Maple Heights Health & Rehab Center, LLC

Based on review of policies, as well as observations and staff interviews, it was determined that the facility failed to maintain a clean and homelike environment for one of 51 residents reviewed (Resident 142). Findings include:The facility's policy regarding routine environmental cleaning and disinfecting, dated September 13, 2025, indicated that proper cleaning and disinfecting of environmental surfaces is necessary to break the chain of infection. A quarterly Minimum data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 142, dated September 5, 2025, revealed that the resident was cognitively intact, usually understood and understands, was highly hearing impaired and had diagnoses that included a stroke with residual right sided weakness.Observations on November 17, 2025, at 12:17 p.m. and November 18, 2025, at 8:45 a.m. and 2:35 p.m. revealed that the resident was lying in her bed resting. The bilateral enablers located on her bed were noted to have a thick amount of a blackish/brown removable substance on them, especially the…

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

Based on a review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that a baseline care plan was developed for one of 51 residents reviewed (Resident 173). Findings include: The facility's policy regarding Comprehensive Care Plans, dated September 23, 2025, included that an interdisciplinary plan of care be established and updated as indicated for every resident in accordance with state and federal regulatory requirements. An interim care plan was to be developed within 48 hours of admission to ensure that the resident's needs were met until a comprehensive care plan was completed.A nursing note dated November 13, 2025, at 7:45 p.m. revealed Resident 173 was admitted to the facility from the hospital.Physician's orders, dated November 13 and 14, 2025, included orders for the resident to receive 500 milligrams (mg) of levetiracetam (anticonvulsant medication) twice a day for seizures, 50 mg of Tramadol (narcotic pain medication) every six hours as needed for pain, and a wanderguard (device that alerts 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 review of facility policies, clinical records, and staff interviews, it was determined that the facility failed to develop a comprehensive care plan that included specific and individualized interventions to address the care needs of residents for two of 51 residents reviewed (Residents 18 and 38). Findings include: A facility policy for Comprehensive Care Planning, dated September 23, 2025, included that an interdisciplinary plan of care be established and updated as indicated for every resident in accordance with state and federal regulatory requirements. The comprehensive care plan will be developed within seven days after completion of the comprehensive assessment. An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's care needs and abilities) for Resident 18 dated October 30, 2025, indicated that the resident was able to make herself understood and could understand others, required assist from staff for daily care needs, received routine and as needed pain medication, had almost constant pain, and had diagnosis that included noninfective…

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, as well as staff interviews, it was determined that the facility failed to ensure that a resident's care plan was updated/revised to reflect the resident's specific care needs for four of 51 residents reviewed (Residents 23, 28, 38, and 129).Findings include: A facility policy for Comprehensive Care Planning, dated September 23, 2025, included that an interdisciplinary plan of care be established and updated as indicated for every resident in accordance with state and federal regulatory requirements. The care plan is reviewed on an ongoing basis and revised as indicated by the residents' needs, wishes, or a change in condition. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 23, dated October 24, 2025, indicated that the resident was moderately cognitively impaired, required assistance from staff for daily care tasks and, had diagnoses that included malignant melanoma of the left upper limb and shoulder. Physician's orders for Resident 23, dated September 24, 2025,…

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 reviews and staff interviews, it was determined that the facility failed to ensure that physician's orders regarding medications and treatment administration were followed for 12 of 51 residents reviewed (Residents 3, 4, 40, 44, 46, 52, 87, 96, 99, 115, 157, and 158). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 3, dated August 28, 2025, indicated that the resident was cognitively intact, required assistance from staff with daily care needs, had diagnoses that included benign prostatic hyperplasia (a noncancerous enlargement of the prostate gland that causes urinary problems). Physician's order for Resident 3 dated October 30, 2024, revealed 0.4milligram (mg) of tamsulosin (a medication used to treat benign prostatic hyperplasia) was to be administered once a day between 3:00 p.m. and 5:00 p.m. A nursing note for Resident 3 dated September 29, 2025, at 1:30 a.m. and a review of the resident's Medication Administration Record (MAR) revealed that the resident 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 review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that a resident's environment remained free of accident hazards by failing to ensure care-planned interventions were in place for two of 51 residents reviewed (Resident 15, 23) who were at risk for falls. Findings include:The facility's policy regarding fall prevention and management, dated September 13, 2025, indicated that the facility will identify those residents at risk for falls upon admission, readmission, and quarterly and provide appropriate interventions to modify and/or compensate for risk factors. The care plan will be updated to reflect resident-specific safety needs and interventions. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 15, dated October 22, 2025, revealed that the resident was severely cognitively impaired, required a mechanical lift for transfers, had a recent fall 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 clinical record reviews, as well as observations and staff interviews, it was determined that the facility failed to ensure that a dialysis emergency kit was at the resident's bedside for two of 51 residents reviewed (Residents 10 and 11). Findings include: A hemodialysis care policy dated September 23, 2025, indicated that a smooth clamp should be kept at bedside of resident with a dialysis vascular access dialysis catheter in place. An admission MDS assessment for Resident 10, dated October 24, 2025, indicated that the resident was cognitively intact and required hemodialysis (a process of cleaning the blood of toxins and returning it into the body). Physician's orders, dated October 18, 2025, included an order for the resident to have dialysis. Observations of Resident 10 on November 20, 2025, at 11:40 a.m. revealed that she was sitting beside her bed in a wheel chair, and had a hemodialysis port in her left chest. There was no emergency equipment at her bedside. Interview with Licensed Practical Nurse 5 on November 20, 2025, at 11:45 a.m. indicated that if the emergency…

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

Based on review of facility policies, manufacturer's instructions, and clinical records, as well as observations and staff interviews, it was determined that the facility failed to maintain a medication administration error rate of less than five percent. Findings include:The facility's medication Administration Policy, dated September 23, 2025, revealed that staff were to verify each time a medication was administered that it was the correct medication, at the correct dose, at the correct route, at the correct rate, at the correct time, for the correct resident and with the correct technique. Observations during medication administration on November 19, 2025, revealed that two medications errors were made during 27 opportunities for error, resulting in a medication administrator error rate of 7.41 percent.Current manufacturer's instructions for use of Breo ellipta (fluticasone furoate and vilanterol inhalation powder) 100 micrograms (mcg) /25 mcg (used to treat chronic obstructive pulmonary disease (COPD) and Asthma) revealed that serious side effects including thrush (a fungal…

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 reviews and staff interviews, it was determined that the facility failed to obtain laboratory studies as ordered by the physician for three of 51 residents reviewed (Residents 12, 46, 157). Findings include: An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 12, dated September 21, 2025, revealed that the resident was cognitively impaired, was frequently incontinent of urine, was receiving an anticoagulant, and had diagnoses that included dementia. A nursing note, dated September 17, 2025, at 8:51 a.m. revealed there was a moderate amount of bright red blood in Resident 12's toilet. The Certified Registered Nurse Practitioner (CRNP) was notified. A nursing note, dated September 19, 2025, at 1:40 a.m. revealed Resident 12 urinated in the toilet and it was blood tinged. A verbal order was received from the physician to place the resident's Xarelto on hold related to hematuria (blood in the urine) and obtain a urinalysis with a culture and sensitivity (UA C&S, test used to identify a…

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

Based on review of policies, as well as observations and staff interviews, it was determined that the facility failed to store and prepare food under sanitary conditions.Findings include:The facility's policy for the storage of refrigerated foods, dated September 23, 2025, revealed that refrigerated foods, prepared and held more than 24 hours would be marked to indicate the date the food would be consumed or discarded. Refrigerators in the facility used to store facility purchased food for residents would be equipped with an internal thermometer, were to be checked at least two times a day, and the unit temperature logs were to be retained for one year.Observations of the reach-in freezer in the main kitchen on November 17, 2025, at 8:56 a.m. revealed there was a block of sliced cheese in a plastic bag that was not dated or labeled when it was opened.Interview with the Dietary Manager on November 17, 2025, at that time confirmed that staff should have labeled and dated the bag of cheese.Observations in the main kitchen on November 17, at 8:50 a.m. revealed that there was a piece of…

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

Based on review of hospice contracts and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that the designated interdisciplinary team member obtained the required information from the contracted hospice provider for four of 51 residents reviewed (Residents 17, 23, 36 and 46). Findings include: The Hospice care policy dated September 23, 2025, indicated that the facility and hospice provider (provider of end-of-life services) would work collaboratively and indicated that the hospice provider would provide information to the facility to facilitate coordination of care that included the most recent hospice plan of care specific to each patient, physician certification or recertification, a hospice benefit of elections form (a form signed to indicate that the individual waives all rights to traditional Medicare Part A payments for treatment related to the terminal illness) and updated nursing documentation . Physician's order for Resident 17, dated September 25, 2025, revealed that the resident was receiving hospice services for terminal…

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

Based on review of policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that proper medication handling procedures were followed, and that proper infection control practices were followed for one of 18 residents reviewed (Resident 9). Findings include: The facility's policy regarding medication administration, September 25, 2025, indicated medication should not come in contact with any surface except the medication cup, and staff should avoid touching medication with bare hands when opening a bottle or unit does package. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 9, dated December 22, 2025, indicated that the resident was severely cognitively impaired, and received anticonvulsant (blood thinner) medications. Current physician orders for Resident 9, included an order for the resident to receive 300 milligrams (mg) of Gabapentin (anticonvulsant) in the morning.Observations on January 30, 2026, at 9:16 a.m. revealed that Licensed…

