Harborview Rehabilitation Care Center at Doylestow

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident interview, and staff interview, it was determined that the facility failed to provide a working call bell for four of six residents (Residents 1, 2, 5, 6) on one of three nursing units. (First Floor) Findings include: Clinical record review revealed that Resident 1 had diagnoses that included heart disease and diabetes. The Minimum Data Set (MDS) assessment dated [DATE], indicated that the resident was alert and oriented. Observation on February 5, 2025, at 11:00 a.m. through 12:15 p.m., revealed that the call light above resident room [ROOM NUMBER] was lit, but there was no audible alert. In an interview at 11:00 a.m., Resident 1 stated that his call bell did not work and that staff did not respond to the light because there was no sound. Clinical record review revealed that Resident 5 had diagnoses that included adult failure to thrive and diabetes. Review of nursing documentation dated February 1, 2025, indicated that the resident was alert and oriented and able to make 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident interview, staff interview, and results of a test tray audit, it was determined that the facility failed to ensure that residents were served food that was palatable and at acceptable temperatures on one of three nursing units (First Floor) for five of six sampled residents. (Residents 1, 2, 4, 5, 6) Findings include:. Observation on February 5, 2025, at 11:46 a.m., revealed that the food cart for the First Floor nursing unit left the kitchen at 11:46 a.m. and arrived on the nursing unit at 11:47 a.m. The cart sat in the dining room until 11:59 a.m., when staff began to distribute the food trays to residents. The last tray was served at 12:05 p.m., 18 minutes after the food cart had arrived on the nursing unit. At that time, the temperatures of the food on the tray were as follow: The main entree of penne pasta and [NAME] sauce was 122 degrees Fahrenheit. The chef's blend vegetables that included broccoli and carrots was 100 degrees Fahrenheit. The main entree and the vegetables…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 maintain sanitary conditions and functional equipment in the dietary department. Findings include: Observation of the dietary department on September 24, 2024, at 9:40 a.m., revealed the following: There were two sets of convection ovens. The first set of convection ovens was soiled on the inside of the doors and on the bottoms of the ovens. There was splattered, dark grease on the racks and on the inside of the doors of the ovens. In addition, the oven doors were rusted in the middle which made the doors difficult to close all the way. The second set of convection ovens was not operational. Observation of the range top stove revealed that there were only three of six burners on top of the stove that were functional. There was a black substance splattered and stained on the backsplash behind the range. In addition, both bottom ovens were not operational. In an interview at this time, the Director of Dietary stated that the second set of convection ovens did not work and that both of the bottom…

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

Based on a review of facility policy, review of employee files, and staff interview, it was determined that the facility failed to conduct required criminal background checks in a timely manner prior to employment for three of five newly hired employees. (Employees 3, 4, 5) Findings include: Review of the facility policy entitled, Abuse Neglect Exploitation Mistreatment, and Misappropriation of Property Prevention, last reviewed September 5, 2024, revealed that the facility was to screen and train employees on the prevention, identification, investigation, and reporting of abuse, neglect, mistreatment, and misappropriation of property, to include the use of physical and chemical restraints. The procedure was for the faciltiy, prior to employment, to screen potential employees for a history of abuse, neglect, or mistreating residents. This included attempts to obtain information from previous employers and checking with the appropriate licensing boards and registries. Review of employee files revealed the following background checks that were not completed prior to employment:…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 Minimum Data Set (MDS) assessment was complete to accurately reflect the current status of one of 22 sampled residents. (Resident 7) Findings include: Clinical record review revealed that Resident 7 had an indwelling urinary catheter that was discontinued on July 29, 2024. The MDS assessment, dated August 27, 2024, incorrectly indicated in Section H that the resident still had the indwelling urinary catheter during the previous seven days. In an interview on September 26, 2024, at 10:30 a.m., the Director of Nursing confirmed that Resident 7's MDS assessment was inaccurate.

