Sweden Valley Manor

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and family and staff interview, it was determined that the facility failed to ensure assessments accurately reflected a resident's status for three of 22 residents reviewed (Residents 6, 14, and 65).Findings include: Clinical record review for Resident 6 revealed a diagnoses list that included Parkinson's disease (progressive neurological disorder that affects movement due to degeneration of nerve cells in the brain) since October 1, 2023, contracture (permanent shortening of muscles, tendons, or other soft tissues that restrict normal joint movement and cause deformity) of the left hand since October 25, 2022, and contracture of muscle, unspecified, since November 8, 2021. An active physician's order dated September 15, 2023, instructed staff to place a carrot splint (soft, tubular, positioning device) to Resident 6's left hand every shift with gentle passive range-of-motion for management of hand range-of-motion. A quarterly MDS (Minimum Data Set, an assessment tool completed at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, review of facility documentation, and staff and resident interview, it was determined that the facility failed to implement a comprehensive person-centered care plan for two of 22 residents reviewed (Residents 2 and 97). Findings include: Clinical record review for Resident 2 revealed a diagnosis list that included the presence of a cardiac pacemaker (an electronic device to help regulate the beating of the heart). A quarterly Minimum Data Set Assessment (MDS, an assessment completed at specific intervals to determine care needs) for Resident 2 dated May 17, 2026, revealed an active diagnosis of the presence of a cardiac pacemaker. Documentation dated March 31, 2026, at 5:16 PM revealed a chest x-ray that was completed and noted a pacemaker. Review of Resident 2's care plan revealed no current comprehensive, person-centered care plan that addressed the resident's pacemaker, any pertinent assessments related to the pacemaker and/or clinical care, or any associated precautions. 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 resident and staff interview, it was determined that the facility failed to provide care and services to maintain or improve the ability to perform activities of daily living for one of two residents reviewed for rehabilitation concerns (Resident 104). Findings include: Clinical record review for Resident 104 revealed a diagnoses list that included a displaced intertrochanteric fracture of the right femur (a type of broken hip). A Medicare 5-Day Minimum Data Set Assessment (MDS, an assessment completed at specific intervals to determine care needs) dated June 8, 2026, revealed that facility staff assessed Resident 104 as having a BIMS (Brief Interview for Mental Status) of 3, which indicated cognitive impairment. Review of clinical documentation revealed a PT (physical therapy) Daily Note dated July 2, 2026, at 12:00 AM which noted the physical therapy discharge report was completed and an RNP (Restorative Nursing Program) was developed. Documentation for Resident 104 titled, PT Discharge Summary, for June 30, 2026, to July 2, 2026, revealed a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, review of facility documentation, and staff interview, it was determined that the facility failed to provide the highest practical care regarding ordered weights for two of seven residents reviewed for nutrition concerns (Residents 11 and 104).Findings include: Clinical record review for Resident 11 revealed that the resident was admitted to the facility on [DATE]. A current physician order for Resident 11 dated May 22, 2026, instructed staff to obtain weight every week for four weeks and then monthly and as needed. Clinical record review for Resident 11 revealed a care plan that noted a nutritional problem or potential nutritional problem related to the medical history. An intervention dated May 25, 2026, included weigh per orders, monthly, and as needed (PRN). Review of the current documented weights for Resident 11 revealed the weights were measured on May 22, 2026, June 30, 2026, and July 4, 2026. There were no documented weights for the weeks of May 25, 2026, June 1, 2026,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 family and staff interview it was determined that the facility failed to assist a resident to replace lost glasses for one of two residents reviewed for vision/hearing concerns (Resident 14).Findings include: Interview with Resident 14's husband on July 21, 2026, at 12:54 PM revealed that Resident 14 wears glasses; however, she lost her glasses while living at the facility and staff cannot find them. Clinical record review for Resident 14 revealed that the facility admitted her on April 10, 2026. Resident 14's profile picture in her electronic medical record revealed that she wore glasses. A nursing admission progress note dated April 10, 2026, at 4:30 PM indicated that Resident 14 had glasses and that she was wearing a corrective vision appliance on admission. Review of available plans of care for Resident 14 since her admission to the facility failed to provide evidence that the facility incorporated Resident 14's use of glasses in her plan of care. Interview with the Nursing Home Administrator and the Director of Nursing on July 22, 2026, at…