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

Based on review of facility policy and clinical records, as well as resident and staff interviews, it was determined that the facility failed to maintain clinical records that were complete and accurately documented for one of 10 residents reviewed (Resident 4).Findings include: The facility policy for Activities of Daily Living (ADL) documentation, dated September 23, 2025, indicated that Provisions of ADL care will be documented each shift by staff providing the care. This shall include, but not limited to, documentation of food intake, toileting, ambulation, bathing, dressing, and transferring. Actual meal consumption will be documented. An annual Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 4 dated July 1, 2025, indicated that the resident was cognitively impaired, was dependent on staff for personal care needs including eating, and had diagnoses that included dysphagia (difficulty swallowing food or liquids).The care plan for Resident 4 dated August 2, 2023, indicated that the resident required a texture…

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

Based on review of policies, clinical records and investigation documents, as well as staff interviews, it was determined that the facility failed to ensure that residents were free from abuse for one of 10 residents reviewed (Resident 1).Findings include:The facility's abuse policy, dated December 30, 2024, indicated that the facility will not tolerate abuse, neglect, mistreatment, exploitation of residents, and misappropriation of resident property by anyone. It is the facility's policy to investigate all allegations, suspicions and incidents of abuse, neglect, involuntary seclusion, intimidation, exploitation of residents, misappropriation of resident property and injuries of unknown source.A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated June 10, 2025, indicated that the resident was cognitively intact, required assistance from staff with daily care needs, had recent falls, and had diagnoses that included diabetes mellitus, atrial fibrillation (irregular heartbeat) and seizures.Facility…

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 state laws, facility policies and residents' clinical records, as well as staff interviews, it was determined that the facility failed to ensure that all alleged violations involving abuse were reported to the State Survey Agency (Department of Health) and to other state agencies in accordance with state law for one of 10 residents reviewed (Resident 1). Findings include: The Older Adult Protective Services Act of November 6, 1987, amended by Act 1997-13, Chapter 7, Section 701, requires that all administrators or employees who have reasonable cause to suspect that a resident was a victim of sexual abuse, that abuse/neglect resulted in serious physical injury and/or serious bodily injury, or that a death was suspicious, were to make an immediate report to the Protective Services Agency, the Pennsylvania Department of Aging (PDA), and to law enforcement officials. The facility's policy regarding abuse, dated December 30, 2024, revealed that facility staff all allegations of abuse, neglect, involuntary seclusion, injuries of unknown source, and misappropriation of…

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

Based on clinical record reviews, observations, and staff interviews, it was determined that the facility failed to ensure that each resident received assistance devices to prevent accidents for one of ten residents reviewed (Resident 8). Findings include:A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 8, dated May 16, 2025, revealed that the resident was cognitively impaired, required assistance from staff for personal care needs, and had diagnoses that included dementia ( a group of conditions that cause a decline in cognitive abilities sever enough to interfere with daily life).Physician's orders for Resident 8, dated May 15, 2025, included an order for the resident to be out of bed to a high back wheelchair with bilateral elevating leg rests for transport and outside. Observations of Resident 8 on August 27, 2025, at 11:50 a.m. revealed that the resident was transported in his chair by Nurse Aide 3 from a common area near the nurse's station to his bedroom for lunch with no leg rests on his chair. 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 policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that the residents' environment remained free of accident hazards for one of ten residents (Resident 2). Findings Include:The facility's policy regarding elopement, dated December 30, 2024, indicated that if staff discover a resident is missing a head count will be completed, and if the resident is unable to be found a code green will be announced. The designee will notify the administrator, director of nursing, and the attending physician. If the resident is not found in a reasonable period of time the local emergency responders will be notified.A social services admission note for Resident 2 dated July 10, 2025, revealed that the resident was admitted from the hospital. He was recently evicted from his home, and they are working with senior life to try and find placement for him. The resident would like to return to his father's home that he inherited. The resident stated that he likes to drink and smoke cigarettes and marijuana, and plans to be at…

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

Based on review of facility policies, investigation reports, and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that residents were free from abuse or neglect for 14 of 14 residents reviewed (Residents 1,2,3,4,5,6,7,8,9,10,11,12,13 and 14). This deficiency is being cited as past non-compliance. Findings include:The facility's policy regarding abuse, neglect, and exploitation, dated December 30, 2024, indicated that the facility will not tolerate abuse, neglect, mistreatment, exploitation of residents, or misappropriation of resident property by anyone. Abuse was defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Abuse also includes the deprivation by an individual including a caretaker of goods or services that are necessary to attain or maintain physical, mental, and psychological well-being. Neglect was defined as the failure of the facility, its employees, or services providers to provide goods and services to a resident that…

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

Based on review of policies and clinical records, as well as staff and resident interviews, it was determined that the facility failed to provide medication as ordered by the physician, resulting in significant medication errors for three of 14 residents reviewed (Residents 2, 7 and 14). This deficiency is being cited as past non-compliance. Findings include:The facility's policy for medication administration, dated December 30, 2024, indicated that medication would be administered according to physician orders.Facility investigation documents, dated June 18, 2025, revealed that Agency Licensed Practical Nurse 1, did not give multiple residents on the 3rd floor their medications between the hours of 7:00 p.m. and 3:00 a.m. The facility's Electronic Medication Administration Record (EMAR) went down, causing a short system outage. Registered Nurse 2 called the nursing units and there were no reported issues except for the system being down. Registered Nurse 2 placed a ticket in for IT to let them know of the outage. Licensed Practical Nurse 1 told Registered Nurse 2 that she did not…

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

Based on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that physician-ordered 15-minute safety checks were completed for one of 10 resident's reviewed (Resident 5). Findings include: The facility's policy for safety checks dated, December 30, 2024, revealed that if a resident is on 15 or 30-minute safety checks, the staff member much have visual of the resident during each timeframe and utilize the observation/monitoring tool to document completing the observation and the status of the resident to ensure the resident is safe. The facility's policy for change of shift report, dated December 30, 2024, revealed that report is to be given in a clear and concise manner that may include observations that would be helpful to personnel caring for the resident. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) assessment for Resident 5, dated June 5, 2025, revealed that the resident was usually understood and sometimes could understand others, was…

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

Based on review of facility , as well as observations and staff interviews, it was determined that the facility failed to use proper infection control practices for handling linen. Findings include: The facility's environmental services policy for laundry, dated December, 30, 2024, indicated that linens will be handled, transported, and processed in a manner which reduces the risk of contamination or cross-contamination in a safe sanitary manner. facility will handle all used linen as potentially contaminated and use standard precautions when handling, sorting or rinsing. Soiled linens will be bagged at point of care and placed in a soiled linen container in the soiled utility room or deposited into a laundry chute. Observations on June 16, 2025, at 10:17 a.m. revealed that there was soiled linen and a soiled brief lying on the floor inside a resident room. There was no staff in the room or in the hallway. Interview with Registered Nurse 2 on June 16, 2025, at 10:30 a.m. confirmed that the soiled linen and brief should not be on the floor, it should have been bagged and placed in…

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

Based on resident and staff interviews, it was determined that the facility failed to have sufficient dietary staff to perform essential kitchen duties. Findings include: Interview with Resident 3 on May 13, 2025, at 12:24 p.m. revealed that there are times when their meals were served on styrofoam plates with plastic silverware. This occurs on random days with no explanation. Interview with Resident 5 on May 13, 2025, at 12:26 p.m. revealed that there were times when they get their food on styrofoam plates with plastic silverware only it happens randomly with no explanation. Interview with Resident 7 on May 13, 2025, at 11:40 a.m. revealed that there were times when they get their food on styrofoam plates with plastic silverware, about fifty percent of the time, due to staffing. Resident 7 revealed that they had plastic silverware just this morning for breakfast. Interview with the Assistant Nursing Home Administrator on May 13, 2025, at 3:12 p.m. confirmed that plastic silverware was provided to the residents this morning for the breakfast meal due to low staffing in the kitchen.…

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, as well as staff interviews, it was determined that the facility failed to ensure that pressure ulcer treatments were provided to prevent infection for one of eight residents reviewed (Resident 2). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 2, dated April 2, 2025, revealed that the resident was cognitively impaired, required assistance with care, had diagnoses that included quadriplegia (condition that causes a complete or severe loss of motor function in all four limbs), a traumatic brain injury, had no unhealed pressure ulcers (wounds caused by pressure), and had moisture-associated skin damage. A nursing note for Resident 2, dated March 29, 2025, at 10:42 p.m. revealed that the registered nurse was called to assess the resident for a reported new open area measuring 1.0 centimeters (cm) x 0.5 cm. Intervention to prevent further occurrences was to place blue incontinent pads and to cleanse wound with wound cleanser and apply Thera honey topically…

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

Based on observations and staff interviews, it was determined that the facility failed to provide a clean and homelike environment for five of 11 residents reviewed (Residents 7, 8, 9, 10, 11). Findings include: Observations of Resident 7's wheelchair on April 8, 2025, at 11:42 a.m. revealed that the resident's wheelchair was beside her bed and it had a moderate accumulation of removable, dried-on debris on the metal supports of the chair. Observations of Resident 8's wheelchair April 8, 2025, at 11:47 a.m. revealed that the resident's wheelchair had a moderate to large amount of thick, removable dust/debris on the metal supports under the seat. Observations of Resident 9's wheelchair on April 8, 2025, at 11:55 a.m. revealed that there was a large amount of removable dust/debris on the wheels and the metal supports under the chair, as well as removable dirt on the seat cushion. Observations of Resident 10's wheelchair on April 8, 2025, at 12:10 p.m. revealed that the wheels of the wheelchair had an accumulation of removable, dried-on debris. Interview with Licensed Practical Nurse 4…