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 a comprehensive care plan that addressed individual resident needs as identified in the comprehensive assessment for two of 22 sampled residents. (Resident's 7, 59) Findings include: Clinical record review revealed that Resident 7 was admitted to the facility on [DATE], and had diagnoses that included vascular dementia, kidney disease, and Crohn's disease (inflammatory bowel disease). The Minimum Data Set (MDS) Care Area Assessment (CAA) summary dated May 28, 2024, noted that the resident's urinary incontinence was to be addressed in the care plan. There was no evidence that interventions to address Resident's 7 urinary incontinence was included in the current care plan. Clinical record review revealed that Resident 59 was admitted to the facility on [DATE], and had diagnoses that included heart failure and renal insufficiency (kidney disease). The MDS CAA summary dated August 5, 2024, noted that the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, it was determined that the facility failed to provide a safe, sanitary, and comfortable environment on three of three nursing units. (First, Second, and Third Floor) Findings include: Observation on the first floor nursing unit on August 5, 2024, at 9:30 a.m., revealed the following: There were stained ceiling tiles above the nurses station. In room [ROOM NUMBER], the soap dispenser in the bathroom as broken. The wall adjacent to the shower door was chipped and the plaster was crumbling. In the shower room, the soap dispenser was broken off of the wall. There was a light without a cover and another light with a broken cover. Observation on the second floor nursing unit on August 5, 2024, at 10:12 a.m., 12:25 p.m., 2:25 p.m., and 3:50 p.m., revealed the following: In room [ROOM NUMBER], the hot water in the bathroom sink was not functioning. In room [ROOM NUMBER], the wall above the window was cracked. In room [ROOM NUMBER], there was hole in the wall under the sink. In room [ROOM NUMBER],…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 provide adequate supervision to monitor a resident's whereabouts and prevent an elopement for one of four sampled residents. (Resident 8) Findings include: Clinical record review revealed that Resident 8 had diagnoses that included mood disorder, amnesia, bipolar disorder, and depression. Review of a facility incident report dated August 2, 2024, revealed that at 8:18 p.m., staff noted that the resident was not in his room. Further review of the clinical record revealed that staff documented that the resident had not been seen since before dinner and that his dinner meal tray remained in his room untouched. The facility was unable to locate the resident and was unaware of his location until the following day, August 3, 2024. In an interview on August 5, 2024, at 11:57 a.m. the Administrator confirmed that the facility was unable to locate the resident on August 2, 2024. In an interview on August 5, 2024, at 4:28 p.m. the Assistant Director of Nursing…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation it was determined that the facility failed to provide a safe, sanitary, and comfortable environment on three of three nursing units. (First, Second, and Third Floor) Findings include: Observation on the First floor nursing unit on July 1, 2024, from 10:30 a.m. through 2:00 p.m. revealed the following: In the bathroom in room [ROOM NUMBER] there was brown spots on the ceiling tile frames, black marks on the wall behind the toilet, and white splash marks on the walls. In the bathroom in room [ROOM NUMBER] there was a ceiling tile with brown stains above the toilet. In room [ROOM NUMBER] there were towels on the floor under the air conditioning unit. There was dirt, debris, and two drink containers on the floor. In the bathroom the soap dispenser was broken off the wall, the ceiling tile above the toilet was stained brown, and the molding was missing from the wall on the left side of the toilet. In room [ROOM NUMBER] there were towels on floor under the air conditioning unit and holes in the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff interview, it was determined that the facility failed to develop a comprehensive care plan that addressed individual resident needs as identified in the comprehensive assessment for three of seven sampled residents. (Residents 1, 2, and 3) Findings include: Clinical record review revealed that Resident 1 was admitted to the facility on [DATE], with diagnoses that included a traumatic brain injury and psychosis. According to an elopement risk evaluation completed on May 9, 2024, the resident was at risk for elopement (leaving the facility unsupervised) and needed interventions. According to the comprehensive care plan, the risk for elopement had not been added to the care plan until June 21, 2024. Clinical record review revealed that Resident 2 was admitted to the facility on [DATE], with diagnoses that included cerebral palsy and deafness. A Minimum Data Set (MDS) assessment completed on May 16, 2024, indicated that the resident was highly impaired with hearing.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility documentation review and staff interview, it was determined that the Nursing Home Administrator and the Director of Nursing failed to effectively manage the facility regarding the elopement of a resident (Resident 1). This was identified as an Immediate Jeopardy situation for one of seven residents reviewed. Findings include: Review of the job description for the Administrator revealed that the Administrator is responsible for maintaining appropriate guidelines and and regulations to assure (sic) the highest degree of attention and care is provided to all residents. Essential job functions included: Ensures that the most current resident care policies .necessary to remain in compliance with required laws regulations and guidelines are available and followed, and Ensures that an adequate number of personnel are employed to met the needs of the residents and State requirements. Review of the job description for the Director of Nursing (DON) revealed that the DON is responsible for developing,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 interview, it was determined that the facility failed to provide a reasonable accommodation of needs for one of seven sampled residents. (Resident 2) Findings include: Clinical record review revealed that Resident 2 had diagnoses that included multiple sclerosis, depression, and anxiety. Review of the care plan revealed that the resident was incontinent and staff were to keep her skin clean and dry. Further review of the care plan revealed that the resident required assistance from staff for activities of daily living. On April 29, 2024, at 10:48 a.m., Resident 2 was observed in bed. The resident stated that her brief needed to be changed, she had not received any care that morning, and that she would like assistance to get out of bed. The resident stated that staff were aware. Observation revealed that the resident did not receive staff assistance or care until 11:29 a.m. In an interview on April 29, 2024, at 1:50 p.m., Resident 2 confirmed that she waited over 40 minutes for her soiled brief to be changed and was not assisted out of bed or…

