Complete Care At Harston Hall LLC

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, review of resident clinical records, and interview with resident and staff, it was determined the facility fail to ensure physician orders were followed related to the administration an anticoagulant medication for one of 12 residents reviewed. (Resident R1)Findings include: Review a facility policy titled Reconciliation of Medication on admission revised July 2017, revealed the purpose of this procedure is to ensure medication safety by accurately accounting for a residence medication, including drug names, dosages, roots, and frequencies, upon emission or remission to the facility. Proper medication reconciliation is essential to prevent unintended omissions, duplications, or dosing errors that may occur during transitions of care. Medication and reconciliation involve comparing the medications a resident was taking prior to admission with those ordered upon admission. This comparison must include both prescription and over the counter medications and should reflect an…

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

Based on review of clinical records, observations, review of facility policy and interviews with residents, it was determined that the facility failed to ensure a resident was treated with dignity and respect during wound care for one of 12 residents reviewed (Resident R1). Findings include: Review of Facility policy titled Clean dressing change, date implemented September 1, 2024, under Policy explanation and Compliance Guidelines, step 1 states Explain the procedure to the resident and screen for privacy. Review of Resident R1's clinical record revealed resident was admitted to facility on August 13, 2025, with the diagnosis of Sepsis (infection in the blood stream), Paraplegia (paralysis on the lower half of the body), and Pressure Ulcer of Left Buttocks. Review of Resident R1's Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) dated September 11, 2025, revealed that the resident has a BIMS (Brief interview for Mental Status) score of 15 indicating that resident cognitively intact. Observation of Resident R1's wound care 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of facility policies, facility documentation, review of clinical records and interviews with residents and staff, it was determined that the facility failed to conduct a thorough investigation related to potential resident abuse and/or neglect related to a grievance for one of 12 residents reviewed. (Resident R2)Findings include:Review of facility policy titled Abuse, Neglect and Exploitation, implemented on September 1, 2025, revealed It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. Further review revealed definition of Mental Abuse includes, but is not limited to, humiliation, harassment, threat of punishment or deprivation. Mental abuse also includes abuse that is facilitated or caused by nursing home staff taking or using photographs or recording in any manner that would…

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 of the food and nutrition services department, it was determined that foods were not being stored, prepared, distributed and served in accordance with professional standards for food service safety. Findings include: Observations on March 22, 2025 of the main kitchen where foods and beverages were stored, prepared and assembled for distribution and service to the residents revealed that the low temperature dish machine was not fully functioning since March 14, 2025. The director of dietary service could not demonstrate with the use of litmus test strip that the hypochlorite was registering an acceptable 50 ppm (parts per million) to effectively sanitize the dishes, utencils, pots, pans, cups, bowls, plates and trays for resident and dietary staff use. Interview with the Director of Dietary Services, Employee E15 revealed that the main kitchen operation had been waiting on a customized part (squeeze tube and rinse assembly metal connector) for the mechanics of the dish machine, since March 14, 2025. All of the dome lids and plate holders contained a white film…

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 facility policy and observations, it was determined that the facility failed to provide a sanitary, clean, comfortable, homelike environment for one out the two units observed. (Third floor nursing unit). Findings include: A review of the policy titled Home Environment revised on July 1, 2024, under the Policy Guidelines #3 Housekeeping and maintenance services will be provided as necessary to maintain a sanitary, orderly and comfortable environment. On April 22, 2025, at 12:51 p.m. observation of room [ROOM NUMBER]B had a significant urine smell. On April 24, 2025, an observation of room [ROOM NUMBER]A revealed that Resident R10, who had passed away on April 22, 2025, had not had her room cleaned or cleared. Her personal belongings remained in place, including her reclining chair, which, according to Licensed Nurse Employee E6, was broken and being used to store random items. The items included ankle protectors and uncovered pillows. Both bedside dressers were covered with a noticeable layer of dust.…

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 interviews with staff and residents, it was determined that the facility did not ensure that residents were free of misappropriation of resident property related to diversion of narcotic medication for two of 24 residents records reviewed (residents R69 and R262). Findings include: Review of clinical documentation for Resident R69 revealed that she was admitted to the facility on [DATE], and had diagnoses including of dementia (progressive degenerative disease of the brain), chronic pain and arthritis (join inflamation). Conintued review of the resident's clinical record revealed that the resident signed on to receive hospice care in February 2024. Review of Resident R69's [DATE] physican orders revealed an order obatined dated [DATE], for Morphine sulphate .20MG (milligrams)/ML .give 0.25 ml by mouth every four hours as needed for pain. Review of her most recent MDS (Minimum Data Set, a periodic assessment of resident care needs) section C, Cognitive Patterns, dated…

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 interview, it was determined that the facility failed to address the care needs of a resident when answering call bells for one of 23 residents reviewed (Resident R29), and did not ensure sufficient staffing was maintained on a daily basis for all nursing units. (2nd and 3rd floors) Findings include: During a resident council meeting on April 24, 2025, at 10:00 a.m. with six residents, (Residents R37, R36, R81, R84, R89, and R31) who were identified as being alert and oriented, reported that call bells were not answered in a timely manner and staff were coming in and turn off the call bells without providing assistance. On April 24, 2025, at 11:07 a.m., an observation was made of Resident R29 lying flat in bed. The resident, who is non-verbal and communicates using head nods and facial expressions, clearly indicated a desire to be transferred into her wheelchair. The surveyor recommended the use of the call bell, and Resident R29 pressed it at 11:08 a.m. On April 24, 2025, at 11:11 a.m., Licensed Nurse, Employee E6 responded to the call. Upon entering…

