Elizabethtown Nursing And Rehabilitation

Based on observation, policy review, and staff interviews, it was determined that the facility failed to maintain an infection prevention and control program designed to provide a safe and sanitary environment and to help prevent the transmission of diseases and infections for two of two resident rooms observed (Residents 1 and 2). Findings Include: An entrance interview with the Director of Nursing (DON) and Nursing Home Administrator (NHA) on March 4, 2025, at approximately 8:50 AM, revealed the facility has several residents who tested positive for COVID-19, and the facility is following its COVID-19 infection policy and procedures. Visitors are encouraged to wear surgical masks and screen for signs and symptoms of infection while in the building, and staff providing direct care to those infected residents to wear the required personal protective equipment (PPE). A review of the facility's policy, titled Covid-19 Infection Control Protocols to Minimize Expose, updated February 2024, revealed residents/resident rooms with Covid-19 exposure and positive tests will require staff 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 staff interview and facility policy review, it was determined the facility failed to maintain a data collection system of surveillance for 10 of 12 months reviewed (October 2023, November 2023, December 2023, January 2024, February 2024, March 2024, April 2024, May 2024, June 2024, and July 2024). Findings include: Review of the facility policy, titled Infection Control, last reviewed June 2024, revealed the facility will maintain a monthly line list of residents with infections for trending and outbreak potential, follow-up review of lab data is compared, and a monthly review is completed to identify trends to facilitate infection control surveillance. The purpose of the surveillance of infections is to identify both individual cases and trends of epidemiologically significant organisms and health-care associated infections, to guide appropriate interventions and required reporting, and to prevent future infections. The facility's monthly infection control logs for October 2023 through July 2024 were unable to be provided by the facility. The infection control log book 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 staff interviews and state regulations, it was determined that the facility failed to have an Infection Preventionist (IP) that completed an approved program for specialized training in infection prevention and control. Findings include: The Centers for Medicare and Medicaid Services regulation §483.80(b)(4) stated, The facility must designate one or more individual(s) as the Infection Preventionist(s) (IP(s) who are responsible for the facility's IPCP (Infection Prevention Control Program) that have completed specialized training in infection prevention and control. During an interview with the Director of Nursing (DON) on July 15, 2024, at 10:00 AM, Employee 4's (Registered Nurse) IP credentials were requested. The DON confirmed Employee 4 is currently doing the modules that are required to obtain certification for the IP position. The DON also informed the surveyor that no Infection Control data has been tracked since September 2023. 28 Pa. Code 201.18(b)(2) Management

Based on facility policy review, clinical record reviews, and staff interview, it was determined that the facility failed to offer the option to formulate an advance directive, as evidenced by utilization of only the POLST (Pennsylvania Orders for Life-Sustaining Treatment) and no documentation of the resident's choices pertaining to advanced directives or documenting how the resident was informed of his or her right to develop a living will or advance directive for four of 35 records reviewed (Residents 1, 20, 33, and 45). Findings include: The facility's admission packet referring to the advance directive section stated, . if the resident has a health care directive, he or she must provide a valid executed original advance directive to the Nursing Home Administrator (NHA). There is no indication that residents are offered the opportunity to formulate an advance directive. A review of Resident 1's clinical record failed to include a discussion regarding the opportunity to formulate an Advance Directive. There was no Advance Directive/Living Will present in the clinical record. A…

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

Based on observation, document review, policy review, and staff interviews, it was determined that the facility failed to make prompt efforts to resolve resident grievances for two of 10 grievances reviewed, and failed to post in prominent locations the contact information of the identified Grievance Official, including the name, business address (mailing and email), and business phone number in one facility area observed (facility bulletin board). Findings Include: A review of the facility's policy, titled Resident and Family Concerns and Grievances Policy and Procedure, dated 2022, defines its purpose as To provide for the prompt resolution of medical and non-medical grievances while maintaining confidentiality, in accordance with applicable federal and state statutes and regulations. The policy continued, The Facility will provide the resident with a written Grievance Decision, which shall include: a. the date the grievance was received; b. a summary statement of the resident's grievance; c. the steps taken to investigate the grievance; d. a summary of the pertinent findings or…