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

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 or review the care plan within seven days after the completion of the comprehensive assessment for four of eight sampled residents. (Residents 1, 2, 3, 4) Findings include: Clinical record review revealed that Resident 1 was admitted on [DATE], and had diagnoses that included anxiety and depression. The Quarterly Minimum Data Set (MDS) assessment was completed on December 22, 2023. There was a lack of documentation to support that the facility had conducted an interdisciplinary care plan meeting to review the care plan. Clinical record review revealed that Resident 2 was admitted on [DATE], and had diagnoses that included kidney failure and hypotension (low blood pressure). The admission MDS assessment was completed on December 22, 2023. There was a lack of documentation to support that the facility had conducted an interdisciplinary care plan meeting to develop the care plan. Clinical record review…

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

Based on clinical record review, it was determined that the facility failed to ensure that physician prescribed medications were provided timely to one of seven residents sample. ( Resident 6) Findings include: Clinical record review revealed that Resident R6 was admitted to the facility with diagnoses that included kidney disease and hyperkalemia (elevated potassium level). On December 11, 2023, a physician directed staff to administer an oral medication every other day (Veltassa) to lower elevated potassium levels. Review of the Medication Administration Record (MAR) for December 2023 revealed that the medication was not adminstered on December 18, 20, 22, 24, 2023 due to unavailability from the pharmacy. 28 Pa. Code 211.9 (a)(d) Pharmacy services. 28 Pa. Code 211.12(d)(1) (3)(5) Nursing services.

Based on review of the Resident Assessment Instrument Users Manual (RAI), clinical record review and staff interview, it was determined that the facility failed to complete Minimum Data Set (MDS) assessments in a timely manner for nine of ten sampled residents. (Residents 2, 3, 4, 5, 6, 7, 8, 9, 10) Findings include: Review of the Long Term Care Facility RAI User's Manual which provided instructions and guidelines for completing required MDS assessments, (federally mandated assessment tool), dated October 2019, revealed that significant change in status assessments, quarterly assessments, and admission assessments were to be completed no longer then 14 days after the Assessment Reference Date (ARD) which refers to the last day of the assessment observation period. Clinical record review revealed that Residents 2, 7, and 8, had quarterly MDS assessments noted as still in progress and had not yet been completed as per the time requirements. Clinical record review revealed that Residents 3, 4, 6. 9, and 10, had admission MDS assessments noted as still in progress and had not yet been…

