Accela Rehab And Care Center At Springfield

Based on review of facility policy, resident's clinical record, observation and interview with staff, it was determined that the facility failed to ensure the safety of the resident's environment related to medication found on the floor bedside for one of nineteen residents reviewed. (Resident R5)Findings Include: Review of facility policy titled Administrating Medications revised April 2019 states, Policy Statement- Medications are administered in a safe and timely manner, and as prescribed. Review of Resident R2's admission Minimum Data Set (MDS- a federal mandated assessment tool for all residents) dated, revealed Resident R5 was admitted into the facility on December 21, 2024 with the diagnosis of Chronic Heart Failure ( a long-term, progressive condition where the heart cannot pump blood efficiently to meet the body's needs), Morbid Obesity (s a chronic, severe disease defined by a Body Mass Index (BMI) , Schizoaffective Disorder (a chronic mental health condition blending schizophrenia symptoms like hallucinations or delusions), Anemia (condition marked by a lack of healthy…

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, clinical record review, and interviews with staff and residents revealed the facility failed to ensure sufficient nursing staff were available to administer medications in a timely manner, resulting in widespread delayed medication administration, resident complaints, and observed symptoms potentially related to missed or delayed medications for 18 pf 18 resident reviewed. Observation of resident R 81 on February 2, 2026, at approximately 11:20 AM, Resident R81 was observed slumped over against his dresser, appeared to be lethargic, uncomfortable with facial grimacing.Interview with Resident R 81at time of the above observation revealed that this resident reported feeling wooziness, dizziness, and blurred vision:Interview with Assistant Director of Nursing (ADON)employee E4 at 11:22am on the first-floor unit hallway revealed that she is preparing the morning medication pass for the unit. Employee E4 assessed the resident, including checking blood sugar, and confirmed the resident had not yet received his scheduled morning medications. Employee E4 stated 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 Narcotic Shift Count Records, Medication Administration Record, and staff interview, it was determined that the facility failed to implement procedures to promote accurate narcotic medication records on one of three medication carts reviewed. On February 5, 2026, at 10:07 a.m., a review of the Narcotic and Controlled Substances Shift to Shift Count Sheets for the First-Floor Main Medication Cart, and the Medication Administration Record of R43, revealed that even though the medication named Lorazepam 0.5 mg oral tablet was dispensed to R43 on February 1, 2026, at 9 a.m., the same information was not documented in the Narcotic book.Interviewed the charge nurse, an LPN, E14, at the time of the finding, and E14 confirmed the findings.28 Pa Code 211.9(a)(1)(k) Pharmacy services.28 Pa Code 211.12 (a)(c)(d)(1)(3)(5) Nursing services.

Based on observations, review of clinical records, and interviews with facility staff, it was determined that the facility failed to ensure that it was free of medication error rate of five percent or greater for three of six residents observed during medication administration (Resident R13, R83, R88).On February 2, 2026, at 9:53 a.m., observed that Employee E12, a Licensed Nurse, decanted Colace (Docusate) 100MG, two capsules; and Aspirin Chewable 81MG, one tablet for Resident R13. E12 crushed the Aspirin Chewable 81MG tablet in a plastic pouch. E12 opened the Colace (Docusate) capsules and poured the medication into a dispenser- cup. E12 poured the crushed Aspirin Chewable 81MG tablet into the same dispenser cup which had the Colace medication. E12 mixed all the medications with one and half teaspoon of apple sauce and administered half of the mixture to R13 by mouth; and quickly discarded the remaining medications in the dispenser-cup, by throwing it away into the trash can, in R13's room, before being prevented from discarding the half quantity of the medications for R 13.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.

Based on observation, interview, and clinical record review, it was determined that the facility failed to correctly administer medications in accordance with physician orders for three of six residents during medication administration observation, resulting in significant medication error (Resident R13, R83, R88), and also the facility failed to ensure medications were administered in accordance with physician orders at the prescribed times, resulting in delayed medication administration for multiple residents, placing them at risk for adverse outcomes. Review of the facility policy titled Administering Medications, revised 2019, revealed that the facility is responsible for ensuring medications are administered safely and timely as prescribed. The policy states that staffing schedules must be arranged to allow medication administration without unnecessary interruptions. Medications are to be administered in accordance with prescriber orders, including required administration timeframes. The policy further states that medication administration times are determined by resident need…

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, observation, and staff interview it was determined that the facility failed to provide specialized rehabilitative services based on a resident's comprehensive plan of care for one of 19 residents reviewed (Resident R2). Findings Include: Review of Resident R2's comprehensive Minimum Data Set (MDS - federally mandated resident assessment and care screening) dated January 20, 2026, revealed the resident was admitted to the facility on [DATE], was rarely/never understood, and had diagnoses of dementia (decline in memory or other thinking skills severe enough to reduce a person's ability to perform everyday activities), adult failure to thrive (a state of decline that is multifactorial and manifested by weight loss, decreased appetite, poor nutrition and inactivity) and muscle weakness.Continued review of Resident R2's MDS dated [DATE], revealed the resident had impairment in functional limitation in range of motion in the upper and lower…

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 procedure and interviews with staff, it was determined that the facility failed to maintain an effective infection control program related to hand hygiene, on one of the six Medication Administration Reviews, and Enhanced Barrier Precautions on one of the one Wound Treatment Observations. Review of Resident R3's Annual Minimum Data Set (MDS), a federally mandated assessment tool for all residents, dated November 23, 2025, revealed the resident was admitted to the facility on [DATE]. Diagnoses included peripheral vascular disease (PVD), a condition involving narrowing of the blood vessels that reduces blood flow to the limbs; diabetes mellitus, a chronic condition affecting how the body processes blood glucose; and a Stage IV pressure ulcer of the sacral region, indicating full-thickness tissue loss with extensive tissue destruction over the tailbone area. Observation of wound care being performed on Resident R3 on February 4, 2026, at approximately 4:45 p.m.,…