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 provided documentation and interview with staff, it was determined that facility did not ensure annual performance evaluation was completed for three nurse aides out of three nurse aides' trainings reviewed (Employee E21, E22 and E23) Findings include: Review of facility policy titled Required Training Certification and Continuing Education on Nurse Aides, revised in 2024, indicates that the facility will provide at least 12 hours of in-service training annually, based on the employment date, not calendar year. Review of facility provided performance evaluations on Thursday, April 25, 2025, revealed that nurse aides, Employees E21, E22 and E23 did not have any 12 hours of in-service training. Interview with Development Coordinator on April 25, 2025, at 1:40 p.m, confirmed that there was no 12 hours of in-service training annually. 28 Pa Code 201.19(2) Personnel policies and procedures

Based on observations of the food and nutrition services department, reviews of policies and procedures and interviews with staff and residents, it was determined that the facility failed to ensure that foods and drinks were being served palatable, attractive and at safe and appetizing temperatures during meal times for the residents. (Third floor, noon meal) Resident council (Residents R37, R36, R81, R84, R89, and R31) Findings include: A review of the facility's policy titled resident test tray assessment dated April, 2025 indicated that hot food entrees and vegetables were to be served at a temperature of 130 degrees Fahrenheit and all cold foods and beverages were to served at 45 degrees Fahrenheit. The temperatures were established to ensure safety and resident satisfaction at point of service, with the foods and fluids prepared by the food service department. On April 22, 2025, at 12:54 p.m., an interview was conducted with Resident R15, who stated that the food at the facility is terrible. Observation of the resident's plate revealed that only a piece of bread, juice, and ice…

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, observations, and staff interviews, it was determined that the facility failed to store bed linens in a sanitary environment, increasing the risk of infection and contamination. (Laundry room) Findings: A review of the policy titled 'Laundry Services revised July 1, 2024, it revealed the facility lauders and delivers linens and clothing in accordance with current CDC guidelines to prevent transmission of pathogens. On April 22, 2025, at 1:23 p.m., a tour of the laundry area located in the basement was conducted with the housekeeping supervisor, Employee E4, where laundry operations occur. During the tour, it was observed and confirmed that new linens were unfolded and placed directly on the bare floor inside the extra linen closet. These linens were neither boxed nor covered, leaving them exposed to potential contamination. Additionally, an inspection of the second-floor linen closet revealed that clean pillows, although sealed in plastic bags, were stored directly on the floor. Extra pads use for a mechanic lifts, were not sealed or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, review of facility policy and interviews with residents, it was determined that the facility failed to promote and maintain dignity and respect for two of 24 residents reviewed (Resident R100 and R40). Findings include: Review of facility policy Promoting/ Maintaining Resident Dignity, implemented on September 1, 2024, revealed it is the practice of this facility to protect and promote resident rights and treat each resident with respect and dignity as well as care for each resident in a manner and in an environment, that maintains or enhances resident's quality of life by recognizing each resident's individuality. Under Compliance guidelines, all staff members are involved in providing care to residents to promote and maintain resident dignity and respect resident rights. Review of Resident R100's clinical record revealed that Resident R100 was admitted to the facility on [DATE] with diagnoses of, but not limited to, Parkinson's Disease (movement disorder that affects the nervous system…

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 procedures, employee personnel records, and staff interviews, it was determined that the facility failed to develop and implement an abuse prohibition policy that required a thorough investigation of prospective employees' employment history for two of six newly hired employees reviewed. (Employees E26 and E29) Findings include: A review of the Facility Policy titled Abuse revised on June 30, 2023, revealed Centers prohibit abuse, mistreatment, neglect, misappropriation of resident/ patient (hereinafter patient), and exploitation for all patients. The center will implement an abuse prohibition program through the following: Screening of potential hires: training of employees (both new employees and ongoing training for all employees. A review of the Licensed Practical Nurse (LPN), Employee E26's personnel file revealed that Employee E26 was hired on March 1, 2025, and criminal background was done April 1, 2025. Register nurse (RN), Employee E29 was hired on January 1, 2025, and had her criminal background done on January 8, 2025. An…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of clinical records, facility policies and interviews with staff, it was determined that the facility failed to conduct a complete and thorough investigation of one incident related to the provision of incontinence care for one of 23 residents reviewed. (Resident R 30). Findings include: Reviewed the facility policy title Abuse date on June 30, 2023 stated Centers prohibit abuse, mistreatment, neglect, misappropriation of resident/ patient ( hereinafter patient) property, and exploitation for a patients. Neglect is the failure of the facility, its employees or service providers to provide goods and service to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Review of Resident R30's clinical record revealed that the resident was admitted to the facility on [DATE], with a BIMS (Brief interview for mental status) of 8 and diagnosies of Alzheimer's Disease (progressive degenerative disease of the brain), encephalopathy (disease that affects the brain…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policies and clinical records, and staff interviews, it was determined that the facility failed to develop comprehensive care plans for oxygen therapy (Resident 10), a safety device and elopement (Resident R73) and a repositioning program (Resident R82) for three of 23 residents reviewed (Resident R10, R73, R82). Findings include: A review of the policy titled Comprehensive Care Plans dated February 25, 2025 revealed It is the policy of this facility to develop and implement a comprehensive person-centered care plan or each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing and mental and psychosocial needs and ALL services that are identified in the resident's comprehensive assessment and meet professional standards of quality. Review of Resident R10's clinical record revealed that the resident was initially admitted to the facility on [DATE]; diagnosed with emphysema (chronic lung condition), dyspnea…