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

Based on facility policy review, observation, and interview, it was determined that the facility failed to store food in a sanitary manner in the kitchen and on three of three nursing units. (First, Second, and Third floors) Findings include: Review of the facility policy entitled, Nourishment Rooms and Kichenettes, last reviewed August 31, 2023, revealed that containers of resident food would be labeled with the resident's name, room number, and date the item was placed in the refrigerator. Perishable items would be discarded after 72 hours. Observation of the kitchen on October 1, 2023, at 9:45 a.m., revealed a container of coleslaw in the refrigerator with a use by date of September 26, 2023. There was a black substance on the shelves in the refrigerator. There were three rubber spatulas with chipped rubber. There was an accumulation of dirt and various substances on the ledge over the stove top. There was an accumulation of a black substance on the deflector and inside wall of the ice machine. In an interview during the tour, dietary employee DE1 stated that ice in the machine…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 physicians' orders were implemented for five of 21 sampled residents. (Residents 3, 11, 29, 86, 288) Findings include: Clinical record review revealed that Resident 3 had diagnoses that included hypertension. A physician's order dated July 13, 2019, directed staff to administer a medication (lisinopril) once daily for hypertension. Staff were not to administer the medication if the resident's systolic blood pressure (SBP, the first measurement of blood pressure when the heart beats and the pressure is at it's highest) was less than 110 millimeters of mercury (mm/Hg). Review of Resident 3's medication administration records (MAR) revealed that staff administered the medication when the resident's SBP was less than 110 mm/Hg two times in August and two times in September of 2023. Clinical record review revealed that Resident 11 had diagnoses that included remission for psychoactive substance dependence, anxiety, depression, borderline personality disorder, and psychoactive…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, it was determined that the facility failed to provide a safe, sanitary, and comfortable environment on three of three nursing units. (Nursing units 1, 2, and 3) Findings include: Observations throughout the facility at various times during all days of the survey revealed the following: A wall mounted fan at the nurse's station on the first floor had a heavy accumulation of dust and dirt. The first floor hallway was missing a ceiling tile over the oxygen storage room door and there were six stained ceiling tiles. Wall corners at the shower and opposite corner were marred and crumbled with significant dust on the floor. On October 1, 2023, there was no sheet on the mattress in room [ROOM NUMBER], and the resident was observed laying directly on the mattress. During the rest of the survey a sheet that did not fit was observed on the mattress and the resident was observed laying on exposed mattress. In the room [ROOM NUMBER] bathroom, there was a stained ceiling tile. The molding tile 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 observation and interview, it was determined that the facility failed to provide services to promote a dignified dining experience in one of three dining rooms. (Third floor) Findings include: Observation of the lunch meal served in the third-floor dining room on October 1, 2023, at 11:45 a.m., revealed that Residents 2, 4, 47, 66, and 188 were served hot beverages in Styrofoam cups. In an interview during the observation period, Registered Nurse 1 stated that hot beverages are typically served in handled mugs. In an interview on October 2, 2023, at 12:52, the Director of Dining Services confirmed that the hot beverages should have been served in handled mugs, not Styrofoam cups. CFR 483.10(a)(1) Resident Rights Previously Cited 11/03/2022 28 Pa. Code 201.18(b)(3) Management.

Based on clinical record review, resident interview, and staff interview, it was determined that the facility failed to ensure that the resident and/or the resident representative were offered the opportunity to participate in the development, review and/or revision of their care plan for four of 21 residents sampled (Resident 24, 31, 53, 86) Findings include: Clinical record review revealed that Resident 24 had diagnoses that included stroke and paralysis on one side of the body. The resident was identified as being alert and oriented and very capable of making needs known. The resident reported during a resident council meeting held on October 3, 2023, at 1:09 p.m., that he and his resident representative had not been offered the opportunity to be involved in the development and revision of his care plan. Review of the resident's clinical record revealed that the resident had a Minimum Data Set (MDS) assessment completed on April 5, 2023, and July 5, 2023. A care plan meeting should have been scheduled within seven days of these assessments. There was no documented evidence that…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, observation, and staff interview, it was determined that the facility failed to provide services to maintain adequate grooming and personal hygiene and assistance with transfer out of bed for four of six sampled residents who required assistance with activities of daily living. (Residents 3, 19, 86, 238) Findings include: Clinical record review revealed that Resident 3 had diagnoses that included paraplegia (paralysis of the lower body), anxiety, and depression. Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated that the resident required extensive assistance from staff for personal hygiene. Review of the care plan revealed a problem for self-care deficit. The intervention was for staff to provide nail care as needed. Review of the Resident's bathing record revealed that the resident was bathed on September 30, 2023. On October 1, 2023, at 12:37 p.m., Resident 3 was observed in bed and her nails were long and discolored. In an interview at that time 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, observation, and interview, it was determined that the facility failed to provide interventions to prevent pressure ulcers for one of 21 sampled residents. (Resident 29) Findings include: Clinical record review revealed that Resident 29 had diagnoses that included chronic kidney disease, diabetes mellitus, chronic pain, and depression. A physician's order dated September 28, 2023, directed staff to provide a Roho cushion (a pressure reduction device) to the resident's chair when out of bed and during dialysis. On October 1, 2023, at 11:23 a.m., Resident 29 was observed in bed. There was a cushion on the resident's dresser. Resident 29 stated that the cushion was to be used while out of bed, at dialysis. Observation on October 2, 2023, at 11:26 a.m., revealed the cushion remained on Resident 29's dresser and the resident was not in the room. At 11:32 a.m., on the same date, Resident 29 was observed sitting in the chair at dialysis treatment. There was no cushion observed under the resident. During the same observation period, Registered Nurse 2 stated…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 the environment remained free of accident hazards in two of three shower rooms. (1st floor shower room and 2nd floor shower room) Findings include: On all days of the survey, observations of the first floor shower room revealed that there was a bagged disposable razor on top of a box of gloves. Observations of the second floor shower room revealed that there was an unlocked cabinet that contained antiperspirant, skin/hair cleanser, a container of petroleum jelly, a resident's prescription blended topical cream, skin cream, vitamin A & D cream, shaving cream and a dirty electric razor with hair and debris on the razor head. In an interview on October 3, 2023, at 12:10 p.m., the Director of Nursing confirmed that there were four ambulatory residents that were cognitively impaired and had access to the potentially hazardous materials. CFR 483.25(d)(1)(2) Accidents. Previously cited 11/3/2022 28 Pa. Code 211.12(d)(1)(5) Nursing services.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff interview, it was determined that the facility failed to timely assess the nutritional status of two of three sampled residents at nutrition risk. (Residents 4, 29) Findings include: Review of the facility policy entitled, Weight Management, last reviewed August 31, 2023, revealed that a reweigh would be obtained for any weight change of plus or minus five pounds from the previous weight, unless other parameters were ordered by the physician. All reweighs would be obtained within 24 hours and were to be documented in the resident's record. Clinical record review revealed that Resident 4 had diagnoses that included depression, anemia, anxiety, dementia, and dysphagia. Review of the care plan revealed that the resident was at nutrition risk related to weight loss. On December 28, 2022, the resident weighed 261.6 pounds (lbs.), on January 2, 2023, the resident weighed 236.2 lbs., which reflected a 25.4 pound (lb.) (9.7%) weight loss. There was no evidence that a reweigh was…

