Emmanuel Center For Nursing

Based on observation and staff interview, it was determined that the facility failed to maintain acceptable practices for the storage and service of food to prevent the potential for contamination and microbial growth in food, which increased the risk of food-borne illness in the food and nutrition services department and one of two resident pantries. Findings include: Food safety and inspection standards for safe food handling indicate that everything that comes in contact with food must be kept clean and food that is mishandled can lead to foodborne illness. Safe steps in food handling, cooking, and storage are essential in preventing foodborne illness. You cannot always see, smell, or taste harmful bacteria that may cause illness according to the USDA (The United States Department of Agriculture, also known as the Agriculture Department, is the U.S. federal executive department responsible for developing and executing federal laws related to food). During the initial tour of the food and nutrition services department with the foodservice director (FSD) conducted on January 9,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of clinical records, observation, and resident and staff interviews, it was determined that the facility failed to provide care in a manner respectful of each resident's dignity for one resident (Resident 1), and failed to provide care in a manner and environment that promotes each resident's quality of life by failing to respond timely to residents' request for assistance as reported by two residents out of 11 sampled (Residents 12 and 11). Findings include: A review of Resident 1's clinical record revealed he was admitted to the facility on [DATE], with diagnoses which have included malignant neoplasm of the prostate, chronic kidney disease, diabetes, COVID-19, bronchopneumonia, and clostridium difficile [C-diff] (a bacterium infection that causes an infection of the colon). A review of a nurses progress note dated February 11, 2024, at 1:19 AM, revealed that the resident was positive for C - diff, and was placed on contact precautions, and began treatment, Vancomycin (antibiotic).…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 policy and minutes from Resident Council meetings and resident and staff interviews it was determined that the facility failed to put forth sufficient efforts to promptly resolve continued resident complaints/grievances expressed during Resident Council Meetings including those voiced by five of five residents attending a resident group meeting (Residents 29, 46, 26, 49, and 16) Findings include: Review of the facility's current Grievance policy provided during the survey ending January 11, 2024, indicated that it is the facility's policy to provide an opportunity for residents to express concerns at any time. The facility's goal is to resolve resident and family concerns in a timely basis. Review of the minutes from the Resident Council meetings held between October 2023 through December 2023, revealed that residents in attendance at these resident group meetings voiced their concerns regarding facility services during the meetings. During the October 2023 Resident Council meeting the residents in attendance relayed concerns with staff responding…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 the facility's abuse prohibition policy and employee personnel files and staff interviews, it was determined that the facility failed to implement their established procedures for screening four of five employees for employment (Employee 1, 2, 3, and 4) Findings include: A review of the facility's Resident Abuse policy last reviewed March 16, 2023, revealed procedures for screening potential employees that included obtaining references from current/previous employers. Review of employee personnel files revealed that Employee 1 (Activity aide) was hired October 9, 2023. The employee's application indicated that she had previous employers. There was no indication that the facility obtained any references for this employee's previous employers. Review of employee personnel files revealed that Employee 2 (dietary aide) was hired September 19, 2023. The employee's application indicated that she had previous employers. There was no indication that the facility obtained any references from the prior employers. Review of employee personnel files revealed that Employee 3…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of clinical records and resident incident/accident reports, and staff interviews, it was determined that the facility failed to provide necessary staff supervision to monitor a resident's whereabouts to prevent an elopement from the facility for two residents (Resident 25 and 73) out of 18 reviewed. Findings included: Review of clinical record of Resident 25 revealed that the resident was admitted to the facility on [DATE], with diagnoses including anxiety and depression. A review of an Elopement Risk assessment dated [DATE], revealed that the resident was considered at high risk for elopement and a wanderguard bracelet was applied. A review of Resident 25's Quarterly Minimum Data Set Assessment (MDS - a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated September 28, 2023, revealed that the resident was cognitively intact. A review of a nursing progress note dated September 27, 2023, revealed that At around 13:25 (1:25 PM) {Resident 25} 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 a review of clinical records and pharmacy recommendations and staff interview it was determined that the pharmacist failed to identify irregularities in the drug regimen of one resident (Resident 57) out of 18 residents reviewed. Findings include: A review of Resident 57's, clinical record revealed that the resident was admitted to the facility on [DATE], with diagnoses to include vascular dementia with behavioral disturbances (a condition characterized by progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change). A review of the resident's clinical record revealed a physician's order dated May 16, 2023, for Seroquel (an antipsychotic medication) 25 mg by mouth at