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

Based on review of policies and clinical records, as well as observations and staff interviews, it was determined that facility failed to determine if residents were safe to self-administer medications for one of 11 residents reviewed (Resident 1). Findings include: The facility's policy regarding the self-administration of medications, dated December 20, 2024, indicated that residents who desired to self-administer medications would have a physician's order to do so. An quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated January 31, 2025, indicated that the resident was understood and could understand. Current physician's orders did not include orders for self-administration of medication, the resident's record contained no documented evidence that an evaluation was completed to determine if the resident was capable of self-administering medications, and the resident did not have a care plan in place regarding the self-administration of medication. Observations on April 8, 2025, at 9:40 a.m. revealed…

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 employee records, as well as staff interviews, it was determined that the facility failed to maintain an environment free of potential safety hazards related to resident transportation to appointments for one of 11 residents (Resident 6). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 6, dated March 16, 2025, indicated that the resident was cognitively impaired, was usually understood, and sometimes understood others. A nursing note for Resident 6, dated March 20, 2025, at 5:41 p.m., revealed that the resident was unable to go to her orthopedic appointment on the above date due to transportation issues. Interviews with Nurse Aide 2 on April 8, 2025, at 11:09 a.m. revealed that she was escorting Resident 6 to her orthopedic appointment on March 20, 2024. She waited for 45 minutes on the floor for Van Driver 1 to arrive and help escort Resident 6 to the van. When Van Driver 1 arrived he was just making statements that he was hungry. When he started to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policies, investigation reports, and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that residents were free from abuse or neglect for three of 66 residents reviewed (Residents 58, 130, 134). This deficiency is being cited as past non-compliance. Findings include: The facility's policy regarding abuse, neglect, and exploitation, dated December 30, 2024, indicated that the facility will not tolerate abuse, neglect, mistreatment, exploitation of residents, or misappropriation of resident property by anyone. Abuse was defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Abuse also includes the deprivation by an individual including a caretaker of goods or services that are necessary to attain or maintain physical, mental, and psychological well-being. Neglect was defined as the failure of the facility, its employees, or 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 the Resident Assessment Instrument User's Manual and clinical records, as well as staff interviews, it was determined that the facility failed to complete accurate Minimum Data Set assessments for seven of 66 residents reviewed (Residents 12, 17, 18, 25, 41, 93, 122). Findings include: The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which provides guidance and instructions for the completion of MDS assessments, dated October 2024, indicated that the intent of Section N was to record the number of days, during the seven-day assessment period, that any type of injection, insulin, and/or select medications were received by the resident. Section N0415B was to be coded if the resident received an antianxiety medication during the seven-day assessment period, Section N0415G1 Diuretic Medications (medications that promote the excretion of urine by the kidneys) was to be coded if the resident took the medication during the seven-day assessment period, Section N0451H…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that care plans were updated to reflect changes in residents' care needs for seven of 66 residents reviewed (Residents 2, 25, 41, 64, 79, 106, 130). Findings include: The facility's policy regarding care plans, dated [DATE], revealed that the facility was to develop a comprehensive, person-centered care plan for each resident that included measurable objectives and timetables to meet the resident's medical, nursing, mental and psychosocial needs that were identified in the comprehensive assessments. The comprehensive care plan was to be reviewed and updated at least every 90 days by the interdisciplinary team, and in cases of significant changes in the resident's condition, the care plan was to be updated within seven days of the new full assessment. An annual Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for…

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

Based on a review of facility policies and clinical records, as well as resident family and staff interviews, it was determined that the facility failed to provide adequate, ongoing activities designed to meet the needs of residents for one of 66 residents reviewed (Resident 9). Findings include: The facility's life enrichment programming policy, dated December 30, 2024, indicated that an ongoing resident-centered life enrichment program, based on comprehensive assessments and care plans, will be provided. The program will be designed to meet the interests (including hobbies and cultural preferences) and the abilities of each resident including their physical, mental, emotional, social, spiritual, psychological, and leisure needs. Programs will be scheduled and offered seven days a week, including evening and weekend programs. Adaptations will be made as necessary to enhance the resident's enjoyment of, or participation in, programming. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 9, dated November 4,…

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

Based on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to maintain accountability for controlled medications (drugs with the potential to be abused) for two of 66 residents reviewed (Residents 44, 149). Findings include: The facility's policy/procedure regarding fentanyl patch destruction, dated December 30, 2024, indicated that licensed nurses would remove fentanyl patches, when appropriate, using gloved hands and fold the patch in half so that the adhesive side adhered to itself. With a witness, the patch would be disposed of in the sharps container (a puncture-resistant container used to safely dispose of sharp objects like needles and syringes). Two licensed nurses were to witness and document the disposal of all fentanyl patches. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 44, dated November 20, 2024, indicated that the resident was cognitively impaired, received pain medication routinely, and received an opioid. Physician's…

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

Based on review of the facility's plans of correction for previous surveys, and the results of the current survey, it was determined that the facility's Quality Assurance Performance Improvement (QAPI) committee failed to maintain compliance with nursing home regulations and ensure that plans to improve the delivery of care and services effectively addressed recurring deficiencies. Findings include: The facility's deficiencies and plans of corrections for State Survey and Certification (Department of Health) surveys ending February 14, 2024; June 4, 2024; June 20, 2024; and August 1, 2024, revealed that the facility developed plans of correction that included quality assurance systems to ensure that the facility maintained compliance with cited nursing home regulations. The results of the current survey, ending January 30, 2025, identified repeated deficiencies related to a failure to prevent resident abuse/neglect; timely completion of comprehensive assessments; accuracy of Minimum Data Set (MDS) assessments (mandated assessment of a resident's abilities and care needs);…

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

Based on observations and staff interviews, it was determined that the facility failed to ensure that essential equipment was in safe operating condition in the facility's kitchen. Findings include: Observations in the facility's kitchen on January 29, 2025, at 9:38 a.m. revealed that the first rinse cycle on the dishwashing machine was not registering a temperature during dishwashing and that water was leaking onto the floor from underneath the dishwasher. A steam kettle with a plastic bucket underneath it was catching water that was leaking. Interview with the Dietary Manager on January 30, 2024, at 11:15 a.m. revealed that the dishwasher was washing dishes correctly and providing the final sanitizing rinse that was required; however, it had been leaking water and not properly functioning to full capacity since September 2024. The Dietary Manager also revealed that the steam kettle has been broken since June 2024 and needs a new seal; an upright cooler has been out of service since May 2024; the garbage disposal was not being used because it was making a loud noise when turning it…

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

Based on clinical record reviews, observations, and staff interviews, it was determined that the facility failed to ensure that assistance with hygiene was given in a manner that maintained dignity for one of 66 residents reviewed (Resident 84). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 84, dated December 17, 2024, revealed that the resident was understood and could understand others. A care plan for the resident, dated January 20, 2025, revealed that the resident had an activity of daily living (ADL - refer to basic tasks necessary for self-care and independent living) self-care performance deficit and staff was to help with morning and evening care. The facility's bath schedule indicated that Resident 84 was to receive a shower during the evening shift on Tuesdays and Fridays. The resident's clinical record revealed that the resident refused the shower and accepted a bed bath on January 24, 2025. However, there was no documented evidence that staff had asked the resident and/or that…

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

Based on review of residents' clinical records and facility's grievance/complaint logs, as well as staff interviews, it was determined that the facility failed to honor the resident's right to make informed choices and participate in his/her treatment for one of 66 residents reviewed (Resident 79). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 79, dated November 21, 2024, revealed that the resident was understood and could understand others. Physician's orders for Resident 79, dated November 14, 2024, included an order to inform the resident of his treatment plan. A concern form for Resident 79, dated September 4, 2024, revealed that the resident presented a concern that he is not being informed of when his appointments are, and he wants to know his appointments in advance. The results of the action that were taken after the investigation indicated that the resident would be given at least a week's notice. Interview with Resident 79 on January 27, 2025, at 11:46 a.m. revealed that he was…

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

Based on review of policies, clinical records, and facility grievance forms, as well as resident and staff interviews, it was determined that the facility failed to make ongoing efforts to resolve the grievances of residents for one of 66 residents reviewed (Resident 18). Findings include: The facility's grievance policy, revised October 19, 2018, indicated that the facility's grievance review would be completed in a reasonable time frame consistent with the type of grievance, but in no event would the review exceed 30 days. If the Grievance Committee/Grievance Official determined that a resident rights violation had occurred, the violation was to be corrected within 10 days. Upon completion of the review, the Grievance Official would complete a written grievance decision that included the following: the date the grievance was received, a summary of the statement of the resident's grievance, the steps taken to investigate the grievance, a summary of the pertinent findings or conclusions regarding the resident's concerns, a statement as to whether the grievance was confirmed or not…

