Greenfield Healthcare And Rehabilitation Center

Based on observations and interviews, it was determined that the facility did not ensure the garbage and refuse was disposed of properly for one dumpster. Findings include: No facility policy provided. Observations on 1/24/26, at 5:15 p.m. revealed the dumpster open, without a full lid to secure the top of the dumpster, allowing garbage to be freely exposed. During an interview on 1/24/26, at 5:15 p.m. the Dietary Manager confirmed that the top of the dumpster was open without a lid, allowing the garbage to be freely exposed. He/She further confirmed that the dumpster lids should always be closed and tightly fitted when not in use to prevent insect/rodents to be attracted to area. 28 Pa. Code 201.18(b)(3) Management

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy and review of clinical and facility records and resident and staff interview, it was determined that the facility failed to maintain accurate and complete documentation related to falls for one of 17 residents reviewed (Resident R6). Findings include: Review of facility policy entitled, Fall Prevention Program dated 11/01/25, revealed Each resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls. When any resident experiences a fall, the facility will a. Assess the resident. b. Complete a post-fall assessment. c. Complete an incident report. d. Notify physician and family. e. Review the resident's care plan and update as indicated. f. Document all assessments and actions. g. Obtain witness statements in the case of injury. Resident R6's clinical record revealed an admission date of 2/08/25, with diagnoses that included shock, closed head injury (occurs when a sudden,…

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 provide the resident and/or resident representative with a written notice of the facility bed-hold policy (explanation of how long a bed can be held during a leave of absence and the cost per day) and failed to make certain that the necessary resident information was communicated to the receiving health care provider upon transfer to the hospital for four of four residents reviewed for hospitalization (Residents R2, R5, R6, and R7).Findings include: Facility policy entitled Bed-Hold Notice dated 1/7/26, indicated that It is the policy of this facility to provide written information to the resident and/or the resident representative regarding bed hold practices both well in advance, and at the time of, a transfer for hospitalization or therapeutic leave. The policy further states In the event of an emergency transfer of a resident, the facility will provide written notice of the facility's bed-hold policies to the resident and/or the resident representative…

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, and staff interview, it was determined that the facility failed to initiate a baseline care plan and provide a written summary of the baseline care plan and order summary to the resident and/or representative for three of 29 residents reviewed (Closed Record Residents CR1, CR2, and CR3). Findings include:A facility policy entitled Baseline Care Plan dated 11/01 /25, revealed the facility will develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of care. The baseline care plan will be developed within 48 hours of a resident ' s admission. Include the minimum healthcare information necessary to properly care for a resident including, but not limited to: Initial goals based on admission orders, Physician orders, Dietary orders, Therapy services, Social services, Preadmission Screening and Resident Review (PASARR) recommendation, if applicable. A written summary of the baseline care plan…

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 and staff interview, it was determined that the facility failed to transcribe and act upon physician orders for medications ordered at time of admission for one of six residents reviewed (Resident R2) and failed to follow physician's orders regarding the administration of seizure medications for one of five residents reviewed (Resident R2).Findings include: Facility policy entitled Medication Orders dated 1/7/26, indicated for written transfer orders sent with a resident by a hospital or other health care facility the facility will Implement a transfer order without further validation, if it is signed and dated by the resident's current attending physician, unless the order is unclear or incomplete, or the date signed is different from the date or admission. If the order is unsigned, or signed by another physician, or the date is other than the date of admission, the receiving nurse should verify the order with the current attending physician before medications are administered. The nurse should document verification on 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 policy and documentation, clinical records, and staff interview, it was determined that the facility failed to have complete and accurate documentation regarding showers on four of four residents reviewed (Residents R1, R2, R3, and R4).Findings include: Review of facility policy entitled Resident Showers dated 11/1/24, indicated .to assist residents with bathing to maintain proper hygiene., Partial baths may be given between regular shower schedules. and Document resident shower in Point of Care (an area where nursing assistants document in the clinical record). Review of facility shower schedule revealed resident room numbers and the day of the week that the residents in that room number are scheduled to receive a shower. Review of Resident R1's clinical record revealed an admission date of 9/19/25, with diagnoses that included diabetes (a health condition that is caused by the body's inability to produce enough insulin), and hypertension (high blood pressure). Review of Resident R1's shower sheets (a sheet of paper that the nursing assistants document…

