility determined that a care plan for dementia and cognitive loss would be developed. A review of Resident 2's care plan revealed that there was no indication that the facility had developed and implemented a person-centered care plan to address the resident's dementia and cognitive loss. The…

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

Based on clinical record review and staff interview, it was determined that the facility failed to ensure that the resident's attending physician addressed and responded appropriately to pharmacy recommendations for three of five residents reviewed (Resident 18).Findings include: Clinical record review revealed the facility admitted Resident 18 on May 22, 2025. Further review of Resident 18's clinical record revealed a consultant pharmacy review dated June 30, 2025, noting Resident 18 is receiving Risperdal (an antipsychotic medication) but lacks an allowable diagnosis to support its use. A pharmacy recommendation dated December 30, 2025, revealed the consultant pharmacist again noted Resident 18 is receiving Risperdal but lacks an allowable diagnosis to support its use. There was no documentation noting Resident 18's physician addressed and responded appropriately to the June 30, and December 30, 2025, pharmacy recommendations. Interview with Employee 1 (registered nurse regional consultant) on May 1, 2026, at 12:49 PM confirmed the above findings Resident 18. 483.45(c) Drug…

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

Based on observation, and staff interview, it was determined that the facility failed to ensure that all drugs used in the facility are stored and disposed of in accordance with professional standards, on one of four nursing units (G nursing unit).Findings include: Observations on the G nursing unit on April 29, 2026, at 10:05 AM, revealed half of a white oval pill, with a 2 on one side and an F on the other side, on the floor in a corner at the end of the hallway, located next to the emergency exit G door. During a concurrent interview with Employee 19, LPN, they indicated they did not know how the pill would come to be on the floor in that location, and no trash is taken out through this doorway. The above information was reviewed with the Nursing Home Administrator and the Director of Nursing on April 29, 2026, at 2:15 PM. 483.45(h) Storage of Drugs and BiologicalsPreviously cited 5/2/24 28 Pa. Code 211.12 (c)(d)(1)(5) Nursing services

Based on a review of Quality Assurance and Performance Improvement (QAPI) meeting attendance and staff interview it was determined that the facility failed to ensure the committee consisted of the minimum members (Medical Director) at least quarterly.Findings include: Review of facility documentation (after a request from the surveyor to review the quality assessment and assurance QAA / QAPI committee meeting attendance) titled QAPI Committee Members, from March 4, 2025, to the current survey ending May 1, 2026, revealed that the facility's most recent QAPI committee meeting occurred in March 2026. Attendance records indicated that the facility medical director or designee did not attend any of the meetings and there was no associated sign-in for the medical director on the meeting sign-in sheets provided by the facility (dated March 4, 2025; April; July 2025; October 2025; November 2025; December 2025; January 2026; and March 2026). The above information was reviewed in a meeting with the Nursing Home Administrator on May 1, 2026, at 9:46 AM and the facility provided no further…

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

Based on observations and staff interviews it was determined that the facility failed to ensure all electrical equipment was in safe operating condition (facility bathroom - kitchen).Findings include: Observations on April 30, 2026, at 9:50 AM of the staff bathrooms outside the main kitchen revealed an electrical outlet located on the wall behind the sink, a foot away from the faucet. The outlet was noted to have a metal cover that appeared rusted. The hot air hand dryer was plugged in to the outlet and functioning. The outlet was not equipped with a GFCI (Ground Fault Circuit Interrupter, required to protect people from electrical shocks by detecting ground faults and quickly interrupting power). Interview with Employee 18, maintenance director, on April 30, 2026, at 9:57 AM, confirmed that both the men's and the women's bathrooms were not equipped with a GFCI outlet, and that an outlet located near a water source should be equipped with GFCI. A follow up interview with Employee 18 on April 30, 2026, at 12:15 PM, revealed that the outlets were not located on a GFCI circuit at 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 clinical record review and staff interview, it was determined that the facility failed to provide written notice, including the reason for the change, prior to moving a resident to another room, for 2 of 3 residents reviewed for room moves (Residents CR2 and 3).Findings include: Review of Resident CR2's closed clinical record revealed that the facility admitted him on September 28, 2025, to the B-wing unit. A social service progress note dated January 12, 2026, at 4:29 PM revealed that social service received a notice from the interdisciplinary team to discuss a room move with Resident CR2 to one of the facility's long term care units. The note indicated that social service went to see Resident CR2 on this date, after he returned from his dialysis (a treatment for kidney failure that filters the waste and excess fluid from the blood when the kidneys can no longer function) treatment, to discuss the room move and staff on the wing stated that he was already moved to long term care unit F. Interview with…

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

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 notify the responsible party of a resident's change in condition requiring hospitalization for one of 12 residents reviewed (Resident CR2). Findings include: Clinical record review revealed the facility admitted Resident CR2 on [DATE]. Nursing documentation dated [DATE], at 11:03 AM noted the facility received a call from dialysis noting Resident CR2 complained of weakness prior to hemodialysis (medical treatment that filters waste and excess fluids from the blood when the kidneys can no longer perform this function effectively). Documentation revealed Resident CR2's fasting blood sugar (measures the amount of glucose in your bloodstream, when it is at its lowest) was 48 (generally recommended to be between 70 and 180 milligrams per deciliter). Resident CR2 was sent to the emergency room for evaluation. Further review of Resident CR2's closed clinical record revealed nursing documentation dated [DATE], at 11:30 AM…

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

Based on clinical record review, review of facility documentation, and staff interview, it was determined that the facility failed to maintain clinical records that were complete and accurate for four of 12 residents reviewed (Residents 1, 2, 8, and CR1).Based on clinical record review, review of facility documentation, and staff interview, it was determined that the facility failed to maintain clinical records that were complete and accurate for two of 12 residents reviewed (Residents 1, 2, 8, and CR1). Findings include: Review of information provided to the Department of Health through the Event Reporting System (ERS, platform for facilities to report incidents, or unusual events) dated February 3, 2026, noted Resident CR1 was observed in Resident 8's room at 2:30 PM pulling up Resident 8's pants. ERS documentation revealed Resident CR1 reported that he wanted to have sex with Resident 8. Resident CR1 admitted to rubbing his penis against Resident 8's hip. Review of facility investigation into Residents CR1 and 8 incident dated February 3, 2026, revealed at shift change a nurse…