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, and staff interviews, it was determined that the facility failed to provide activities of daily living (ADL) assistance necessary to maintaining good grooming for one out of 4 residents reviewed. ( Resident 24) Findings include: A review of the clinical record of Resident R24 revealed admission date of August 31, 2022, with diagnosis of chronic atrial fibrillation (irregular rapid heart beat), osteoarthritis, adult failure to thrive, low back pain. Review of Resident R24's quarterly MDS (Minimum Data Set - a mandatory periodic resident assessment tool), dated March 7, 2025, revealed a Brief Interview for Mental Status (BIMS- is a screening test that aides in detecting cognitive impairment) indicated a score of 13 which revealed that the resident was cognitively intact. The section of Functional Abilities indicated that Resident R24 requires maximum assist with personal hygiene. On April 22, 2025, at 12:00 p.m., an observation conducted with Licensed Nurse Employee E12 confirmed that Resident R24 had long and dirty…

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, review of clinical record, and staff interview, it was determined that the facility failed to provide pressure ulcer treatment, consistent with professional standards of practice, for one of two residents reviewed for pressure ulcers (Resident R106). Findings Include: Review of facility policy Pressure Ulcer Prevention dated July 1, 2024, revealed to prevent the formation of avoidable pressure injuries and to promote healing of existing pressure injuries, it is the policy of this facility to implement evidence-based interventions for all residents who are assessed at risk or who have a pressure injury present. Review of Resident R106 's clinical record revealed that Resident R106 was admitted to the facility on [DATE]. Resident R106 has right heel Stage 3 (ulcer involving full thickness of skin loss). Review of Resident R106's comprehensive care plan revised on February 4, 2025, revealed Resident R106 has impaired tissues integrity with a right heel wound and interventions…

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 review, interviews with staff and policy and procedure review, it was determined that the facility failed to implement nutritional interventions for one of three residents at nutritional risk related to pressure sore development and deteriation of wounds. (Resident R82) Findings include: A review of the policy titled nutritional management dated September 1, 2025 revealed that it was the responsibility of the facility to provide care and services to ensure that each resident maintained acceptable parameters of nutritional status related to his/her medical condition. The policy also indicated that the facility was responsible for revising ntritional interventions based on identification and routine assessment of resident's care needs. A review of the undated policy titled weight assessment and intervention revealed that it was the multidisciplinary teams' responsibility to prevent monitor and intervene for unplanned weight loss for the residents. The policy indicated that weekly weights…

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 observation, clinical record review, review of facility policy and staff interview, it was determined that the facility failed to provide appropriate respiratory, tracheostomy and tracheal suctioning care and services for four of 23 residents reviewed (Resident R1, R10, R72, R51). Findings include: Review of the Facility Policy titled Oxygen Administration last revised July 1, 2024, indicated that The purpose of this procedure is to provide guidelines for safe oxygen administration. It further stated under Preparation verify that there is a physician's order. Review of Resident R10's clinical record revealed that the resident was initially admitted to the facility on [DATE]; diagnosed with emphysema (chronic lung condition), and dyspnea (shortness of breath). Review of clinical record indicated that Resident R10 was ordered, dated March 25, 2025, oxygen at 2 Liters/Min, via nasal cannula, as needed for diagnosis of dyspnea. On April 22, 2025, at 12:22 p.m. an observation with Registered nurse, Employee…

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, review of clinical records and interviews with residents and staff, it was determined that the facility did not ensure proper pain management interventions were provided for one of 23 residents reviewed (Resident R48). Findings include: Review of facility policy Pain Management, last reviewed on March 6, 2025, revealed the facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. Review of Resident R48's clinical record revealed that Resident R48 was admitted to the facility on [DATE] with diagnoses of, but not limited to, COPD (Chronic obstructive pulmonary disease), contracture of left knee, osteoarthritis of right shoulder. Review of Resident R48's comprehensive care plan on April 22, 2025 revealed that resident exhibited or was at risk for alterations in functional mobility related to contracture…

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 obervations, review of facility policy, review of employee personnel files and interviews with staff, it was determined that the facility did not ensure staff was qualified and competent to perform tracheostomy care and suctioning care for one of one resident reviewed (Resident R1). Findings Include: Review of facility policy Orientation, implemented on September 1, 2024, revealed it is the policy of this facility to develop, implement and maintain an effective orientation process for all new staff, individuals providing services under a contractual arrangement and volunteers, consistent with their expected roles. Further review of section Policy Explanation and Compliance Guidelines part 6., Competency evaluation form process: section e., the completed form represents initial competency in skills needed to care for residents and perform job functions. Review of facility policy Tracheostomy Care- Suctioning, implemented on September 1, 2024, revealed the facility will ensure that residents who need respiratory care, including tracheal suctioning, are provided such 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.