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

Based on clinical record reviews and staff interviews, it was determined that the facility failed to ensure that a written notice was provided to the resident's responsible party regarding the reason for transfer to the hospital for three of 66 residents reviewed (Residents 12, 32, 84). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 12, dated December 10, 2024, indicated that the resident was understood, could understand others, and was cognitively intact. A nursing note, dated November 2, 2024, at 11:50 a.m., revealed that Resident 12 was observed lying on her left side on the floor between her bed and wheelchair. The resident was confused, had a tremor to her right hand, and stated that she had pain in her lower extremities. She was observed to be hyperventilating, staring blankly into the corner of the room, and had a nonproductive, moist cough. The resident's responsible party was notified and requested she be transferred to the hospital. Interview with the Social Service Director on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the Resident Assessment Instrument User's Manual and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that comprehensive admission Minimum Data Set assessments were completed in the required time frame for five of 66 residents reviewed (Residents 141, 143, 147, 152, 165). Findings include: The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which provides instructions and guidelines for completing required Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2023, indicated that an admission MDS assessment was to be completed no later than 14 days (admission date + 13 calendar days) following admission. A comprehensive admission MDS assessment for Resident 141, dated October 28, 2024, revealed that the resident was admitted to the facility on [DATE], and the resident's admission MDS assessment was dated as completed on November 5, 2024, which was 16 days…

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

Based on a review of facility policies, clinical record reviews, and staff interviews, it was determined that the facility failed to ensure that a resident's baseline care plan included information regarding the resident's immediate care needs for one of 66 residents reviewed (Resident 94). Findings include: A facility policy for interim/baseline care plans, dated December 30, 2024, revealed that within 48 hours of admission, the facility will develop and implement an interim/baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident until a comprehensive assessment can be completed, leading to a comprehensive care plan. The base line care plan will be used until the comprehensive assessment and care plan is developed by the interdisciplinary team. The base line care plan will include the minimum healthcare information necessary to care for a resident. A nursing note for Resident 94, dated December 14, 2024, revealed that the resident was a new admission to the facility from the hospital; 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 review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included specific and individualized interventions for one of 66 residents reviewed (Resident 44). Findings include: The facility's policy regarding care plans, dated December 30, 2024, revealed that the facility was to develop a comprehensive, person-centered care plan for each resident that included measurable objectives and timetables to meet the resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessments. The comprehensive care plan was to be reviewed and updated at least every 90 days by the interdisciplinary team, and in cases of significant changes in the resident's condition, the care plan was to be updated within seven days of the new full assessment. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 44, dated November 20, 2024 revealed…

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 Pennsylvania's Nursing Practice Act and clinical records, as well as staff interviews, it was determined that the facility failed to clarify an order for treatment for one of 66 residents reviewed (Resident 69). Findings include: The Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.11 (a)(1)(2)(4) indicated that the registered nurse was to collect complete and ongoing data to determine nursing care needs, analyze the health status of individuals and compare the data with the norm when determining nursing care needs, and carry out nursing care actions that promote, maintain and restore the well-being of individuals. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs), dated November 2, 2024, indicated that Resident 69 was alert and oriented, required assistance from staff with care, and had a non-healing surgical wound. A wound consult report for Resident 69, dated December 24, 2024, recommended that the resident's wound was to be cleansed with VASHE (a wound…

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 reviews and staff interviews, it was determined that the facility failed to ensure that discharge instructions that included post-discharge medications and a post-discharge plan of care was completed for one of three discharged residents reviewed (Resident 149). Findings include: A nursing note for Resident 149, dated October 31, 2024, at 7:31 p.m. revealed that the resident was picked up by a transport company to discharge to another facility. As of October 30, 2024, there was no documented evidence that Resident 149 was provided discharge instructions that included post-discharge medications or a post-discharge plan of care. Interview with the Assistant Nursing Home Administrator on January 30, 2025, at 3:25 p.m. confirmed that there was no documented evidence that Resident 149 was provided discharge instructions that included post-discharge medications or a post-discharge plan of care. 28 Pa. Code 211.5(d) Clinical Records. 28 Pa. Code 211.9(j.1)(4) Pharmacy Services.

Based on review of clinical records and personnel files, as well as staff interviews, it was determined that the facility failed to ensure that physician's orders were followed for one of 66 residents reviewed (Resident 44), and failed to follow recommendations from a interventional radiology consultation for one of 66 residents reviewed (Resident 79). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 44, dated November 20, 2024, indicated that the resident was cognitively impaired, received pain medication routinely, and received an opioid. Physician's orders, dated November 25, 2024, included an order for the resident to receive 12 micrograms per hour (mcg/hr) of fentanyl (a narcotic pain patch) patch to be applied every 72 hours for pain. A physician's order, dated December 19, 2024, included an order to hold the fentanyl patch until December 20, 2024. A controlled drug accountability record (tracks each dose of a controlled medication) for Resident 44's 12 mcg/hr fentanyl patches revealed…

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 reviews, observations, and staff interviews, it was determined that the facility failed to ensure that each resident received assistance devices to prevent accidents for two of 66 residents reviewed (Residents 64, 120). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 64, dated November 6, 2024, revealed that the resident was cognitively impaired, required assistance from staff for personal care needs, and had diagnoses that included dementia. Physician's orders for Resident 64, dated January 20, 2025, included an order for the resident to be out of bed to an evolution chair in the upright position with bilateral standard leg rests for transport and outside only. Review of the care plan for Resident 64, dated July 11, 2023, revealed that the resident was at risk for falls and that bilateral leg rests were to be used for transport only and outside. Observations of Resident 64 on January 27, 2025, at 10:35 a.m. revealed that the resident was transported in her chair by…

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 reviews and staff interviews, it was determined that the facility failed to ensure that the physician and the Certified Registered Nurse Practitioner (CRNP - a registered nurse with advanced training) wrote, signed, and dated progress notes with each visit for two of 66 residents reviewed (Residents 79, 84). Findings include: A nursing note for Resident 79, dated December 31, 2024, revealed that the resident was seen at the bedside by the physician. New verbal orders were received. As of January 30, 2025, there was no documented evidence in Resident 79's clinical record that the physician completed a progress note for his visit on December 31, 2024. Interview with the Director of Nursing on January 30, 2025, 11:10 a.m. confirmed that there was no documented evidence in Resident 79's clinical record that the physician completed a progress note for his visit on December 31, 2024, until today when he faxed the progress note to the facility. A nursing note for Resident 84, dated November 2, 2024, revealed that the resident was a new admit to the facility from…

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

Based on a review of facility policies, manufacturer's instructions, and clinical records, as well as observations and staff interviews, it was determined that the facility failed to label multi-dose containers of medications with the date they were opened in one of four medication carts observed (First-Floor Southeast medication cart). Findings include: The facility's policy regarding storage and expiration dating of medications, dated December 30, 2024, revealed that once any medication or biological package is opened, the facility should follow manufacture/supplier guidelines with respect expiration dates for opened medications. Facility staff should record the date opened on the primary medication container when the medication has a shortened expiration date once opened. Manufacturer's directions on the container for use of fluticasone propion-salmeterol (used to control and prevent symptoms (wheezing and shortness of breath) caused by asthma or ongoing lung disease) inhaler revealed that the inhaler was to be discarded one month after being removed from the foil pouch.…

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

Based on clinical record review and staff interview, it was determined the facility failed to ensure timely completion of prescribed laboratory services for two of 66 residents reviewed (Residents 58, 120). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 58, dated October 25, 2024, revealed that the resident was understood and could understand others, required assistance from staff for daily care needs, and had a diagnosis of dementia. Physician's orders for Resident 58, dated October 8, 2024, included an order for staff to obtain a urinalysis (lab test that can detect a urinary tract infection) and culture and sensitivity (identifies the specific microorganism causing an infection). May straight catherize (use a small, flexible tube to drain urine from the bladder) the resident to obtain. Once obtained, place specimen in laboratory refrigerator and call the lab for pick up. A nurse's note for Resident 58, dated October 8, 2024, at 2:05 p.m., revealed that a urine for a urinalysis was…

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

Based on clinical record reviews and staff interviews, it was determined that the facility failed to obtain laboratory studies as ordered by the physician for one of 66 residents reviewed (Resident 18) and failed to obtain a physician's order for an invasive procedure to collect a specimen for a laboratory test for one of 66 residents reviewed (Resident 84). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 18, dated December 16, 2024, revealed that the resident was cognitively intact and had diagnoses that included hypothyroidism (a condition in which the thyroid gland does not produce enough thyroid hormone). Physician's orders for Resident 44, dated June 2, 2024, included an order for staff to obtain a TSH (Thyroid Stimulating Hormone - test used to identify the amount of hormones secreted by the thyroid) on the first Monday of March, June, September, and December. There was no documented evidence that staff obtained Resident 18's TSH for September and December 2024. Interview with…

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

Based on review of established infection control guidelines, facility policy, and residents' clinical records, as well as observations and staff interviews, it was determined that the facility failed to follow infection control guidelines from the Centers for Medicare/Medicaid Services (CMS) and the Centers for Disease Control (CDC) to reduce the spread of infections and prevent cross-contamination for one of 66 residents reviewed (Resident 79). Findings include: CDC guidance on isolation precautions and Implementation of Personal Protective Equipment (PPE) use in Nursing Homes to Prevent Spread of Multidrug-Resistant Organisms (MDRO's - bacteria that have become resistant to certain antibiotics, and these antibiotics can no longer be used to control or kill the bacteria), dated July 12, 2022, indicates that MDRO transmission is common in skilled nursing facilities, contributing to substantial resident morbidity and mortality and increased healthcare costs. Enhanced Barrier Precautions (EBP's) are an infection control intervention designed to reduce transmission of resistant…