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

Based on observations and staff interview, it was determined that the facility failed to provide a clean, comfortable, homelike environment on two of four nursing units (A and B Nursing Units), the facility chapel area, a common dining area, and the main kitchen. Findings include: Observation of the facility chapel area on September 17, 2025, at 10:29 AM revealed the following: A blue colored carpeted area was heavily stained, especially where it abutted the tiled flooring. The black transition strip between the two floors was broken and also loose in areas. The personal laundry area had a build-up of lint on the floor, in a small sized plastic trash can, and on the walls surrounding the dryer. There were two large water stains on the ceiling tiles. There was a lidded trash can near the entrance to the chapel that had paper products sticking out from underneath the lid. A used linen cart next to it had a used maroon colored food bowl on top of it. A follow-up observation on September 17, 2025, at 1:57 PM revealed these items were still present. Observation of a common dining area…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 select facility policies and procedures, clinical record review, and staff interview, it was determined that the facility failed to provide the highest practicable care regarding elopements for one of one resident reviewed (Resident 1).Findings include: The current facility policy entitled Elopement/Missing Resident, revealed it is the policy of the facility to provide a safe environment for all residents regardless of orientation status and to supervise those residents at risk for elopement based upon the comprehensive assessment and specific care plan of each resident. Clinical record review revealed the facility admitted Resident 1 on December 16, 2024, with diagnosis including dementia, with behavior disturbance. Resident 1 resided on the locked memory care unit from December 16, 2024, to May 12, 2025, when Resident 1 was moved the F nursing unit. Review of Resident 1's most recent quarterly MDS (Minimum Data Set, an assessment completed at specific intervals to determine care needs) dated June 20, 2025, revealed nursing staff assessed Resident 1 as having 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 clinical record review, review of facility documentation, and staff interview, it was determined that the facility failed to maintain clinical records that were complete, accurate, and readily accessible for one of five residents reviewed (Resident 1). Findings include: Clinical record review for Resident 1 revealed a diagnoses list that included a pressure ulcer of the right heel. Further clinical record review for Resident 1 revealed current physician orders for treatment and wound care related to the pressure ulcer of the right heel. Resident 1's current care plan revealed the resident has actual and potential for pressure ulcer development related to immobility and an unstageable pressure ulcer right heel. A wound care consultation appointment for Resident 1 dated May 5, 2025, revealed the resident has an unstageable right heel pressure injury. The assessment and plan from the medical provider noted the following: Offloading; continue anterior wedge shoe to right for all weight bearing and hold off on weight bearing PT (physical therapy) for now until wound heals. 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 observation and staff interview, it was determined that the facility failed to store food and maintain food service equipment in accordance with professional standards for food service safety in the facility's main kitchen, and two of four open nursing units (F, G, and B). Findings include: An observation in the facility's main kitchen on April 29, 2025, at 9:30 AM with Employee 7, director of dining services, revealed the following: Shelving units in the dishwashing area, with clean food service equipment stored on them, contained dust and debris on the shelves. The ceiling tiles surrounding the exhaust unit extending from the dish machine to the ceiling were bulging wet and stained. Employee 8, dietary aide, was observed with gloved hands taking racks of clean dishware from the clean end of the dish machine and putting the items away onto to clean carts. Employee 8 then retrieved a meal delivery cart from the other end of the machine in which other employees were removing dirty/used meal trays from and moved the cart to another area in the dish room. Employee 8 then…

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

Based on observation and staff and resident interview, it was determined that the facility failed to provide a clean, comfortable, homelike environment on two of four open nursing units (F Nursing Unit: Resident 114 and G Nursing Unit: Residents 148 and 131). Findings include: Observation of Resident 114's room on April 29, 2025, at 1:02 PM revealed brown spots and stains on the resident's privacy curtain. Concurrent observation of the resident's bathroom revealed the ceiling light cover contained several dead insects. The wall beside the toiled contained a dried brown substance, and the cold-water handle of the sink was covered in rust and a black substance from the base to the top. The hot water handle was covered in white buildup. The above information regarding Resident 114's room and bathroom was reviewed with the Nursing Home Administrator and Director of Nursing on April 30, 2025, at 2:20 PM. Observation of Resident 148's room on April 29, 2025, at 10:23 AM revealed his overbed table and bed was covered by unorganized newspapers. His bedside stand was covered with unorganized…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, clinical record review, and staff interview, it was determined that the facility failed to complete restorative nursing programs related to range of motion for three of four residents reviewed (Residents 23, 47, and 151). Findings include: Review of Resident 23's clinical record revealed a minimum data set assessment (MDS, a form completed at specific intervals to determine care needs) dated January 13, 2025, indicated that the facility assessed her as having limited range of motion to one side of her upper extremities. A physician's order dated February 25, 2025, directed nursing staff to complete passive range of motion to Resident 23's upper extremities. There was no documented evidence in Resident 23's clinical record to indicate that nursing staff were completing the range of motion to Resident 23's upper extremities since February 2025. Interview with Employee 2, assistant director of nursing, on May 2, 2025, at 9:18 AM confirmed the above findings for Resident 23. Clinical record…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 documentation, clinical record review, employee personnel record information, and staff and resident interview, it was determined that the facility failed to ensure that nursing staff possessed the specific competencies and skill sets related to medication administration, the care and assessment of residents with indwelling urinary catheters, gastrostomy tubes, and transfer techniques for two of three employees reviewed (Employees 3 and 5, G nursing unit: Residents 36, 104, 43, and 101). Findings include: The Centers for Medicare and Medicaid Services (CMS) QSO-24-13-NH memo dated June 18, 2024, noted that requirements specify that the facility assessment must include an evaluation of diseases, conditions, physical or cognitive limitations of the resident population, acuity (the level of severity of residents' illnesses, physical, mental, and cognitive limitations, and conditions) and any other pertinent information about the resident population as a whole that may affect the services the facility must provide. The assessment of the resident population…