Based on review of facility records and staff interviews, it was determined that facility did not ensure that the narcotic reconciliation record was complete related to missing signatures and initials on the narcotic count sheet for three of three medication carts reviewed. (2nd Floor Medication Cart, and two medication carts on 3rd Floor) Findings include: Review of Facility In-service Shift to Shift count, implemented in October 2024, revealed nursing staff must count controlled medications at the end of each shift. The nurse coming on duty and the nurse going off duty must make the count together. Observation of Medication Cart on 2nd Floor on April 24, 2025 at 2:20 p.m., revealed multiple missing signatures during the month of April 2025 for oncoming and outgoing nurses on Narcotic Reconcilation Sheet. Licensed Practical Nurse, Employee E9. confirmed at the time of the observation that the narcotic reconcilation sheet was missing signatures from oncoming and outgoingt nurses confirming the narcotic count. Observation of Medication Cart on 3rd Floor on April 24, 2025 at 2:33…

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 observations and staff interviews, it was determined that facility did not ensure that opened medications were properly labeled with the date that the medication was opened for two of three medication carts reviewed and one of one medication room reviewed. (2nd floor medication cart, 3rd floor medication cart and 2nd floor medication room). Findings include: Observation of Medication cart on 2nd floor on April 24, 2025 at 2:20 pm revealed 5 opened bottles of medication, including B12, Cranberry, Vitamin D, Ferrous Sulfate and B1, not labeled with an open date. Interview with Licensed nurse, Employee E9 on April 24, 2025 at 2:21pm confirmed 5 opened bottles of medication not labeled with an open date. Observation of Medication Cart on 3rd floor on April 24, 2025 at 2:33pm revealed 1 opened bottle of medication, including Vitamin D 1250mg, not labeled with an open date. Interview with Employee E10 on April 24, 2025 at 2:35 pm confirmed 1 open bottle of Vitamin D, no label with open date. Observation in 2nd Floor Med Room on April 24, 2025 at 2:25pm revealed open bottle 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical records review, staff interview and review of facility policy, it was determined that the facility failed to ensure that clinical records wer completed for one of 23 clinical records reviewed. (Resident R82) Findings include: Review of facility policy Turning and repositioning, implemented on September 1, 2024, revealed all residents at risk of, or with existing pressure injuries, will be turned and repositioned, unless it is contraindicated due to medical condition. The frequency of turning and repositioning will be documented in the resident's plan of care. Review of Resident R82 's clinical record revealed that Resident R82 was admitted to the facility on [DATE] with diagnoses of, but not limited to, Dementia (progressive degenerative disease of the brain), Heart failure, Type 2 Diabetes (failure of the body to produce insulin) and Acute Kidney failure. Review of Resident R82' s MDS (Minimum Data Set- resident assessment of care needs) revealed that resident had a BIMS (Brief interview 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 interviews with dietary and administrative staff, it was determined that essential food service equipment was not maintained in safe operating condition. Findings include: Observations on March 22, 2025 of the main kitchen where foods and beverages were stored, prepared and assembled for distribution and service to the residents revealed several pieces of equipment that were not fully functioning. Observations of the dish machine revealed that it was not being maintained according to manufacturer's recommendations. The low temperature dish machine was not fully functioning since March 14, 2025. The director of dietary service could not demonstrate with the use of litmus test strip that the hypochlorite was registering an acceptable 50 ppm (parts per million) to effectively sanitize the dishes, utencils, pots, pans, cups, bowls, plates and trays for resident and dietary staff use. Interview with the director of dietary services, Employee E15 revealed that the main kitchen food service operation had been waiting on a customized part (squeeze tube and rinse…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, resident and staff interviews, review of the pest control logs and the pest control operator's management program, review of policies and documentation, it was determined that the facility failed to maintain an effective pest control program in the kitchen and one of two nursing units. (3rd Floor Nursing Unit and Kitchen) Findings include: A review of facility Pest Control policy revised July 1, 2024, states that It is the policy of this facility to maintain an effective pest control program that eradicates and contains common household pest and rodents. On April 22, 2025, at 12:00 p.m., an observation conducted with Licensed Nurse Employee E12 confirmed that Resident R24 had gnat flies in his room. Employee E12 further stated that always had gnat flies' issues. On April 24, 2025, at 9:45 a.m., an interview was conducted with the Maintenance Director, Employee E8, who reported that the facility receives pest control treatments on a weekly basis. However, a review of pest control invoices…

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 personnel record review, and staff interview, it was determined that the facility failed to provide abuse, neglect and exploitation training at the time of hire for four of six staff reviewed (Employee E26, E27, E28, and E29). Findings: A review of the Facility Policy titled Abuse revised on June 30, 2023, revealed Centers prohibit abuse, mistreatment, neglect, misappropriation of resident/ patient (hereinafter patient), and exploitation for all patients. The center will implement an abuse prohibition program through the following: Screening of potential hires: training of employees (both new employees and ongoing training for all employees. Reviewed six new hires employee records revealed the following: -Licensed practical nurse, Employees E26 hired on March 1, 2025, abuse training was not completed until April 2, 2025, -Register nurse,Employee E27 was hired on February 10, 2025, abuse training was completed until March 14, 2025. -Nurse aide, Employee E28 was hired on March 1, 2025, abuse training was completed until on April 11, 2025. -Register nurse, Employee E29 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of clinical records, staff interview, and review of the facility policy, it was determined the facility failed to ensure physician orders were followed for one of the three residents reviewed (Resident CL1). Findings include: Review of facility policy titled Administering Medication updated October 2022 revealed Medication shall be administered in a safe and timely manner and as prescribed. Under policy interpretation bullet #2 it further stated Medication must be administered in accordance with the order including any required time frames. Review of Resident CL1's clinical record revealed that the resident was admitted to the facility on [DATE], at approximately 12:38 p.m. with a diagnosis of hospice care. Review of Resident CL1's physician order dated January 6, 2025, revealed an order of -Morphine Sulfate (concentrate) Oral Solution 20 MG/ML give 0.25 ml by mouth every 2 hours as needed for moderate pain, scale 4-6. - Morphine Sulfate (concentrate) Oral Solution 20 MG/ML give 0.5 ml by mouth…