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

Based on clinical record review, observation, and staff interview, it was determined that the facility failed to provide the highest practical care to promote pressure ulcer healing for one of one resident reviewed for pressure ulcers (Resident 104). Findings include: Clinical record review for Resident 104 revealed social services documentation dated June 4, 2026, at 9:42 PM that noted the resident was admitted to the facility. Clinical record review for Resident 104 revealed a diagnoses list that included a displaced intertrochanteric fracture of the right femur (a type of broken hip). A Medicare 5-Day Minimum Data Set Assessment (MDS, an assessment completed at specific intervals to determine care needs) dated June 8, 2026, revealed that facility staff assessed Resident 104 as having a BIMS (Brief Interview for Mental Status) of 3, which indicated cognitive impairment. A skin and wound note dated June 5, 2026, at 2:36 PM noted the resident has two unstageable (severe full-thickness skin and tissue loss with undetermined depth) pressure ulcers present on admission which included…

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

Based on clinical record review, observation, and staff interview, it was determined that the facility failed to ensure an environment free from potential accident hazards for two of seven residents reviewed for accident hazards (Residents 5 and 14).Findings include: Observation of the nurses' station on July 22, 2026, at 9:42 AM revealed a device on the wall with a red flashing light with an audible hi-pitched alarm sounding. A computer screen below the flashing red light noted, Door Alarm, Common Smokers Patio, with the Age of the alarm at 27 minutes at that time. The alarm continued to sound with the visual signal until 9:47 AM without evidence that staff who were in the nurses' station at the time responded to the area indicated by the system to have a concern for a potentially unsecured exit door. Observation of the nurses' station on July 22, 2026, at 10:34 AM again revealed that the smoker's patio door was alarming by the visual and audible alarm. Observation of the smoker's patio from the common hallway on July 22, 2026, at 10:36 AM revealed a male resident sitting on his…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, clinical record review, observation, and resident and staff interview, it was determined that the facility failed to implement care consistent with professional standards of practice to prevent potential complications from a dialysis access site for one of one resident reviewed for dialysis concerns (Resident 117).Findings include: Review of the facility's current procedure entitled Disconnecting PD (peritoneal dialysis) includes step by step directions for the procedure after completion of Resident 117's peritoneal dialysis (a treatment that uses the lining of your belly to filter blood when kidneys fail, accessed through a port located directly through the abdominal wall and connected to external tubing, also referred to as PD). This order of events in this document state that the resident's door should closed, staff should apply a mask, and then wash hands and apply gloves, prior to accessing the PD port. Observations on July 23, 2026, at 8:10 AM of Resident 117's disconnecting PD procedure, revealed that Employee 6,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of select facility policies and procedures, clinical record review, observation, and resident and staff interview, it was determined that the facility failed to assess all potential risk areas for entrapment for two of seven residents with enabler bars for accident hazards (Residents 86 and 99); and obtain informed consent for use of enabler bars for one of seven residents reviewed for accident hazards (Resident 86). Findings include: Clinical record review for Resident 99 revealed a diagnosis list that included difficulty in walking and muscle weakness. A quarterly Minimum Data Set Assessment (MDS, an assessment completed at specific intervals to determine care needs) dated June 28, 2026, revealed that facility staff assessed Resident 99 as having a BIMS (Brief Interview for Mental Status) of 15, which indicated no cognitive impairment. Review of the care plan for Resident 99 revealed the resident is at risk for falls related to difficulty in walking. An intervention included: requires the 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 and staff interview, it was determined that the facility failed to properly store resident medications on one of three nursing units reviewed (Nursing Unit B). Findings include: Observation on July 23, 2026, at 9:16 AM during the medication pass on the Nursing Unit B revealed a medication cart being utilized by Employee 4, licensed practical nurse. Further observation of the medication cart revealed the following: There were several unsecured and unidentified medications found in the bottom of the drawers where medication blister cards were stored that included the following: two oblong yellow tablets, a round beige pill, half of an oblong shaped tablet, an oblong green colored tablet, a while round pill, and a smaller white round pill. The above findings were reviewed in a meeting with the Nursing Home Administrator and Employee 5, registered nurse, during a meeting on July 23, 2026, at 2:00 PM. 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.12(d)(1) Nursing services

