Ephrata Manor

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of clinical records, hospital records, and staff interviews, it was determined that the facility failed to ensure appropriate social services were provided to ensure a safe discharge to home for one of the two residents reviewed (Resident CL1).Findings include: Review of Resident CL1 diagnosis list includes the following diagnoses: Altered mental status (Unusual changes in a person's emotional response, thinking, and behavior) and Metabolic Encephalopathy (A non-traumatic brain dysfunction caused by illnesses or chemical imbalance, resulting in altered mental status). Review of Resident CL1's admission Visit Physician Orders, dated December 4, 2025, revealed Resident is not capable of understanding rights and exercising own rights. Interview with Licensed Employee E3 was conducted on February 2, 2026, at 11:00 a.m. Employee E3 reported being the social worker (SW) assigned to Resident CL1. It was further reported that Resident CL1's emergency contact was an ex-husband who does not reside with the…

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

Based on a review of the facility's policy, clinical records, and staff interview, it was determined the facility failed to monitor potential side effects of anti-psychotropic medication for one of five residents reviewed (Resident 99). Findings include: Review of the facility's policy titled Psychotropic Medications, dated March 2021, revealed the facility would make every effort to comply with state and federal regulations related to the use of psychotropic medications to include regular review for continued need, appropriate dosage, side effects, risk, and benefits. The same policy also indicated potential adverse medication reactions and side effects will be evaluated. Review of Resident 99's physician order dated June 7, 2024, revealed an order for Quetiapine (anti-psychotic medication) 25 mg tablet, three tablets by mouth daily for delusional disorder (mental health condition in which a person cannot tell what is real from what is imagined). Anti-psychotic side effect (monitoring) 1-No side effect; 2-Confusion; 3-Sleep disturbance; 4-Hangover effect; 5-Restlessness 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 upon clinical record review and interview it was determined the facility failed to notify resident's physician regarding the development of a pressure ulcer for one of two residents reviewed (Resident 40). Findings include: Review of Resident 40's diagnosis list revealed diagnoses including Alzheimer's disease (irreversible progressive degenerative disease of the brain, resulting in loss of reality contact and functioning ability) and Peripheral Vascular Disease (poor circulation of the extremities). Review of facility's Skin/Wound Tracking Report revealed on August 15, 2023, the facility identified an open left heel wound, unstageable with slough measuring 1.3 centimeters (cm) x 2.6 cm. Review of Resident 40's clinical record revealed a Wound Healing Solutions report dated August 28, 2023, indicating resident was seen for evaluation and management for newly noted areas of skin breakdown along the left heel. Review of Wound Healing Solutions report dated August 28, 2023, revealed full-thickness wound of the left heel - 1.3 cm x 2.6 cm - wound base 100% stable eschar (dry scab,…

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 interviews with staff, it was determined that the facility failed to complete a Quarterly MDS assessment at least every three months as required for one of eight residents reviewed (Resident 100). Findings include: Review of Resident 100's MDS (Minimum Data Set - a mandatory periodic assessment) assessments revealed that the resident had an admission MDS assessment completed on May 29, 2023. Continued review revealed that no further MDS assessments had been completed for Resident 100 since May 29, 2023. Interview on November 3. 2023, at 10:20 a.m. with Employee E3, Registered Nurse Assessment Coordinator, confirmed that Resident 100 had not had an MDS assessment since her admission in May 2023. Employee E3 could not provide an explanation as to why no additional assessments were performed for Resident 100. 28 Pa. Code 211.5(f) Clinical records 28 Pa. Code 211.5(h) Clinical records

Based upon clinical record review and interview it was determined the facility failed to develop a comprehensive care plan for prevention and treatment of pressure ulcers for one of 22 residents reviewed (Resident 40). Findings include: Review of Resident 40's diagnosis list revealed diagnoses including Alzheimer's disease (irreversible progressive degenerative disease of the brain, resulting in loss of reality contact and functioning ability) and Peripheral Vascular Disease (poor circulation of the extremities). Review of Resident 40's admission Braden Scale for Predicting Pressure Sore Risk dated June 16, 2023, revealed a score of 15. If the score is 18 or less resident is at risk for developing a pressure ulcer. Review of Resident 40's admission Minimum Data Set (MDS - periodic assessment of resident needs) dated June 22, 2023, revealed Resident 40 required extensive assistance of two plus staff members for bed mobility (turning and repositioning while in bed). Review of facility's Skin/Wound Tracking Report revealed on August 15, 2023, the facility identified an open left heel…