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 policy review, resident clinical record review, and resident and staff interviews, it was determined that the facility failed to implement and enforce the facility compliance and ethics program, so that it is likely to be effective in preventing and detecting criminal, civil, and administrative violations under the Act and in promoting quality of care related to misappropriation and exploitation of resident property, unauthorized access of resident's financial information, theft of money from resident's bank account, unauthorized purchase on resident's account, and receiving monetary assistance by the facility staff. One of three residents reviewed. (Resident R1) Findings include: Review of current Employee Hand book revealed that Employee Conduct and Ethics: All employees are expected to have the highest level of integrity. Employees may not solicit or accept gratuities, gifts, or loans from patients or residents, their families or visitors. In the case where a gratuity is forced upon you, it must immediately be given to your department head or supervisor who will return.…

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 group interview and staff interviews, it was determined that the facility failed to provide access to mail delivered to the facility in a timely manner. Facility failed to ensure privacy in their use of electronic communications related to unauthorized access of resident's personal cell phone for one of three residents reviewed (Resident R1). Findings include: Interview with Resident R1 on August 15, 2024, at 10:30 a.m. stated he was not receiving the statements for a long time, he used to receive it every month. He stated activity staff who was responsible to give the mails to him were taking the mail and hiding or destroying the mails. Continued interview with Resident R1 stated staff (alleged perpetrators) accessed his personal cell phone while facility was doing an invetigation into his allegation of misappropriation of his funds and deleted electronic information pertaining to the investigation to hide evidences. Interview with the Nursing Home Administrator on August 15, 2024, at 12:00 p.m. stated activity staff were responsible for delivering the mail and packages…

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 resident group interview, interviews with resident and staff, and review of a facility policy, it was determined that the facility failed to ensure the rights of resident's privacy by opening residents' mail without resident consent for one of three residents reviewed (Resident R1). Findings include: Interview with Resident R1 on August 15, 2024, at 10:30 a.m. stated Resident R1 stated he was not receiving the statements for a long time, he used to receive it every month. He stated activity staff who was responsible to give the mail to him were taking the mail and hiding or destroying the mails. Resident stated he received an open mail of his personal bank statement on July 31, 2024, when he realized staff stole money from his account. Interview with the Nursing Home Administrator on August 15, 2024, at 12:00 p.m. stated activity staff were responsible for delivering the mail and packages for the residents, they hide or remove residents mail or packages. Nursing Home Administrator stated business office manager received residents mail and kept it in her possession without…

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 the review of clinical records, job descriptions, facility documentation and interviews with staff, it was determined that the Nursing Home Administrator (NHA) and the Director of Nursing (DON) did not effectively manage the facility to make certain that proper procedures were followed in the facility related to the right of residents to be free misappropriation and exploitation of property, unauthorized access of Resident R1's financial information, theft of money from resident's bank account, unauthorized purchase on resident's account, and receiving monetary assistance by the facility staff. This failure resulted in an Immediate Jeopardy situation to Resident R1 who experienced financial loss, mental health decline, and psychosocial harm for one of three residents reviewed. (Resident R1) Findings Include: Review of the job description for the Nursing Home Administrator (NHA) revealed that The primary purpose of the job position is to manage the Facility in accordance with current applicable federal, state, and local standards, guidelines, and regulations that govern…

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 interview with residents and staff and review of facility documentation, it was determined that facility failed to promote an environment that enhancement residents quality of life related to fresh air brakes to be free from residents who smoke for eight of 24 residents reviewed (Residents R87, R37, R69, R47, R85, R107, and R35). The facility failed to ensure that each resident was treated with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. (Resident R2) Findings include: June 17, 2024, at approximately 9:00 a.m. observation was conducted of one resident smoking in his wheelchair outside. June 18, 2024, at 9:32 a.m. Resident R90 was observed outside on the front porch and there was another resident who was observed smoking. The cigarette smell was strong. On June 17, 2024, at 10:07 a.m. an entrance meeting was conducted with the Administrator, Employee E1…

