Pennknoll Village

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's environment remained free of accident hazards by failing to ensure care-planned interventions were in place for two of 37 residents reviewed (Resident 17, 57) who were at risk for falls. Findings include:The facility's policy regarding fall prevention and management, dated January 19, 2026, indicated that the facility will identify those residents at risk for falls upon admission, readmission, and quarterly and provide appropriate interventions to modify and/or compensate for risk factors, and that environmental interventions would be used to decrease the risk of the resident falling. The care plan will be updated to reflect resident-specific safety needs and interventions. The facility had no policy regarding the use of foot plates while transporting residents in the facility. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 17, dated November…

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 policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to store medications properly for one of 37 residents reviewed (Resident 47).Findings include:The facility's policy regarding medication storage, dated January 19, 2026, revealed that all drugs and biologicals would be stored in locked compartments (i.e. medication carts, cabinets, drawers, refrigerators, medication rooms) under proper temperature controls. During medication pass, medications must be under the direct observation of the person administering medications or locked in the medication storage area/cart.Current physician's orders for Resident 47, included orders for the resident to receive 100 milligrams (mg) of Allopurinol (used to treat gout) once a day, 10 mg of Fluoxetine (anti-depressant) one time day, 300 mg of Gabapentin (used to treat neuropathy/pain) three times day, and 1 gram of Methenamine Hippurate (antibiotic) one time a day.Observations on January 22, 2026, at 9:01 a.m. revealed that Registered Nurse 4 prepared…

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, clinical record reviews, observations, and staff interviews, it was determined that the facility failed to ensure that residents were provided with assistive devices for eating as ordered by the physician for one of 13 residents reviewed (Resident 1). Findings include:A review of the facility's policy regarding Use of Assistive Devices, dated January 19, 2026 revealed that the use of assistive devices for eating will be based on the resident's comprehensive assessment, in accordance with the resident's plan of care.A comprehensive Minimum Data Set (MDS) assessment for Resident 1, dated January 17, 2026, revealed that the resident was cognitively intact, is dependent on staff for daily care tasks, including assistance with eating. Physician's orders for Resident 1, dated March 18, 2026, included an order to provide a rimmed plate for meals (a plate that has high sides), maroon spoons (special order to help the resident take small bites), and two handled cup with a spouted lid (special order to help with resident to not spill drinks). 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 the facility's plans of correction for previous surveys, and the results of the current survey, it was determined that the facility's Quality Assurance Performance Improvement (QAPI) committee failed to correct quality deficiencies and ensure that plans to improve the delivery of care and services effectively addressed recurring deficiencies.Findings include:The facility's deficiencies and plans of corrections for State Survey and Certification (Department of Health) surveys ending January 15 and May 29, 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 regulations. The results of the current survey, ending January 23, 2026, identified repeated deficiencies related to homelike environment, ensuring that the resident's environment was free from accident hazards, failure to serve palatable food at appropriate temperatures, and to store and prepare food under sanitary conditions . The facility's plan of correction for a deficiency regarding 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 policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that the proper hand-washing procedures were followed, and that proper infection control practices were followed for two of 37 residents reviewed (Residents 47, 80).Findings include:The facility's policy regarding hand hygiene, November 13, 2025, indicated that when staff washed their hands, they were to dry them with a single use towel and then turn the faucet off with a clean towel. Observations on January 22, 2026, at 8:55 a.m. revealed that Registered Nurse 4 administered medications to Resident 80. He then washed his hands and turned the faucet off with his clean hand and dried his hands with a paper towel. Observations on January 22, 2026, at 9:01 a.m. revealed Registered Nurse 4 administered medications to Resident 47. He then washed his hands and turned the faucet off with his clean hand and dried his hands with a paper towel.Interview with Registered Nurse 4 on January 22, 2026, at 9:03 a.m. confirmed that he should not have…

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, as well as resident and staff interviews, it was determined that the facility failed to serve palatable food that was at appropriate temperatures. Findings include: Review of food committee meeting minutes for 2024 revealed that the food is burnt, has been cold, and tasted bad. Interview with Resident 66 on January 12, 2025, at 10:47 a.m. indicated that the food tastes burnt and does not taste good, and it is cold at times. Interview with Resident 74 on January 12, 2025, at 1:22 p.m. indicated that the food is terrible and has no taste, there is too much pork, and it is cold. Observations of the kitchen's lunch meal tray line on January 14, 2025, revealed that it began at 12:10 p.m. and included macaroni and cheese, chicken, mashed potatoes, fruit cocktail, and coffee. The last tray was placed on the cart at 12:15 p.m. The cart left the kitchen and arrived on the unit at 12:16 p.m. and the last tray was removed from the cart and served at 12:27 p.m. The test tray was removed from the cart at 12:28 p.m. The macaroni and cheese was 141 degrees Fahrenheit (F),…