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

Based on clinical record review and staff interview, it was determined that the facility failed to ensure that the resident's attending physician addressed and responded appropriately to pharmacy recommendations for three of five residents reviewed (Residents 30, 48, and 133). Findings include: Clinical record review for Resident 30 revealed a consultant pharmacy review dated December 30, 2024, noting Resident 30 has been receiving Ferrous Sulfate (iron supplement) 325 milligrams (mg) since October 2023. The consultant pharmacist requested Resident 30's physician evaluate for discontinuation of Resident 30's iron supplement. Clinical record review for Resident 48 revealed a consultant pharmacy review dated December 17, 2024, noting Resident 48 receives Colestipol (medication used to lower high cholesterol levels) for hyperlipidemia (condition with a high level of fats or lipids in the blood). The consultant pharmacist requested Resident 48's physician recheck her lipids and/or evaluate the use of her Colestipol. Clinical record review for Resident 133 revealed a consultant…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, observation, and resident and staff interview, it was determined that the facility failed to obtain professional dental services for four of eight residents reviewed for dental concerns (Residents 43, 30, 47, and 133). Findings include: Interview with Resident 43 on April 30, 2025, at 11:02 AM revealed that he was edentulous (had no natural teeth). Resident 43 stated that he lost his dentures before his admission to his facility; and he would like to obtain dentures again. Clinical record review of social services documentation dated April 30, 2025, at 1:13 PM (following the surveyor's questioning) revealed that social services staff confirmed that Resident 43 stated that he needed new dentures, that the facility obtained Resident 43's consent for their contracted professional provider, and that the plan was for Resident 43 to receive services on May 16, 2025. Review of a significant change MDS (Minimum Data Set, an assessment tool completed at specific intervals to determine…

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

Based on observation and resident and staff interview, it was determined that the facility failed to serve food that is palatable and attractive on three of four open nursing units (Nursing Units B, F, and G; Residents 60, 76, 100, 131, 151, 157, 170, and 172) and in one of two dining areas reviewed (Cranberry Dining Room; Residents 106 and 148). Findings include: Review of facility grievance/concerns forms for February 2025, revealed several food concerns initiated from the resident council meeting on February 27, 2025, including concerns the food was different, the serving sizes were smaller, the temperature of all the foods served was the same, the quality of the food was terrible, the food comes burnt, and the fish was gross. The grievance response by facility staff on March 4, and 5, 2025, indicated the cooks would be educated on serving sizes, cooking times, and plate displays, and due to a change in food vendors the dietary director was working to find the best products. A review of facility grievance/concern forms dated March 21, 2025, revealed several concerns initiated…

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

Based on observation, review of facility scheduled mealtimes, and resident and staff interview, it was determined that the facility failed to ensure the provision of a nourishing (satisfying to the resident) evening snack when greater than 14 hours elapsed from the supper meal to breakfast on two of four open nursing units (F and G; Residents 8 and 43). Findings include: Review of the facility's Meal Cart Delivery Times document last revised May 26, 2023, revealed the supper meal service line is to start at 4:15 PM with service to the facility dining rooms and nursing units, and the breakfast service line is to start at 6:30 AM with service to the same areas, indicating a time span exceeding 14 hours. Further review of the meal cart delivery times revealed the facility does not have dining rooms open for breakfast meal service and dining room (Overlook, Chapel, and Cranberry) carts are to be delivered for supper at 4:15 PM, 5:00 PM, and 5:05 PM, and residents would be served breakfast from the hall cart in which they reside. Breakfast service for hall carts indicated the carts are…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 select facility policies and procedures, clinical record review, and staff interview, it was determined that the facility failed to offer and administer a COVID immunization for four of five residents reviewed for immunizations (Resident 47, 151, 31, and 133). Findings include: The policy entitled Coronavirus, Prevention, and Control, last reviewed without changes on January 17, 2025, revealed the facility follows current guidelines and recommendations for the prevention and control of coronavirus. Each resident and staff member will be educated about and offered an FDA (U.S. Food and Drug Administration) approved COVID vaccine unless the immunization is medically contraindicated, or the resident or staff member has already been fully immunized. Clinical record review revealed the facility admitted Resident 47 on September 18, 2023. Review of Resident 47's clinical record revealed she refused the COVID booster on December 21, 2023. Review of Resident 47's COVID 19 vaccine consent form dated May 3, 2024, revealed Resident 47's guardian requested the facility 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 observation and resident and staff interview, it was determined that the facility failed to ensure an effective pest control program to ensure a pest free environment on three of four nursing units, and in the facility's main kitchen (Nursing Unit B, F and G; Residents 43, 60, 100, 114, 131, 148, 157, and 170). Findings include: During an interview with Resident 60 on April 30, 2025, at 10:19 AM revealed that she sees black winged insects (flies) in her room all the time. Observation of the F nursing unit shower room on April 30, 2025, at 10:45 AM revealed a flying blacked winged insect (fly). The shower room does not have any windows, and the door is kept closed. During an interview with Resident 157 on April 29, 2025, at 12:59 PM revealed that he sees flies all the time in his room and in his bathroom. Observation of the F nursing unit on April 30, 2025, at 10:20 AM revealed multiple flies at the nursing station and flies going in and out of the pantry area on the same nursing unit. An interview with Resident 170 on April 30, 2025, at 9:42 AM revealed that 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.