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 meal schedule, and resident and staff interview, it was determined that the facility failed to ensure that meals were served at regularly scheduled times on the nursing unit. Findings include: Review of the facility's tray delivery logs revealed that meals are expected to be delivered within 10 minutes before or after scheduled time for meal delivery. On January 6, 2025, the breakfast meal for 300 North hall was to be delivered at 7:15 a.m. Review of the tray delivery log provided by the facility revealed that the tray was delivered to the unit at 7:37 a.m., 22 minutes late. The breakfast meal delivery for rooms 417-424 and 425-433 was scheduled for 7:20 a.m.; however, review of the tray delivery log revealed that the tray was delivered to the unit at 7:48 a.m., 28 minutes late. On January 5, 2025, the breakfast meal for 300 East and [NAME] halls was scheduled for 6:45 a.m.; however, review of the tray delivery log revealed that the breakfast meal trays were delivered to the unit at 7:06 a.m., 21 minutes late. The breakfast meal for 100 East 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 observations and staff interviews, it was determined that the facility failed to ensure that food was served under sanitary conditions. Findings include: Observations in the main kitchen cooking area on January 7, 2025, at 9:25 a.m. revealed an area where two steam kettles had a large amount of water accumulated on the floor underneath them, running out to an area where staff can walk. Observations in dishwashing area on January 7, 2025, at 9:30 a.m. revealed a significant amount of water accumulated on the floor under and around the sides of the dishwasher. A noticeable leak of water was observed coming from a pipe on the side of the dishwasher and running underneath it. Condensation was noted on the ceiling and water was observed dripping onto the floor from the ceiling. Observations on January 7, 2025, at 9:35 a.m. of the walk-in freezer on the lower level of the dietary department revealed that there was a buildup of ice on the floor in front of the racks against the back wall. Interview with the Dietary Manager on January 7, 2025, at 9:40 a.m. revealed that one steam…

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 job descriptions and the deficiencies cited during the current survey, it was determined that the Nursing Home Administrator (NHA) and the Director of Nursing (DON) failed to assume responsibility for effective management of the facility to ensure that the residents' environment remained free of accident hazards. Findings include: The job description for the NHA, dated July 19, 2024, indicated that the NHA is to lead, direct, and manage the overall operations of the community in accordance with policies and procedures and current federal, state and local standards, guidelines and regulations that govern the community. As the NHA, it is their responsibility to organize, develop and direct resources to maintain the highest degree of quality care for each resident at all times. The job description for the DON, July 27, 2021, indicated that the DON was responsible for managing all nursing functions, including planning, organizing, directing and controlling nursing services. Coordinates related services to ensure total quality care of geriatric residents and residents…

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

Based on review of facility policies, clinical records, and shower schedules, as well as staff interviews, it was determined that the facility failed to ensure that residents were provided with showers as scheduled for two of six residents reviewed (Residents 2, 4). Findings include: A facility policy for bath and shower scheduling, dated December 12, 2023, included that each resident will be scheduled to receive bathing at a minimum of two times per week unless they prefer less frequent baths. When the bath or shower is complete, the nursing assistant will document the activity on the shower sheet or in the point of care section of the electronic record. An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 2, dated April 12, 2024, revealed that the resident was cognitively impaired, required partial to moderate assistance from staff for showering, and had diagnoses that included dementia. Physician's orders for Resident 2, dated December 30, 2023, included an order for the resident to receive a shower every…

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

Based on review of policies, as well as observations and staff interviews, it was determined that the facility failed to store food in accordance with professional standards of food service safety by failing to properly label and date frozen and refrigerated foods. Findings include: The facility's policy regarding preparation and handling, dated December 12, 2023, revealed that foods were to be properly labeled and dated. Observations in the kitchen on June 20, 2024, at 11:44 a.m. revealed that the reach-in freezer had a metal container of frozen macaroni and cheese that was not labeled and dated, and the walk-in refrigerator had a plastic container of diced tomatoes, a metal pan of sliced tomatoes, and multiple plates containing lettuce and tomato that were not labeled or dated. Interview with [NAME] 2 on June 20, 2024, at 11:50 a.m. confirmed that all food in the freezers and refrigerators were to be labeled and dated. 28 Pa. Code 211.6(f) Dietary Services.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that staff used proper infection control techniques during incontinent care for two of six residents reviewed (Residents 5, 6). Findings include: The facility's policy regarding hand hygiene, dated December 12, 2023, indicated that unless hands were visibly soiled, an alcohol-based hand rub was preferred over soap and water in most clinical situations due to evidence of better compliance compared to soap and water. Healthcare personnel were to use an alcohol-based hand rub or wash with soap and water for the following clinical indications: immediately before touching a resident, before performing an aseptic task (free from contamination) or handling invasive medical devices; before moving from work on a soiled body site to a clean body site on the same resident; after touching a resident or the resident's immediate environment; after contact with blood, body fluids,…

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

Based on review of policies, clinical records, and investigation documents, as well as staff interviews, it was determined that the facility failed to ensure that allegations of physical abuse were reported in a timely manner for one of 10 residents reviewed (Resident 2). Findings include: The facility's abuse policy, dated December 12, 2023, indicated that it is the facility's policy to investigate all allegations, suspicions, and incidents of abuse. Staff must immediately report all such allegations to the Nursing Home Administrator/Abuse Coordinator. The Nursing Home Administrator/Abuse Coordinator would immediately begin an investigation and notify the applicable local and state agencies in accordance with the procedures in the policy. If the event that caused the allegation involves an alleged abuse, it should be reported to the Department of Health immediately, but no later than two hours after the allegation is made. An annual MDS assessment for Resident 2, dated May 17, 2024, revealed that the resident was sometimes understood, could usually understand others, required…

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 Pennsylvania's Nursing Practice Act and clinical records, as well as staff interviews it was determined that the facility failed to ensure that an assessment was completed by a professional (registered) nurse after an injury occurred for one of 10 residents reviewed (Resident 2). Findings include: The Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.11 (a)(1)(2)(4) indicated that the registered nurse was to collect complete and ongoing data to determine nursing care needs, analyze the health status of individuals and compare the data with the norm when determining nursing care needs, and carry out nursing care actions that promote, maintain, and restore the well-being of individuals. An annual minimum data set (MDS) assessment (mandated to assess the resident abilities and care needs) for Resident 2, dated May 17, 2024, revealed that the resident was sometimes understood and could usually understand others, required substantial or maximum assistance with personal hygiene, was independent with ambulation, and had…

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

Based on review of facility policies and personnel records, as well as staff interviews, it was determined that the facility failed to ensure that reference checks were obtained prior to hire for four of five new employees reviewed (Nurse Aides 3 and 4, Licensed Practical Nurse 5, Registered Nurse 6). Findings include: The facility's policy regarding abuse, dated December 12, 2023, indicated that prior to hiring a new employee the facility would generally attempt to obtain references from two prior employers for an applicant. The personnel file for Nurse Aide 3 revealed that she was hired on October 22, 2023, and there was no documented evidence that reference checks from previous employers were obtained prior to the staff's start date. The personnel file for Nurse Aide 4 revealed that she was hired on December 7, 2023, and there was no documented evidence that reference checks from previous employers were obtained prior to the staff's start date. The personnel file for Licensed Practical Nurse 5 revealed that she was hired on December 18, 2023, and there was no documented evidence…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the Resident Assessment Instrument User's Manual and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that comprehensive admission and annual Minimum Data Set assessments were completed in the required time frame for six of 65 residents reviewed (Residents 16, 55, 118, 123, 129, 130). Findings include: The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which provides instructions and guidelines for completing required Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2023, indicated that an admission MDS assessment was to be completed no later than 14 days following admission, that the Assessment Reference Date (ARD - the last day of an assessment's look-back period) must be set within 366 days after the ARD of the previous comprehensive assessment, and that the assessment was to be completed no later than the ARD plus 14 calendar days. An admission…

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 Resident Assessment Instrument User's Manual and clinical records, as well as staff interviews, it was determined that the facility failed to complete accurate Minimum Data Set assessments for five of 65 residents reviewed (Residents 21, 41, 51, 90, 113). Findings include: The Resident Assessment Instrument (RAI) User's Manual, which gives instructions for completing Minimum Data Set (MDS) assessments (required assessments of a resident's abilities and care needs), dated October 2023, revealed that Section N0415E1 Anticoagulant (medicines that help prevent blood clots) Medications was to be coded if an anticoagulant medication was taken by the resident at any time during the seven-day look-back period. Physician's orders for Resident 21, dated January 9, 2024, included an order for the resident to receive one 3 milligram (mg) tablet of Warfarin (an anticoagulant) at bedtime. Review of the Medication Administration Record (MAR) for Resident 21, dated January 2024, revealed that staff had administered the 3 mg tablet of Warfarin to the resident 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.