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, resident council minutes, group interview, resident interviews, and staff interviews, it was determined that the facility failed failed to demonstrate a response to residents' concerns for resident group meeting and to meet privately for seven and seven residents reviewed. (Residents R87, R37, R69, R47, R85, R107, and R35) Findings include: A review of facility policy and procedure titled, Grievance Policy and Procedure revised June 24, 2023, indicated All residents, responsible parties, interested family members and staff of Complete Care have the right to voice grievances that are free form interference, coercion, discrimination, and reprisal concerning. Further under procedures it states Concerns can be filed verbally, or in writing and grievances may also be filed anonymously in receptacle boxes located in the facility. All information regarding in regard to the grievance will remain anonymous. Review of the Resident Council minute notes over the past three months from March 2024-June 21, 2024, revealed on going concerns with nursing staff 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews with staff and residents, it was determined that the facility failed to maintain a safe, clean, homelike environment for two of two nursing units reviewed. (Second Floor Unit and Third Floor Unit). Findings include: Observations conducted of the made Third floor (unit two) between 10:02 a.m. - 11:00 a.m. revealed the following: room [ROOM NUMBER] bed A's trash can was dirty and had no trash can liner in it. Behind the head of the bed along the wall the floor was soiled with a brown spilled liquid and food crumbs. Observation of room [ROOM NUMBER] bed B revealed a trash can full of trash with no trash can liner. The resident's left side bedrail was soiled. Observation of room [ROOM NUMBER] revealed the resident in A bed had a lot of items that were not stored appropriately. The resident had peanuts, cereal, bread, honey, peanut butter stored in numerous places in his room including on top of his bed. The resident had a bariatric bed which did not have a sheet to cover the…

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

Based on a resident group interview, resident interview, review of facility policy and procedures, and staff interview, it was determined that the facility failed to ensure that the grievance forms were available and accessible to residents on the nursing units for 7 of 24 residents (Residents R87, R37, R69, R47, R85, R107, and R35). Findings include: A review of facility policy and procedure titled, Grievance Policy and Procedure revised June 24, 2023, indicated All residents, responsible parties, interested family members and staff of Complete Care have the right to voice grievances that are free form interference, coercion, discrimination, and reprisal concerning. Further under procedures it states Concerns can be filed verbally, or in writing and grievances may also be filed anonymously in receptacle boxes located in the facility. All information regarding in regard to the grievance will remain anonymous. On June 17, 2024, at 2:20 p.m. an tour was conducted with the Social Worker Director, who was also a Grievance Officer, Employee E5 which revealed no grievance forms available…

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 review and interviews with staff, it was determined that the facility failed to ensure that appropriate respiratory care was provided related to oxygen therapy for four of four residents receiving respiratory therapy. (Residents R1, R16, R31 and R52 ) Findings include: Review of facility provided policy, titled Oxygen Administration, dated June 24, 2023, revealed that Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administrations. Observation of Resident R1 on June 17, 2024, at 10:04 a.m. revealed that the resident was on tracheostomy. Resident had a tracheostomy collar and trach tie dated June 4, 2024. Observation of Resident R1 on June 18, 2024, at 1:20 p.m. revealed that the resident was on tracheostomy. Resident had a tracheostomy collar and trach tie dated June 4, 2024. This observation was confirmed by Employee E16, Licensed Practical Nurse. Employee E16 stated the trach ties get changed twice weekly.…

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

Based on clinical record review and interview with staff, it was determined that the facility did not ensure that nurse aides received a minimum of 12-hour annual training to ensure continuing competence as required. Findings include: A request for evidence of annual inservice training for nurse aides was made on June 20, 2024, at 2:30 p.m., to Employees E1, the Nursing Home Administrator, and Employee E2, the Director of Nursing, requested to be provided the following day. Multiple attempts were made on June 21, 2024, to obtain the information. At 1:00 p.m. on June 21, 2024, Employee E1 stated if we can't find it, we probably don't have it. The facility was unable to provided documented evidence that nurse aides received a minimum of 12 hours annual training. 28 Pa. Code 201.18(b)(1)(3) Management 28 Pa. 211.12(c) Nursing services

Based on observation and staff interview, it was determined that the facility failed to accurately display facility daily nurse staff hours as required. Findings include: Observation in the entrance of the facility on June 17, 2024, at 2:00 p.m., revealed that posted nurse staffing numbers were for June 10, 2024. Employee E1, Nursing Home Administrator confirmed that the posted information was not accurate and timely for the current day. 28 Pa. Code 201.18(b)(1)(3) Management 28 Pa. 211.12(c) Nursing services

Based on review of clinical records and staff interviews, it was determined that the facility failed to ensure a response to the consultant pharmacist's recommendation related to the potentially unnecessary medications for two of five residents reviewed. (Resident R63 and Resident R8). Findings include: Review of pharmacy's consultant report for February 1, 2024, revealed a pharmacy consultant recommendation for Resident R63 which stated, Currently with 2 active orders for PRN (as needed) Guaifenesin liq which have not been used in over 30 days Please evaluate current need and discontinue these orders, if appropriate. Further review of the report revealed that the physician agreed to the recommendation and signed on February 1, 2024. Review of pharmacy's consultant report for June 4, 2024, revealed a pharmacy consultant recommendation for Resident R63 which stated, Currently with 2 active orders for PRN (as needed) Guaifenesin liq which have not been used in over 30 days Please evaluate current need and discontinue these orders, if appropriate. Further review of the report revealed…