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

Based on observation, review of facility policy, and staff interviews, it was determined that the facility failed to store and serve food/beverages in accordance with professional standards for food safety in the kitchen and in one of one nourishment pantries observed and for one of one meal observed. Findings include: Review of facility policy, Outside Food, revised July 2023, read, in part, food brought in from outside sources will be labeled with content and date and discarded after 5 days. Review of facility policy, Food Storage, revised June 6, 2024, read, in part, open items should be labeled with content and open date. Observation in the kitchen on July 15, 2024, at 9:31 AM, revealed one plastic container with bulk thickener wasn't marked with a label or date. During an interview with Employee 1 (Director of Dinning), revealed the container should be labeled with contents and date. Observation at the three-compartment sink on July 15, 2024, at 9:32 AM, the pH test strips were not available. During an interview with Employee 1, it was revealed that the pH test strips are…

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

Based on a review of clinical records, the facility's infection prevention and control policy, and staff interview, it was determined that the facility failed to maintain an antibiotic stewardship program that includes a system to effectively monitor antibiotic usage as evidenced by two of three residents reviewed (Residents 6 and 23). Findings include: A review of the facility policy, titled Antibiotic Stewardship-Review and Surveillance of Antibiotic Use and Outcomes, last reviewed June 2024, stated, antibiotic usage and outcome data will be collected and documented using a facility-approved antibiotic surveillance tracking form. The data will be used to guide decisions for improvement of resident antibiotic prescribing practices and facility-wide antibiotic stewardship. The IP (infection preventionist), or designee will review antibiotic utilization as part of the antibiotic stewardship program and identify specific situations that are not consistent with the appropriate use of antibiotics. a. Therapy may require further review and possible changes if: (1) The organism is 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, facility policy, and staff interview, it was determined that the facility failed to ensure that residents were offered influenza and pneumococcal as required for two of five residents reviewed (Residents 33 and 41). Findings include: Review of facility policy for influenza, pneumococcal, and COVID 19, last reviewed June 2024, indicated that before any of the vaccine is received, the resident or their legal representative shall receive information regarding risks and benefits of the vaccine. The policy also revealed that consents and refusals would be documented in the resident's clinical record. A review of Resident 33's clinical record on July 18, 2024, confirmed that Resident 33 was admitted to the facility on [DATE]. The clinical record revealed Resident 33 refused the influenza in 2022 and 2023. There was no record of pneumococcal vaccine for Resident 33. Further review of the clinical record revealed no education on risks and benefits, and no consent or refusal documentation…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, facility policy, and interview, it was determined that the facility failed to ensure that residents were offered any current COVID-19 vaccinations as required for four of five residents reviewed (Residents 1, 12, 33, and 41). Findings include: Review of facility policy for COVID 19, last reviewed June 2024, indicated that before any of the vaccine is received, the resident or their legal representative shall receive information regarding risks and benefits of the vaccine. The policy also revealed that consents and refusals would be documented in the resident's clinical record. The physician will assess the resident for any contraindications to receiving the vaccine. A review of Resident 1's clinical record on July 18, 2024, confirmed that Resident 1 was admitted to the facility on [DATE]. Further review of the clinical record revealed no historical (past) COVID-19 vaccine or any documentation to confirm that the COVID-19 vaccine was offered by the facility since admission. 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 observation and staff interview, it was determined that the facility failed to post, in a form and manner accessible and understandable to residents, a list of names, addresses (mailing and email), and telephone numbers of all pertinent State agencies, advocacy groups, and a statement that the resident may file a complaint with the State Survey Agency concerning suspected violations of state or federal nursing facility regulations for one area observed (facility bulletin board). Findings Include: An observation of the facility's bulletin board, containing information for resident review, on July 15, 2024, at 11:04 AM, revealed no information listing resident advocacy groups, the State agency information, including mailing and email addresses, telephone numbers, and statements regarding the resident's right to file complaints with State and Federal agencies. An interview with the Nursing Home Administrator, on July 17, 2024, at 1:40 PM, revealed the required information is now posted and accessible for resident review. 28 Pa. Code 201.14 (a) Responsibility of licensee