Based on clinical record reviews and staff interviews, it was determined that the facility failed to ensure that the Certified Registered Nurse Practitioner/physician wrote, signed, and dated progress notes with each visit for one of 65 residents reviewed (Resident 8). Findings include: Nursing notes for Resident 8, dated July 21 and 28, 2023; August 2, 7, and 29, 2023; September 18, 2023; October 9, 2023; November 1, 2023; December 13, and 28, 2023; and February 5, 2024, revealed that the resident was seen by Certified Registered Nurse Practitioner 8 (CRNP - a registered nurse with advanced training). As of February 13, 2024, there was no documented evidence in Resident 8's clinical record that CRNP 8 had completed a progress note for her visits to the resident on the above dates. A nursing note for Resident 8, dated December 14, 2023, revealed that the resident was seen by the physician for a regulatory visit. As of February 13, 2024, there was no documented evidence in Resident 8's clinical record that the physician had completed a progress note for his visit to the resident on…

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

Based on review of facility policies and observations, as well as resident and staff interviews, it was determined that the facility failed to serve food items at appetizing temperatures. Findings include: The facility's policy regarding food temperatures, dated December 12, 2023, revealed that hot food items may not fall below 135 degrees Fahrenheit (F) while holding after cooking. Hot food should be at least 135 degrees F when plated. Hot food should be palatable at point of delivery. Interview with Resident 41 on February 11, 2024, at 10:00 a.m. revealed that she does not like the taste of the food. Interview with Resident 143 on February 11, 2024, at 10:08 a.m. revealed that the meat is dry, there is no flavor, and the meals are sometimes cold when she gets her tray. Interview with Resident 26 on February 11, 2024, at 10:20 a.m. revealed that the food is awful, never tastes good, and is not warm when he gets his tray. Observations in the main kitchen on February 13, 2024, revealed that the Third Floor South Shoe cart left the main kitchen at 12:37 p.m. and arrived on the Third…

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 reviews and observations, as well as resident and staff interviews, it was determined that the facility failed to ensure that residents' drink preferences were honored for 16 of 65 residents reviewed (Residents 3, 10, 25, 38, 41, 45, 51, 65, 67, 87, 98, 102, 105, 106, 112, 117). Findings include: Interview with a group of residents on February 12, 2024, at 3:00 p.m. revealed that they wanted to have soda as a drink choice, either for meals or for a snack. They stated that there was no soda available for them at all. The residents stated that they were told that they could purchase their own soda from the vending machines in the building, or they could have someone bring in soda for them, but it would no longer be supplied for them by the facility. Interview with the Dietary Manager on February 13, 2024, at 11:59 a.m. revealed that the facility has some soda that he will use for special occasions; however, he is not permitted to order soda for the residents on a regular basis. He indicated that the decision came from his corporate office that they could no…

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

Based on review of facility policies, as well as observations and staff interviews, it was determined that the facility failed to ensure that food was stored and served under sanitary conditions, in accordance with professional standards for food service safety, and failed to ensure that food items were stored in accordance with professional standards for food service safety in three of three nursing unit pantry refrigerators (first, third, fourth floor pantries). Findings include: The facility's policy regarding food storage, dated December 12, 2023, indicated that dented cans shall be stored separately or immediately returned to the food supplier. If dented cans are stored in the storeroom, they are to be clearly marked to prevent usage. Observations in the main kitchen in the dishwashing area on February 11, 2024, at 8:51 a.m. and February 13, 2024, at 11:55 a.m. revealed that the ceiling and wall by the door exiting the dish room into the hallway had large areas where the paint was cracked, peeling, and hanging down. The ceiling that leads from the dish room to the tray line…

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 the facility's plans of correction for previous surveys, and the results of the current survey, it was determined that the facility's Quality Assurance Performance Improvement (QAPI) committee failed to maintain compliance with nursing home regulations and ensure that plans to improve the delivery of care and services effectively addressed recurring deficiencies. Findings include: The facility's deficiencies and plans of corrections for State Survey and Certification (Department of Health) surveys ending February 16, 2023; March 9, 2023; March 29, 2023; June 6, 2023; July 13, 2023; August 23, 2023; September 15, 2023; October 18, 2023; and November 6, 2023, revealed that the facility developed plans of correction that included quality assurance systems to ensure that the facility maintained compliance with cited nursing home regulations. The results of the current survey, ending February 14, 2024, identified repeated deficiencies related to a failure to notify residents' physician/responsible parties regarding changes in condition, to provide a clean and homelike…

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

Based on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that a resident's physician was notified about the need to alter treatment for one of 65 residents reviewed (Resident 51). Findings include: The facility's policy regarding Diabetic Protocol, dated December 12, 2023, indicated that the provider and staff will work together give appropriate treatments to manage diabetes. An annual Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 51, dated November 10, 2023, indicated that the resident was cognitively intact, required assistance with daily care needs, and had diagnoses that included diabetes (a disease that interferes with blood sugar control). Physician's orders for Resident 51, dated January 22, 2024, included an order to check the resident's blood sugar before meals and at bedtime and notify the physician if the blood sugar was greater than 400 milligrams per deciliter (mg/dL). A review of Resident 51's Medication Administration…

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

Based on review of policies, as well as observations and staff interviews, it was determined that the facility failed to maintain a clean and homelike environment for one of 65 residents reviewed (Resident 33). Findings include: The facility's policy regarding cleaning and disinfecting, dated December 12, 2023, indicated that housekeeping was to remove visible debris from surfaces and that proper cleaning was necessary to reduce infection. A quarterly Minimum data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 33, dated January 17, 2024, revealed that the resident was cognitively impaired and had diagnoses that included acute respiratory disease (a serious blood condition that causes low blood oxygen) and a history of atrial fibrillation (irregular heart rhythm). The resident was receiving continuous oxygen via nasal cannula (tubes that deliver oxygen into the nostrils). Observations on February 11, 2024, at 12:20 p.m. and 2:27 p.m. revealed that the resident was lying in her bed with a stand-up fan blowing directly on her. The fan…

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 the Resident Assessment Instrument Manual and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that quarterly Minimum Data Set assessments were completed within the required timeframe for three of 65 residents reviewed (Residents 45, 47, 77). Findings include: The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which provides instructions and guidelines for completing Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2023, indicated that the assessment reference date (ARD - the last day of the assessment's look-back period) of a quarterly MDS assessment must be no more than 92 days after the ARD of the most recent assessment of any type, and the assessment was to be completed no later than the ARD plus 14 calendar days. A quarterly MDS assessment for Resident 45, with an ARD of January 16, 2024, was due to be completed by January 30, 2024, but was not signed as completed until February 8, 2024, which was 23 days from the…

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

Based on review of facility policies and clinical record reviews, as well as staff interviews, it was determined that the facility failed to develop comprehensive care plans that included specific and individualized interventions to address the care needs of two of 65 residents reviewed (Residents 57, 109). Findings include: A policy regarding care plans, dated December 12, 2023, indicated that the facility was to develop a comprehensive person-centered care plan for each resident that included measurable objectives and timetables to meet the resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessments. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 57, dated November 13, 2023, revealed that the resident was cognitively intact, and was receiving an anti-depressant and an anti-psychotic medication. Physician's orders for Resident 57, dated November 7, 2023, included an order for the resident to receive 40 milligrams (mg) of Celexa (anti-depressant) once…

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, as well as observations and staff interviews, it was determined that the facility failed to provide an environment that was free of accident hazards by failing to follow physician's orders and care-planned interventions for one of 65 residents reviewed (Resident 119) who was at risk for skin breakdown. Findings include: A quarterly Minimum data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 119, dated November 10, 2023, revealed that the resident was cognitively impaired and had diagnoses that included Alzheimer's disease. A care plan, dated November 14, 2023, revealed that the resident was at risk for skin breakdown. Physician's orders for Resident 119, dated June 30, 2023, included orders for the resident to have a wedge seat cushion on her wheelchair, a red foam cover on the right brake handle, palm guards (guards worn on the hands to protect the fingers from injuring the palms) around both leg rest brackets of the wheelchair frame, and geri-sleeves (material sleeves that provide protection…

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

Based on review of policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that residents received oxygen as ordered by the physician for one of 65 residents reviewed (Resident 33). Findings include: The facility's policy regarding oxygen therapy, dated December 12, 2023, indicated that oxygen was to be administered by licensed staff and in accordance with physician's orders. A quarterly Minimum data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 33, dated January 17, 2024, revealed that the resident was cognitively impaired and had diagnoses that included acute respiratory disease (a serious condition that causes low blood oxygen) and a history of atrial fibrillation (irregular heart rhythm). A care plan, dated January 25, 2022, indicated that Resident 33 was to receive continuous oxygen at 2 liters per minute via nasal cannula (tube that delivers oxygen into the nostrils). Physician's orders for Resident 33, dated June 19, 2023, included an order for 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, as well as staff interviews, it was determined that the facility failed to ensure that a physician performed the initial comprehensive visit with the resident for one of 65 residents reviewed (Resident 96). Findings include: Resident 96's clinical record revealed that the resident was admitted to the facility on [DATE]. A Certified Registered Nurse Practitioner's (CRNP, a registered nurse who has advanced education and clinical training in a health care specialty area) note for Resident 96, dated September 18, 2023, revealed that the resident was seen by the CRNP. Additional CRNP notes, dated October 26, 2023; November 8, 2023; and November 20, 2023, revealed that all visits were completed by the CRNP and not the attending physician. There was no documented evidence in Resident 96's clinical record to indicate that the physician saw the resident until January 9, 2024, which was four months after the resident was admitted to the facility. Interview with the 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.

Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure the accountability of controlled medications for one of 65 residents reviewed (Resident 113). Findings include: The facility's policy regarding medication administration, dated December 12, 2023, indicated that during medication administration, facility staff should take all measures required by facility policy and applicable law, document the administration of controlled substances in accordance with applicable law and observe the resident's consumption of the medication(s), and document necessary medication administration/treatment information on appropriate forms. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 113, dated January 3, 2024, revealed that the resident was alert and oriented, received an antianxiety medication, and had diagnoses that included anxiety (a feeling of fear, dread, and uneasiness). Physician's orders for Resident 113, dated November 16, 2023, and…

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

Based on review of manufacturer's instructions and facility policy, as well as observations and staff interviews, it was determined that the facility failed to label medication when opened for one of two medication storage rooms reviewed. Findings include: The manufacturer's instructions for Aplisol (an injectable medication used to detect exposure to the bacteria that causes tuberculosis), dated March 2016, indicated that opened and in-use vials of Aplisol were to be discarded in 30 days. The facility policy regarding storage and expiration dating of medications, biologicals, dated December 12, 2023, indicated that if a multi-dose vial of an injectable medication had been opened or accessed, the vial should be dated and discarded within 28 days unless the manufacturer specifies a different date for that opened vial. Observations in the first floor medication refrigerator on February 14, 2024, at 9:57 a.m. revealed that there were two 1.0 milliliter (ml) vials of Aplisol, each in its own box. The safety cap (a plastic cap put on by the manufacturer and that is removed prior to…

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

Based on review of policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that proper infection control practices and techniques were followed during the administration of medications. Findings include: The facility's policy regarding medication and administration through certain routes, dated December 12, 2023, indicated that staff were to cleanse their hands and wear gloves, draw up the medication dose, and select the appropriate injection site. After the injection, staff were to dispose of equipment according to facility policy and cleanse hands. Physician's orders for Resident 82, dated November 29, 2023, included an order for the resident to receive 32 units of Lantus Insulin (a long-acting Insulin) once a day in the a.m. Physician's orders for Resident 82, dated July 6, 2023, included an order for the resident to receive Humulin R regular insulin (a fast-acting Insulin) via a sliding scale (varies the dose of insulin based on blood glucose level). If the blood sugar is less than 60 milligram/deciliter…

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 Pennsylvania's Nursing Practice Act and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that nursing services provided met professional quality of standards for one of 14 residents reviewed (Resident 6). This deficiency was cited as past non-compliance. Findings include: The Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing 21.11 (a)(1)(2)(4) indicated that the registered nurse was responsible for assessing human responses and plans, implementing nursing care, analyzing/comparing data with the norm in determining care needs, and carrying out nursing care actions that promote, maintain, and restore the well-being of individuals. A nursing note for Resident 6, dated November 22, 2023, at 6:00 p.m. revealed that this nurse was called to the unit for the resident being on the floor. The resident was sitting on the floor with multiple staff members present. The unit nurse was wiping blood from the resident's hands where he touched the skin tear on his nose/above his nose. A…

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

Based on review of clinical records, as well as staff interviews, it was determined that the facility failed to follow recommendations from a gastroenterologist (a medical doctor who specializes in conditions affecting your digestive system) for one of 14 residents reviewed (Resident 8). Findings include: A nursing note for Resident 8, dated December 21, 2023, revealed that the registered nurse received a call from the gastroenterologist's representative regarding the results from an Esophagogastroduodenoscopy (EGD - a test to examine the lining of the esophagus, stomach, and first part of the small intestine) that was done in October 2023. The resident was scheduled to return for follow-up appointment and discussion of the results on December 15, 2023, but the appointment was rescheduled to January 29, 2024, at 1:00 p.m. They were going to fax the results to the facility but provided the results over the phone. The results showed inflammation and Barrett's Esophagus (damage to the lower portion of the tube that connects the mouth and stomach). The gastroenterologist recommended an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to investigate injuries of unknown origin to rule out abuse or neglect for one of five residents reviewed (Resident 2) who suffered a fracture of the wrist. Findings include: The facility's abuse policy, dated October 9, 2023, indicated that all incidents or accidents, including injuries of unknown origin, involving residents were to be reported to administration and that an investigation would be conducted immediately. An annual Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 2, dated November 30, 2023, indicated that the resident was severely confused, unable to verbally communicate, was dependent on staff for all her daily care needs, and had diagnoses that included intellectual disabilities (a limited ability to learn at an expected level and function in daily life). A note by Certified Registered Nurse Practioner 1 (CRNP -…

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

Based on review of policies, clinical records, and information provided by the facility, as well as family and staff interviews, it was determined that the facility failed to make ongoing efforts to resolve the grievances of residents and/or their legal representatives and ensuring that a written copy of the grievance/complaint decision was provided to the resident and/or resident representative for one of 11 residents reviewed (Resident 4). Findings include: The facility's policy regarding grievances and concerns, dated October 9, 2023, revealed that the facility recognizes that residents have the right to voice grievances to the facility, or other agencies or entities that hear grievances, without discrimination or reprisal and without fear of discrimination or reprisal. Upon receipt of an oral, written, or anonymous grievance submitted by a resident, the grievance official will take immediate action to prevent further potential violations of any resident right while the alleged violation is being investigated, if indicated. The grievance committee/grievance official shall…

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 Pennsylvania's Nurse Practice Act, policies, and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that the physician's orders were clarified for tracheostomy care for one of the 11 residents reviewed (Resident 2). Findings include: The Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.11 (a)(1)(2)(4) indicated that the registered nurse was to collect complete and ongoing data to determine nursing care needs, analyze the health status of individuals and compare the data with the norm when determining nursing care needs, and carry out nursing care actions that promote, maintain and restore the well-being of individuals. The facility policy for physician's orders, dated October 9, 2023, indicated that the charge nurse was to review all physician's orders. An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 2, dated October 9, 2023, revealed that the resident had a tracheostomy (an opening into the…

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

Based on review of facility policies, observations, and staff interviews, it was determined that the facility failed to ensure that food was served under sanitary conditions. Findings include: The facility's policy for the use of disposable gloves, dated October 9, 2023, indicated that single-use gloves were to be worn when handling food directly with hands to prevent cross contamination. Bare-hand contact with ready-to-eat foods was prohibited. Observations of Resident 9 on November 6, 2023, at 1:14 p.m. revealed that Nurse Aide 1 prepared the resident's meal and directly touched two sandwich buns with his bare hands while making the resident's pulled pork sandwiches. Observations of Resident 10 on November 6, 2023 at 1:21 p.m. revealed that Nurse Aide 1 prepared the resident's meal and directly touched the sandwich bun with his bare hands while making the resident his pulled pork sandwich. Interview with Nurse Aide 1 on November 6, 2023 at 1:24 p.m. confirmed that he should have had gloves on while handling the sandwich buns. Interview with the Director of Nusing on November 6,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that a resident who displayed mental or psychosocial adjustment difficulties received appropriate treatment and services to correct the problem for one of 15 residents reviewed (Resident 4). Findings include: The facility's behavior management policy, dated October 9, 2023, revealed that the facility was to improve the management of behaviors and move closer to the goal of ending any inappropriate or unnecessary use of antipsychotic medications. The facility would assess and track a behavior that negatively impacted each resident in regards to their quality of life. The interdisciplinary team (IDT) would review newly identified behaviors during risk rounds to ensure appropriate documentation was in place for new behaviors and/or different behaviors for a resident. The IDT would complete the behaviors/psychotropic review form and identify the root cause for the behavior utilizing the…

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

Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to maintain accountability for controlled medications (drugs with the potential to be abused) for one of 14 residents reviewed (Resident 5). Findings include: The facility's current policy regarding the administration of oral medications, indicated that the nurse will document on the Medication Administration Record (MAR) with their initials, at the appropriate date and time for the medication administered, after witnessing the ingestion of the medication. An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 5, dated September 25, 2023, revealed that the resident could understand others and was able to make himself understood, required extensive assist of two staff for daily care needs, had diagnoses of end-stage renal disease and diabetic neuropathy, and was receiving routine and as-needed pain medications. Physician's orders for Resident 5, dated September 22, 2023, included an order for…

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

Based on review of Pennsylvania's Nursing Practice Act and clinical records, as well as staff interviews, it was determined that the facility failed to correctly transcribe physician's orders for one of nine residents reviewed (Resident 2) and failed to clarify a physician's order for one of nine residents reviewed (Resident 4). Findings include: The Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.11 (a)(1)(2)(4) indicated that the registered nurse was to collect complete and ongoing data to determine nursing care needs, analyze the health status of individuals and compare the data with the norm when determining nursing care needs, and carry out nursing care actions that promote, maintain and restore the well-being of individuals. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 2, dated July 26, 2023, revealed that the resident was able to make himself understood and could understand others, required extensive assistance from staff for his daily care tasks, 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 facility policy and clinical record reviews, as well as staff interviews, it was determined that the facility failed to provide care and treatment in accordance with professional standards of practice, by failing to follow physician's orders for one of nine residents reviewed (Resident 2) and failing to monitor skin and wound conditions for one of nine residents reviewed (Resident 4). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 2, dated July 26, 2023, revealed that the resident was able to make himself understood and could understand others, required extensive assistance from staff for his daily care tasks, and had a diagnosis which included dementia. Physician's orders for Resident 2, dated July 17, 2023, included an order for the resident to wear Geri-Sleeves (knitted arm protectors to help prevent skin tears, bruises and abrasions) to both arms at all times. Observations of Resident 2 on September 12, 2023, at 9:31 a.m. revealed that he was sitting in his wheelchair in the…