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, and staff interviews, it was determined that the facility failed to ensure that the physician sign and date all orders during each of his/her visits for five of five residents reviewed (Residents R1, R3, R4, and R5). Findings include: Review of facility policy entitled Physician Visits and Physician Delegation dated 11/1/24, indicated The physician should: See resident within 30 days of initial admission to the facility. The resident must be seen at least once every 30 calendar days for the first 90 calendar days after admission and at least every 60 days thereafter by physician or physician delegate as appropriate by state law. Sign and date all orders. Resident R1's clinical record revealed an admission date of 6/6/25, with diagnoses that included hyperlipidemia (high cholesterol), and bipolar disorder (a mental illness that causes extreme mood swings with emotional highs and emotional lows). Review of Resident R1's clinical record lacked evidence of the last time his/her physician reviewed, signed, and dated his/her…

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 plan of correction for previous survey, and the results of the current survey, it was determined that the facility's Quality Assurance Performance Improvement (QAPI) committee failed to correct quality deficiency and ensure that the plan to improve the delivery of care and services effectively addressed recurring deficiencies.Findings include: Review of facility policy entitled Quality Assurance and Performance Improvement (QAPI) dated 11/1/24, indicated Program systematic analysis and systemic action to ensure improvements are sustained. The facility's deficiency and plan of correction for a complaint survey ending March 18, 2025, revealed that the facility developed plans of correction that included quality assurance systems to ensure that the facility maintained compliance with cited nursing home regulation. The results of the current survey, ending September 5, 2025, identified repeated deficiency related to a failure to ensure that the physician sign and date all orders during each of his/her visits. The facility's plan of correction 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.

Based on review of clinical records, facility documentation, and facility policy, and staff interview, it was determined that the facility failed to maintain complete and accurate records for two of six residents reviewed (Closed Record Resident CR2 and Resident R5). Findings include: A facility policy entitled Assessing Falls and Their Cause dated 11/01/24, indicated that when a resident falls, the following information should be recorded in the resident's medical record: 1. The condition in which the resident was found (e.g. resident found laying on the floor between bed and chair). 2. Assessment data, including vital signs and any obvious injuries. 3. Interventions, first aid, or treatment administered. 4. Notification of the physician and family, as indicated. 5. Completion of a falls risk assessment. 6. Appropriate interventions taken to prevent future falls. 7. The signature and title of the person recording the data. Resident CR2's clinical record revealed an admission date of 5/03/23, with diagnoses including Parkinson's disease with dyskinesia uncontrollable (age-related…

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, and staff interview, it was determined that the facility failed to ensure that the physician sign and date all orders and write, date, and sign a progress note during each of his/her visits for six of seven residents reviewed (Residents R1, R3, R4, R5, R6 and R7). Findings include: Review of facility policy entitled Physician Visits and Physician Delegation dated 11/1/24, indicated The physician should: See resident within 30 days of initial admission to the facility. The resident must be seen at least once every 30 calendar days for the first 90 calendar days after admission and at least every 60 days thereafter by physician or physician delegate as appropriate by state law. Date, write and sign a progress note for each visit. Sign and date all orders . Resident R1's clinical record revealed an admission date of 1/1/25, with diagnoses that included fibromyalgia (a disorder that causes widespread muscle pain, tiredness, sleep problems and thought difficulties), and diabetes (a health condition that caused by the body'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 facility policy and clinical records, observations, and resident and staff interviews, it was determined that the facility failed to maintain resident privacy and dignity related to the resident's room environment for one of 11 residents reviewed (Resident R2). Findings include: Review of facility policy entitled, Promoting/Maintaining Resident Dignity dated 11/1/24, revealed It is the practice . treat each resident with respect and dignity as well as care for each resident in a manner and in an environment, that maintains or enhances residents' quality of life . and All staff members are involved in providing care to residents to promote and maintain resident dignity and respect . Review of Resident R2's clinical record revealed an admission date of 1/5/24, with diagnoses that included anxiety (a condition that causes a person to be nervous, uneasy, or worried about something or someone), difficulty walking, and hypertension (high blood pressure). Review of Resident R2's physician orders revealed an order dated 1/6/24, for bedside commode at all times. Review 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 facility employee in-service training records and staff interview, it was determined that the facility failed to assure that staff completed all the required mandatory trainings for the yearly Nurse Aide (NA) 12-hour mandatory trainings. Findings include: Review of requested records or evidence of in-service mandatory training for all NA's from 1/2024 through 1/2025 was incomplete upon review. The facility was unable to provide complete evidence of completed competencies the the past year. During an interview on 1/31/25, at 2:30 p.m. the Nursing Home Administrator confirmed that no evidence could be provided of NA's 12-hour mandatory in-service trainings as required. 28 Pa. Code 211.12(d)(3)(5) Nursing services 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 201.19(7) Personnel policies and procedures