Based on observations and staff interview, it was determined that the facility failed to ensure its residents the right to examine the results of the most recent survey and that those results are posted in a place readily accessible to its residents for one area observed (facility lobby). Findings Include: An observation in the facility's lobby, on July 15, 2024, at 10:32 AM, revealed the facility's survey results book in an area accessible only by using a code to gain entrance and exit. Observations in resident areas, beyond the locked lobby area, revealed no survey books for resident review in the dining area, the resident common area, the nurses' station, or the designated activities area. An interview with the Nursing Home Administrator, on July 17, 2024, at 1:38 PM, revealed the facility's survey results book is now accessible in resident areas and confirmed the book should not only be present in the facility's locked area. 28 Pa. Code 201.14 (a) Responsibility of licensee

Based on document review and staff interviews, it was determined that the facility failed to ensure each resident is periodically informed of any charges for services not covered under Medicare for two of three residents reviewed at the end of a Medicare stay (Residents 1 and 148). Findings Include: A review of Resident 1's Skilled Nursing Facility Beneficiary Notification Review form revealed the last covered day of Medicare A coverage on April 30, 2024. A review of the facility-provided Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage form (SNF-ABN), revealed Resident 1 would no longer receive Medicare covered therapy services after April 30, 2024, and the estimated cost of those non-covered services was not provided to Resident 1 or her responsible party. A review of Resident 148's Skilled Nursing Facility Beneficiary Notification Review form revealed a last covered day of Medicare A coverage on February 17, 2024. A review of the facility-provided SNF-ABN form revealed Resident 148 would no longer receive Medicare covered therapy services after February 17,…

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

Based on clinical record review and resident and staff interviews, it was determined that the facility failed to notify the resident/resident representative and the representative of the Office of the State Long-Term Care Ombudsman of resident transfers in writing to include to include the following: the reason for the transfer or discharge, date of transfer, location of transfer, statement of the resident's appeal rights, and name, address (mailing and email) and telephone number of the Office of the State Long-Term Care Ombudsman, for two of three resident records reviewed for hospital transfers (Residents 19 and 46 ). Findings include: Review of Resident 19's clinical record documented diagnoses that included depression (feelings of severe despondency and dejection), diabetes mellitus (the body's ability to produce or respond to the hormone insulin is impaired, resulting in abnormal metabolism of carbohydrates and elevated levels of glucose in the blood and urine), hemiparesis left non-dominant side (muscle weakness or partial paralysis on one side of the body that can affect the…

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

Based on clinical record review and resident and staff interviews, it was determined that the facility failed to ensure that the resident and resident representative received written notice of the facility bed-hold policy at the time of transfer for one of three resident records reviewed for hospital transfers (Resident 19). Findings Include: Review of Resident 19's clinical record documented diagnoses that included depression (feelings of severe despondency and dejection), diabetes mellitus (the body's ability to produce or respond to the hormone insulin is impaired, resulting in abnormal metabolism of carbohydrates and elevated levels of glucose in the blood and urine), hemiparesis left non-dominant side (muscle weakness or partial paralysis on one side of the body that can affect the arms, legs and facial muscles), stroke (damage to the brain from interruption of blood supply), and epilepsy (a disorder in which nerve cell activity in the brain is disrupted, causing seizures). During an interview with Resident 19 on July 15, 2024, 10:39 AM, it was revealed she was transferred to…