Based on clinical record review and resident, and staff interview, it was determined that the facility failed to develop and implement a discharge planning process to align with the resident's goals for one of two residents reviewed (Resident 60). Findings include: Review of Resident 60's clinical record revealed that the facility admitted her on May 28, 2024. A minimum data set assessment (MDS, a form completed at specific intervals to determine care needs) dated June 4, 2024, indicated that Resident 60's goal was to discharge to another facility. The facility answered no to the question on the MDS regarding if active discharge planning is occurring for the resident to return to the community. There was no documented evidence that the facility developed a plan of care to align with Resident 60's goals to be transferred to another facility. Interview with Resident 60 on April 30, 2025, at 10:05 AM revealed that she wants to move closer to her family. Resident 60 indicated that she has wanted to transfer out to another facility since she was admitted . Resident 60 indicated that she…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 resident and staff interview, it was determined that the facility failed to implement a comprehensive person-centered care plan regarding a pacemaker (Resident 112) and percutaneous endoscopic gastrostomy tube (Resident 81) out of 35 residents reviewed. Findings Include: Clinical record review for Resident 81 revealed a current physician's order for bolus tube feedings and water through a percutaneous endoscopic gastrostomy tube (PEG tube, a type of medical tubing passed through the abdominal wall and into the stomach to facilitate feeding and hydration). Observation of Resident 81 on May 1, 2025, at 12:42 PM revealed that he had a capped PEG tube present in his abdomen. Further review of Resident 81's clinical record revealed no evidence of a comprehensive care plan (a care plan addressing care such as the tube feedings, assessment, complications, and emergency procedures) related to the PEG tube. An interview with the Director of Nursing on May 2, 2025, at 12:40 PM confirmed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, observation, and staff interview, it was determined that the facility failed to revise a resident's comprehensive care plan for one of 35 residents reviewed (Resident 104). Findings include: Clinical record review for Resident 104 revealed that the facility completed a comprehensive significant change MDS (Minimum Data Set, an assessment tool completed at specific intervals to determine resident care needs) assessment dated [DATE]. Care areas that triggered for care plans included falls, pressure ulcers, and nutritional status (including feeding tube, a flexible tube inserted through the abdomen into the stomach for the purpose of administering fluids, nutrition, and medications). An active physician's order dated June 24, 2022, instructed staff to implement a low bed (bed positioned lower to the ground than a standard height). Review of Resident 104's plan of care to address her potential for falls revealed interventions that included a low bed (initiated June 24, 2022).…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 resident and staff interview, it was determined that the facility failed to implement interventions to maintain mobility for one of one resident reviewed for rehabilitation concerns (Resident 61). Findings include: Interview with Resident 61 on [DATE], at 10:28 AM revealed that she no longer received skilled therapy services (e.g., physical therapy), and she believed that her ability to walk was getting worse because she was not walking. Resident 61 stated that she needed staff to follow behind her with a wheelchair in the event she grew tired when walking. Resident 61 stated, I was on a PT (physical therapy) and OT (occupational therapy) plan, but it expired on Friday. This other plan is supposed to take over according to the girl in the office, but not doing any this week. Clinical record review for Resident 61 revealed a PT Discharge summary dated (Thursday) [DATE]. The discharge recommendations included one staff to assist with a roller walker for transfers and 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 observation, clinical record review, and resident and staff interview, it was determined that the facility failed to ensure a dependent resident received assistance with shaving for one of four residents reviewed for activities of daily living concerns (Resident 129). Findings include: Interview with Resident 129 on April 30, 2025, at 9:33 AM revealed that he preferred not to have facial hair. Resident 129 stated that he preferred shaving, down to the skin. Resident 129 stated that he had not received staff assistance with shaving in three weeks. Observation of Resident 129 on the date and time of the interview revealed he had a full beard and mustache with hair along his neck below his chin and jaw line. Review of the identification picture in Resident 129's electronic medical record revealed he had a mustache, but no beard. Clinical record review of social services documentation dated April 18, 2025, at 2:36 AM revealed that the writer met with Resident 129 on April 8, 2025, for an MDS (Minimum Data…

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

Based on observation, clinical record review, and staff interview, it was determined that the facility failed to implement a physician ordered positioning device for one of four residents reviewed for range of motion concerns (Resident 104). Findings include: Clinical record review for Resident 104 revealed an active physician's order dated September 4, 2024, for staff to implement a left palm guard (device applied to the hand that is used to provide a barrier between fingers and the palm to prevent injury to the palm from severe finger flexion/contracture) at all times; remove for care and skin checks every shift. An active physician's order dated August 6, 2024, repeated the instruction for staff to apply a left palm guard at all times except for care and skin checks every shift. Observation of Resident 104 on the following dates and times revealed no device on her left hand: April 30, 2025, at 11:15 AM April 30, 2025, at 12:40 PM May 1, 2025, at 1:55 PM Interview with Employee 19 (licensed practical nurse) on May 1, 2025, at 1:55 PM confirmed that Resident 104 did not have any…

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

Based on clinical record review and resident and staff interview, it was determined that the facility failed to arrange vision practitioner services for one of three residents reviewed for vision and hearing concerns (Resident 129). Findings include: During an interview with Resident 129 on April 30, 2025, at 9:48 AM he stated, I should have a pair (of glasses), but I don't. Resident 129 claimed that he had not received services from a professional practitioner for eye exams or glasses in at least a year. Clinical record review of social services documentation dated April 18, 2025, at 2:36 AM revealed that the writer met with Resident 129 on April 8, 2025, for an MDS (Minimum Data Set, an assessment tool completed at specific intervals to determine resident care needs) assessment, and Resident 129 was cognitively intact. Social services documentation dated July 19, 2024, at 4:30 PM revealed that Resident 129 consented to the facility's consultant eye care provider for vision services. The writer indicated that a referral was sent to the facility's contracted eye care provider. 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 observation, clinical record review, and staff interview, it was determined that the facility failed to implement necessary treatment and services to promote healing for one of five residents reviewed for pressure ulcer concerns (Resident 104). Findings include: Clinical record review for Resident 104 revealed skin/wound note documentation dated February 25, 2025, at 10:17 AM that staff noted an open area measuring 0.25 centimeters (cm) round to Resident 104's left elbow with redness noted to the area. Nursing staff notified the physician's assistant and initiated a treatment. Review of Resident 104's treatment administration record (TAR, electronic documentation of the completion of treatments) dated February and March 2025, revealed that staff implemented a topical treatment to Resident 104's left elbow of Bacitracin (antibacterial ointment) and a foam dressing (dry dressing used to absorb drainage and provide cushion) every three days. Staff initialed completion the treatment on the evening shift on February 25 and 28, 2025, and March 3, 2025. An incident investigation…