Based on observations, clinical record review, and staff interview, it was determined that the facility failed to ensure complete and accurate clinical documentation for one of 22 residents reviewed (Resident 117).Findings include: The surveyor made an observation on July 23, 2026, at 8:10 AM of Employee 6, registered nurse, complete the disconnection procedure for Resident 117 after completion of their peritoneal dialysis treatment (a treatment to complete dialysis in a home setting that uses the lining of your belly to filter blood when kidneys fail, accessed through a port located directly through the abdominal wall and connected to external tubing which is run through a filtration machine, also referred to as PD). Review of Resident 117's clinical record revealed that the nurse who initialed (documented) completing this procedure was Employee 4, licensed practical nurse. Further review revealed that there was no documented completion for this task on three additional dates in July of 2026, including July 15, 16, and 18. Additionally, there was no documentation on the resident'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 observation, review of resident council meeting minutes, and resident and staff interview, it was determined that the facility failed to ensure resident grievances were addressed timely for one of 13 residents interviewed (Resident 2).Findings include: Interview with Resident 2 on August 5, 2025, at 12:46 PM revealed that she asked for cups of hot water for her hot chocolate and the cups are stained brown. Observation of the clean racks of coffee cups in the kitchen on August 6, 2025, at 10:44 AM with Employee 6 (dietary supervisor) revealed that most of the cups were stained brown. Employee 6 stated that an evening shift dietary staff member is supposed to clean the cups once a week, by soaking and scrubbing them. She stated that the staff are to sign off on the cleaning of the coffee cups weekly. Review of the weekly cleaning tasks documentation for June 23, June 30, July 7, July 14, July 28, and August 4, 2025, revealed staff only de-stained the coffee cups on June 30, and July 23, 2025. Employee 6 confirmed these findings on August 6, 2025, at 10:51 AM. Review of the…

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

Based on resident and staff interview, clinical record review, and review of a resident fund account facility documents, it was determined that the facility imposed a charge against a resident's personal funds for a service which payment is made under Medicaid, for one two residents reviewed (Resident 60).Findings include: Interview with Resident 60 on August 6, 2025, at 9:59 AM revealed that she has new eyeglasses ready to be picked up, but she has to pay for them first. She indicated that she could see out of the glasses that she has but sometimes it is blurry. She said that she would not have her new glasses paid off until October 2025, because she has to pay for them with her monthly allowance of $45.00 dollars. She said since she has to pay for the glasses, she would not receive any personal spending money until October 2025, when her glasses were paid off. Clinical record review for Resident 60 revealed that her current insurance is a Medicaid plan. Further clinical record review revealed that Resident 60 was sent out to a local eye doctor for an acute problem on February 11,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 provide required notification to a resident whose Medicare covered services ended for one of three residents reviewed (Resident 107). Findings include: A review of the form Instructions for the Notice of Medicare Non-Coverage (NOMNC) CMS-10123, (a notice that informs the recipient when care received from the skilled nursing facility is ending; and how to contact a Quality Improvement Organization (QIO) to appeal) revealed instructions that a Medicare provider must ensure that the notice is delivered at least two calendar days before Medicare covered services end. The provider must ensure that the beneficiary or their representative signs and dates the NOMNC to demonstrate that the beneficiary or their representative received the notice and understands the termination of services can be disputed. If the provider is personally unable to deliver a NOMNC to a person acting on behalf of an enrollee, then the provider should telephone the representative to advise him or her when the…