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

Based on observation, clinical record review, policy review, and staff interview, it was determined that the facility failed to develop and implement a comprehensive person-centered care plan for one of three residents receiving oxygen therapy reviewed (Resident 40). Findings Include: A review of the facility's policy, titled Care Planning-Interdisciplinary Team, revised September 2013, read, in part, Our facility's care planning/interdisciplinary team is responsible for the development of an individualized comprehensive care plan for each resident. A review of Resident 40's physician orders revealed diagnoses that included chronic obstructive pulmonary disease (COPD - A group of lung diseases that block airflow and make it difficult to breathe) and muscle weakness. An observation of Resident 40, on July 15, 2024, at approximately 11:00 AM, revealed the use of an oxygen concentrator while in bed in her room. A review of Resident 40's interdisciplinary plan of care revealed none developed to address the use of oxygen, goals, and interventions. An interview with the Director 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 facility policy review, clinical record review, and staff interview, it was determined that the facility failed to ensure care and services were provided in accordance with professional standards regarding medication and treatment administration for two of 23 residents reviewed (Residents 24 and 40). Findings Include: Review of facility policy, Administering Medication, revised April 2019, read, in part, medications are administered in a safe and timely manner and as prescribed. Staffing schedules are arranged to ensure that medications are administered without unnecessary interruptions. If a drug is withheld, refused, or given at a time other than the scheduled time, the individual administering the medication shall initial and circle the Medication Administration Record (MAR- recording of physician orders being administered or completed) space provided for that drug and dose. The individual administering the medication initial the resident's MAR on the appropriate line after giving each medication and before administering the next one. Review of Resident 24's clinical…

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

Based on observation, clinical record review, and staff interview, it was determined that the facility failed to ensure that a resident who needs respiratory care is provided care consistent with professional standards of practice for one of three residents receiving oxygen therapy reviewed (Resident 40). Findings Include: A review of Resident 40's clinical record revealed diagnoses that included chronic obstructive pulmonary disease (COPD - A group of lung diseases that block airflow and make it difficult to breathe) and muscle weakness. An observation of Resident 40, on July 15, 2024, at approximately 11:00 AM, revealed the use of an oxygen concentrator while in bed in her room. A review of Resident 40's physician orders revealed none documenting the Resident's need and use of oxygen. An interview with the Director of Nursing on July 18, 2024, at 9:28 AM, revealed that the facility could not locate an order from the physician for Resident 40's use of oxygen. 28 Pa. Code 211.5 (f) Medical records 28 Pa. Code 211.12 (d) 5) Nursing services

Based on facility policy review, clinical record review, and staff interviews, it was determined that the facility failed to ensure that the licensed pharmacist's report of a medication irregularity was reviewed and acted upon for one of five residents reviewed for unnecessary medications (Resident 24). Findings include: Review of facility policy, Medication Therapy, revised April 2007, read, in part, the consultant pharmacist shall review each resident's medication regimen monthly, as requested by the staff or practitioner, or when a clinically significant adverse consequence is confirmed or suspected. Review of Resident 24's clinical record documented diagnoses that included depression (feelings of severe despondency and dejection), diabetes mellitus (the body's ability to produce or respond to the hormone insulin is impaired, resulting in abnormal metabolism of carbohydrates and elevated levels of glucose in the blood and urine), and schizoaffective disorder (a mental health condition including schizophrenia and mood disorder symptoms such as depression. Symptoms may include…

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, staff interviews, and policy review, it was determined that the facility failed to ensure adherence to appropriate labeling of medication for one of two medication carts (front hall cart). Findings include: Review of facility policy, titled Administering Medications, last reviewed June 2024, revealed that the expiration/beyond use date on the medication label is checked prior to administering. When opening the multi-dose medication, the date opened is recorded on the medication container. The policy also stated, Insulin pens are clearly labeled with the resident's name, or other identifying information prior to use. Observation during the front hall medication cart review on July 16, 2024, at 1:35 PM, revealed one Novolog insulin pen (aka insulin aspart-a fast acting insulin) in Resident 1's medication compartment opened, without a resident identifier, or the date it was removed from the refrigerator. This insulin is to remain in the refrigerator until opened for use, and then expires in 28 days after opening. During an interview with Employee 10 (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 state regulations, review of facility documents, and staff interview, it was determined that the facility failed to ensure that the Medical Director and Infection Preventionist (IP) was in attendance at least quarterly at the Quality Assurance Process Improvement (QAPI) Committee meetings, and failed to provide sign-in records for QAPI Committee meetings for one of four quarters (first quarter). Findings include: Review of the CFR (Code of Federal Regulations) revealed: §483.75(g) Quality assessment and assurance. §483.75(g) Quality assessment and assurance. §483.75(g)(1) A facility must maintain a quality assessment and assurance committee consisting at a minimum of: The director of nursing services, The Medical Director or his/her designee, At least three other members of the facility's staff, at least one of who must be the administrator, owner, a board member, or other individual in a leadership role, The Infection Preventionist, and Meet at least quarterly and as needed to coordinate and evaluate activities under the QAPI program, such as identifying issues with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on document review and staff interviews, it was determined that the facility failed to implement an effective discharge planning process that focuses on the resident's discharge goals, the preparation, and the transition to post-discharge care for one of three residents reviewed (Resident 2). Findings Include: Review of the facility's Social Services/Social Worker job description, described the essential duties and responsiblities as, Works with the resident, family and other members of the health care team to formulate a discharge plan that provides the resident services in the appropriate post-acute setting. Review of Resident 2's clinical record revealed diagnoses that included cerebral cysts (fluid filled sacs in the brain) and Diabetes Mellitus Type II (a disease that occurs when your blood glucose, also called blood sugar, is too high). Review of Resident 2's order summary sheet revealed the need for the use of a Peripherally Inserted Central Catheter (PICC-a type of long catheter that is inserted…