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

Based on clinical record review, observation, and staff interview, it was determined that the facility failed to implement an intervention to prevent potential resident injury for one of eight residents reviewed for falls (Resident 104). Findings include: Clinical record review for Resident 104 revealed a physician's order dated June 24, 2022, for staff to implement a low bed (approximate average bed height is 24 to 25 inches from the floor to the top of the mattress (about knee level); low-profile beds are 11 inches or less). A plan of care developed by the facility for Resident 104 because of her potential risk for falls listed interventions that included a low bed (last revised February 7, 2025). Observation of Resident 104 on April 29, 2025, at 12:26 PM revealed that she was in a bed that was not in a low position. The bed height was higher than a standard bed, approximately hip level. Observation of Resident 104 on May 1, 2025, at 1:08 PM with Employee 19 (licensed practical nurse) revealed that she was in a bed that was not in a low position. The bed remained at a height…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, review of select facility policies and procedures, and staff interview, it was determined that the facility failed to implement interventions to promote acceptable parameters of nutrition for two of eight residents reviewed (Residents 181 and 104). Findings include: The policy entitled Impaired Nutrition/Unplanned Weight Loss- Clinical Protocol, last reviewed without changes on January 17, 2025, revealed the staff and physician will define residents current nutritional status, significant weight loss or gain, and high risk residents with acute symptoms that may be causing weight gain or increasing risk of weight loss. The staff will report to the physician significant weight gains or losses or any abrupt or persistent change from baseline appetite or food intake. The physician and staff will monitor nutritional status, the resident's response to interventions, and possible complications of such interventions. Clinical record review revealed the facility admitted Resident 181 on…

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

Based on clinical record review, observation, and staff interview, it was determined that the facility failed to provide respiratory, and tracheostomy care consistent with professional standards of practice for one of one resident reviewed with a tracheostomy (Resident 81) and one of four residents reviewed for respiratory concerns (Resident 435). Findings include: Clinical record review for Resident 81 revealed a diagnosis list that included a tracheostomy (trach, an artificial opening through which a medical tube is placed through the front of the neck into the airway to facilitate breathing). Review of the current physician orders for Resident 81 revealed orders for daily tracheostomy care that included changing the inner cannula. Resident 81's current care plan revealed that the resident has a tracheostomy, and one intervention included emergency procedures if the tracheostomy became dislodged. These emergency interventions included: Keep an extra trach tube and obturator (a curved device to help facilitate the placement of a trach) at the bedside If the tube is coughed out,…

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

Based on clinical record review and staff and resident interview, it was determined that the facility failed to identify triggers related to a resident's diagnosis of Post-Traumatic Stress Disorder, to provide culturally, competent, trauma-informed care, and to eliminate or mitigate re-traumatization for one of four residents reviewed for mood/behavior (Resident 165). Findings include: Clinical record review for Resident 165 revealed a diagnosis of Post Traumatic Stress Disorder (PTSD, a mental and behavioral disorder that develops related to a terrifying event) since her admission to the facility on October 14, 2024. Review of Resident 165's care plan revealed she uses psychotropic medications related to PTSD. There were no identified triggers (everyday situations that cause a person to re-experience the traumatic event as if it was reoccurring). The facility failed to identify and care plan triggers that may retraumatize Resident 165 related to her diagnosis of PTSD. These findings were reviewed with the Nursing Home Administrator and Director of Nursing on May 1, 2025, at 2:05…

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

Based on clinical record review, observation, and resident and staff interview, it was determined that the facility failed to develop and implement behavior health interventions that were individualized to attain or maintain the highest practical physical, mental, or psychosocial well-being for one of four residents reviewed for behavior concerns (Resident 135). Findings include: Observation of Resident 135 on April 29, 2025, at 11:59 AM revealed she was seated across from the nursing station yelling non-sensical things every few minutes. Observation of Resident 135 on April 30, 2025, at 9:54 AM revealed she was seated across from the nursing station yelling on and off things like Ow, oh my God, and just moaning loudly. Interview with Resident 60 on April 30, 2025, at 10:05 AM revealed that she is constantly hearing Resident 135 yell, and it's disruptive. During this same interview, Resident 76's daughter also voiced concerns over the constant yelling, saying it disrupts the homelike environment. Observation of Resident 135 on May 1, 2025, from 11:42 AM until 12:07 PM 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.

Based on review of select facility policies and procedures, observation, clinical record review, and staff interview, it was determined that the facility failed to ensure adequate storage of medications and biologicals on one of four nursing units (F nursing unit); and failed to ensure accurate labeling of administered medication for one of nine residents observed during medication administration pass (Resident 101). Findings include: Observation of the F nursing unit on April 30, 2025, at 12:18 PM revealed an unlocked and unattended treatment cart. The treatment cart was sitting in a heavily occupied area across from the nursing station, which was accessible to non-licensed staff, visitors, and residents. The treatment cart contained items such as liquid betadine, Triamcinolone cream (a topical steroid cream), wound cleanser sprays, clotrimazole cream (for fungal infections), mupirocin (topical antibiotic), and zinc oxide (for skin rashes). The treatment cart remained unattended until an interview with Employee 1, licensed practical nurse, on April 30, 2025, at 12:24 PM, and she…

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

Based on observation, clinical record review, and resident and staff interview, it was determined that the facility failed to implement transmission-based contact precautions for one of 35 residents reviewed (Resident 14) and failed to provide the highest practicable care regarding Enhanced Barrier Precautions for one of 35 residents reviewed (Resident 81). Findings include: Review of the memo entitled Enhanced Barrier Precautions (EBP, gown and glove use) in Nursing Homes to Prevent the Spread of Multi-drug Resistant Organisms released by the Center for Medicaid and Medicare Services (CMS) on March 20, 2024, with an implementation date of April 1, 2024, revealed that nursing care facilities are to use EBP for residents with chronic wounds or indwelling medical devices during high-contact resident care activities regardless of their multidrug-resistant organism status. High-contact activity would include things like dressing, transferring, changing linens, providing hygiene, changing briefs, wound care, or device care. Clinical record review for Resident 81 revealed a diagnosis list…