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 Food Committee meeting minutes, and resident and staff interviews, it was determined that the facility failed to make ongoing efforts to resolve resident grievances regarding cold food. Findings include: The facility's policy regarding food quality and palatability, dated March 18, 2024, revealed that food will be palatable, attractive, and served at a safe and appetizing temperature. Food Committee meeting minutes for January through August 2024 and October through December 2024 indicated that the residents were receiving cold food. A meeting with a group of residents on January 13, 2025, at 11:15 a.m. revealed that the residents have been served food that was cold and unpalatable. They stated that they have requested food that is served at the correct temperature. They stated that this had been occurring for at least one year. Interview with Director of Dietary on January 14, 2025, at 12:14 p.m. confirmed that she was aware that residents complained about cold food, and that it was brought up during the Food Committee meetings. She stated…

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, as well as staff interviews, it was determined that the facility failed to ensure that physician's orders were followed for two of 30 residents reviewed (Residents 40, 53). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 40, dated November 13, 2024, revealed that the resident was cognitively intact, was independent with daily care needs, had diagnoses that included high blood pressure, diabetes, and Parkinson's. Current physician's orders for Resident 40 included orders for the resident to receive 10 milligrams of Cetirizine at bedtime every Monday and Thursday for allergies, 100 micrograms of Synthroid daily for hypothyroidism (when the thyroid gland does not make enough thyroid hormones), 17 grams of Miralax daily for constipation, 30 milligrams of Diltiazem twice a day for high blood pressure, and 500 milligram of Tylenol twice a day for left knee pain. A review of Resident 40's Medication Administration Records (MAR's) 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 facility policy, as well as observations and staff interviews, it was determined that the facility failed to store and serve food in accordance with professional standards for food service safety by failing to store and serve food under sanitary conditions. Findings include: The facility's current policy for outside food indicated that when food items are intended for later consumption the responsible facility staff member will label foods with the resident's name and current date. Frozen foods may be retained for 30 days. Observations in the main kitchen during an initial tour on January 12, 2025, at 9:17 a.m. revealed that Dietary Employee 11 was removing a cake from the cooler and his hair and beard were exposed and not covered with a hair net or beard guard. Interview with Dietary Employee 11 at that time confirmed that he should have been wearing a hair net and beard guard but he was just getting a cake out. Observations in the solarium refrigerator on January 12, 2025, at 9:35 a.m. revealed that the following items that had resident names but were open 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 the facility's plans of correction for previous surveys, and the results of the current survey, it was determined that the facility's Quality Assurance Performance Improvement (QAPI) committee failed to maintain compliance with nursing home regulations and ensure that plans to improve the delivery of care and services effectively addressed recurring deficiencies. Findings include: The facility's deficiencies and plan of correction for a State Survey and Certification (Department of Health) survey ending February 23, 2024, revealed that the facility developed plans of correction that included quality assurance systems to ensure that the facility maintained compliance with cited nursing home regulations. The results of the current survey, ending January 15, 2025, identified repeated deficiencies related to a failure to ensure that grievances were resolved, care plans were revised/updated, quality of care-physician's orders were followed, nurse aide performance reviews were conducted, and food and drink preferences were honored. The facility's plan of correction 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 observations and staff interviews, it was determined that the facility failed to provide a clean and homelike environment in resident rooms for two of 30 residents reviewed (Residents 5, 29). Findings include: The facility's policy, dated March 18, 2024, indicated that resident care equipment, including durable medical equipment, will be kept clean, and resident rooms will be maintained in such a way as to present a homelike appearance. Observations of Resident 5 on January 12, 2025, at 12:10 p.m. and January 14, 2025, at 2:03 p.m. revealed that the resident was lying in her bed with a feeding pump (machine that administers liquid nutrition) running at 50cc/hr. The feeding pump had a moderate amount of a light brown, sticky substance on the front and back, and the resident's overbed table top had two areas measuring approximately one inch by two inches of a yellowish/white removable substance. In addition, a red stethoscope dangling from the feeding pump was observed to have a large amount of a bright white, dried substance on it. Interview with Licensed Practical Nurse 1…

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 policies, clinical records, personnel files, and investigative reports, as well as interviews with staff, it was determined that the facility failed to ensure that the abuse policy was followed for one of 30 residents reviewed (Resident 28), and failed to complete a professional licensure verification with the Pennsylvania State Board of Nursing prior to hire for one of four employees reviewed (Registered Nurse 1). Findings include: The facility's abuse policy, dated March 18, 2024, indicated that no employee may at any time commit an act of physical, psychological, or emotional abuse; neglect; mistreatment and/or misappropriation of property against any resident, and persons applying for employment with the center will be screened for a history of abuse, neglect, exploitations, or misappropriation of resident property, including but not limited to employment history, criminal background check, abuse check with appropriate licensing board and registries prior to hire, and licensure or registration verification prior to hire. A quarterly Minimum Data Set (MDS)…

