Twinbrook Healthcare And Rehabilitation Center

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 ensure adequate assistance and supervision with meals was provided for one of four residents observed in the [NAME] Dining Room (Resident R1); failed to ensure assessment of a resident's nutritional status on admission and as needed thereafter and failed to complete a comprehensive nutritional assessment for a resident identified as being at risk for unplanned weight loss and/or compromised nutritional status for five of 26 residents (Residents R3, R4, R5, R6, and R7); and failed to ensure nutritional interventions were implemented for two of 26 residents reviewed (Residents R8 and R9). Findings include: A facility policy dated 2/02/26, entitled Weight Monitoring and Nutritional Assessment, revealed policy statement - to maintain acceptable parameters of nutritional status, the facility shall establish a consistent process for weighing residents and conducting nutritional…

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 interviews, it was determined that the facility failed to ensure the physician was notified timely regarding laboratory studies for one of four residents reviewed (Resident R2).Findings include: A facility policy, Change in a Resident's Condition, dated 2/02/26, revealed Our facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status (e.g., changes in level of care, billing/payments, resident rights, etc.). Resident R2' s clinical record revealed an admission date of 1/22/22, with diagnoses that included Alzheimer's (a disease of the brain affecting mood, behavior, and decision making), atrial flutter (a type of fast heart rhythm where the heart's upper chambers, the atria, beat rapidly in a regular pattern), muscle weakness, and high blood pressure. Resident R2's clinical record revealed a lab finding report dated as - collected 11/26/25, received 11/27/25, reported 11/27/25, with an abnormal potassium…

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, facility documents, and clinical records, and staff interviews, it was determined that the facility failed to have sufficient staff with the appropriate skill sets to provide nursing services. Findings include: A facility policy entitled Nursing Services and Sufficient Staff dated 11/8/24, indicated, The facility will supply services by sufficient numbers of each of the following personnel types on a 24-hour basis to provide nursing care to all residents in accordance with resident care plans . Providing care includes, but is not limited to, assessing, evaluating, planning and implementing resident care plans and responding to resident's needs. Review of Resident R1's clinical record and documentation for 5/25/25, revealed that Resident R1 was ordered an enteral feeding (method of providing nutrition directly to the stomach through a tube) to be started at 4:00 p.m. and Lispro Insulin (medication to control blood sugar levels) before meals. The May 2025 Medication Administration Record (MAR) revealed that the feeding was not started until 9:42…

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 dishwashing machine manufacturer's instructions, and staff interviews, it was determined that the facility failed to maintain dishwashing machine water temperatures in accordance with manufacturer recommendations for food service safety for the kitchen dishwasher. Findings include: Review of manufacturer's instructions for the facility dishwashing machine revealed that the hot water sanitizing mode minimum wash temperature and recommended wash temperature was 150-165 degrees Farenheit (F). The rinse temperature was 180-194 degrees F. Review of the Dishwashing/Warewashing machine temperature log sheet revealed that the minimum temperature requirements for the wash cycle was: Wash 150 degrees F and the Rinse 180 degrees F. If temperatures were below standard, the person in charge was notified and dismachine was stopped. Observations of the dishwashing machine operation on 4/25/2025, at 10:10 a.m. in the kitchen dishroom, in the presence of the Dietary Manager, revealed a dishwasher temperature of 152-154 degrees F during the wash cycle and 166-168…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policies, observations, and staff interviews, it was determined that the facility failed to follow acceptable infection control practices regarding enhanced barrier precautions (EBP) for five of five resident units (South East, South, West, East One and East Two units). The facility also failed to prevent the potential for cross-contamination during medication administration and completion of a wound dressing change for two of 21 residents reviewed (Residents R81 and Resident R92). Findings include: A facility policy entitled, Transmission-Based Precautions and Isolation Policy, dated 11/8/24, revealed Enhanced Barrier Precautions (EBP) - EBP are intended to prevent transmission of multi-drug resistant organisms (MDROs) via contaminated hands and clothing of healthcare workers to high risk residents. EBP are indicated for high contact care activities for residents with chronic wounds and indwelling devices (such as central lines, urinary catheters, and tracheostomy) and for all those…