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

Based on clinical record review, review of select facility policies and procedures, and staff interview, it was determined that the facility failed to provide recommended pneumococcal immunizations for one of five residents reviewed for immunizations (Resident 47). Findings include: The facility policy entitled Pneumococcal Vaccine, last reviewed without changes January 17, 2025, revealed all residents will be offered pneumococcal vaccines to aid in preventing pneumococcal infections. Prior to or upon admission, residents will be assessed for eligibility to receive the pneumococcal vaccine series, and when indicated, they will be offered the vaccine series within 30 days of admission to the facility unless medically contraindicated, or resident has already been vaccinated. Administration of the pneumococcal vaccines or revaccinations will be made in accordance with current Centers for Disease Control and Prevention (CDC) recommendations at the time of the vaccination. Clinical record review revealed the facility admitted Resident 47 on September 18, 2023. Documentation in 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 a review of employee personnel and education records and staff interview, it was determined that the facility failed to ensure that each nurse aide received 12 hours of in-service training annually for one of one nurse aide reviewed (Employee 5). Findings include: Review of Employee 5's personnel record revealed that the facility hired her on February 20, 2015. The surveyor requested training records for Employee 5 during an interview with the Nursing Home Administrator and the Director of Nursing on April 30, 2025, at 1:30 PM. Review of training records provided by the facility for Employee 5 dated February 20, 2024, to February 19, 2025, revealed that Employee 5 completed only six hours of in-service education. The evidence provided indicated that Employee 5 completed only one hour of in-service education after March 27, 2024, to the date of the onsite survey. Interview with the Director of Nursing and the Nursing Home Administrator on May 2, 2025, at 12:33 PM confirmed the above findings for Employee 5. 28 Pa. Code 201.19(7) Personnel policies and procedures 28 Pa. Code…

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

Based on observation and staff interview, it was determined that the facility failed to provide a clean, comfortable, homelike environment on three of four nursing units ( A, B, and F Wing Nursing Units) and Chapel, (Residents 1, 7, 8, 9, and 10). Findings include: Observation on the F Wing Nursing Unit on February 20, 2025, at 12:15 PM revealed the following: The floor in the main hallway in front of the nurse's station was scuffed with a build-up of dirt. An indentation in the floor that spanned across the hallway contained various debris. A lidded garbage can in the hallway had an extensive build-up of dried liquid stains on the front. A dining/sitting area located across from the nurse's station was open and utilized by residents per an interview with Employee 1, licensed practical nurse, on February 20, 2025, at 12:26 PM. Observation of this area revealed the following: A vent on the wall under the window contained a significant amount of various debris. The windowsill contained a thermos and three clear, large-sized plastic cups from a fast-food restaurant each partially…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 select facility policies and procedures, facility grievance log documentation, and resident and staff interview, it was determined that the facility failed to make a prompt effort to resolve resident grievances for two of nine residents reviewed (Residents 8 and 9, Unit B). Findings include: The facility policy entitled, Grievance/Complaints - Residents, Resident Representatives, Family Members, or Resident Advocates, last reviewed August 21, 2023, revealed that as necessary, immediate action to prevent further potential violations of any resident rights will be taken by the facility while the alleged violation is being investigated. A grievance official will be appointed by the facility who will be responsible for overseeing the grievance process, receiving, and tracking grievances through to their conclusion, leading any necessary investigations by the facility, maintaining the confidentiality of all information associated with grievances, and issuing written grievance decisions to the resident or person filing the grievance. The resident or concerned person…

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

Based on clinical record review, review of facility documentation, and resident and staff interview, it was determined that the facility failed to ensure that the resident environment remains free of accident hazards for two of two residents reviewed (Residents 1 and 2). Findings include: Clinical record review for Resident 1 revealed a diagnosis list that indicated the resident is dependent on renal dialysis. Current physician orders for Resident 1 indicated the resident had a chair time for dialysis (a procedure to remove waste products and excess fluid from the blood when the kidneys stop working properly) at a dialysis center three days a week. The resident utilizes a wheelchair and is transported to and from these appointments by the facility. A quarterly Minimum Data Set Assessment (MDS, an assessment completed at specific intervals to determine care needs) for Resident 1 dated June 11, 2024, indicated that staff had assessed the resident as having a BIMS (Brief Interview for Mental Status) of 15, which indicated the resident was not cognitively impaired. An interview with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and resident and staff interview, it was determined that the facility failed to provide a clean, comfortable, and homelike environment on four of four nursing units reviewed (Nursing Units A, B, F, and G; Residents 54, 95, 122, and 163). Findings include: Observation of Resident 54's room on the F unit on June 5, 2024, at 2:11 PM revealed an eight inch by eight inch section of wall at the head of the resident's bed that was marred and damaged with the cove base separating from the wall. A pile of dust from the damaged wall was accumulating on the floor underneath the damaged section. A concurrent interview with Employee 1, nurse aide, about Resident 54's damaged wall revealed it was unclear how long the wall has been damaged. The above information for Resident 54 was reviewed with the Nursing Home Administrator and Director of Nursing on June 6, 2024, at 1:45 PM. Observation of G unit on June 4, 2024, at 12:00 PM noted the wall on both sides of the hallway between rooms 10-18 were patched in…