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 reviews, and staff interviews, it was determined that the facility failed to notify the resident, responsible party, and Ombudsman, in writing, regarding the reason for hospitalization for two of 30 residents reviewed (Residents 68, 70). Findings include: The facility policy for Transfer/Discharge Notification, dated March 18, 2024, revealed that before a resident is transferred or discharged , the facility will notify the resident and resident representative of the transfer or discharge and the reason for the move in writing and will send a copy of the notice to a representative of the Office of the State Long Term Care Ombudsman. A significant change Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 68, dated November 7, 2024, indicated that the resident was cognitively intact and required assistance from staff for daily care needs. A nursing note for Resident 68, dated October 28, 2024, at 3:42 a.m. revealed that the resident complained of difficulty 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 facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that appropriate parties were notified about the facility's bed-hold policy upon transfer to the hospital for two of 30 residents reviewed (Residents 68, 70). Findings include: The facility policy for Bed Hold Notice, dated March 18, 2024, revealed that in accordance with state and federal law the facility provides written notice of its bed-hold information to each resident and resident representative. A significant change Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 68, dated November 7, 2024, indicated that the resident was cognitively intact and required assistance from staff for daily care needs. A nursing note for Resident 68, dated October 28, 2024, at 3:42 a.m., revealed that the resident complained of difficulty breathing. Despite interventions she continued to have difficulty breathing and requested to go to the emergency department, and she was transferred to 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 policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that care plans were updated to reflect changes in residents' care needs for one of 30 residents reviewed (Resident 29). Findings include: The facility's policy regarding care plans, dated March 18, 2024, indicated that an individualized person-centered plan of care will be established by the interdisciplinary team with the resident or resident representative to the extent practicable and will be updated in accordance with state and federal regulatory requirements. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 29, dated December 14, 2024, revealed that she was cognitively impaired, was dependent on staff for activities of daily living, and had a diagnoses that included dementia and high blood pressure. A consult note for Resident 29 from the wound doctor, dated January 7, 2025, revealed that the consultant company was signing off on the resident and that she has no…

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

Based on clinical record reviews and resident and staff interviews, it was determined that the facility failed to provide adequate, ongoing activities designed to meet the needs of residents for seven of 30 residents reviewed (Residents 3, 14, 20, 24, 36, 63, 66). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 3, dated December 6, 2024, indicated that the resident was cognitively intact and was dependent on staff for daily care needs, and that it was very important for the resident to be provided with books to read, be involved in group activities, participate in favorite activities, and participate in religious activities. A quarterly MDS assessment for Resident 14, dated December 11, 2024, indicated that the resident was cognitively intact and dependent on staff for daily care needs, and that it was very important for the resident to listen to music, participate in favorite activities, go outside when the weather is nice, and participate in religious activities. A quarterly MDS…

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

Based on a review of clinical records, as well as staff interviews, it was determined that the facility failed to ensure that a resident's transfer status was followed for one of 30 residents reviewed (Resident 68). Findings include: A significant change Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 68, dated November 7, 2024, revealed that the resident was cognitively intact, required two-person assistance for transfers, and had diagnoses of acute respiratory failure and muscle weakness. A nursing note for Resident 68, dated December 20, 2024, at 10:45 a.m. revealed that the resident was being transferred from the bed to a wheelchair by one nurse aide when the resident became weak and was slowly lowered to a sitting position on the floor. Resident was wearing black sneakers and was assessed, no injuries were found and there were no complaints of pain. Interview with the Nursing Home Administrator on January 15, 2025, at 9:41 a.m. confirmed that Resident 68 was transferred by one staff member and she should have been…

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, as well as resident and staff interviews, it was determined that the facility failed to ensure that there was sufficient nursing staff available to transport residents to activities and to provide licensed nursing staff in the facility's main dining area for the lunch and dinner meals. Findings include: A grievance from Resident 68, dated November 15, 2024, revealed that the resident was unable to go to activities due to nursing aides not being able to take her there. Staff were educated on the importance of ensuring residents were out of bed and transferred to their activities per each resident's preference. Review of the facility's dietary delivery times, undated, revealed that breakfast meals were to be delivered to the units from 7:00 a.m. to 8:15 a.m., lunch meals were to be delivered to the units from 12:40 a.m. to 1:00 p.m., the main dining room was to be served at 1:10 p.m., and dinner meals were to be delivered to the units from 5:00 p.m. to 6:15 p.m. Observations in the main dining room for lunch on January 12, 2025, at 1:02 p.m. revealed that only…