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 the facility policy, review of planned written menus, and staff interviews, it was determined that the facility failed to follow approved emergency menus for two of two nursing units. (Second-floor and Third-floor). Findings Include: The facility Emergency Food Policy was reviewed, and the policy stated, Emergency Menu Guide for No Electricity, No Gas, Day one lunch menu was listed as eight ounces Beef Stew, half a cup of carrots, six crackers, half a cup of peaches, two cookies, eight ounces of milk (reconstituted), and four ounces of water. Observation during the kitchen tour on June 17, 2024 at 9:41 a.m. revealed that there was a gas leak outside of the facility by the dumpster area. Due to the leak the facility gas was turned off for the day at 9:30 a.m. Observation of the lunch meal on the Third floor in the dining room on June 17, 2024 at 12:27 p.m. revealed most resident were being served a cold sandwich, pasta salad, and a fruit cup for lunch. The residents were not served the items from the Emergency Menu due to the facility not having 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, review of facility policy, and interviews with staff, it was determined the facility failed to store food according to food service standards and failed to performed proper hand hygiene during the dining in one of two nursing units. (Second floor dining) Findings Include: Review of the facility policy titled Food Storage: Cold Folds dated February 2023 states, All Time/Temperature Control for Safety (TCS) foods, frozen and refrigerated, will be appropriately stored in accordance with guidelines of the FDA Food Code. Under procedures the policy states, 5. All foods will be stored wrapped or in covered containers, labeled and dated and arranged in a manner to prevent cross contamination. Review of the policy titled Food Storage: Dry Goods dated February 2023, states All dry goods will be appropriately stored in accordance with the FDA Food Code. Under procedures the policy states, 6. Storage areas will be neat, arranged for easy identification, and date marked as appropriate. An initial…

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 documentation, facility policies, Centers for Disease Control and Prevention (CDC) guidelines and staff interview, it was determined that the facility failed to maintain an effective antibiotic stewardship program that includes a system to effectively monitor antibiotic usage for two of two months of antibiotic stewardship program data reviewed. (April 2024 and May 2024). Findings include: A review of CDC (Centers for Disease Control and Prevention) guidelines, The core element of Antibiotic Stewardship for Nursing Homes, revealed that Improving the use of antibiotics in healthcare to protect patients and reduce the threat of antibiotic resistance is a national priority. 1. Antibiotic stewardship refers to a set of commitments and actions designed to optimize the treatment of infections while reducing the adverse events associated with antibiotic use.2 The Centers for Disease Control and Prevention (CDC) recommends that all acute care hospitals implement an antibiotic stewardship program (ASP) and outlined the seven core elements which are necessary 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 the review of facility policy, observations, and staff interviews, it was determined that the facility failed to ensure a safe and sanitary environment related to hand sanitizers for two of two nursing units reviewed. (Second Floor and Third Floor) Findings Include: Review of the facility policy titled Hand Hygiene undated states, Purpose: Cleaning your hands is one of the most effective ways to prevent the spread of germs. The policy states hand hygiene should be completed, Before and after contact with the resident, Before performing an aseptic task, After contact with blood, body fluids, visibly contaminated surfaces or after, contact with objects in the resident's room, After removing personal protective equipment (e.g., gloves, gown, facemask), After using the restroom, Observation of June 17, 2024 of the third floor at 10:15 a.m. revealed six wall hand sanitizers in a row on one side of the wall were not working. Observation of three of the six wall hand sanitizer revealed the sanitizer had a black x placed on them. Interview on June 17, 2024 at 9:50 a.m. confirmed…

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 observation and staff interview, it was determined that the facility failed to ensure that one of 24 residents reviewed was assessed for self administration of an inhaler medication. (Resident R47) Findings include: Observation of the Resident R47's and Resident R20's room on June 17, 2024 at 10:21 a.m. revealed that on the dresser near to Resident R20, there was an inhaler which was purple in color. Interview with Employee E14 on June 17, 2024 at 10:24 a.m. stated she gave the inhaler to Resident R47. Review of MDS (Minimum Data Set- Assessment of resident care needs) dated May 4, 2024 for Resident R47 with a BIMS (Brief Interview for Mental Status) score of 10, which indicated that the resident's cognitive status was moderately impaired. Review of care plan for Resident R47 dated June 6, 2024, revealed no evidence that the resident was care planned for self administration of medication or safe use of medication independently. Interview with the Assistant Director of Nursing, Employee E2, on June 21, 2024, at 11:00 a.m. confirmed that the nurse leaving the medication 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, review of the activities calendar and staff interview, it was determined that the facility failed to meet the recreational needs of one of 24 residents reviewed. (Resident 13) Findings include: Review of Resident R13's clinical record revealed that Resident R13 was admitted to the facility on [DATE], and interview preferences was conducted on February 12, 2024, which indicated that going outside to get a fresh air was very important for Resident R13. Review of Resident R13's Minimum Data Set (MDS A periodic assessment of resident care needs) dated March 30 , 2024, revealed a brief interview for mental status (BIMS) with a score of 2 (measured 0-7 severely impaired cognition). On June 17, 2024, at approximately 11:30 a.m. Resident R13 was observed being in bed and License nurse, Employee E4 came into the room to take Resident R13 into the dining room to eat lunch. On June 18, 2024, at 12:19 p.m. a telephone interview was held with Resident's R13's family member who reported the importance…