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

Based on clinical record review, review of select policies and procedures, and staff interview, it was determined that the facility failed to implement their abuse policy regarding completion of a thorough investigation and reporting for allegations of abuse for five of five residents reviewed (Residents 34, 64, 66, 80 and 102). Findings include: The policy entitled Resident Abuse and Neglect Prevention Program reviewed on August 21, 2023, indicates that upon discovery of an allegation of abuse or situation with the potential for abuse or harm, the facility will take all reasonable measures to separate the alleged perpetrator from access to the alleged victim. A written statement will be obtained from the suspect. The facility will investigate bruises/marks of unknown origin for investigation of possible abuse. The policy also indicates that as a part of the reporting requirements, the provider bulletin 22 (PB-22, am electronic form utilized for the submission and investigation for allegations of abuse to the Department of Health) will be completed and submitted within five working…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 reported incident investigations, review of staff scheduling and timecards, and staff interview, it was determined that the facility failed to protect residents from an alleged perpetrator of abuse during investigation for three of five residents reviewed (Resident 34, 64, and 102). Findings include: Review of the facility policy entitled Resident Abuse and Neglect Prevention Program reviewed on August 21, 2023, indicated that immediately upon discovery of an allegation of abuse or situation with the potential for abuse or harm, the facility will take all reasonable measures to separate the alleged perpetrator from access to the alleged victim. An abuse suspect will be informed of the accusation and will be ordered to leave the area immediately and escorted to a non-resident location. Any employee identified as the alleged perpetrator will be placed on immediate automatic suspension pending the outcome of the investigation. Upon notification of abuse, the staff member is immediately suspended pending the outcome of the investigation. If the alleged…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 develop and implement individualized person-centered care plans to address dementia and cognitive loss displayed by three of three residents reviewed (Residents 32, 90, and 163). Findings include: Clinical record review for Resident 32 revealed that the facility admitted him on July 28, 2022, with diagnoses including dementia (loss of memory, language, problem-solving, and other thinking abilities that interfere with daily life) with other behavioral disturbances being added on March 7, 2023. A review of Resident 32's most recent Minimum Data Set Assessment (MDS, a form completed at specific intervals to determine care needs) dated April 8, 2024, indicated that the facility assessed Resident 32 as having a diagnosis of dementia. The facility determined that a care plan for dementia and cognitive loss would be developed. A review of Resident 32's care plan revealed that there was no indication that the facility had…

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

Based on clinical record review and staff interview, it was determined that the facility failed to ensure that the resident's attending physician addressed pharmacy recommendations for five of seven residents reviewed (Residents 32, 43, 55, 130, and 165). Findings include: Review of Resident 130's clinical record revealed that the pharmacist made recommendations to his physician on October 17, 2023, February 20, 2024, and March 27, 2024. There was no documented evidence in Resident 130's clinical record to indicate that the recommendations were acted upon. Interview with the Director of Nursing (DON) on June 7, 2024, at 12:13 PM confirmed the findings for Resident 130. The DON indicated that the facility cannot find the recommendations that were made by the pharmacist on those dates. Review of Resident 165's clinical record revealed a pharmacy recommendation dated February 19, 2024, that indicated Resident 130 is on Alprazolam 0.5 mg (milligrams) every six hour as needed for anxiety, and that all as needed psychoactive medications must have a stop date and a rationale. 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 clinical record review and staff interview, it was determined that the facility failed to ensure a resident's medication regime was free from potentially unnecessary medications for three of five residents reviewed (Residents 55, 130, and 163). Findings include: Review of Resident 130's clinical record revealed a physician's order dated October 16, 2023, for nursing staff to administer Haldol 2 mg (milligrams) every four hours as needed and Ativan 0.5 mg every four hours as needed, both are indicated to be used for agitation. There was no documented evidence in Resident 130's clinical record to indicate that Resident 130's orders for psychoactive as needed medications contained the required 14 day use limit, or that the facility clarified the orders regarding use of multiple medications for the same indication. Interview with the Director of Nursing on June 7, 2024, at 12:13 PM confirmed the above findings for Resident 130. Clinical record review for Resident 163 revealed that the facility admitted her on December 8, 2023, with diagnosis of anxiety (a feeling of fear,…

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

Based on observation, review of select facility policies and procedures, and staff interview, it was determined that the facility failed to store food and maintain equipment in a sanitary manner to prevent the potential spread of foodborne illness in the facility's main kitchen. Findings included: An observation of the facility's main kitchen with Employee 9 (certified dietary manager) on June 5, 2024, at 9:32 AM revealed the following: Observation of the spices rack revealed a container of parsley dated June 22, 2022, ground cumin dated March 2021, and a container of browning and seasoning sauce with no date. A review of the facility policy entitled Food Storage, last reviewed without changes on August 21, 2023, revealed that these spices should have been discarded six months after opening. Observation of the first oven revealed grease spills down the front of the oven. The second oven had water on the floor in front of it, with pink rags on the tray below. Observation of the dry storage room revealed two bags of egg noodles opened and undated. Observation of the walk-in freezer…

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

Based on clinical record review, observation, and resident and staff interview, it was determined that the facility failed to accommodate resident needs regarding the accessibility to a call bell for two of 35 residents reviewed (Residents 17 and 54). Findings include: Clinical record review for Resident 54 revealed a diagnoses list that included: muscle weakness and hemiplegia (paralysis on one side of the body) and hemiparesis (weakness on one side of the body) following unspecified cerebrovascular disease affecting the left non-dominant side. A current care plan for Resident 54 revealed the resident has a communication problem related to a cerebrovascular accident (stroke). An intervention listed on the care plan included to ensure/provide a safe environment and have the call light in reach. Further review of the care plan for Resident 54 revealed the resident has activities of daily living self-care deficits related to the resident's medical history. An intervention included encouraging the resident to use the call bell to call for assistance. Another care plan for Resident 54…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 establish clear and consistent resident wishes regarding advance directives for one of seven residents reviewed (Resident 32). Findings include: Clinical record review revealed the facility admitted Resident 32 on [DATE]. A review of Resident 32's POLST (Physician Orders for Life-Sustaining Treatment, a document for specific medical orders to be honored by health care workers during a medical crisis) form dated [DATE], indicated Resident 32's responsible party chose CPR (cardiopulmonary resuscitation, a lifesaving procedure performed when the heart stops beating). An updated POLST dated [DATE], also indicated Resident 32's responsible party chose CPR. Review of Resident 32's physician orders revealed a current order dated [DATE], indicating that Resident 32 was a limited code, no CPR. A previous physician's order dated February 19, 2024, indicated that Resident 26 was a DNR (do not attempt resuscitation). 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 observations and staff interview, it was determined that the facility failed to ensure confidentiality of personal health information and a resident's right to privacy for one of five nursing units reviewed (Nursing Unit F; Resident 23). Findings include: Observation on June 6, 2024, at 10:21 AM revealed the Nursing Unit F medication/supply room supplies were being restocked by Employee 4, supplies staff. Employee 5, licensed practical nurse (LPN), was also present. Further observation of the medication/supply room revealed a computer on top of a medication cart that was clearly visible to Employee 4 who was a non-clinical staff member. The computer was logged into Resident 23's medical record. An interview with Employee 5 revealed that the computer belonged to Employee 6, LPN, who was not present and currently on break. Employee 6's name was also visible on the screen confirming she was logged into the medical record. It was unclear how long the resident's chart was left unsecured. The above information for Resident 23 was reviewed in a meeting with the Nursing Home…