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 personnel files, as well as staff interviews, it was determined that the facility failed to ensure that nurse aide performance evaluations were completed annually based on hire dates for one of three nurse aides reviewed (Nurse Aide 10). Findings include: A list of nurse aides provided by the facility revealed that based on their months and days of hire, an annual performance evaluation for Nurse Aide 10 was due September 24, 2024. As of January 15, 2025, there was no documented evidence that the annual performance evaluation was completed as required for Nurse Aide 10. Interview with the Director of Human Resources on January 15, 2025, at 2:03 p.m. confirmed that there was no documented evidence that the annual performance evaluation for Nurse Aide 10 was completed as required. 28 Pa. Code 201.14(a) Responsibility of Licensee. 28 Pa. Code 201.18(b)(1)(3)(e)(1) Management. 28 Pa. Code 201.20(a)(c) Staff Development.

Based on observations, as well as resident and staff interviews, it was determined that the facility failed to ensure that residents' drink and food preferences were honored. Findings include: Interview with a group of residents on January 13, 2025, at 11:15 a.m. revealed that they would enjoy soda, but you can only get soda now if you are sick. They have requested dippy eggs, hot dogs, sausage, kielbasa, and also asked for ice cream as a snack but were told no. One resident stated, We have no joy in our lives, we may as well be in prison. Interview with the Dietary Manager and Nursing Home Administrator on January 14, 2025, at 1:07 p.m. revealed that she is not able to purchase any of the requested drink or snack items for residents and that everything she receives was determined by corporate. She revealed that the beverages on the menu are juices and not soda, and that with the increased cost of food there is no money left to buy the requested snacks such as soda and ice cream. Residents have to purchase the items themselves. She indicated that sometimes she uses her own money to…

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

Based on review of clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that staff provided assistive devices to eat in accordance with occupational therapy recommendations for one of four residents reviewed (Resident 3). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 3, dated October 8, 2024, indicated that the resident was cognitively intact, was dependent with personal hygiene needs and eating, and had diagnoses that included, tremors, spinal stenosis, contractures of the hands, and kyphosis (an abnormal curvature of the neck and/or spine). Occupational Therapy recommendations for Resident 3, dated October 11, 2024, included a recommendation for the use of slightly built-up utensils (black handled) for meals. Observations of Resident 3 during the breakfast meal on October 22, 2024, at 8:30 a.m. revealed that the resident was in her room eating her meal and she had a large handled (good grip) spoon on her tray. The 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 clinical records, as well as staff interviews, it was determined that the facility failed to ensure that pressure ulcers were assessed and documented on for two of four residents reviewed (Residents 1, 3). Findings include: The facility's policy regarding pressure ulcer monitoring, dated February 13, 2024, indicated that the facility would document the presence of skin impairments/new skin impairment related to pressure when first observed, and weekly thereafter until the site is resolved. An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated July 24, 2024, revealed that the resident was cognitively impaired, required assistance with daily care needs, and had diagnoses that included left femur fracture (large leg bone). A skin integrity care plan for Resident 1, dated July 17, 2024, indicated that the care and treatment included weekly wound assessments with documentation to include the width, length, depth, type of tissue, exudate, and any other notable changes or observations 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 the facility's job descriptions and interviews with staff, it was determined that the facility failed to ensure the consistent services of a full-time Director of Nursing (35 or more hours a week) in the facility. Findings include: The facility's job description for the Director of Nursing (DON), undated, revealed that as a Health Care Director of Services, the DON is entrusted with the responsibility of caring for the facility's residents, families, co-workers, visitors, and all others. The primary purpose of the job position is to plan, organize, develop, and direct the overall operation of the nursing service department in accordance with current federal, state, and local standards, guidelines, and regulations that govern the facility. Interview with the Regional Nurse Consultant on July 17, 2024, at 11:53 a.m. revealed that she is trying to cover the Director of Nursing position but that she has to work the floor too much and cannot get the Director of Nursing job duties done. She stated that they are in the process of hiring someone, but that person has not…

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

Based on review of the facility's job descriptions, and interviews with staff, it was determined that the facility failed to ensure the consistent services of a full-time Director of Nursing (35 or more hours a week) in the facility. Findings include: The facility's job description for the Director of Nursing (DON), undated, revealed that as a Health Care Director of Services, the DON is entrusted with the responsibility of caring for the facility's residents, families, co-workers, visitors, and all others. The primary purpose of the job position is to plan, organize, develop, and direct the overall operation of the nursing service department in accordance with current federal, state, and local standards, guidelines, and regulations that govern the facility. Information reported to the State Department of Health indicated that Registered Nurse 1 started as the DON for the facility on May 1, 2024. Interview with the Registered Nurse Assessment Coordinator (RNAC - a registered nurse who is responsible for completion of MDS assessments) on May 13, 2024, at 3:34 p.m. revealed that…