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy and clinical record, and staff interview, it was determined that the facility failed to include the recapitulation of stay (summary of resident's stay and course of treatment in the facility) that included a reconciliation of all pre-discharge medications with the resident's post-discharge medications for one of four closed record residents reviewed (Closed Record Resident CR82). Findings include: A facility policy entitled Discharge Summary dated 11/01/24, indicated that upon discharge of a resident a discharge summary will be provided to the receiving care provider at the time the resident leaves the facility. Resident CR82's clinical record revealed and admission date of 10/05/24, with diagnoses that included osteoarthritis of left knee (type of arthritis that occurs when flexible tissue at ends of bones in knee that wears down), pancytopenia (a blood disorder that occurs when the bone marrow does not form all three types of blood cells - red, white, and platelets), history…

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 resident interviews and observations, it was determined that the facility failed to provide sufficient nursing staff to promote the physical and mental well-being and meet the needs of seven of 21 residents interviewed (Residents R2, R55, R34, R6, R186, R68, R36, R2, R41, and R19). Findings include: Interviews during the Resident Council meeting on 1/29/25, between 1:00 p.m. and 1:45 p.m., revealed seven out of seven alert and oriented residents in attendance had concerns related to staff not responding to their call bells timely. Resident R68 indicated that it could take 45 minutes or more for his/her call bell to be answered and staff are observed on their phones and occasionally have earbuds in and talking on the phone when performing care. Resident R68 stated that he/she is left wet for long periods of time waiting for assistance. Resident R68 also disclosed that on weekends there is no use asking to get out of bed, because you will wait all day for assistance to get back in bed. Resident R6…

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 and facility records, observation, and resident and staff interviews, it was determined that the facility failed to ensure the use of dentures for two of 21 residents reviewed (Residents R51 and R187 ). Findings include: Review of a facility policy entitled, Care of Dentures with an annual review date of 11/01/2024, revealed Dentures that are missing, damaged, or lost and the facility or facility are at fault, a referral will be made promptly within three days. Facility responsibilities include dropped, stolen, and/or broken by our employees. facility is not responsible for the resident discarding themselves or ill fitting dentures or partials at admission. Facility will assist resident/responsible party with non-facility related denture issues. Resident's R51's clinical record revealed an admission date of 3/23/22 with diagnoses that included multiple sclerosis (a disease in which the immune system destroys the protective covering of nerves resulting in nerve damage disrupting…

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 and clinical records, resident and staff interviews, and observations, it was determined that the facility failed to provide a bath/shower as resident preference for two of 21 residents reviewed (Residents R2 and R68). Findings include: A facility policy, Resident Showers, dated 11/01/24, revealed it is the practice of this facility to assist residents with bathing to maintain proper hygiene, stimulate circulation and help prevent skin issues as per current standards of practice. Residents will be provided showers as resident preference. Resident's R2's clinical record revealed an admission date of 12/28/23, with diagnoses that included lupus (a disease when the immune system attacks your own tissue and organs), chronic obstructive pulmonary disease (a group of diseases that affects the lungs and breathing), heart disease, and rheumatoid arthritis (a chronic inflammatory disorder that typically affects the hands and feet). During an interview with Resident R2 on 1/28/25, at 2:25 p.m., he/she indicated their bath/shower was scheduled for Wednesday and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy and clinical records, review of the Long Term Care Facility Resident Assessment Instrument 3.0 User's Manual 2019 (RAI-assessment guide used to plan the provision of care for residents), and staff interviews, it was determined that the facility failed to notify the resident's representative of a change in condition timely for one of 21 residents reviewed (Resident R51). Findings include: The facility policy entitled The purpose of this policy is to ensure the facility promptly informs the resident, consults the resident's physician; and notifies, consistent with his or her authority, the resident's representative when there is a change requiring notification. Resident's R51's clinical record revealed an admission date of 3/23/22, with diagnoses that included multiple sclerosis (a disease in which the immune system destroys the protective covering of nerves resulting in nerve damage disrupting communication between body and brain), Alzheimer's disease (a disease of the brain…