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 assure physician orders and resident's Pennsylvania Order for Life Sustaining Treatment (POLST- a legal document specifying the resident/responsible party choices regarding life-sustaining treatments) were consistent for one of 24 residents reviewed (Resident R78). Findings include: Review of Resident R78's clinical record revealed an admission date of [DATE], with diagnoses that included dementia (a disease that affects short term memory and the ability to think logically), anxiety (a condition that causes a person to be nervous, uneasy, or worried about something or someone), and gastroesophageal reflux disease (a condition when stomach acid repeatedly flows back up into your throat). Review of Resident R78's POLST, revealed that POLST must be completed by a health care professional based on patient preferences and medical indicators or decisions by the patient or a surrogate, and must be signed by 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, observations, and resident and staff interview, it was determined that the facility failed to maintain a clean and sanitary resident room for three of three rooms (rooms [ROOM NUMBER]). Findings include: Review of facility policy entitled Maintenance Service dated 11/8/24, indicated The maintenance department is responsible for maintaining the building, grounds, and equipment in a safe and operable manner at all times. and Maintaining the building in good repair and free from hazards. Review of facility policy entitled Safe and Homelike Environment dated 11/8/24, indicated Housekeeping and maintenance services will be provided as necessary to maintain a sanitary, orderly, and comfortable environment. Observations on 4/22/25, at 2:00 p.m. and again on 4/23/25, at 9:45 a.m. in rooms [ROOM NUMBERS] revealed in room [ROOM NUMBER] a black substance on the wall where the paint had lifted next to the bottom corners of the window sill. Observation of room [ROOM NUMBER] revealed 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 and 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 two of seven residents reviewed (Residents R59 and R92). Findings include: Review of facility policy entitled Care Plans-Baseline dated 11/8/24, revealed The resident and their representative will be provided a summary of the baseline care plan . Review of Resident R59's clinical record revealed an admission date of 6/7/24, with diagnoses that included diabetes (a health condition that caused by the body's inability to produce enough insulin), and hypertension (high blood pressure). Resident R59's clinical record lacked evidence that a written summary of the baseline care plan and order summary was provided to Resident R59 and/or his/her representative. Review of Resident R92's clinical record revealed an admission date of 11/4/24, with diagnoses that included diabetes, paraplegia (a condition where a person is paralyzed from the waist down), 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, and staff interview, it was determined that the facility failed to develop comprehensive care plans for one of 21 residents reviewed (Resident R92). Findings include: Review of facility policy entitled Care Plans, Comprehensive Person-Centered dated 11/8/24, revealed Assessments of residents are ongoing, and care plans are revised as information about the resident and the residents' condition change. Review of Resident R92's clinical record revealed an admission date of 11/4/24, with diagnoses that included diabetes (a health condition that caused by the body's inability to produce enough insulin), paraplegia (a condition where a person is paralyzed from the waist down), and hypertension (high blood pressure). Review of Resident R92's therapy Discharge summary dated [DATE], revealed Patient will safely wear a resting hand splint on left hand for up to 8 hours . Review of resident R92's physician's orders revealed an order dated 12/24/24, for patient to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of 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 three residents reviewed (Resident R92). Findings include: Review of Resident R92's clinical record revealed an admission date of 11/4/24, with diagnoses that included diabetes (a health condition that caused by the body's inability to produce enough insulin), paraplegia (a condition where a person is paralyzed from the waist down), and hypertension (high blood pressure). Review of Resident R92's therapy Discharge summary dated [DATE], revealed Patient will safely wear a resting hand splint (a splint placed on the hand to help with contractures) on left hand for up to 8 hours . Review of Resident R92's physician's orders revealed an order dated 12/24/24, for patient to wear palm roll splint 4 hours in the a.m. and 4 hours in the p.m. for…

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

Based on review of facility documents and staff interview, it was determined that the facility failed to have a Director of Nursing (DON) working full-time of 35 hours per week in the building. Findings include: Review of the facility deployment sheets documented that the DON was assigned to work as a charge nurse on 4/22/25, as a floor nurse 4/23/25, and worked on 4/25/25 as a charge nurse. During interview on 4/25/25, at approximately 1:40 p.m. the DON confirmed that he/she worked in the above capacities as documented on the deployment sheets rather than as the DON which did not meet the required hours to fulfill the DON full-time position. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 211.12(b) Nursing services

Based on review of facility policies, observations and staff interviews, it was determined that the facility failed to appropriately discard outdated medications for three of three medication carts reviewed and one of three medication rooms reviewed (West, East One, and South medication carts and East One medication room). Findings include: Review of facility policy entitled Administering Medications dated 11/8/24, indicated The expiration/beyond use date on the medication label is checked prior to administering. When opening a multi-dose container, the date opened is recorded on the container. Review of manufacturer's guidelines revealed that an open pen of Lispro/Humalog Insulin must be used within 28 days after opening or be discarded. Review of manufacturer's guidelines revealed that an open pen of Lantus Insulin must be used within 28 days after opening or be discarded, even if the vial still contains insulin. Review of manufacturer's guidelines revealed that an open vial of Tubersol should be discarded within 30 days after opening. Observation of drug storage on 4/22/25, at…