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

Based on review of clinical records and grievance records, as well as resident and staff interviews, it was determined that the facility failed to make ongoing efforts to resolve a grievance regarding dietary complaints. Findings include: The facility's policy regarding complaint and grievances, dated February 13, 2024, indicated that residents should have reasonable expectations of care and services and the facility should address those expectations in a timely, reasonable, and consistent manner. The grievance log from December 2023 revealed that there were three grievances from the resident council meeting on December 10, 2023, regarding residents not receiving food that they requested, receiving tiny portions of food, and hair found in the soup. Education was provided to dietary. The grievance log from February 2024 revealed that the rice was undercooked, foods that were to be served cold were being served on the hot plates, the dietary department ignores resident requests, portions were small, food was not palatable and was terrible, poor food quality, and residents were served…

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, as well as staff interviews, it was determined that the facility failed to ensure that weights were obtained and documented as ordered for residents with weight loss for two of 51 residents reviewed (Residents 12, 42) and failed to ensure supplements were provided and documented as ordered for two of 51 residents reviewed (Residents 77, 97). Findings include: The facility's policy for weighing residents, dated February 13, 2024, indicated that weights will be completed as indicated and documented in the clinical record. A significant change Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 12, dated December 13, 2023, revealed that the resident was moderately cognitively impaired, had diagnoses that included coronary (heart) artery disease and dysphagia (difficulty swallowing foods or liquids), required tube feedings for nutrition, and had weight loss that was not a physician-prescribed weight loss regimen. Current care plans indicated that the resident was 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 policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure the accountability of controlled medications (drugs with the potential to be abused) for two of 51 residents reviewed (Residents 15, 29). Findings include: The facility's policy regarding controlled drug disposal, dated February 13, 2024, indicated that controlled drugs should be wasted using a commercial controlled drug disposal system signed by two nurses witnessing the destruction of the controlled drug. The facility's policy regarding medication administration, dated February 13, 2024, indicated that the nurse will document on the Medication Administration Record (MAR) immediately prior to administration or immediately post administration based on the preferred individual practice of the nurse. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 15, dated December 28, 2023, revealed that the resident was cognitively intact, was dependent on staff for care needs, had constant…

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 individual resident interviews and an interview with a group of residents, as well as a meal test tray, it was determined that the facility failed to serve food items that were palatable to residents. Findings include: Interview with Resident 7 on February 20, 2024, at 1:01 p.m. revealed that the food was awful and there was nothing good about it. Interview with Resident 11 on February 20, 2024, at 2:00 p.m. and Resident 93 during the initial tour on February 21, 2024, at 10:11 a.m. revealed that the food was bad. Interview with Resident 115 during the initial tour on February 20, 2023, at 11:03 a.m. revealed the food was not palatable as it did not taste good. Resident 115 would frequently order take out or have family bring in food. Interview with a group of residents on February 21, 2024, at 11:43 a.m. revealed that the food was bland, the vegetables were overcooked, and condiments do not come on the trays. Observations of the lunch meal on February 22, 2024, at 12:23 p.m. revealed that food items on a test tray were not palatable to taste. The brussel sprouts were…

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

Based on clinical record reviews, observations, and staff interviews, it was determined that the facility failed to provide reasonable accommodation of a resident's needs by failing to ensure that the call bell was within reach for one of 25 residents reviewed (Resident 31). Findings include: An annual Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 31, dated January 29, 2024, indicated that the resident was understood and could understand, and he required maximum assistance for transfers and toileting. The resident's current care plan indicated that the resident had decreased mobility and that staff were to ensure the call bell was within reach. Observations of Resident 31 on February 20, 2024, at 1:05 p.m. revealed that the resident was lying in bed, and the call bell was hanging off the back of the bed onto the floor and was not within his reach. Interview with Licensed Practical Nurse 1 at that time revealed that Resident 31 was capable of using his call bell and it should have been placed within his reach. 28 Pa.…

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 a review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that a resident's attending physician was notified about changes in weight for one of 51 residents reviewed (Resident 19), failed to notify the physician regarding an elevated blood sugar and change in skin condition for one of 51 residents reviewed (Resident 47), and failed to notify the physician of purulent drainage from a resident's nephrostomy tube for one of 51 residents reviewed (Resident 97) . Findings include: The facility's policy regarding weight monitoring, dated February 13, 2024, indicated to record weight and alert the nurse to any significant weight change. When there is a significant variance from the previous recorded weight, the scale should be rebalanced and the resident re-weighed and a licensed nurse is to validate. The nurse is responsible to notify the physician of any significant weight change and to consult with the Director of Dietary Services…