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 employee files, review of facility policies and procedures, and interviews with staff, it was determined that the facility failed to ensure residents were free from abuse by failing to conduct license verification for new employees for three of four employees (Employees 2, 3, and 6) Findings include: Review of facility policy, titled Residents Right to Freedom from Abuse, Neglect, and Exploitation Policy and Procedure, dated 2022, revealed, The Facility will not employ or otherwise engage individuals who: Have disciplinary action in effect against his or her professional license by a state licensure body as a result of a finding of abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property. Review of Employee file for Employee 2 revealed a date of hire of June 28, 2023. Further review of the employee file failed to reveal any license verification or check with the state licensing board for disciplinary action against Employee 2's license. Review of Employee file for Employee 3 revealed a date of hire of July 20, 2023. Further…

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

Based on observation, clinical record review, and resident and staff interviews, it was determined that the facility failed to ensure that a comprehensive, person-centered care plan was developed for four of 16 residents reviewed (Resident 29, 32, 145, and 146). Findings include: Review of Resident 29's clinical record documented diagnoses that included bladder cancer, protein calorie malnutrition, and diabetes mellitus (the body's ability to produce or respond to the hormone insulin is impaired, resulting in abnormal metabolism of carbohydrates and elevated levels of glucose in the blood and urine). Clinical record review for Resident 29 documented her physician ordered hospice care on March 10, 2023. Review of Resident 29's care plan documented a focus area for Hospice services as of March 10, 2023, with an initiated date of July 14, 2023. During an interview with the Assistant Nursing Home Administrator and the Nursing Home Administrator (NHA) on August 16, 2023, at 2:23 PM, it was revealed that the hospice care plan for Resident 29 should've been initiated upon admission to…

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

Based on clinical record review, observations, and resident and staff interviews, it was determined that the facility failed to ensure there were sufficient staff to assure residents attain or maintain the highest practicable physical, mental, and psychosocial well-being for eight of 16 residents reviewed (Residents 3, 4, 7, 17, 19, 23, 26, and 30). Findings Include: During the initial pool process on August 14, 2023, Residents 3, 7, and 17 expressed concern to the survey team about call bell response time and/or staffing. Review of resident council meeting minutes and interviews with Residents 4, 19, 23, 26, and 30 during the group meeting, revealed concerns with call bell response times and insufficient staff. Review of Resident 3's clinical record revealed diagnoses including hypertension (elevated blood pressure) and anxiety disorder (a feeling of worry, nervousness, or unease). Review of Resident 3's most recent quarterly Minimum Data Set (MDS - assessment tool utilized to identify a resident's physical, emotional, and psychosocial needs), dated August 2, 2023, revealed that…