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 facility policy, and resident and staff interviews, it was determined that the facility failed to assess and ensure safe smoking practices for one of 21 residents reviewed (Resident R50). Findings include: A facility policy entitled, Resident Smoking/Nonsmoking Facility dated 11/01/24, indicated that the facility will provide a safe and healthy environment for residents, visitors, and employees, including safety as related to smoking; smoking is prohibited; all residents and family members will be notified of this policy during the admission process, and as needed; and included electronic cigarettes. Resident R50's clinical record revealed an initial admission date of 4/12/22, with diagnoses that included nicotine dependence, respiratory failure, chronic obstructive pulmonary disease (lung disease causing restricted airflow and breathing problems), end-stage renal disease and dependence on dialysis (a procedure to remove waste products and excess fluid from the blood when the kidneys stop working properly), and dependence on supplemental…

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, observations, and resident and staff interviews, it was determined that the facility failed to maintain proper care of respiratory equipment for two of 21 residents reviewed (Residents R27 and R50). Findings include: A facility policy entitled Oxygen Concentrator dated 11/01/24, indicated that the concentrator filters are cleaned weekly and that the main body cabinet should be dusted when needed and can be wiped down clean with a damp cloth and mild cleanser. A facility policy entitled CPAP/BiPAP [continuous positive airway pressure/bilevel positive airway pressure] Support dated 11/01/24, revealed the following: -Only a qualified and properly trained nurse or respiratory therapist should administer oxygen through a CPAP mask. -Review the resident's medical record to determine his/her baseline oxygen saturation or arterial blood gases (ABGs- measures the balance of oxygen and carbon dioxide in your blood to see how well your lungs are working), respiratory(organs that are involved in breathing), circulatory (delivers…

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 documents and clinical records, and resident and staff interview, it was determined that the facility failed to maintain complete and accurate records relating to dialysis communication for one of 21 residents reviewed (Resident R50). Findings include: The Nursing Home Dialysis Transfer Agreement signed on 1/02/25, revealed that the facility shall ensure that all appropriate medical, social, administrative, and other information accompany all Designated Residents at the time of transfer to the center, and that the facility will provide for the interchange of information useful or necessary for the care of the Designated Resident and will inform the Center of a contact person at the Facility whose responsibilities include oversight of provision of dialysis services by Center to the Designated Residents of Facility. Resident R50's clinical record revealed an initial admission date of 4/12/22, with diagnoses that included nicotine dependence, respiratory failure, chronic obstructive pulmonary disease (lung disease causing restricted airflow and breathing…

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 and facility records, and resident and staff interviews, it was determined that the facility failed to ensure medications were administered, whether prescribed on a routine, emergency, or as needed basis, to not impede timely administration and adversely affect a resident's condition for one of 21 residents reviewed (Resident R234). Findings include: Facility pharmacy policy, Specialty Rx, Inc. PA ADS [Automated Dispensing System] Station Medication Policies and Procedures, dated 11/01/24, revealed Nursing and Pharmacy will use the ADS Station as an inventory, charging and information system for the control and distribution of medications for Emergency, First-Dose use and other situations where medications are not available from pharmacy. (NOT TO BE USED FOR CONTINUOUS DOSING). Emergency doses for narcotic medications removed from the ADS system will require a written order from a prescriber (order should include that medication can be taken from the ADS) and would require signature within 48 hours per regulations. The facility must contact the pharmacy…