bedtime for altered mental status. Review of a consultant pharmacist drug regimen reviews conducted from May 2023 to January 2024 revealed that the pharmacist failed to identify the lack of a clinically supportable diagnosis for Resident 57's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review clinical records and staff interviews, it was determined that the facility failed to ensure that a resident was free from unnecessary psychoactive medications by failing to attempt a gradual dose reduction, failing to ensure the presence of documented clinical rationale for the continued use of psychotropic medication and failing to monitor for potential adverse consequences of psychoactive drug use for two residents of 18 residents reviewed. (Resident 57 and 51) Findings include: A review of Resident 57's, clinical record revealed that the resident was admitted to the facility on [DATE], with diagnoses to include vascular dementia with behavioral disturbances (a condition characterized by progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change). The resident was transferred to the hospital on May 8, 2023, for a change in mental status and returned to the facility on May 16, 2023, after being treated…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, test tray results, resident and staff interviews, and test tray results it was determined that the facility failed to serve meals at safe and palatable temperatures. Findings include: According to the federal regulatory guidance at 483.60(i)-(2) Food safety requirements - the definition of Danger Zone, found under the Definitions section, is food temperatures above 41 degrees Fahrenheit and below 135 degrees Fahrenheit that allow rapid growth of pathogenic microorganisms that can cause foodborne illness. During an interview on January 9, 2024, at 10:47 AM, Resident 12 stated that the food served was rarely ever hot, and she will often send it back to be reheated. She mentioned that she likes vegetables but could never eat them due to being mushy or not cooked. During an interview on January 9, 2024, at 11:00 AM, Resident 29 stated that the food has gone downhill and always comes out cold. She mentioned that she spoke with dietary staff related to a steam table and has voiced concerns during resident council meetings about the temperature of the food. During an…

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

Based on review of select facility policy and the minutes from Residents' Council meetings, and resident and staff interviews, it was determined that the facility failed to routinely offer bedtime snacks to residents as desired. Findings include: A review of facility policy titled Residents Snacks reviewed March 16, 2023, revealed that bedtime snacks will be offered to residents daily. During a group meeting held on January 10, 2024, at 10:30 a.m., with five (5) alert and oriented residents, five of five residents (Residents 29, 46, 26, 49, and 16) stated that they have not received bedtime snacks in a very long time. The residents stated that they have repeatedly brought this particular complaint to the facility staff's attention without resolution to date. During an interview on January 10, 2024, at 2 p.m., the Nursing Home Administrator and Director of Nursing were unable to verify that residents are routinely offered and provided snacks at bedtime as preferred by each resident on nightly basis. 28 Pa. Code 211.12 (d)(3)(5) Nursing Services 28 Pa. Code 211.10(a) Resident care…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of clinical records, select facility policy, CDC and Pennsylvania Department of Health guidelines, observations, and staff interview it was determined that the facility failed to follow infection control practices designed to deter spread of RSV (Respiratory Syncytial Virus) infections in the facility. Findings included: Review of the facility's policy entitled Management of Respiratory Syncytial Virus last reviewed by the facility on March 16, 2023, indicated it is the policy of the facility to ensure that proper and appropriate infection control principles are utilized to help decrease the risk of transmission of RSV. RSV is a highly contagious respiratory virus that can affect any age but is greater risk for older adults. It is easily spread through air uninfected respiratory droplets or through direct contact. The use of proper infection control principles can help decrease the risk of transmission of RSV. Further it was indicated the nurse will observe residents for signs and symptoms 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 a review of clinical records, select facility incident reports, and the facility's abuse prohibition policy and staff interview it was determined that the facility failed to thoroughly investigate injuries of unknown origin to rule out abuse, neglect, or mistreatment as a potential cause of the injury sustained by one resident out of 18 sampled (Resident 19). Findings included: A review of the facility's policy, entitled Investigation of Abuse last reviewed by the facility March 16, 2023, indicated that a complete investigation will be conducted. In case of injury of unknown origin, the facility will try to determine the source of the injury and rule out neglect or abuse. When investigating injuries of unknown origin the facility will interview staff and anyone coming in contact with the resident over the course of 24 hours prior to the noted injury. The investigation will include the signed statements of these contact people. Additionally, the facility will identify anyone who provided services to the resident during this 24 hour period and document the specific services…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of clinical records and staff interview, it was determined that the facility failed to develop person-centered comprehensive care plans to meet the current needs and problems of three out of 18 residents sampled (Residents 33, 64, and 22). Findings include: A review of the clinical record revealed that Resident 33 was admitted to the facility on [DATE], with diagnoses that included hypertensive heart disease. A