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

Based on review of facility policy, clinical records, and staff interview, it was determined that the facility failed to follow physician's orders related to laboratory blood draws for three of the four residents reviewed for laboratory testing (Residents R1, R2, and R3). Findings include: Review of a facility policy entitled, Provision of Physician Ordered Services dated 11/08/24, revealed Facility will maintain a schedule of diagnostic tests (laboratory and radiology) in accordance with the physician's orders. Review of Resident R1's clinical record revealed an admission date of 7/31/24, with diagnoses that included chronic obstructive pulmonary disease (COPD-a group of lung diseases that make it difficult to breath), muscle weakness, and respiratory failure. Review of Resident R1's clinical record revealed a physician's order dated 12/18/24, for a follow-up Comprehensive Metabolic Panel (CMP-a group of laboratory tests that measure various substances in the blood to assess overall health and detect potential medical conditions) and a Complete Blood Count (CBC) with differential…

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, observations, and staff interview, it was determined that the facility failed to ensure an organized system and adequate supplies were in place for timely and accurate laboratory services for four of four residents reviewed for laboratory testing (Residents R1, R2, R3, and R4). Findings include: Review of a facility policy entitled, Laboratory Services and Reporting dated 11/08/24, revealed The facility must provide or obtain laboratory services to meet the needs of its residents. The facility is responsible for the timeliness of the services. Should the facility provide its own laboratory services, the services must meet the applicable requirement for laboratories. Observations made on 12/22/24, at approximately 10:45 a.m. in the laboratory supply room revealed the facility lacked adequate supplies to obtain laboratory blood draws in-house. Review of Resident R1's clinical record revealed an admission date of 7/31/24, with diagnoses that included chronic obstructive pulmonary disease (COPD-a group of lung…

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 maintain a homelike environment for one of nine residents reviewed (Resident R5). Findings include: Review of a facility policy entitled Safe and Homelike Environment dated 11/08/24, revealed Housekeeping and maintenance services will be provided as necessary to maintain a sanitary, orderly, and comfortable environment. Observation of Resident R5's room on 12/22/24, at approximately 10:30 a.m. revealed the baseboard heating system was detaching from the wall creating a noticeable gap between the baseboard heating system and the wall. During an interview on 12/22/24, at approximately 1:08 p.m. the Director of Nursing confirmed that the gap between the baseboard heating system and the wall was not homelike and should have been repaired or replaced. 28 Pa. Code 201.18 (e)(2.1) Management 28 Pa. Code 201.14(a) Responsibility of licensee

Based on review of facility policy and clinical records and staff interview, it was determined that the facility failed to ensure that physicians wrote, signed, and dated progress notes at required visits for six of six residents reviewed (Residents R1, R2, R3, R4, R5, and R6). Findings include: A facility policy entitled, Attending Physician Documentation Responsibility revealed: the attending physician will seek, provide, and analyze information regarding a resident's current status, recent history, medications, and treatments to enable safe, effective continuing care and to support facility compliance with regulations and care standards; and at each visit, the attending physician will provide a progress note (written, typed, or electronic) in a timely manner for placement in the medical record; the note should either be written or entered at the time of the visit or, if dictated or otherwise prepared after the visit, should be returned to the facility for placement on the chart within 30 days of the visit. Resident R1's clinical record revealed an admission date of 7/10/24, with…

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

Based on review of facility policy and clinical records, and staff interview, it was determined that the facility failed to develop and implement resident centered comprehensive care plans for four of 20 residents reviewed (Residents R19, R51, R54, and R66). Findings: A facility policy entitled Oxygen Administration dated 4/26/24, indicated the resident's care plan shall identify the interventions for oxygen therapy, based upon the resident's assessment and orders, such as, but not limited to a. type of oxygen delivery system; b. when to administer, such as continuous or intermittent and/or when to discontinue; c. equipment setting for the prescribed flow rates; d. monitoring of SpO2 (oxygen saturation) levels and/or vital signs, as ordered; and e. monitoring for complications associated with the use of oxygen. Resident R19's clinical record revealed an admission date of 8/16/22, with diagnoses that included heart disease, irregular heartbeat, heart failure, and obstructive sleep apnea (condition that occurs when the throat muscles relax and block the airway). A physician's order…

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 review and revise comprehensive care plans to reflect the current care and services for three of 20 residents reviewed (Residents R4, R20, and R58). Findings include: Review of facility policy entitled Care Plan Revision Upon Status Change dated 4/26/24, indicated that The comprehensive care plan will be reviewed, and revised as necessary, when a resident experiences a status change. Resident R4's clinical record revealed an admission date of 1/31/22, with diagnoses that included obstructive sleep apnea (a sleeping disorder where a person's breathing repeatedly stops and starts while sleeping), hypertension (high blood pressure), diabetes, and hyperlipidemia (high cholesterol). Review of care plan meeting documentation for Resident R4 revealed a care plan meeting was completed on 3/14/24. Review of Resident R4's clinical record revealed a physician order dated 12/5/23, for continuous positive airway pressure (CPAP), must wear every night. Review of Resident…