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

Based on policy review, clinical record review, and interview, it was determined that the facility failed to ensure that staff provided services consistent with professional standards of practice for one of three dialysis residents sampled. (Resident 86) Findings include: Review of the facility policy entitled, Obtaining Blood Pressures in Dialysis Residents, dated August 31, 2023, revealed that staff was not to take a blood pressure on a resident's arm where a chest wall catheter was present for access to provide dialysis. Clinical record review revealed that Resident 86 had diagnoses that included heart failure, kidney failure, and dependence on dialysis. The resident had a catheter inserted into the right chest wall for dialysis access and a physician order dated August 5, 2023, directing that staff was not to take blood pressure measurements in the resident's right arm. The care plan revealed that the resident was not to have blood pressures taken in the right arm. Review of Resident 86's blood pressure summary revealed that from August 5, 2023 through October 4, 2023, nursing…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, policy review, and staff interview, it was determined that the facility failed to adequately monitor residents on psychoactive medications for one of 21 sampled residents. (Resident 19) Findings include: Review of the facility policy entitled, Behavior Management, last reviewed August 31, 2023, revealed that staff was to assess and monitor a resident for abnormal involuntary movements and adverse side effects upon a new order for antipsychotic medication and every six months when on an antipsychotic medication. Clinical record review revealed that Resident 19 was admitted to the facility on [DATE], with diagnoses of schizophrenia and dysphagia (difficulty swallowing). On March 15, 2023, the physician ordered that the resident receive an antipsychotic medication (lorazepam). On July 5, 2023, the physician ordered that the resident receive an antipsychotic medication (haloperidol). The care plan revealed that the resident was to be monitored for adverse side effects related to the…