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

Based on review of select facility policies and procedures, employee personnel records, and staff interview, it was determined that the facility failed to implement an abuse prohibition policy that required a thorough investigation of prospective employee's employment history for two of five newly hired employees reviewed (Employees 3 and 4).Findings include: The facility policy entitled Abuse, Neglect, Exploitation and Misappropriation of Resident Property, last reviewed without changes December 10, 2024, revealed it is the policy of the facility to undertake background checks of all employees and to retain on file applicable records of current employees regarding such checks. The facility would attempt to obtain reference checks from prior employees for an applicant. Review of the facility policy entitled Reference Check Request Policy, last reviewed December 10, 2024, revealed the Administrator will be responsible for ensuring that each applicant seeking employment with the facility will be required to complete a release regarding reference checks. Upon receipt of satisfactory…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 facility documentation, and staff interview, it was determined that the facility failed to thoroughly and timely investigate and implement interventions after a resident elopement for one of three residents reviewed (Resident 52). Findings include: Clinical record review revealed Resident 52 was admitted to the facility on [DATE]. An elopement evaluation completed the same day indicated the resident had a history of elopement (leaving unsafely) at home and had wandering behavior. A social service note dated May 30, 2025, indicated the resident had severely impaired cognition related to Alzheimer's disease, had the ability to ambulate without a device, may wander, and was to be monitored for exit-seeking. A social service note dated June 3, 2025, at 8:10 AM revealed that Resident 52 was reviewed by the inter-disciplinary team and was disoriented with poor safety awareness, can ambulate without a device and noted as an elopement risk as evidenced by wandering from her…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 the facility failed to initiate timely interventions for a resident with significant weight loss for one of six residents reviewed for nutrition concerns (Resident 52). Findings include: Clinical record review for Resident 52 revealed the resident had a weight change from June 17, 2025, to July 17, 2025, decreasing from 135.2 pounds to 125.6 pounds reflecting a 9.6-pound, 7.1 percent significant weight loss in 30 days. Further clinical record review revealed a nutrition services note by the registered dietitian dated July 21, 2025, at 6:13 PM that noted the significant weight loss as indicated above and indicated the resident had a decline in meal intakes. The note indicated Boost (nutrition supplement) would be added twice a date for the resident to provide extra calories and fluid to help the resident meet nutritional needs. A review of Resident 52's physician orders revealed Boost two times a day was not ordered for the resident until July 31, 2025, 10 days later. There was no evidence Resident 52 was provided…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 implement appropriate enhanced barrier precautions for two of 19 residents reviewed (Residents 12 and 13) and implement appropriate transmission-based precautions (TBP) for one of one resident reviewed on TBP (Resident 25). Findings include: Review of the Centers for Medicare and Medicaid Services (CMS) memo entitled, Enhanced Barrier Precautions in Nursing Homes, dated March 20, 2024, revealed that CMS was issuing new guidance for State Survey Agencies and long-term care (LTC) facilities on the use of enhanced barrier precautions (EBP) to align with nationally accepted standards. In 2019, CDC (Centers for Disease Control) introduced a new approach to the use of personal protective equipment (PPE) called Enhanced Barrier Precautions (EBP). In July 2022, the CDC released updated EBP recommendations for Implementation of PPE Use in nursing homes to prevent spread of MDROs. The CDC's, Implementation of Personal Protective…