review of Resident 33's laboratory results report dated January 2, 2024, revealed that the resident had tested positive for RSV (Respiratory Syncytial Virus). However, the resident's care plan, in effect at the time of the survey ending January 11, 2024, failed to reflect the resident's diagnosis of RSV and interventions to treat and manage the resident's symptoms. A review of the clinical record revealed that Resident 64 was admitted to the facility on [DATE], with diagnoses that included Alzheimer's disease with late onset and epileptic seizures. A review of Resident 64's laboratory…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of select facility policies and clinical records it was determined that the facility failed to provide nursing services consistent with professional standards of quality by failing to demonstrate that licensed nurses evaluated and recorded the provision of necessary nursing care for a change in condition for one resident out of 18 sampled residents (Resident 39). Findings included: According to the Title 49, Professional and Vocational Standards, Department of State, Chapter 21 State Board of Nursing Subsection 21.11 (a) The register nurse assesses human responses and plans, implements and evaluates nursing care for individuals or families for whom the nurse is responsible. In carrying out this responsibility, the nurse performs all of following functions: (4) Carries out nursing care actions which promote, maintain, and restore the well-being of individuals (6)(b) The registered nurse is fully responsible for all actions as a licensed nurse and is accountable to clients for the quality of care…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 interviews, clinical records, and staff interview, it was determined that the facility failed to timely provide prescribed respiratory care for one resident reviewed for one of 18 residents reviewed (Resident 49). Findings include: Resident 49's clinical record revealed an admission date of November 4, 20220 with diagnoses that included asthma, and sleep apnea. Nursing progress notes revealed that the resident told nursing staff on January 7, 2024, that he was experiencing a sore throat, cough, and congestion. A physician's order was obtained for Albuterol Inhalation Solution 0.5-2.5 (3) MG/3ML (Ipratropium-Albuterol) 1 vial inhale orally every 4 hours as needed for shortness of breath. The resident's January 2024 Medication Administration Record (MAR) indicated that staff administered the above noted breathing treatment to Resident 49 on January 7, 2024, at 4:00 p.m., and January 10, 2024, at 7:00 a.m. During an interview with Resident 49 at approximately 10:30 a.m., on January 10, 2024. Resident 49 stated he had requested a breathing treatment the previous…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, clinical record review and staff interviews, it was determined that the facility failed to ensure each resident received the necessary behavioral health care in a timely manner to attain or maintain the highest practicable mental and psychosocial well-being for one of 18 residents sampled (Resident 25). Findings include: Review of clinical record of Resident 25 revealed that the resident was admitted to the facility on [DATE], with diagnoses including anxiety and depression. A review of Resident 25's Quarterly Minimum Data Set Assessment (MDS - a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated September 28, 2023, revealed that the resident was cognitively intact. Further review of Resident 25's clinical record revealed that the resident exhibited multiple behaviors, including exit seeking and eloping from facility. Resident 25 was noted to display exit seeking behaviors almost daily, throughout the month of September 2023 through end…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of clinical records and staff interview, it was determined that the facility failed to develop and implement an individualized person-centered plan to address a resident's dementia-related behavioral symptoms for one out of 18 residents reviewed (Resident 57). Findings include: A review of Resident 57's, clinical record revealed that the resident was admitted to the facility on [DATE], with diagnoses to include vascular dementia with behavioral disturbances (a condition characterized by progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change). A review of Resident 57's Significant Change Minimum Data Set Assessment (MDS - a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated December 13, 2023, revealed that the resident was severely cognitively impaired. A review of behavior tracking dated from May 2023 to December 2023, 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 a review of clinical records and staff interviews it was determined that the facility failed to ensure that one resident's drug regimen was free of unnecessary antibiotic drugs for one out of 18 residents sampled (Resident 64). Findings included: A review of the clinical record revealed that Resident 64 was admitted into the facility on February 24, 2023, and has diagnoses including Alzheimer's disease, dementia and chronic kidney failure. A review of nursing progress notes dated January 3, 2024, at 2:30 PM revealed that the resident was observed to have light hematuria (blood in urine) with a foul smell. The resident was unable to verbalize discomfort due to cognitive impairment. A physician order dated January 3, 2024, was noted to obtain a urine analysis and culture and sensitivity (microscopic study of the urine culture performed to determine the presence of pathogenic bacteria in patients with suspected urinary tract infection [UTI]). A review of a laboratory report for a urinalysis dated January 3, 2024, revealed that the results were abnormal with blood, protein,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 residents and staff interviews it was determined that the facility failed to provide care in an environment, which promotes each resident's quality of life by failing to respond timely to residents' request for assistance as reported by seven residents out of seven interviewed (Residents 24, 28, 32, 42, 43, 47, and 66). Findings include: Interview conducted on January 18, 2023, at 10:30 a.m. five residents attended a group meeting. All five of these residents, Residents 24, 28, 43, 47, and 66, voiced concerns that staff do not answer their call bells timely and meet their needs for assistance in a timely manner. All five residents stated that staff take longer than 30 minutes, and sometimes up to 45 minutes, to respond to their call bells and/or provide requested care. All residents stated that these long waits and delays may occur at any time of day and any shift of nursing duty. The residents stated that they feel the the facility was short staffed and that insufficient nurse staffing was a part of the problem as to why they wait so long for assistance from staff when…