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

Based on clinical record review and staff interview, it was determined that the facility failed to ensure that a PRN (as needed) psychoactive medication was limited to 14 days unless the physician documented in the clinical record the rationale to extend the PRN for one of 21 sampled residents. (Resident 19) Additionally, the facility failed to ensure the a resident was free from unnecessary use of a psychotropic medication for one of 21 sampled residents. (Resident 4) Findings include: Clinical record review revealed that Resident 4 had diagnoses that included depression with psychotic symptoms, schizoaffective disorder, anxiety, paranoid personality disorder, restlessness and agitation, dementia, and post-traumatic stress disorder. A physician's order dated September 2, 2023, directed staff to administer Klonopin (also known as clonazepam, an antianxiety medication) 0.5 milligrams (mg) every eight hours as needed for anxiety. Review of a progress note dated September 19, 2023, revealed that the resident slept a lot after administration of the medication. The practitioner ordered…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, it was determined that the facility failed to provide a safe, sanitary and comfortable environment on three of three nursing units. (Nursing units 1, 2 and 3) Findings include: Observation throughout the facility during all days of the survey revealed the following: Upon entrance into the main lobby of the building, there was a pervasive odor of urine throughout the lobby and the first floor nursing unit. There was a missing piece of baseboard in the hallway by the dining room door. There was a hole in the wall in room [ROOM NUMBER]. There were several strips of black tape on the floor in the shower area and no toilet paper holder. On the second floor nursing unit the hallway carpets were stained and worn. The resident room threshold strips were missing and there was thick dirt buildup in the gap between the hallway carpet and tile in rooms 207, 209, 212, 214, 215, 216, 217, and 219. The threshold strip in room [ROOM NUMBER] was cracked and broken. The wall across from the nursing station…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, staff and resident interview and observation, it was determined that the facility failed to ensure that residents were assisted with bathing in accordance with individual preference for five of 27 sampled residents. (Residents 19, 41, 56, 77, 82) In addition, the facility failed to ensure that the dietary menus were posted on three of three nursing units. (Nursing units 1, 2, 3) Findings include: Clinical record review revealed that Resident 19 had diagnoses that included major depression and right above the knee amputation. The Minimum Data Set (MDS) assessment dated [DATE], indicated that the resident was alert and oriented, was feeling down and required one person physical assistance with bathing. According to the care plan, the resident needed assistance with bathing. There was an intervention that staff set up and assist with transfers and grooming. Review of the bathing records revealed that the resident was scheduled to receive a shower on Mondays and Thursdays. 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 observation, it was determined that the facility failed to ensure that the resident's environment was free of accident hazards on two of three nursing units (Nursing units 2 and 3) and for four of four sampled residents who had behaviors. (Residents 9, 13, 30, 65) Findings include: Clinical record review revealed that Resident 9 had diagnoses of dementia with behavioral disturbance, anxiety, and bipolar disorder. The Minimum Data Set (MDS) assessment dated [DATE], indicated that the resident had memory impairment and required supervision to limited assistance with activities of daily living. On September 19, 2022, a nurse noted that the resident had poor short term memory and was able to ambulate independently. Clinical record review revealed that Resident 13 had diagnoses of dementia, schizophrenia and psychosis. The MDS assessment dated [DATE], indicated that the resident had memory impairment. A review of the care plan revealed the resident was at risk for yelling 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 resident and staff interview, it was determined that the facility failed to ensure that a call bell was accessible or functioning for three of 27 sampled residents. (Residents 42, 46, 82) Findings include: Clinical record review revealed that Resident 42 had diagnoses that included muscle weakness, gout, and respiratory failure. The Minimum Data Set (MDS) assessment dated [DATE], indicated that the resident was alert and oriented, and was dependent of staff assistance with activities of daily living. The ongoing care plan indicated that the resident was dependent on staff for assistance and at risk for falls and that the call bell should be kept within reach. On November 1, 2022, at 1:00 p.m., the resident's call bell was observed in between the bed rail and mattress. The resident stated that the call bell could not be reached where it was. On November 2, 2022, at 12:32 p.m., the resident's call bell was observed in between the bed rail and the mattress. The resident stated…

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

Based on policy review, clinical record review, and interview it was determined that the facility failed to ensure that staff provided services consistent with professional standards of practice for two of three dialysis residents sampled. (Residents 6, 46) Findings include: Review of the facility policy entitled, Obtaining Blood Pressures in Dialysis Residents, dated December 28, 2021, revealed that staff was not to take a blood pressure on a resident's arm where a fistula or a right chest wall catheter was present for access to provide dialysis. If the blood pressure could not be taken in either arm, nursing staff was to obtain the blood pressure at the ankle level. Clinical record review revealed that Resident 6 had diagnoses that included diabetes, kidney failure and dependence on dialysis. The resident had a catheter inserted into the right chest wall and also had a left arm fistula for dialysis access and a physician order dated November 10, 2021, revealed that staff was not to take the resident's blood pressure in the right and left arm because of these devices. The ongoing…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 faiclity failed to ensure that a resident was served preferred food items on their meal trays and ensure that the resident was aware of alternate meal items for one of 27 sampled residents. (Resident 19) Findings include: Review of the weekly menu revealed that lunch on November 1, 2022, was chicken francaise, angel hair pasta, herb roasted cauliflower and a frosted brownie. There was no alternate meal choice listed on the weekly menu. In an interview on November 1, 2022, at 12:30 p.m., the Director of Dietary stated that there is an alternate Bistro Menu that lists the alternates that are available to residents for all three meals on a daily basis. Clinical record review revealed that Resident 19 had diagnoses of end stage renal disease and dependence on dialysis. The Minimum Data Set assessment dated [DATE], indicated that the resident was alert and oriented and was independent with eating. On on November…

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