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

Based on clinical record review, written transfer and ombudsman notices, and staff interview, it was determined that the facility failed to ensure that a written notice of a facility initiated hospital transfer and discharge of the resident was provided to the resident, the resident's representative, and ombudsman for one of eight residents sampled (Resident 181). The findings include: Clinical record review revealed the facility admitted Resident 181 on January 12, 2024. Nursing documentation dated March 12, 2024, at 8:30 AM revealed that Resident 181 struck another resident five times in the face with his fist. The local police were notified of Resident 181's violent behavior and arrived at A-Wing for prevention of any further violence. Resident 181 was transferred to the hospital at this time for evaluation and treatment of Resident 181's aggressive behaviors with harm to others. The Nursing Home Administrator contacted the Department of Health on March 14, 2024, at 11:11 AM to report that the facility would not accept Resident 181 back for readmission due to the risk presented…

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

Based on observations, clinical record review, and staff interview, it was determined that the facility failed to provide the necessary treatment and services consistent with professional standards of practice regarding pressure ulcer treatment for one of four residents reviewed (Resident 6) Findings include: Clinical record review for Resident 6 revealed a nutrition progress note dated June 4, 2024, at 7:53 AM that indicated she is followed by a wound care consultant related to a Stage 4 pressure ulcer (an injury to the skin from prolonged pressure on an area that extends to the muscle, tendon, or bone) on the right ischium (a paired bone of the pelvis that forms the lower and back part of the hip bone). Review of a wound consultant progress note dated May 28, 2024, revealed that Resident 6 currently had a Stage 4 pressure ulcer on her right ischium that measured 0.3cm x 0.2 cm with no depth. Review of Resident 6's current physician orders revealed an order for a foam dressing with border to her Stage 4 pressure ulcer on her right ischium. Observation of wound care provided to…

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

Based on clinical record review, review of select facility policies and procedures, and staff interview, it was determined that the facility failed to provide appropriate treatment and services regarding incontinence and catheter use for two of five residents reviewed (Residents 130 and 152). Findings include: The policy entitled Bladder and Bowel Screening and Assessment, last reviewed on August 21, 2023, indicated that a resident's bowel and bladder status will be evaluated and assessed at the time of admission. A plan of care is initiated based on the findings. The facility will develop a bowel/bladder program as indicated and if appropriate. Review of Resident 130's clinical record revealed a physician order dated October 4, 2023, for nursing staff to remove his catheter once his sacral wound healed and for nursing staff to do a voiding trial. Documentation was present to indicate that his sacral wound healed on January 23, 2024. There was no documented evidence to indicate that nursing staff removed his catheter after January 23, 2024, to initiate a voiding trial. Resident 130…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 employee personnel review and staff interview, it was determined that the facility failed to complete a performance evaluation of each nurse aide at least once every 12 months for three of three nurse aides reviewed (Employees 1, 7, and 8). Findings Include: The facility noted the following hire dates for three employees reviewed for performance evaluations: Employee 1's hire date of April 18, 2023; Employee 7's hire date of March 22, 2023; and Employee 8's hire date of June 6, 2022. A request to review the annual performance evaluations revealed no documented evidence that the facility is completing the evaluations at least once every 12 months. Interview with the Director of Nursing on June 7, 2024, at 1:00 PM confirmed that performance evaluations were not completed on any staff. 28 Pa. Code 201.19 (2) Personnel policies and procedures

Based on select facility policies and procedures, observation, and staff interview, it was determined that the facility failed to properly store resident medications on two of five nursing units (Unit B and Unit F). Findings include: Review of the policy titled, Medication Storage in the Facility, last reviewed without changes on August 21, 2023, revealed that medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations, or those of the supplier. The section titled Temperature revealed that medications and biologicals are stored at the appropriate temperatures and humidity according to the United States Pharmacopeia guidelines for temperature ranges. Further review of this section revealed the facility should maintain a temperature log in the storage area to record temperatures at least once a day. Further review of the policy revealed a section titled Procedures that indicated only licensed nurses, pharmacy personnel, and those lawfully authorized to administer medications are permitted to access medications. Medication rooms,…

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

Based on clinical record review and staff interview, it was determined that the facility failed to ensure a resident received or was offered pneumococcal conjugate vaccines for two of five residents reviewed for immunization concerns (Residents 7 and 89). Findings include: Clinical record review for Resident 7 revealed that the facility admitted her on August 7, 2020. Review of her immunizations in her clinical record revealed that there was no documentation related to the pneumococcal conjugate vaccines (vaccines administered to prevent pneumonia). Interview with Employee 10, Registered Nurse, Infection Preventionist, on June 7, 2024, at 12:45 PM revealed that she had received consent on May 1, 2024, for Resident 7 to have the pneumococcal vaccine but that the vaccine was not given to Resident 7. Clinical record review for Resident 89 revealed that the facility admitted her on July 18, 2017. The clinical record indicated that Resident 89 refused the pneumococcal vaccine because she already had it on September 14, 2016. There was no other documentation available to the surveyor in…

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