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 upon review of staffing records and performance reviews it was determined the facility failed to ensure performance reviews were completed for three of five staffing records reviewed. Findings include: Review of staffing records and performance reviews revealed three staff members did not have annual performance reviews performed within the appropriate timeframe. Interview with the Nursing Home Administrator (NHA) and Director of Nursing (DON) on November 3, 2023, at 11:27 a.m. confirmed staff performance reviews were not completed timely. Per the DON a performance plan has been made to catch up on past due staff performance reviews. 28 Pa. Code 201.20(a)(c) Staff Development FACILITY

Based upon clinical record review and staff interview, it was determined the facility failed to ensure that a clinical rationale was provided by residents' physician for not performing a Gradual Dose Reduction of an antipsychotic medication and failed to provide a clinical rationale for the continued use beyond 14 days of an as needed anti-anxiety medication for two of five residents reviewed (Resident 38 and Resident 79). Findings include: Review of Resident 38's physician's orders included an order dated December 27, 2022, for Lorazepam (anti-anxiety medication) 0.5 milligrams one tablet by mouth as needed every six hours for anxiety. Review of Resident 38's clinical record revealed a Note to Attending Physician/Prescriber from the consultant pharmacist dated August 11, 2023, with a recommendation to evaluate the use of prn (as needed) Lorazepam. The note indicated that prn psychotropic orders cannot exceed 14 days with the exception that the prescriber documents their rationale in the residents medical record and indicate the duration for the prn order. Review of the…

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

Based upon review of staffing records and inservice documentation, it was determined the facility failed to ensure nurse aides received required 12-hour annual re-training for two of five records reviewed. Findings Include: Review of five staffing records and inservice documentation revealed three nurse aides received the required 12-hour annual retraining. Further review of the staffing records and inservice documentation revealed two of the five records reviewed failed to reveal evidence of retraining. Interview with the Nursing Home Administrator and DON on November 3, 2023, at 11:27 a.m. confirmed that the nurse aides did not receive the required in-service retraining within the appropriate timeframe. 28 Pa. Code 201.20(a)(c) Staff Development

Based upon clinical record review and staff interview, it was determined that the facility failed to ensure that irregularities from the monthly drug regimen review were acted upon by a physician for one of five residents reviewed (Resident 45). Findings include: Review of Resident 45's clinical record revealed that a MRR (Medication Record Review) was completed on June 10, 2022, with a recommendation to evaluate the current dose of Buspar (medication to treat anxiety) and consider a dose reduction. Further review of the clinical record revealed no evidence that the recommendation was acted upon by the physician until a MRR completed on August 17, 2022, revealed a recommendation to address Buspar again. An interview with the Director of Nursing on December 16, 2022, at 9:35 a.m. confirmed that the recommendation was not addressed by the physician until the MRR of August 17, 2022. 28 Pa. Code 211.5(f) Clinical records 28 Pa. Code 211.12(c) Nursing services 28 Pa. Code 211.12(d)(3) Nursing services 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to ensure that residents did not receive psychotropoic medications unless necessary and that non-pharmacological interventions were attempted before the use of a PRN (as needed) psychotropic medication for two of five residents reviewed (Residents 88 and 90). Findings include: Review of facility policy Psychotropic Medications, reviewed March 2021, revealed that residents do not receive psychotropic medications pursuant to a PRN order unless that medication is necessary to treat a diagnosed specific condition that is documented in the medical record. Non-pharmacological interventions (such as behavioral interventions) are considered and used/care planned when indicated, instead of, or in addition to, medication to assist in the allevation of target behaviors. Review of Resident 88's admission MDS (Minimum Data Set - periodic assessment of resident needs) of March 28, 2022, included diagnoses of CVA (cerebrovascular accident - stroke) and Parkinson's disease…

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.