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 review, observation, and resident and staff interview, it was determined that the facility failed to ensure each resident received timely treatment and services to maintain visual abilities for one of one sampled residents. (Resident 16) Findings include: Clinical record review revealed that Resident 16 diagnoses included congestive heart failure (excessive body/lung fluid caused by a weakened heart muscle) and hypertension (high blood pressure). Review of the Minimum Data Set assessment dated [DATE], revealed that the resident required corrective lenses. On June 17, 2024, at 10:23 a.m., Resident 16 stated she had vision problem and was using glasses. She stated she admitted to the facility almost two years ago and did not see an eye doctor since her admission. A request for ophthalmology evaluation for Resident R16 was requested on June 18, 19 and 20, 2024. Facility did not provide evidence of ophthalmology evaluation for Resident R16 as requested. There was no evidence in the clinical…

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

Based on the observations, review of clinical records, facility policies, and interview with staff, it was determined that the facility failed to ensure that a resident with limited range of motion, received appropriate services to prevent further decline in range of motion and maintain appropriate positioning for one of 24 resident s reviewed. (Resident R1). Finding Include: Observation of Resident R1 on June17, 2024, at 10:05 a.m. revealed that the resident was laying in the bed. It was observed that both of the resident's hand's appeared to be contracted. The resident was not using any positioning devices or splints. There were 2 hand splints observed laying on top of the dresser. Observation of Resident R1 on June18, 2024, at 12:59 p.m. revealed that the resident was laying in the bed. Residents was not using any positioning devices or splints to the hands. There were 2 hand splints observed on top of the dresser. Interview with Employee E16, Licensed Practical Nurse, on June18, 2024, at 1:20 p.m., confirmed that the resident should be wearing a splint and a gauze roll 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, staff and resident interviews, it was determined that the facility failed to provide culturally competent, trauma care in accordance with professional standards of practice, accounting for the resident's past experiences and preferences in order to eliminate and/or mitigate triggers that may cause re-traumatization of the resident for two of two residents sampled (Resident R57 and R63). Findings include: Review of facility policy Trauma Informed Care dated June 24, 2023, revealed that It is the policy of this facility to provide care and services which, in addition to meeting professional standards, are delivered using approaches which are culturally-competent, account for experiences and preferences, and address the needs of trauma survivors by minimizing triggers and/or re-traumatization. Definitions: Trauma results from an event, series of events, or set of circumstances that is experienced by an individual as physically or emotionally harmful or life threatening and that has lasting adverse effects on the individual's functioning and mental,…

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 interviews, it was determined that the facility failed to provide food products based on the resident's food preference and intolerance for one of 24 residents (Resident R66). Findings include: Review of facility policy Dining and Food Preferences, last revised October 2022, indicates Individual dining, food and beverage preferences are identified for all residents/patients. The Diet Requisition form will notify dining services department of food allergies, upon admission and prior to any meals served. Dining Services Director or designee, will interview the resident or resident representative to complete a Food Preferences Interview within 72 hours of admission. The purpose of this interview ill be to identify individual preferences for dining location, meal times including times outside of the routine schedule food, beverage preferences. A review of the Food Committee Meeting notes dated May 24, 2024 indicated a concerns brought by the resident council group that there is never any lactose milk. On June 18, 2024, at 9:39…

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 review and interview with staff, it was determined that the facility did not maintain complete and accurate medical records for one of 24 records reviewed (Resident R11). Findings include: Review of clinical documentation revealed that Resident R11 was admitted to the facility on [DATE], and had diagnoses of calculus of the kidney (commonly referred to as kidney stones), presence of urogenital implants (the resident had a suprapubic catheter, a tube inserted into the bladder through the abdominal wall), retention of urine, calculus of the ureter (stones present in the tubes connecting the kidneys to the bladder), acute pyelonephritis (inflammation of the kidney as a result of bacterial infection), hydronephrosis (swelling of the kidneys), encounter for attention to other artificial openings of the urinary tract (referring to the suprapubic catheter), and obstructive and reflux uropathy (a condition which interferes with the normal functioning of the bladder). Further review of the…

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

Based on observation and interviews with resident and review of resident council minutes and facility policies determined with facility failed to provide a private space during the resident council meeting, failed to respond to concerns/requests from group meetings, failed to respond to concerns/requests in a timely manner, and failed to demonstrate their response and rationale for such concerns/requests for six of six residents attending resident council interviews and group meeting (Residents R8, R41, R43, R62, R75, and R90). Findings include: Review of the facility Resident Rights policy and procedure states the purpose is to ensure the preservation of every resident's right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility The right to reside and receive reasonable accommodations of residents' needs. Each resident has the right to organize and participate in a resident or family groups in the facility. The facility shall provide a resident a private space and take reasonable steps to make…

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, review of clinical records, observations, review of diet manual and staff interview, it was determined that the facility failed to ensure therapeutic diets were served per physician orders for 2 of 23 residents observed during mealtime (Resident R39, and R162) Findings include: Review of the facility diet manual titled, National Dysphasia Level 3 Advanced diet by the Academy of Nutrition and Dietetics, undated, revealed easy to cut meats fruits and vegetables. Review of Resident R39's clinical record revealed that the resident was admitted to the facility January 13, 2023, with the diagnoses of encephalopathy (disease of the brain), Parkinson's disease (brain disease causing uncontrollable movements), Alzheimer's disease (brain disease causing decreased function) and dysphagia, (difficulties swallowing). Resident R39's July 2023 physician orders instructed Dysphagia Advanced diet dated July 25, 2023. Review of Resident R39's care plan revealed offering a dysphagia advanced…

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.