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, as well as observations and staff interviews, it was determined that the facility failed to develop care plans for individualized resident care needs for three of 51 residents reviewed (Residents 7, 42, 68). Findings include: The facility's policy on care plans, dated February 13, 2024, indicated that a comprehensive, individualized, person-centered plan of care would be developed for each resident that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs that are identified in the comprehensive assessment. A Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 7, dated December 29, 2023, indicated that the resident was cognitively intact, required moderate to substantial assistance with care needs, and was frequently incontinent of bowel and bladder. An urology consult for Resident 7, dated January 4, 2024, indicated that the resident has a cystoscopy (a procedure to diagnose a treat urinary tract…

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, as well as staff interviews, it was determined that the facility failed to ensure that care plans were updated to reflect changes in care needs for one of 51 residents reviewed (Resident 29). Findings include: The facility's policy on care plans, dated February 13, 2024, indicated that the comprehensive care plan will be reviewed, updated and/or revised based on changing goals, preferences and needs of the resident and in response to current interventions after the completion of each Omnibus Budget Reconciliation Act (OBRA) MDS assessment and as needed. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 29, dated February 3, 2024, revealed that the resident was cognitively intact and required supervision to partial assist with care needs. Clinical record review for Resident 29 revealed that he had a care plan in place for heparin (an anticoagulant or blood thinning medication). The resident did not have an order for heparin or any other anticoagulant.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record reviews and staff interviews, it was determined that the facility failed to ensure that physician's orders were followed for one of 51 residents reviewed (Resident 33) and failed to prevent a delay in care for one of 51 residents reviewed (Resident 97) resulting in his hospitalization. Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 33, dated February 2, 2024, revealed that the resident was cognitively impaired. A nutritional note for Resident 33, dated December 12, 2023, revealed that the resident was to receive a health shake two times per day to meet her protein needs. Physician's orders for Resident 33, dated December 13, 2023, included orders for the resident to receive a 4-ounce health shake two times per day. Review of Resident 33's Medication Administration Records (MAR) and nursing notes for December 2023, as well as January and February 2024, revealed that staff had documented that 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 policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that treatments for pressure ulcers were provided as ordered by the physician for one of 51 residents reviewed (Resident 42). Findings include: The facility's policy regarding dressing changes, dated February 13, 2024, indicated that all dressings were to be applied to wounds by a nurse, as ordered by the physician to promote healing, and then documented in the medical record. A significant correction Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 42, dated February 2, 2024, revealed that the resident was dependent for care needs, was cognitively impaired, had an indwelling foley catheter (a thin, flexible tube inserted into the bladder to drain urine from the bladder), a Stage 2 pressure ulcer (pressure wound with skin loss), a Stage 3 pressure ulcer (pressure wound involving the fat layers beneath the skin), an unstageable pressure ulcer (full-thickness pressure injuries in…

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

Based on a review of clinical records, as well as staff interviews, it was determined that the facility failed to provide suprapubic urinary catheter changes as ordered by the physician for one of 51 residents reviewed (Resident 35). Findings include: An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 35, dated February 8, 2024, revealed that the resident was cognitively intact; was understood; could understand; required partial assistance with dressing, toilet use, and bathing; was independent with bed mobility and eating; had an indwelling catheter (a tube inserted into the bladder to drain urine); and had an active diagnosis of neurogenic bladder (bladder does not function properly due to disease or damage to the central nervous system). A care plan for Resident 35's indwelling catheter, dated February 1, 2024, revealed that she had a suprapubic catheter due to a neurogenic bladder. A nursing note for Resident 35, dated February 10, 2024, at 9:30 a.m., revealed that the consultant physician recommended 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 policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that residents received oxygen as ordered by the physician for one of 51 residents reviewed (Resident 95). Findings include: The facility's policy regarding oxygen therapy, dated December 13, 2023, indicated that oxygen was to be administered by licensed staff and in accordance with physician's orders. A quarterly Minimum data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 95, dated February 16, 2024, revealed that the resident was cognitively intact and had diagnoses that included chronic respiratory failure with hypoxia (a serious condition that causes low blood oxygen). Resident 95's care plan, dated September 1, 2023, indicated that she had difficulty breathing related to respiratory failure. Physician's orders for Resident 95, dated February 9, 2024, included an order for the resident to receive continuous oxygen at a flow rate of 4 liters per minute via nasal cannula (tubes 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 personnel files, as well as staff interviews, it was determined that the facility failed to verify registry verification prior to allowing individuals to work as a nurse aide for one of five newly hired nurse aides reviewed (Nurse Aide 4). Findings include: The personnel file for Nurse Aide 4 revealed that she was hired by the facility on October 9, 2023. However, there was no documented evidence that the facility verified the nurse aide's standing with the state nurse aide registry until February 21, 2024. Interview with the Nursing Home Administrator on February 22, 2024, at 11:21 a.m. confirmed that Nurse Aide 4 did not have a nurse aide registry check completed prior to her start date and that she should have. 28 Pa. Code 201.29 Personnel Policies and Procedures.