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 Centers for Disease Control (CDC) vaccine guidance, facility policy, observation, and staff interview, it was determined that the facility failed to safely store medications in one of two medication rooms observed (East Wing). Findings include: A facility policy entitled Multi-Dose Vials (contain more than one dose of medication) dated [DATE], indicated that when a multiple dose vial is opened it shall be labeled with date open, medications will be discarded as per manufacturer guidelines for vaccines. Observation on [DATE], at 11:44 a.m. of the East Wing medication room revealed a multi-dose vial of Flucelvax (vaccine that protects against the flu) was opened, lacked an opened date, and lacked guidance related to discarding opened vials. During an interview at that time the Assistant Director of Nursing confirmed that the multi-dose vial lacked an open date, and that staff cannot tell when the vaccine should be discarded. Review of the CDC web site revealed that the guidance for opened…

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 and clinical records, observations, and staff and resident representative interviews, it was determined the facility failed to ensure that residents with an indwelling catheter (a tube inserted into the bladder to facilitate urine drainage) receive essential care for one of 21 residents reviewed with indwelling catheters (Resident R14). Findings include: Facility policy entitiled, Catheter Care dated 11/01/24, revealed it is the policy of this facility to ensure that residents with indwelling catheters receive appropriate catheter care and maintain their dignity and privacy when indwelling catheters are in use. Privacy bags will be available and catheter drainage bags will be covered at all times while in use. Ensure drainage bag is located below the level of the bladder to discourage backflow of urine and not to be located on the floor. Resident R14's clinical record revealed an admission date of 9/25/20, with diagnoses that included osteomyelitis of vertebra, sacral, and sacrococcygeal region (inflammation of bones of lower spine caused by infection),…

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, clinical records, and facility documents, and staff interview, it was determined that the facility failed to thoroughly investigate injuries of unknown origin for three of nine residents reviewed (Residents R2, R8, and R9). Findings include: A facility policy entitled, Accidents and Incidents-Investigating and Reporting revised July 2017, revealed that: 1. Designated staff shall promptly initiate and document an investigation of the accident or incident. 2. The report shall include date, time of accident/incident; nature of injury; circumstances surrounding the accident/incident; where; names of witnesses and their accounts of the accident/incident; time physician was notified and the response; date and time of family notification; resident's condition, including vital signs; disposition of injured; corrective action; follow-up, pertinent information; and signature, title of person completing the report. 3. The accident/incident report will be reviewed by the safety committee for trends. Review of Resident R2's clinical record revealed an original…

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, clinical records, and facility documents, and staff interview, it was determined that the facility failed to notify the responsible party and/or the physician of injuries of unknown origin for two of nine residents reviewed (Residents R2 and R9). Findings include: A facility policy entitled, Accidents and Incidents-Investigating and Reporting revised July 2017, indicated that: 1. Designated staff shall promptly initiate and document an investigation of the accident or incident. 2. The report shall include time physician was notified and the response, and the date and time of family notification. Review of Resident R2's clinical record revealed an original admission date of 9/22/17, with diagnoses that included stroke with right-sided weakness, difficulty swallowing, Type 2 Diabetes (a disease that occurs when the body doesn't use insulin properly resulting in high blood sugar levels), high blood pressure, and ataxia (a neurological condition that causes a lack of voluntary muscle coordination, which can affect balance, speech, and eye movements).…

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, facility policy, and facility documentation, and staff interview it was determined that the facility failed to maintain complete and accurate documentation as related to meal intake, medication administration records (MAR), and/or completion of treatment administration records (TAR) for six of six residents reviewed (Residents R2, R3, R4, R7, R8, and R9). Findings include: Review of facility policy dated 1/1/24, entitled Charting and Documentation indicated that any services provided to the resident shall be documented in the resident's medical record. Review of Resident R2's clinical record revealed an admission date of 12/7/17, with diagnoses that included dementia (a condition that affects the brains' ability to think, remember things, and function), stroke, and high blood pressure. Resident R2's clinical record lacked documentation indicating if he/she consumed their breakfast meal and what percent was consumed on 17 (2/27/24, 2/28/24, 3/1/24, 3/2/24, 3/3/24, 3/4/24, 3/5/34, 3/7/24, 3/8/24, 3/9/24, 3/10/24, 3/11/24, 3/12/24, 3/13/24, 3/17/24,…