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

Based on observation and staff interview, it was determined the facility failed to store food and maintain food service equipment in a safe and sanitary manner and prevent the potential for food contamination in the facility's main kitchen. Findings include: An observation of the facility's main kitchen on September 17, 2024, at 11:50 AM with Employee 2, corporate dietitian, revealed the following: The coffee station area contained dried brown liquid spills and dried food splatter on the wall behind the coffee machine, which extended down the wall to the floor area observed under the counter space. The lower shelf of the table area where the coffee dispenser was located contained dust and debris and dried liquid spills, along with a plastic dish rack filled with clear plastic jugs, which the interiors were significantly stained brown making them opaque. A plastic tray beside the rack of pitchers also contained plastic gallon jugs with interior brown staining sitting on the tray, which had dried food debris and dried liquid spills. A carboard box of coffee filters was also sitting on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff interview, it was determined that the facility failed to implement a restorative nursing program as recommended by therapy to maintain range of motion for four of five residents reviewed (Residents 22, 15, 47, and 64). Findings include: Review of Resident 22's clinical record revealed a Minimum Data Set Assessment (MDS, an assessment completed at specific intervals to determine care needs) dated August 2, 2024, that indicated the facility assessed Resident 22 as having range of motion (ROM) limitations to both sides of her lower extremities. A previous MDS assessment dated [DATE], indicated that the facility assessed Resident 22 as having no ROM limitations to her lower extremities. A physical therapy form entitled Restorative Nursing Program Plan, dated July 12, 2024, indicates that physical therapy implemented a restorative program for nursing staff to complete a lower extremity active range of motion program for Resident 22. There was no documented evidence 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 and resident and staff interview, it was determined that the facility failed to ensure that pain management was provided that was consistent with professional standards of practice, for one of one resident reviewed (Resident 48). Findings include: In an interview with Resident 48 on September 17, 2024, at 2:00 PM he indicated that he had been having pain in his tail bone area from a recent fall that still hurts. Clinical record review for Resident 48 revealed a physician's order dated July 11, 2022, for the resident to have Acetaminophen (a medication used to treat mild pain) 325 milligrams (mg), two tablets every six hours as needed for a pain level 1-5. Resident 48 had an additional order for Tramadol HCL (a medication used to treat moderate to severe pain) 75 mg every six hours as needed for a pain level of 6-10. A review of Resident 48's medication administration record (MAR) for August 2024, revealed Resident 48 was administered the Tramadol on August 3, 9, 26, and 30 for a pain level of 5, and on August 29, for a pain level documented as 0.…