Based on review of personnel files, as well as staff interviews, it was determined that the facility failed to ensure that nurse aide performance evaluations were completed annually based on hire dates for four of five nurse aides reviewed (Nurse Aides 5, 6, 7, 8). Findings include: A list of nurse aides provided by the facility revealed that Nurse Aide 5 was hired on June 20, 2019, and that she was due for her annual performance evaluation in June 2023. Nurse Aide 6 was hired December 21, 2017, and was due for her annual performance evaluation in December 2023. Nurse Aide 7 was hired May 4, 2015, and was due for her annual performance evaluation in May 2023. Nurse Aide 8 was hired September 24, 2015, and was due for her annual performance evaluation in September 2023. There was no documented evidence that the annual performance evaluations were completed as required for Nurse Aides 5, 6, 7, and 8. Interview with the Nursing Home Administrator on February 22, 2024, at 12:07 p.m. confirmed that he could not provide evidence that annual performance evaluations were completed as…

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

Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that the physician or designee responded timely to a pharmacy recommendation for one of 51 residents reviewed (Resident 15). Findings include: The facility's policy regarding Monthly Drug Regimen Reviews, dated February 13, 2024, indicated that consultant reports have one recommendation per page. The Director of Nursing or designee would contact the physician with any outstanding recommendations, if no response from the physician notify the medical director for further assistance 15-21 days after the reports are available. During the drug regimen review, routine recommendations were to be communicated to the Director of Nursing or the designee, attending physician, and the Medical Director for response and resolution, after the completion of the monthly medication review. Physician's orders for Resident 15, dated April 11, 2023, included an order for the resident to receive one 20 milligram (mg) tablet of Omeprazole delayed release twice a day 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 policy and clinical records, as well as observations and staff interviews, it was determined that the facility failed to offer routine dental services for one of 51 residents reviewed (Resident 91). Findings include: The facility's policy regarding dental services, dated February 13, 2024, revealed that routine and emergency dental services are available to meet the resident's oral health services in accordance with the resident's assessment and plan of care. An annual Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 91, dated December 16, 2023, revealed that the resident was cognitively intact and was dependent on staff for daily care tasks including oral care. An interview with Resident 91's family members on February 21, 2024, at 9:13 a.m. revealed that the resident and her family had requested that she see the dentist for a regular cleaning since she still had all of her own teeth. Observations of Resident 91 on February 21, 2024, at 9:13 a.m. revealed that the resident still had all 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 the facility's plans of correction for previous surveys, and the results of the current survey, it was determined that the facility's Quality Assurance Performance Improvement (QAPI) committee failed to correct quality deficiencies and ensure that plans to improve the delivery of care and services effectively addressed recurring deficiencies. Findings include: The facility's deficiencies and plans of corrections for a State Survey and Certification (Department of Health) survey ending March 30, 2023, revealed that the facility developed plans of correction that included quality assurance systems to ensure that the facility maintained compliance with cited nursing home regulations. The results of the current survey, ending February 23, 2024, identified repeated deficiencies related to revision of residents' care plans, catheter care, regulations regarding nurse aide annual performance evaluations, and infection prevention and control. The facility's plan of correction for a deficiency regarding revising residents' care plans, cited during the survey ending March…

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 policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that proper infection control practices were followed while providing care for two of 51 residents reviewed (Residents 12, 109). Findings include: The facility's policy regarding catheter care, dated February 13, 2024, indicated that the catheter tubing and drainage bag were to be kept off the floor to prevent catheter-associated urinary tract infections. A significant change Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 12, dated December 13, 2023, revealed that the resident was moderately cognitively impaired and had diagnoses that included acute kidney failure (a condition where the kidneys cannot filter waste from the blood) with dysfunction of the bladder. The resident's care plan, dated February 5, 2024, indicated the use of an indwelling catheter with interventions that included that the catheter tubing and bag should be kept off the floor. Observations on February…

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 policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that residents were free from unnecessary medications for one of four residents reviewed (Resident 1). Findings include: The facility's policy regarding medication administration, dated February 9, 2023, revealed that staff were to review the electronic medication administration record and should there be any uncertainties, to verify the physician's order sheet and seek clarification as needed. An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated December 21, 2023, indicated that the resident was cognitively impaired, required substantial assistance, and had diagnoses that included multiple sclerosis and bone fracture. A medication discrepancy report for Resident 1, dated December 16, 2023, revealed that Resident 1 was administered 15 milligrams of Rivaroxaban (blood thinning medication) in error. A nursing note, dated December 16, 2023, indicated that the medication was…

