Sarah Reed Senior Living

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 obtain weights according to physician's orders for one of eight residents reviewed for weight loss. (Resident R1). Findings include: A facility policy last reviewed on 12/26/24, entitled Height and weight monitoring, directed that all residents were to be weighed by the 10th of each month. Review of Resident R1's clinical record revealed an admission date of 5/3/25, with diagnoses that included stroke, heart failure, and kidney failure. A physician's order dated 5/3/25, revealed that Resident R1 was to be weighed every day shift starting on the 1st and ending on the 10th every month. As of 6/12/25, review of Resident R1's clinical record revealed no documentation that the resident had been weighed as physician ordered since admission on [DATE]. During an interview on 6/12/25, at approximately 11:35 a.m., the Director of Nursing confirmed that Resident R1 had not been weighed since admission.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical records, 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 three of eight residents reviewed (Residents R8, R15, and R60). Findings include: A facility policy entitled, Care Plans dated 2/15/24, stated [NAME] will provide the resident and/or responsible party a copy of the baseline care plan at the new admission care plan meeting, which is typically held within 48 hours of admission. The provision of this will be documented on the New admission Care Plan summary sheet. In addition, the nursing staff will provide the resident/responsible person with: a. A summary of the resident's medications and dietary instructions b. Any services and treatments to be administered by [NAME] or its staff. Resident R8's clinical record revealed an admission date of 11/12/24, with diagnoses that included heart failure, atrial fibrillation (irregular…

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 staff interviews, it was determined that 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 two residents reviewed regarding range of motion (Resident R15). Findings include: Review of facility policy dated 2/15/24, entitled Range of Motion/Contracture Management indicated To increase flexibility and strength, also to prevent and/or decrease contractures. Review of facility policy dated 2/15/24, entitled Splinting indicated Splinting is used to protect joints and surrounding soft tissue. There must be a physician's order for splinting. Resident R15's admission record revealed an admission date of 8/05/24, with diagnoses that included dementia (a disease that affects short term memory and the ability to think logically), osteoarthritis (a joint disease that causes tissues in the joint to break down over time which can cause stiffness in the joint), and hypothyroidism (a…

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

Based on review of facility policy, clinical records, and staff interview, it was determined that the facility failed to have the required 14-day stop date or provide a clinical rationale for the continued use of a PRN (as needed) psychotropic (affecting the mind) medication beyond 14 days for two of 21 residents reviewed (Residents R8 and R15). Findings include: A facility policy entitled Psychoactive Medication Policy dated 2/15/24, stated that Orders for psychotropic drugs are limited to 14 days. If the attending physician or prescribing practitioner believe that it is appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record and indicate the duration for the PRN order. PRN orders for anti-psychotic drugs are limited to 14 days and cannot be renewed unless the attending physician or prescribing practitioner evaluated the resident for appropriateness of the medication. Resident R8's clinical record revealed an admission date of 11/12/24, with diagnoses that included heart failure, atrial fibrillation…

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, manufacturer's recommendations, observations, and staff interview, it was determined that the facility failed to ensure an expired medication was discarded in a timely manner and failed to ensure that a medication was properly dated when opened in one of three medication carts reviewed ([NAME] medication cart). Findings include: Review of a facility policy entitled Medication Storage in the Facility dated [DATE], indicated Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. Insulin vials are stored in the refrigerator until opened. Then dated and placed in the med cart once opened. Manufacturer's recommendations for Humalog insulin (a fast-acting insulin used to manage blood sugar levels in people with diabetes), indicated that after opened, vials and pre-filled pens should be discarded after 28 days. Manufacturer's recommendations for Lantus insulin (a long-acting insulin used to manage…