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

Based on review of facility policy and clinical records, observations, and staff interview, it was determined that the facility failed to promote cleanliness and prevent the potential spread of infection regarding respiratory care equipment according to physician's orders for six of 20 residents (Residents R4, R19, R51, R54, R58, and R66). Findings: A facility policy entitled Oxygen Administration dated 4/26/24, indicated: oxygen is administered to residents who need it, consistent with professional standards of practice, the comprehensive person-centered care plans, and the resident's goals and preferences; infection control measures included, a. clean/rinse oxygen concentrator (take air from your surroundings, extract oxygen and filter it into purified oxygen for you to breathe) filter weekly, change as needed; b. change oxygen tubing (lightweight tube used to delivery supplemental oxygen) and mask/cannula weekly and as needed if it becomes soiled of contaminated; c. clean humidifier bottle when empty, change weekly, use only sterile water for humidification; d. keep delivery…

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 staff interview, it was determined that the facility failed to provide resident privacy and dignity regarding an exposed urinary catheter (a tube placed and held in the bladder to drain urine) bag for two of two residents reviewed for catheters (Residents R8 and R69). Findings include: Review of facility policy entitled, Indwelling Catheter Use and Storage dated 4/26/24, indicated Additional care practices include .keeping the catheter bag covered for resident's dignity and privacy. Review of Resident R8's clinical record revealed an admission date of 4/20/24, with diagnoses that included neuromuscular dysfunction of bladder (a condition when a person lacks bladder control due to the muscles and nerves that control the bladder not working properly), diabetes, and heart failure (a condition where the heart cannot supply the body with enough blood). Observation on 5/14/24, at 1:03 p.m. revealed Resident R8 was in his/her room laying in his/her bed with his/her urinary catheter drainage bag hanging on 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 facility policy and clinical record, 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 20 residents reviewed (Resident R60). Findings include: A facility policy entitled, Baseline Care Plan dated 4/26/24, revealed A written summary of the baseline care plan shall be provided to the resident and representative in a language that the resident/representative can understand. The summary shall include at a minimum the following: a. The initial goals 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. Resident R60's clinical record revealed an admission date of 3/14/24, with diagnoses that included chronic respiratory failure, pneumonia (an infection in the lungs), and epileptic seizures (a sudden uncontrolled electric disturbance in the brain that can cause changes in behaviors and…

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

Based on review of manufacturer's recommendations, facility policy, and clinical records, and staff interviews it was determined that the facility failed to ensure that pain management was provided to residents who require such services, consistent with professional standards of practice for one of 20 residents reviewed (Resident R19). Findings include: Review of manufacturer's recommendations for administering acetaminophen (Tylenol) included not to exceed six tablets in 24 hours. A facility policy entitled Medication Administration dated 4/26/24, indicated that medications will be administered as ordered and in accordance with manufacturer's specifications. Resident R19's clinical record revealed an admission date of 8/16/22, with diagnoses that included heart disease, irregular heartbeat, heart failure, and obstructive sleep apnea (condition that occurs when the throat muscles relax and block the airway). A physician's order dated 4/12/24, instructed staff to administer two acetaminophen 500 milligram (mg) tablets every four hours as needed for pain to Resident R19 (or up to 12…

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 policy and clinical records, and staff interview, it was determined that the facility failed to implement procedures to promote accurate and safe disposition of controlled medication records for one of three closed records reviewed (Resident CR94). Findings include: Review of the facility policy, entitled Disposal of Medications, dated 4/26/24, indicated, Controlled Substances listed in Schedules II, III, IV, and V remaining in the nursing care center after the order has been discontinued are retained in the nursing care center in a securely double locked area with restricted access until destroyed as outlined by state regulation. For the State of Pennsylvania, these controlled substances shall be disposed of by the nursing care center in the presence of appropriately titled professionals two licensed nurses employed by the nursing center. A controlled medication disposition log, or equivalent form shall be used for documentation and shall be retained as per federal privacy and state regulations. This log shall contain the following information,…

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 a pharmacist's recommendation was reviewed and acted upon for one of 20 residents reviewed (Resident R19). Findings: A facility policy entitled Medication Regimen Review dated 4/26/24, indicated that facility staff shall act upon all recommendations according to procedures for addressing medication regimen review irregularities. Resident R19's clinical record revealed an admission date of 8/16/22, with diagnoses that included heart disease, irregular heartbeat, heart failure, and obstructive sleep apnea (occurs when the throat muscles relax and block the airway). Resident R19's departmental progress notes revealed that on 1/27/24, the consultant pharmacist identified irregularities with Resident R19's medication regimen and referred to see the report. Resident R19's clinical record lacked evidence of a pharmacy recommendation report for January 2024 addressing the irregularities. During an interview on 5/16/24, at 2:00 p.m. the Director of Nursing…

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