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, review of facility records and staff interviews, it was determined that the facility failed to maintain kitchen equipment (one of two food steamers, and one of one walk-in coolers) in safe, operating condition. Findings include: A facility policy entitled Equipment-Facility Repair/Maintenance Needs dated 9/14/23, indicated that the facility will ensure timely attention to any facility equipment or items that require attention, repair, or replacement. Observations on 1/30/24, 11:20 a.m. in the main kitchen revealed the walk-in cooler temperature log posted on door as out of order beginning 1/01/24, and one of two food steamers with an out of order sign posted on the front, and Dietary Employee E4 waiting for room in the food steamer to keep food hot. Review of facility records revealed the walk-in cooler has been out of service since the beginning of December 2023, a work order dated 1/19/24, to repair/replace the food steamer and walk-in cooler, lacked signatures indicating acceptance of the estimates. During an interview on 1/31/24, at 11:00 a.m. Dietary…

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, and resident and staff interviews, it was determined that the facility failed to ensure that residents and their responsible parties were afforded the opportunity to participate in the care planning process for three of 23 residents reviewed (Residents R44, R56, and R71). Findings include: Review of the facility policy entitled Care Plan-Interdisciplinary Team dated 09/14/23, revealed that The resident, the resident's family and/or the resident's legal representative/guardian or surrogate are encouraged to participate in the development of and revisions to the resident's care plan. During an interview on 1/30/24, at 1:16 p.m. Resident R44 indicated that he/she didn't remember being invited to or participating in care plan meetings. Resident R44's clinical record revealed an admission date of 01/03/23, that he/she is alert and oriented and had diagnoses that included acute and chronic respiratory failure, chronic pain syndrome, and iron deficiency. The clinical record lacked evidence that Resident R44 was invited to participate…

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 policy and clinical records, and staff interview, it was determined that the facility failed to accurately code the Minimum Data Set (MDS-periodic assessment of resident care needs) for four of 23 residents reviewed (Residents R2, R5, R37, and R72). Findings include: Review of a facility policy entitled, Certifying Accuracy of the Resident Assessment dated 9/14/23, indicated that Any person who completes any portion of the MDS assessment, tracking form, or correction request form is required to sign the assessment certifying the accuracy of that portion of that assessment. The information captured on the assessment reflects the status of the resident during the observation period for that assessment. Resident R2's clinical record revealed an admission date of 10/30/99, with diagnoses that included Type 2 diabetes (disorder of improper blood sugar usage in the body), muscle weakness, and traumatic brain injury. Resident R2's order summary revealed that a Victoza injection (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 clinical records and facility documents and staff interview, it was determined that the facility failed to provide the Notice of Medicare Non-Coverage (NOMNC) Form 10123 as required for two of three residents reviewed for beneficiary notices (Residents R70 and R279). Findings include: The Skilled Nursing Facility (SNF) Beneficiary Notification Review revealed that Resident R70 began receiving skilled services on 9/18/23, that the last covered day of Part A Services was 10/31/23, and that the facility initiated the discharge from Medicare Part A Services when benefit days were not exhausted. Documentation indicated that Resident R70 remained in the facility following the last day covered, and that a NOMNC CMS Form 10123 was not issued. The SNF Beneficiary Notification Review revealed that Resident R279 began receiving skilled services on 10/26/23, that the last covered day of Part A Services was 11/6/23, and that the facility initiated the discharge from Medicare Part A Services when benefit…

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, clinical record review, and staff interview, it was determined that the facility failed to provide a written summary of the baseline care plan and order summary to the resident and/or representative for one of 23 residents reviewed (Resident R37). Findings include: A facility policy entitled, Care Plan-Baseline dated 9/14/23, indicated, The resident and/or representative are provided a written summary of the baseline care plan (in a language that the resident/representative can understand) that includes, but is not limited to the following: a. The stated goals and objectives of the resident; b. A summary of the resident's medications and dietary instructions; c. Any services and treatments to be administered by the facility and personnel acting on behalf of the facility; and d. Any updated information based on the details of the comprehensive care plan, as necessary. Resident R37's clinical record revealed an admission date of 10/02/23, with diagnoses that included end stage renal disease, dependance on renal dialysis, and type 2 diabetes…