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

Based on document review and staff interview, it was determined that the facility failed to complete a performance review of every nurse aide at least once every 12 months for five of five nurse aide performance evaluations reviewed (Employees 7, 8, 9, 10, and 11). Findings Include: Review of annual performance reviews for the following Nursing Assistant Employees 7, 8, 9, 10, and 11 revealed no annual performance reviews were completed. During an interview with Assistant Nursing Home Administrator on August 17, 2023, at 8:50 AM, it was revealed that the facility doesn't have proof that performance reviews were completed for the aforementioned employees. 28 Pa. Code 201.19 Personnel policies and procedures

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility temperature logs and records, observations, and staff interviews, it was determined that the facility failed to maintain acceptable practices for the storage and service of food to prevent the potential for microbial growth in food, which increased the risk of food-borne illness (Walk-in Refrigerator). Findings include: On August 14, 2023, at approximately 9:46 AM, during initial tour of the walk-in refrigerator with the Food Service Director (FSD), the surveyor observed the thermometer on the outside of the walk-in refrigerator to read 41 degrees. The thermometer on the inside of the walk-in refrigerator read 46 degrees. Interview with FSD on August 14, 2023, at approximately 9:49 AM, revealed that they have a quote submitted to get the walk-in refrigerator fixed and reached out to the maintenance director when they first became aware of the issue, which was on July 31, 2023. Review of the walk-in refrigerator temperature log for August 2023, revealed that on August 1 through August…

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 staff interview, select policy review, and documents reviewed for implementation of a water management program, it was determined the facility failed to implement their water management program for the prevention, detection, and control of water-borne contaminants, such as Legionella (a bacteria that may cause Legionnaires' Disease [a serious type of pneumonia]). Findings include: Review of facility provided policy, titled Legionella Water Management Program, revised July 2017, revealed, The water management program includes the following elements: f. The control limits or parameters that are acceptable and that are monitored, h. A system to monitor and control limits and effectiveness of control measures, i. A plan for when control limits are not met and/or control measures are not effective. Review of Facility provided documents on August 17, 2023, failed to reveal any water testing for Legionella or other water-borne pathogens. Interview with the Nursing Home Administrator on August 17, 2023, at 11:45 AM, revealed that the facility has not completed any water testing, but…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of clinical records and staff interview, it was determined that the facility failed to provide the required Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage appropriately, in advance of changes for Medicare covered services, to one of three residents reviewed whose Medicare coverage was discontinued (Resident 36). Findings include: Review of Resident 36's clinical record revealed the Resident was admitted to the facility on [DATE], payor source was Medicare A. Skilled services ended on July 15, 2023, Resident 36's payor source changed to private pay at that time, and Resident 36 remained in the facility. Resident 36 was issued a Notice of Medicare Non-Coverage (NOMNC- indicates when you coverage for care is set to end) on July 11, 2023. The Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNF ABN, a form provides information that as of a specific date Medicare coverage ends and the specific amount of financial liability passed onto the resident) was 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 review and staff interviews, it was determined that the facility failed to ensure that a significant change MDS (Minimum Data Set - an assessment tool to review all care areas specific to the resident such as a resident's physical, mental or psychosocial needs) assessment was completed timely after election of hospice care for two of 16 residents reviewed (Residents 29 and 32). Findings include: Review of the Resident Assessment Instrument 3.0 User's manual (RAI - a standardized process is the basis for the accurate assessment of each nursing home resident) dated October 2021, revealed that the facility must complete a significant change MDS no later than 14 days after the effective date of the election of hospice service. Review of Resident 29's clinical record documented diagnoses that included bladder cancer, protein calorie malnutrition, and diabetes mellitus (the body's ability to produce or respond to the hormone insulin is impaired, resulting in abnormal metabolism of carbohydrates and elevated levels of glucose in the blood and urine). Clinical…