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 ensure that food was stored in accordance with standards for food safety in one of two walk-in coolers and one of one dry storage areas reviewed in the kitchen. Findings include: Review of facility policy entitled Proper Storage of Fresh, Frozen, Leftover and Opened Food Products dated 2/6/24, indicated If a product is found that is past the use-by date, it is to be disposed of in a proper manner. Another policy entitled Food From Outside Sources dated 2/6/24, indicated unconsumed food will be disposed of consistent with the manufacturing guidelines, food labels . Observation of the kitchen areas on 6/5/24, at 10:10 a.m. revealed an open partially used container of pasta salad in the cooler with a use-by date of 5/30/24, observations in the dry storage area revealed eight cans of pureed ham with an expiration date of March 2024, one open gallon jug of molasses with a use-by date of 10/13/23, and two tubs of baking soda with an expiration date of 5/31/24. During an…

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

Based on review of facility policy, observations, and staff interview, it was determined that the facility failed to ensure that food was stored in accordance with standards for food safety and sanitation in the walk-in freezer located in the main kitchen. Findings include: Review of the facility policy entitled, Refrigerated And Frozen Storage dated 2/6/2024, indicated that, The Food Service Department shall receive all food products in a manner that assures safety and quality of food products. All food items shall be placed on shelves and not on floor of refrigerator or freezer. Observations made during the initial kitchen tour on 3/19/2024, at approximately 11:00 a.m. revealed that there were several food items on the floor in the walk-in freezer located in the main kitchen. Interview conducted with the Food Service Director at that time confirmed the food items should not be on the floor in the walk-in freezer. 28 Pa. Code 211.6(f) Dietary services 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1) Management

Based on review of facility policies, clinical record review and staff interview, it was determined that the facility failed to ensure that a discharge summary, which included a recapitulation of the resident's stay and the resident's discharge status, physician's final diagnosis and prognosis or cause of death was completed for three of three closed clinical records reviewed (Residents CR94, CR95, and CR96). Findings include: A facility policy last reviewed 2/15/24, entitled Discharge Policy and Procedure indicated that a recapitulation of the resident's stay, a final summary of the resident's status and the disposition of medications would be part of the interdisciplinary summary discharge summary. A facility policy entitled Closed Record Policy dated 2/06/24, indicated that an interdisciplinary discharge summary is to be completed on all discharges from the facility by each member of the interdisciplinary team (IDT) and include: a short summary of resident's stay; final summary of resident status; disposition of medications; IDT on current caseload to sign off with specific…

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 contracted pharmacist provided separate, written reports of irregularities identified during the medication regimen review (MRR) for one of five residents reviewed for unnecessary medications (Resident R49). Findings include: A facility policy entitled, Medication Regimen Review and Reporting dated 2/06/24, indicated that findings/recommendations of interim (routine interval) MRR are communicated to the Director of Nursing (DON) or designee and medical director, and that the findings are documented and filed with other consultant pharmacist recommendations in the resident's chart. Resident R49's clinical record revealed an admission date of 3/12/18, with diagnoses including left-sided paralysis post stroke, Type 2 Diabetes (condition of improper insulin levels and blood sugar control), heart failure, irregular heartbeat, and dementia. Resident R49's progress notes revealed MRR's were completed monthly and lacked evidence that documented…

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 provide a clinical rationale and duration for the continued use of a PRN (as needed) psychotropic (affecting the mind) medication beyond 14 days for two of five residents reviewed (Residents R34 and R50). Findings include: A facility policy entitled Psychotropic Medication Policy dated 2/6/24, indicated that, PRN orders for psychotropic drugs are limited to 14 days. The attending physician or prescriber may extend the order beyond 14 days if he/she believes the order is appropriate. The prescriber must document the rational and duration when extending the order. PRN orders for anti-psychotic drugs are limited to 14 days and cannot be renewed unless the attending physician or prescribing practitioner evaluates the resident. Review of Resident R34's clinical record revealed an admission date of 2/23/23, with diagnoses that included dementia (a disease that affects short term memory and the ability to think logically), anxiety disorder (a disorder that causes 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.