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 policy and clinical records, observations, and staff interview, it was determined that the facility failed to develop comprehensive care plans for two of 23 residents reviewed (Residents R14 and R72). Findings include: Review of a facility policy entitled Care Plans, Comprehensive Person-Centered dated 9/14/23, indicated that an interdisciplinary team, in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. Review of a facility policy entitled Wanderguard dated 9/14/23, indicated that a physcian's order must be obtained and a careplan will be implemented once a wanderguard (alarming device attached to a resident to alert staff of their leaving a designated area/facility) is placed on a resident. Resident R72's clinical record revealed an admission date of 10/13/23, with diagnoses that included dementia, alcohol abuse and age related cognitive decline. Resident R72'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 review of Pennsylvania Code Title 49 Professional and Vocational Standards, clinical records, and facility documentation, and staff interviews, it was determined that the facility failed to follow nursing standards of practice related to medical diagnosing for one of 23 residents reviewed (Resident R21). Findings include: Review of Pennsylvania Code Title 49. Professional and Vocational Standards § 21.11. General functions. (c) stated: The registered nurse may not engage in areas of highly specialized practice without adequate knowledge of and skills in the practice areas involved. Resident R21's clinical record revealed an admission date of 1/04/23, with diagnoses including right hip fracture, Parkinson's Disease (a progressive disorder that affects the nervous system and the parts of the body controlled by the nerves), Paranoid Schizophrenia (serious mental illness that affects how a person thinks, feels, and behaves - paranoia commonly happens with schizophrenia), and unspecified dementia. The clinical record also revealed a physician's orders dated 5/23/23, for Nuplazid…

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 policy and clinical records, observations, and staff interviews it was determined that the facility failed to obtain a physician's order for the application of a wanderguard bracelet for one of five residents reviewed for their usage (Resident R72) and failed to obtain a physician's order for the application of a Continuous Positive Airway Pressure (CPAP- a machine that uses mild air pressure to keep breathing airways open while you sleep) for one of 23 residents reviewed (Resident R14). Findings include: Review of a facility policy entitled Wanderguard dated 9/14/23, indicated that a physcian's order must be obtained and a careplan will be implemented once a wanderguard (alarming device attached to a resident to alert staff of their leaving a designated area/facility) is placed on a resident. Review of a facility policy entitled Medication and Treatment Orders dated 9/14/23, indicated that orders for medications and treatments will be consistent with principles of safe and effective…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, review of clinical records and facility policy, and staff interviews, it was determined the facility failed to ensure that a resident with limited range of motion received physician ordered treatment and services to prevent further decrease in range of motion for one of one residents reviewed for range of motion (Resident R36). Findings include: Review of facility policy entitled Splints dated 9/14/23, indicated that Caregivers will apply the splint to the affected area, at the times scheduled by therapy. and Splinting will be charted . Review of Resident R36's clinical record revealed and admission date of 9/25/22, with diagnoses that included joint contracture (a condition when there is loss of joint mobility/movement), hypertension (high blood pressure), bradycardia (a condition when the heart beats slow), and atrial fibrillation (a condition when the heartbeat is irregular) Review of Resident R36's clinical record revealed a physician's order dated 9/20/23, for a left knee brace to be…

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, review of facility policy and clinical records, and staff interviews, it was determined that the facility failed to promote cleanliness and help prevent the spread of infection regarding respiratory care equipment according to physician's orders for two of two residents reviewed for oxygen usage (Residents R42 and R14). Finding include: Review of facility policy entitled Treatments - Oxygen Concentrators (machine that uses the air in the atmosphere, filters it, and gives you air that is 90%-95% oxygen) dated 9/14/23, indicated Maintenance: Daily/Weekly: Condenser filters: removed weekly . place filter in unit washing machine . put clean backup filter on concentrator and Change the oxygen tubing and filter every other week. Review of a facility policy entitled CPAP/BiPAP (Continuous Positive Airway Pressure machine that uses mild air pressure to keep breathing airways open while you sleep/Bilevel Positive Airway Pressure machine that provides non-invasive ventilation therapy used to help you breathe) Support dated 9/14/23, revealed machine cleaning involved;…