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

Based on staff interview and a review of employee personnel records it was determined that the facility failed to ensure the qualified part-time professional activities director responsibilities included directing the development, implementation, supervision and ongoing evaluation of the activities program, which includes the completion and/or directing/delegating the completion of the activities component of the comprehensive assessment; and contributing to and/or directing/delegating the contribution to the comprehensive care plan goals and approaches that are individualized to match the skills, abilities, and interests/preferences of each resident. Findings include: Interview with the administrator on January 17, 2023 at 11:30 AM revealed that the previous full-time qualified activities director resigned on November 19, 2022. The administrator stated that no qualified candidates have applied or been interviewed. The administrator stated that since November 19, 2022, Employee 3 (facility corporation Wellness Director) has had oversight of the activities program at the facility and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, and staff interview, it was determined that the facility failed to provide restorative nursing services planned to maintain the functional abilities of two of seven sampled residents (Residents 34 and 43). Findings include: Review of Resident 34's clinical record indicated that the resident was admitted to the facility on [DATE], with diagnoses that included muscle weakness and diabetes. A quarterly Minimum Data Set assessment (MDS- a federally mandated standardized assessment process conducted at specific intervals to plan resident care) dated January 4, 2023, indicated that the resident's cognition was intact and the resident required staff assistance for bed mobility, transfer, dressing, personal hygiene, and toilet use. A physical therapy Discharge summary dated [DATE], indicated that the resident was to receive Restorative Nursing and Active range of motion (AROM) to the right lower extremity (RLE) in all planes at hip, knee and ankle and passive range of motion (PROM) to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of clinical records and select facility policy, resident and staff interview, it was determined that the facility failed to consistently attempt non-pharmacological interventions to alleviate pain prior to the administration of a narcotic pain medication prescribed on an as needed basis (PRN), failed to effectively manage a resident's consistent and repeated use of an opioid pain medication prescribed as needed (PRN), and had failed to administer pain medication as prescribed by the physician, for one resident out of four reviewed (Resident 23). Findings include: According to US Department of Health and Human Services, Interagency Task Force, Executive Summary report May 6, 2021, for Pain Management Best Practices the development of an effective pain treatment plan after proper evaluation to establish a diagnosis with measurable outcomes that focus on improvements including quality of life (QOL), improved functionality, and Activities of Daily Living (ADLs). Achieving excellence in acute and…

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

Based on observation, review of nurse staffing, the minutes from Resident Council Meetings and clinical records, observations and staff and resident interviews it was determined that the facility failed to provide and/or efficiently deploy sufficient nursing staff to consistently provide timely and quality of care to residents, including timely provision of assistance from the dining room back to the residents rooms and monitoring during meal service in the main dining room and timely response to requests for assistance to maintain resident safety and promote the physical and psychosocial well-being of residents, including Residents 24, 28, 43, 47, 66, 42 and 32. Findings include: During a group meeting with residents on January 18, 2023, at 10:30 a.m. the five residents in attendance, Residents 24, 28, 43, 47, and 66, all voiced concerns with the long waits for nursing staff to assist them from the dining room back to their rooms after meals. The residents stated that these long waits have been an ongoing problem for them during the last few months and the have discussed the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of clinical records and staff interview, it was determined that the facility failed to offer routine annual dental services for four Medicaid payor sources out of 17 residents sampled (Residents 29, 33, 34 and 42). Findings include: Review of Resident 29's clinical record indicated that the resident was admitted to the facility on [DATE], and that the resident's payor source was Medicaid. Review of Resident 33's clinical record indicated that the resident was admitted to the facility on [DATE], and that the resident's payor source was Medicaid. Review of Resident 34's clinical record indicated that the resident was admitted to the facility on [DATE], and that the resident's payor source was Medicaid. Review of Resident 42's clinical record indicated that the resident was admitted to the facility on [DATE], and that the resident's payor source was Medicaid. There was no documented evidence that