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

Based on observation, clinical record review, and resident and staff interviews, it was determined that the facility failed to provide care and services necessary for care-dependent residents for two out of 16 residents reviewed (Residents 3 and 19). Findings Include: Review of Resident 3's clinical record revealed diagnoses that included hypertension (elevated blood pressure) and anxiety disorder (a feeling of worry, nervousness, or unease). Review of Resident 3's most recent quarterly Minimum Data Set (MDS - assessment tool utilized to identify a resident's physical, emotional, and psychosocial needs), dated August 2, 2023, revealed that under section C, Cognitive Patterns, more specifically subsection C0500. BIMS Summary Score, Resident 3 is coded to have a BIMS of 14 out of 15. Review of Resident 3's comprehensive care plan on August 15, 2023, under the Focus section for Activities of Daily Living (ADL) care, created on April 19, 2019, and initiated on March 4, 2020, revealed that Resident 3 requires one staff member to move between surfaces. Observation on August 15, 2023, at…

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

Based on clinical record review, facility policy review, and staff interviews, it was determined that the facility failed to ensure that residents receive necessary treatment and services, consistent with professional standards of practice, to promote healing and prevent infection of a pressure ulcer for one of 16 residents reviewed (Resident 21). Findings Include: Review of facility policy, titled Wound Care with a revised date of October 2010, under the Documentation section revealed, The following information should be recorded in the resident's medical record: 1. The type of wound care given. 2. The date and time the wound care was given. Review of Resident 21's clinical record revealed diagnoses that included cerebral palsy (a group of disorders that affect a person's ability to move and maintain balance and posture) and hypertension ( high blood pressure). Further review of Resident 21's clinical record revealed that Resident 21 has a stage 3 pressure ulcer on the sacral region. Review of Resident 21's current physician orders revealed the following treatment for the sacrum…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, and resident and staff interviews, it was determined the facility failed to ensure that residents who require dialysis receive such services consistent with professional standards of practice for one of 16 residents reviewed (Resident 7). Findings include: Review of Resident 7's clinical record revealed diagnoses including Diabetes Mellitus Type II (a long-term metabolic disorder that is characterized by high blood sugar, insulin resistance, and relative lack of insulin) and End Stage Renal Disease (occurs when the kidneys are no longer able to work at a level needed for day-to-day life). An interview with Resident 7 on August 14, 2023, at 12:00 PM, revealed that the Resident attends dialysis every Tuesday, Thursday, and Saturday from 10:00 AM to 3:30 PM. Review of Resident 7's current physician orders on August 14, 2023, revealed that Resident 7 is ordered to have dialysis every Wednesday, Friday, and Sunday. An interview with the Nursing Home Administrator (NHA) on August 16,…

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

Based on facility policy review, observation, staff interview, and clinical record review, it was determined that the facility failed to ensure a medication error rate of less than five percent (two errors in 28 observations, 7.14%). Findings include: Review of facility provided policy, titled Administering Medications, revised April 2019, revealed, Medications are administered in accordance with prescriber orders. Review of Resident 195's current physician's orders on August 16, 2023, at 8:45 AM, revealed a current physician's order for Aspirin 81 mg oral tablet chewable to be administered daily. Further review failed to reveal any physician's order for enteric coated Aspirin. Further review of Resident 195's current physician orders revealed a current order for Budesonide/Formoterol 80/4.5 inhaler, two inhalations orally two times a day, rinse mouth after use. During observation of medication administration on August 16, 2023, at 8:30 AM, Employee 6 was observed preparing a medication for Resident 195. At that time, Employee 6 prepared one 81 mg tablet of enteric coated aspirin…

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 nurse aide in-service records and staff interview, it was determined that the facility failed to ensure that Nursing Assistants received a minimum of 12 hours of in-service education training each year that include the following topics: infection control, dementia, communication, and behavioral health, for five of five nurse aide performance evaluations reviewed (Employees 7, 8, 9, 10, and 11). Findings include: Review of the facility's yearly mandatory in-service training failed to reveal documented evidence that Employees 7, 8, 9, 10, and 11 met the yearly regulatory minimum training requirements (12 hours within one year). Further review of in-service training revealed that Employees 7, 8, 9, 10, and 11 failed to complete training regarding behavioral health and communication. Furthermore, Employees 9 and 10 failed to complete training regarding infection control, and Employee 11 failed to complete dementia training. During an interview with Assistant Nursing Home Administrator on August 17, 2023, at 8:50 AM, it was revealed that competencies are completed as…

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.