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

Based on observations, clinical record review, and resident and staff interview, it was determined that the facility failed to administer medication per physician's orders for one of 24 residents reviewed (Resident 48). Findings include: Observation of Resident 48 on September 17, 2024, at 2:00 PM revealed the resident was lying in bed watching television. A medicine cup with pills in it was observed on the resident's bedside table beside the bed. As the surveyor began speaking with Resident 48, the resident grabbed the medicine cup and proceeded to dump the cup of pills in his mouth and then his water cup before the resident responded to the surveyor. The resident indicated he had just taken his pills. No staff were present in the room or hall near the resident's room. Clinical record review for Resident 48 revealed a physician's order dated April 9, 2023, indicating the resident may not self-administer, due to no request. Review of Resident 48's medication administration record for September 17, 2024, revealed the resident was documented as being administered Propranolol (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 observations and family interview, it was determined that the facility failed to provide a clean, comfortable, homelike environment on one of four nursing units (C Nursing Unit; Residents 7 and 55). Findings include: Observation of the C Unit shower room on September 18, 2024, at 9:25 AM revealed the external sealing located on the floor around the base of the commode was a brownish color and peeling away from the commode in some areas. There was also a significant accumulation of dust on a vent located on the ceiling. An interview with Resident 7's family on September 20, 2024, at 9:00 AM revealed concerns related to the cleanliness of the heating unit on the wall in Resident 7's room. Observation of the heating unit on the wall in Resident 7's room on September 20, 2024, at 9:41 AM revealed an extensive build-up of dust on vents of the unit. There was also an accumulation of debris under the unit. Observation of the heating unit on the wall of Resident 55's room on September 20, 2024, at 9:44 AM revealed an extensive build-up of dust on the vents of the unit. There was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff interview, it was determined that the facility failed to ensure complete and accurate Minimum Data Set (MDS) assessments for one of 20 residents reviewed (Resident 60). Findings include: Resident 60 was admitted to the facility on [DATE], with a diagnosis of pneumonia from the hospital setting. Review of Resident 60's clinical record revealed a Minimum Data Set Assessment (MDS, a form completed at specific intervals to determine care needs) dated August 17, 2024, that indicated the facility assessed him as still having an active pneumonia infection. There was no documented evidence in Resident 60's clinical record to indicate that he continued to have an active pneumonia infection since April 27, 2024. Interview with the Director of Nursing on September 19, 2024, at 9:40 AM confirmed that Resident 60's pneumonia diagnosis was coded in error on the MDS dated [DATE]. 28 Pa. Code 211.5(f)(ix) Medical records 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on clinical record review and staff interview, it was determined that the facility failed to provide care or services to maintain a resident's ambulation status for one of two residents reviewed for ambulation concerns (Resident 15). Findings include: Clinical record review for Resident 15 revealed that she was on a nursing rehabilitation program for ambulation. The program was ordered on November 7, 2023. The program indicated that she was to be ambulated with the assistance of one staff and a wheeled walker. A therapy recommendation form dated October 31, 2023, confirmed the above noted program was a therapy recommended program. Further clinical record review for Resident 15 revealed that there was no documented evidence that the ambulation program was being completed. The Director of Nursing and the Nursing Home Administrator were made aware of concerns related to Resident 15's ambulation program and confirmed the above noted findings on September 19, 2024, at 2:12 PM. The facility failed to provide restorative/rehabilitation services in order to maintain Resident 15'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 observation, clinical record review, and resident and staff interview, it was determined that the facility failed to obtain proper treatment to maintain vision for one of two residents reviewed for vision concerns (Resident 1). Findings include: An interview with Resident 1 on September 17, 2024, at 11:37 AM revealed she feels her vision has gotten worse and reported a history of macular degeneration. The resident was unsure when her last vision appointment was. The resident was admitted in 2019. Clinical record review for Resident 1 revealed a diagnosis list that included diabetes mellitus (a disorder of the metabolism that impacts insulin production and causes high blood sugar levels). There was no listed diagnosis for macular degeneration noted in the electronic health record diagnoses list. A review of the current physician orders revealed an order dated February 2, 2020, that indicated that Resident 1 may be seen by the audiologist, dentist, podiatrist, optometrist, and ophthalmologist. A quarterly Minimum Data Set Assessment (MDS, an assessment completed at specific…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 and resident interview, it was determined that the facility failed to provide foot care and treatment to avoid medical complications for one of one resident reviewed (Resident 49). Findings include: Interview with Resident 49 on September 17, 2024, at 11:30 AM revealed that he has not seen a podiatrist for his left foot. Observation of Resident 49's left foot during the interview revealed that his toenails were elongated. The nail on the first and second toes were thick and yellow, and so long that they were beginning to curve. Review of Resident 49's clinical record revealed that the facility admitted him on March 30, 2024, with a diagnosis of diabetes. There was no documented evidence in Resident 49's clinical record to indicate the facility initiated diabetic foot care to care for his nails and avoid medical complications, until after this surveyor made observations and spoke with Resident 49 about his foot. Interview with the Director of Nursing on September 19, 2024, at 11:49 AM confirmed the above findings for 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 observation, clinical record review, review of select manufacture's guidelines, and staff interview, it was determined that the facility failed to ensure a medication error rate below five percent (Resident 11). Findings include: The facility's medication error rate was 7.69 percent based on 26 medication opportunities with two medication errors. Observation of a medication administration pass on September 17, 2024, at 10:20 AM revealed Employee 1, licensed practical nurse, preparing to administer Potassium Chloride (used as a supplement for heart, nerve, and muscle health) 20 MEq (milliequivalent) ER (extended release) and Metoprolol (treats hypertension) 100 mg (milligrams) ER. Employee 1 proceeded to crush both the Potassium Chloride and the Metoprolol extended-release tablets prior to administering them to Resident 11. According to The Institute for Safe Medication Practices, do not crush list, last updated in 2016, revealed that both the Potassium Chloride ER and the Metoprolol ER should not be crushed. Both medications are indicated as slow release. 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.

Based on clinical record review and resident and staff interview, it was determined that the facility failed to ensure timely dental services for one of one resident reviewed for dental concerns (Resident 29). Findings include: Interview with Resident 29 on September 17, 2024, at 2:08 PM revealed that she was concerned about her top denture that she has never received. She indicated that she was to receive them today, but the dentist indicated that she was not on the list. She said that he did not provide any other information and that he then left the building. She said she has been waiting on this denture since at least June 2024, but that the whole process started much earlier. Clinical record review for Resident 29 revealed a dental consult summary dated August 9, 2023, revealed that dental impressions for upper denture were made. A dental consult summary dated October 17, 2023, revealed that Resident 29 needed to continue treatment with the dentist for denture care. A dental consult summary dated November 10, 2023, revealed that Resident 29's bite registration (taking an…

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