the above residents were offered or had received dental services in the past year. Interview with the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of clinical records and the Resident Assessment Instrument and staff interviews, it was determined that the facility failed to ensure that the Minimum Data Set Assessments (MDS - a federally mandated standardized assessment conducted at specific intervals to plan resident care) accurately reflected the status of two residents out of 17 sampled (Resident 29 and 42). Findings include: A review of the clinical record of Resident 29 revealed a quarterly MDS assessment dated [DATE], noted the resident's ADL assistance as extensive assistance - (resident involved in activity, staff provide weight-bearing support), and a two + persons physical assist. However, the resident was totally dependent, full staff performance every time during entire 7-day period) and a two + persons physical assist. A review of Resident 42's quarterly MDS assessment dated [DATE], indicated in Section N0410 Medications Received that an antibiotic medication was received seven times in the last seven days. 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 clinical record review and staff interview, it was determined that the facility failed to complete a discharge summary, which included a recapitulation of the resident's stay, the course of illness, corresponding treatment, discharge instructions, and post-discharge care plan for one of three closed records reviewed (Resident 64). Findings include: A review of the clinical record review revealed that Resident 64 was admitted to the on October 4, 2022, with diagnosis to include ventral hernia without obstruction (any protrusion of intestine or other tissue through a weakness or gap in the abdominal wall). The resident was discharged to a personal care home on October 25, 2022. Review of Resident 64's closed clinical record revealed a Discharge Instructions form, which included the resident's diet and reconciliation of the resident's pre-discharge and post-discharge medications. However, at the time of the survey ending January 20, 2023, there was no documented evidence a discharge summary was provided to the resident and personal care home, which included a recapitulation of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of clinical records and select facility policy and staff interview it was determined that the facility failed to implement planned fall prevention interventions and effective safety measures, including necessary staff supervision of two residents identified at risk for falls with known unsafe behaviors, to prevent falls with serious injuries, femur/hip fractures, for two residents out of four sampled (Resident 215 and Resident 19). Findings include: A review of the facility policy entitled Falls and injury prevention program last reviewed by the facility April 1, 2022, revealed that the facility will promote an environment that remains as free of accidents as possible, staffing and programming that emphasizes fall prevention and provide resident with adequate supervision and assistance to prevent accidents. A multi-disciplinary falls committee has been developed to ensure each resident receives adequate supervision and assistance to prevent accidents, and review accidents/incidents and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of clinical records and staff interview, it was determined that the facility failed to develop and implement an individualized person-centered plan to address a resident's dementia-related behavioral symptoms for one out of 17 residents reviewed (Resident 48). Findings include: A review of the clinical record revealed that Resident 48 was admitted to the facility on [DATE], with diagnoses that included unspecified dementia without behavioral disturbances (a decline affecting memory, normal thinking, communicating which make it difficult to perform normal activities of daily living such as dressing, eating, and bathing). An admission Minimum Data Set assessment (a federally mandated standardized assessment completed periodically to plan resident care) dated November 22, 2022, indicated that the resident was moderately cognitively impaired for decision making and exhibited a behavior of non-intrusive wandering. Review of the resident's care plan initially dated November 18, 2022, indicated that…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, a review of clinical records and select facility policy and staff interview, it was determined that the facility failed to implement procedures to ensure acceptable storage and use by dates for multi-dose medications on one of two medication carts observed (B hall - 100's) and acceptable labeling of IV solutions for one of four residents reviewed (Resident 26). Findings include: A review of facility policy entitled Medication Labels and Peripheral IV insertion/infusion/maintenance guidelines, last reviewed by the facility April 1, 2022, indicated some medications must be dated upon opening and should be discarded after the expiration date has passed. When opened the following is a list of medications with their accompanying expiration dates, included in this list is all insulins. A peripheral IV is used for administration of fluids and medication. Inspect all solution containers prior to hanging for discoloration, turbidity, leaks, particulate matter and expiration date. Change IV solution…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 clinical records and staff interview, it was determined that the facility failed to timely offer and/or provide the pneumococcal immunization to one of 17 residents reviewed (Resident 32). Findings include: Review of the clinical record of Resident 32 revealed admission to the facility on December 7, 2022. The resident was not offered the pneumococcal immunization until surveyor inquiry on January 19, 2023. Interview with the Administrator on January 18, 2023, at approximately 9:30 a.m. confirmed that Resident 32 was not offered the pneumococcal immunization until surveyor inquiry on January 19, 2023. 28 Pa. Code 211.12 (a)(c)(d)(5) Nursing services