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

Based on facility policy and observations, as well as family, resident and staff interviews, it was determined that the facility failed to serve food items that were palatable and at proper temperatures. Findings include: The facility's policy regarding food temperatures, dated February 9, 2023, indicated that all hot food items were to be cooked to appropriate internal temperatures and held at a temperature of at least 135 degrees Fahrenheit (F) for hot foods and less than 41 degrees F for cold foods. Observations in the kitchen for the lunch meal service on December 28, 2023, at 11:58 a.m. revealed that a test tray left the kitchen and arrived on the nursing unit at 11:58 a.m. Trays were passed to the residents in their rooms, and the last resident was served and eating at 12:12 p.m. At 12:13 p.m. the temperature of the chicken with maple dijon glaze was 120.1 degrees Fahrenheit (F), brussel sprouts were 116.5 degrees F, and the broccoli was 119.4 degrees F and was lukewarm to taste. The pudding cup was 53.7 degrees and was not cold to taste Interview with the Dietary Manager on…

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, as well as staff interviews, it was determined that the facility failed to maintain clinical records that were complete and accurately documented for one of three residents reviewed (Resident 2). Findings include: A facility policy regarding skin and wounds, dated February 9, 2023, revealed that residents were to be provided weekly skin evaluations documented in the medical record. An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 2, dated September 4, 2023, revealed that the resident was admitted on [DATE], was cognitively intact, was dependent on staff for all daily care needs, and had a Stage II pressure ulcer (a wound caused by pressure) that was present on admission to the facility. Resident 2's care plan, dated August 28, 2023, indicated that she had a chronic pressure ulcer/wound of the coccyx related to immobility. Staff were to assess, record, and monitor by the facility wound team. A pressure…

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 policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that staff followed proper infection control practices during wound care for one of three residents reviewed (Resident 2). Findings include: The facility's policy regarding the hand washing and hand hygiene, dated February 9, 2023, indicated that alcohol-based hand rub containing at least 62 percent alcohol, or alternatively soap and water, was to be used before and after direct contact with resident, before and after handling clean or soiled dressing, before moving from a contaminated body site to clean body site during resident care, after handling used dressings and contaminated equipment, and after removing gloves. An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 2, dated September 4, 2023, revealed that the resident was cognitively intact, was dependent on staff for all daily care needs, and had a pressure ulcer (a wound caused by pressure) that was present…

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 policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to review and revise residents' care plans for one of nine residents reviewed (Resident 3). Findings include: The facility's policy regarding care plans, dated February 9, 2023, indicated that individualized, person-centered plans of care would be established with the interdisciplinary team. The care plan would be reviewed, updated, and revised based on changing goals, preferences, and needs of the resident and in response to current interventions after the completion of each OBRA Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) and as needed. A Significant Change in Status MDS assessment for Resident 3, dated July 11, 2023, revealed that the resident was understood, could understand, and required extensive assistance from staff for her daily care tasks, including with ambulation. A care plan for the resident, dated April 26, 2023, revealed that she had an activities of daily living self-care…

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, as well as observations and staff interviews, it was determined that the facility failed to provide an environment that was free of accident hazards by failing to follow physician's orders and care-planned interventions for one of nine residents reviewed (Resident 2), who was at risk for falls. Findings include: An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 2, dated July 14, 2023, revealed that the resident was understood, could understand, required extensive assistance from staff for her daily care tasks as well as with her transfers and ambulation, and had diagnoses that included cerebral vascular accident (CVA - commonly referred to as a stroke) and traumatic brain injury. A care plan for the resident, dated July 7, 2023, revealed that she had a self-care performance deficit, required extensive assist of two staff for toileting and transfers, and that she was at risk for falls. A [NAME] (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 clinical record reviews and staff interviews, it was determined that the facility failed to ensure that residents' clinical records were complete and accurately documented for one of six residents reviewed (Resident 2). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 2, dated July 17, 2023, revealed that the resident was cognitively intact, was dependent on staff for transfers, and needed assistance of two staff members for daily care needs. Resident 2 had diagnoses of kyphosis, cervical region (spine curves toward the front of the body) and general muscle weakness. A nursing note for Resident 2, dated July 25, 2023, at 5:30 a.m. revealed that Resident 2 complained to nurse aide that her neck was very sore and stinky. The nurse went to the room and asked the resident what was wrong. Resident stated that her neck treatment had not been done for three days. The nurse removed the old dressing from her neck, which was dated from Friday July 21, 2023. The treatment was performed per…

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.