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, observations, and staff interview, it was determined that the facility failed to label a multi-dose injection pen of Lantus insulin (a long-acting insulin which is used to treat elevated blood sugar levels) with the date it was opened in one of two medication carts reviewed (West South Cart). Findings include: Review of a facility policy entitled, Medication Labeling and Storage dated 9/14/23, indicated that multi-dose vials that have been opened or accessed are dated and discarded within 28 days unless the manufacturer specifies a shorter or longer date for the open vial. Observation on 01/31/24, at 7:53 a.m. of the [NAME] South Cart revealed an opened multi-dose injection pen of Lantus insulin without an open date and instructions from the pharmacy on the storage bag to discard the medication 28 days after it is opened. At the time of the observation, Licensed Practical Nurse Employee E1 confirmed that the multi-dose injection pen of Lantus insulin did not have an open date. 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.9(a)(1) Pharmacy…

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, review of facility policy, and staff interview, it was determined that the facility failed to prevent the potential for cross contamination (the spreading of germs/microorganisms from one surface to another) during wound care for one of five residents reviewed for wounds (Resident R16). Findings include: A facility policy entitled Handwashing/Hand Hygiene dated 9/14/23, indicated that staff are to perform hand hygiene after removing gloves. A facility policy entitled Dressing, Dry/Clean dated 9/14/23, indicated that staff are to change gloves and/or perform hand hygiene after removing the soiled dressing, and after opening clean supplies. Observation on 2/02/24, at 9:20 a.m. of wound care revealed Licensed Practical Nurse (LPN) Employee E6 removed the soiled wound dressing, changed his/her gloves, and failed to perform hand hygiene prior to donning (put on) clean gloves. LPN Employee E6 cleansed the wound, changed his/her gloves, and failed to perform hand hygiene prior to donning clean gloves. During an interview at that time LPN Employee E6 confirmed 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 clinical records, and staff interviews, it was determined that the facility failed to provide appropriate services to maintain personal hygiene for one of four residents reviewed (Resident R1). Findings include: Review of Resident R1's clinical record revealed an admission date of 8/21/23, with diagnoses that included encephalopathy (abnormality of brain function or structure and can cause a wide range of symptoms depending on the cause), respiratory failure, need for assistance with personal care, and generalized muscle weakness. Review of the Quarterly Minimum Data Set (MDS-a mandated assessment of a resident's abilities and care needs) assessment for Resident R1, dated September 20, 2023, Section GG0130E revealed that the resident was totally dependent on staff for bathing. Review of Resident R1's current physician's orders lacked evidence that a frequency for bathing was ordered. Review of Resident R1's clinical record revealed lack of documentation for routine bathing and that Resident R1 was bathed on 10/07/23, 10/15/23, and 10/24/23, or three times during…

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, facility policies and documents, and the Pennsylvania Department of Health PAHAN-694, observations, and staff interviews, it was determined that the facility failed to ensure SARS-CoV-2 (COVID-19) infection control protocols were followed to help prevent the development and transmission of communicable diseases and infections on one of two nursing units (East Wing). Findings include: Review of a facility policy entitled COVID-19 Prevention, Response, and Reporting dated 9/14/23, indicated that all staff who enter the room of a resident with suspected or confirmed COVID-19 infection should adhere to standard precautions and use a National Institute for Occupational Safety and Health (NIOSH)-approved particulate respirator with N95 filter masks (fit over the nose and mouth, and when properly fitted, can filter 95% of particles) or higher, gown, gloves, and eye protection. Review of the Pennsylvania Department of Health PAHAN-694 dated 5/11/23, instructed facilities to ensure everyone is aware of recommended IPC (Infection Prevention and Control)…

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 facility assessment, and staff interview, it was determined that the facility lacked evidence that clinical staff completed their competencies for their resident population of seven residents requiring respiratory treatments. Findings include: Review of the General Information policy, dated 1/5/23, indicated that evaluating and documenting competency of staff is required upon hire, annually and as otherwise indicated. Review of the Facility Wide Self Assessment dated 3/6/23, revealed that staff competency is required for Respiratory Treatment due to the Resident Population Assessment. The assessment also identified that seven residents were identified that required respiratory treatments. During an interview on 8/23/23, at approximately 12:54 p.m. the Nursing Home Administrator confirmed the facility lacked evidence that the clinical staff competencies were completed related to respiratory treatments. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services