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

Based on observations and staff interviews, it was determined that the facility failed to serve food items that were palatable and at proper temperatures. Findings include: The facility's policy regarding food temperatures, dated November 8, 2022, indicated that cold foods must be served at temperatures of 41 degrees Fahrenheit (F) or below. Observations in the kitchen on September 12, 2023, at 11:37 a.m. revealed that a lunch test tray left the kitchen and arrived on the third floor nursing unit at 11:43 a.m. Trays were passed to the residents in their rooms, and the last resident was served and eating at 12:00 p.m. The temperature of the macaroni salad on the test tray at 12:03 p.m. was 61 degrees F and the marinated green beans (which are to be served cold) was 71 degrees F. Both of the food items were not cold or palatable. Interview with the Dietary Director on September 12, 2023, at 12:03 p.m. confirmed that foods should be served to residents at proper temperatures, and that cold foods should be served at 41 degrees F or below. 28 Pa. Code 201.18(b)(1)(2)(e) Management. 28…

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, as well as observations and staff interviews, it was determined that the facility failed to ensure that dependent residents were given proper nail care for one of nine residents reviewed (Resident 6). Findings include: An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 6, dated May 29, 2023, revealed that the resident was cognitively impaired and required extensive assistance from staff for daily care needs. Observations of Resident 6 during wound care on his neck September 12, 2023, at 1:10 p.m. revealed that the resident's fingernails were one-quarter inch long, dirty and had a dried, removable substance under them. Interview with Registered Nurse 2 on September 12, 2023, at 1:15 p.m. confirmed that Resident 6's fingernails were long and dirty. Registered Nurse 2 revealed that Resident 6 scratches the wound on his neck and that there is dried blood under his fingernails. Interview with Nursing Home Administrator on September 12, 2023, at 4:25 p.m. confirmed that Resident…

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

Based on clinical record reviews, observations, and interviews with residents and staff, it was determined that the facility failed to provide foot care for one of nine residents reviewed (Resident 1). Findings include: An annual Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated June 15, 2023, revealed that the resident was alert and oriented; required extensive assistance with bed mobility, dressing, toileting, and hygiene; was dependent on staff for bathing; and has a current diagnosis of Type 2 Diabetes (problem in the way the body regulates and uses sugar as a fuel). Physician's orders for Resident 1, dated July 5, 2023, indicated that she may see a podiatrist as needed. An interview with Resident 1 on September 12, 2023, at 12:24 p.m. revealed that she has not had podiatry care for months. Observations of Resident 1's toe nails revealed that the toe nails were yellow and over grown, with some of the nails curling over the top of the toes on both feet. A podiatry consult for Resident 1, dated February 21,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that residents maintained acceptable parameters of nutritional status, by failing to ensure timely notification of the physician for one of nine residents reviewed (Resident 4). Findings include: A facility policy for food and nutrition anthropometrics (measurements), dated November 8, 2022, indicated that any resident with a new significant weight change (five percent or more in one month) will be weighed weekly until stable or unless the provider orders otherwise. All significant weight changes must be communicated to the resident, the attending physician, and responsible party. An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 4, dated August 25, 2023, revealed that the resident could make himself understood and could understand others, required extensive assistance for personal care needs, and…

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

Based on review of clinical records, as well as staff interviews, it was determined that the facility failed to ensure that physician's orders were obtained to flush long-term intravenous catheters (small tube inserted into a vein to deliver fluids or medication) for one of nine residents reviewed (Resident 4). Findings include: An admission minimum data set (MDS) assessment (mandated to assess the resident abilities and care needs) for Resident 4, dated August 25, 2023, revealed that the resident could make himself understood and could understand others, required extensive assistance for personal care needs, received intravenous medication, and had diagnoses that includes cellulitis (a bacterial skin infection) and diabetes. Physician's orders for Resident 4, dated September 1, 2023, included an order for the resident's single lumen midline (a type of intravenous catheter) to his right upper arm to be checked for patency and signs and symptoms of infection every shift. Physician's orders, dated August 19 and 21, 2023, and September 1 and 5, 2023, included an order for the resident…

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

Based on clinical record reviews, and resident and staff interviews, it was determined that the facility failed to provide food consistency in accordance with each resident's needs for one of nine residents reviewed (Resident 5). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 5, dated August 4, 2023, revealed that the resident was cognitively impaired and needed extensive assistance of one staff for eating. Physician's orders, dated June 28, 2023, included and order for the resident to receive a regular, pureed diet (for people who have trouble chewing and swallowing). Observations of Resident 5 during the lunch meal on September 12, 2023, at 1:17 p.m. revealed that she was in her room and her daughter was feeding her. There was a bowl of fruit on the lunch tray and Resident 5's daughter gave her a bite of it. Resident 5 began to spit out chunks of fruit. The resident's meal ticket indicated that the resident was to receive a pureed fruit cup with her lunch meal. Interview with Registered…

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 dietary records, as well as observations and staff interviews, it was determined that the facility failed to ensure that residents were served food in accordance with their preferences and requests for one of nine residents reviewed (Resident 5). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 5, dated August 4, 2023, revealed that the resident was cognitively impaired and needed extensive assistance of one for eating. Physician's orders, dated June 28, 2023, included an order for the resident to receive a regular, pureed diet (for people who have trouble chewing and swallowing) with special instructions for double portion of gravy. Observations of Resident 5 during the lunch meal on September 12, 2023, at 1:17 p.m. revealed that she was in her room and her daughter was feeding her. The dietary ticket on her lunch tray indicated that she was to receive a double portion of gravy in a bowl. However, her lunch tray did not have a bowl of gravy on it.…

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

Based on clinical record reviews and staff interviews, it was determined that the facility failed to ensure that residents' clinical records were complete and accurately documented for one of nine residents reviewed (Resident 7). Findings include: Physician's orders for Resident 7, dated July 7, 2023, included an order for the resident to receive 30 cubic centimeter (cc) of Prostat (a protein supplement) twice a day. Physician's orders for Resident 7, dated June 23, 2023, included an order for the resident to receive one 81 milligram (mg) tablet of aspirin every day. Physician's orders for Resident 7, dated July 1, 2023, included an order for the resident to receive one 5 mg tablet of Eliquis (a blood thinner) twice a day. Physician's orders for Resident 7, dated July 2, 2023, included an order for the resident to receive one 250 mg tablet of erythromycin (used to prevent and treat infections in many different parts of the body) twice a day. Physician's orders for Resident 7, dated July 1, 2023, included an order for the resident to receive one 250 mg capsule of Florastor (a…

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

Based on clinical record reviews and pharmacy proof of delivery slips, as well as staff interviews, it was determined that the facility failed to ensure that the resident's physician was notified timely about the unavailability of a medication for one of nine residents reviewed (Resident 7). This deficiency was cited as past non-compliance. Findings include: Physician's orders for Resident 7, dated July 2, 2023, included an order for the resident to receive one 250 milligram (mg) tablet of erythromycin (used to prevent and treat infections in many different parts of the body) twice a day. A pharmacy proof of delivery for Resident 7, dated July 5, 2023, revealed that the resident's erythromycin was not filled due to being out of stock and being on a manufacturer's back order. However, there was no documented evidence that Resident 7's physician was contacted on July 5, 2023, regarding the resident's erythromycin not being filled due to being out of stock and on a manufacturer's back order. Interview with the Director of Nursing on August 25, 2023, at 5:55 p.m. confirmed that there…

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

Based on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that a baseline care plan included instructions regarding fall precautions for one of nine residents reviewed (Resident 3). Findings include: The facility's policy for baseline care plans, dated November 8, 2022, indicated that the facility would develop a baseline care plan within 48 hours of admission. The baseline care plan will include the instructions needed to provide effective and person-centered care of the resident. A nursing note for Resident 3, dated August 11, 2023, at 4:45 p.m. indicated that the resident was admitted to the facility at that time. A nursing note for Resident 3, dated August 11, 2023, at 5:17 p.m. indicated that the nurse aide who was passing dinner trays entered the resident's room and observed the resident on the floor. The resident was noted to be lying on the floor in front of her wheelchair on her left side, and the resident had a hematoma (caused by injury, blood collects and pools under the skin) to the left…

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

Based on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to provide medications as ordered by the physician for two of nine residents reviewed (Residents 2, 4). This deficiency was cited as past non-compliance. Findings include: The facility's medication administration observation form, undated, indicated that the nurse was to properly verify the medication, dose, route and labeled directions for use against the medication administration record, and the resident was to be identified prior to giving the medication. A significant change Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 2, dated July 17, 2023, revealed that the resident was cognitively intact, required extensive assist from staff for personal care needs, had a colostomy (an opening for the colon, or large intestine, through the stomach) and had diagnoses that included obstructive uropathy (condition in which the flow of urine is blocked) and diabetes. Physician's orders for Resident 2,…

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

Based on review of facility policies and clinical record reviews, as well as resident and staff interviews, it was determined that the facility failed to provide colostomy care for two of nine residents reviewed (Resident 2). Findings include: The facility's policy for Ostomy Care Procedures, dated November 8, 2023, revealed that nursing personnel with demonstrated competence may provide routine ostomy site care including colostomy. A significant change Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 2, dated July 17, 2023, revealed that the resident was cognitively intact, required extensive assist from staff or personal care needs, had a colostomy (an opening for the colon, or large intestine, through the stomach), and had diagnosis that included obstructive uropathy (condition in which the flow of urine is blocked) and diabetes. Review of the Medication Administration Record (MAR) for Resident 2, dated July 2023 and August 2023, revealed that the resident had no orders for routine colostomy care and that there was no…

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.