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 documentation, observations, and resident and staff interviews, it was determined that the facility failed to provide food and drink that was palatable and served at the proper temperature. Findings include:Review of facility policy titled, Food Temperatures, undated, revealed that Foods sent to the units for distribution (such as meals, snacks, nourishments, oral supplements) will be transported and delivered to unit storage areas to maintain temperatures at or below 41 Fahrenheit (F) for cold foods and at or above 135 F for hot foods. Interview with Resident R2 on August 14, 2025, at 12:00 p.m. revealed that food is not good. Interview with Resident R4 on August 14, 2025, at 11:00 a.m. revealed food temperatures are often cold. Observations during a test tray conducted with the Food Service Director, Employee E3, on August 14, 2025, at 12:28 a.m. revealed that milk registered at 59.9 degrees Fahrenheit (F); tangerines registered 70.8 degrees F; and apple juice registered 58.6 degrees F. Follow-up interview with the Food Service Director, at 12:33 p.m.…

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 interviews, the facility failed to ensure that moist, ready-to-eat food items were protected from contamination during transportation to residents. Findings Include:On August 14, 2025, at approximately 12:00 p.m. during observation of the lunch meal delivery to the first-floor unit, the surveyor observed a dietary staff member transporting meal tray in a mobile tray cart with doors. Upon inspection of the trays, it was observed that each tray included a serving of canned fruit, pears and tangerines, placed in a small bowl without a cover or lid. In an interview conducted on August 14, 2025, at 12:15 p.m., with the Food Service Manager, Employee E3, confirmed that there are no coverings available for all nursing units. The facility served uncovered canned fruit in open bowls, placing residents at risk for foodborne illness due to potential cross-contamination. 28 Pa. Code 201.14(a) Responsibility of licensee

Based on facility policy reviews, clinical record review, and staff interview, it was determined that the facility failed to ensure the written discharge notice included the location to which the resident is transferred or discharged for one of seven residents reviewed. (Resident R2) Findings Include:Review of Resident R2's clinical record revealed the resident received a discharge notice dated, June 19, 2025, which indicated that the facility initiated the transfer due to, the safety or health of individuals in the facility would be endangered by the patient being here. Continued review failed to reveal the location to which the resident is transferred or discharged . Interview with the facility Social Worker, Employee E3, conducted on July 21, 2025, at approximately 1:00 p.m. confirmed that the discharge notification did not include the location to which the resident is to be discharged . Continued interview revealed that, the facility was unaware of this requirement. 28 Pa. Code 201.14(a) Responsibility of licensee

Based on the review of clinical records, observations, review of employee records, and staff interviews, it was determined that the facility failed to ensure that there was sufficient staff, with the appropriate competencies and skills sets which included knowledge of and appropriate training and supervision for care for residents with mental and psychosocial disorders, to provide direct services to residents to assure resident safety for four of four employee records reviewed. (Employee E4, E5, E6 and E7).Review of facility documentation dated July 5, 2025, revealed Resident R1 who was alert and oriented to self only, was noted to be off of the unit by nurse during 3pm-llpm shift. Search initiated by nurse, staff on unit notified and participated. Once it was determined Resident R1 was not on unit, nurse left unit to notify supervisor. It was at that point that nurse encountered supervisor returning Resident R1 to the unit. Resident R1 was returned back to the facility by local police. Police reported resident found around the corner at neighbor's house, resident had rang bell 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 clinical records, facility policy, and staff interviews, it was determined that the facility failed to ensure that a resident with a diagnosis of dementia (a syndrome characterized by a progressive decline in cognitive abilities, such as memory, thinking, reasoning, and judgment, that interfere with daily functioning and social relationships), received appropriate treatment and services resulting in the resident eloping from the facility for one of seven residents reviewed. (Resident R1) Findings include: Review of undated facility policy Wandering and Elopements, revised March 2019, revealed that The facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents.l. If identified as at risk for wandering, elopement, or other safety issues, the resident's care plan will include strategies and interventions to maintain the resident's safety.2. If an employee observes a resident leaving the premises, he/she should:a. attempt to prevent the resident from leaving in a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of the facility's policy, clinical records, and staff interviews, it was determined that the facility failed to administer pain medication in accordance with professional standards of practice for one of one resident reviewed (Resident R1). Findings include: Review of facility policy Administering Medication Policy, revised April 2019, revealed that Medication are administered in a safe and timely manner, and as prescribed. Under #29 it further stated If a resident uses PRN (as needed) medication frequently, the attending physician and interdisciplinary care team, with support from the consultant pharmacist as needed, shall reevaluate the situation, examine the individual as needed, determine if there is a clinical reason for the frequent PRN use, and consider whether a standing dose of medicine is clinically indicated. A review of the resident clinical file revealed that Resident R1 was admitted to the facility on [DATE], with diagnosis of hidradenitis suppurative (chronic inflammatory skin…

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 upon review of facility policies and procedures, review of clinical records and facility documentation and interviews with staff, it was determined that the facility did not ensure that a complete and thorough investigation was completed to rule out neglect for one of four fall investigations reviewed (Residents R1). Findings include: Review of the facility's policy revised April 2021, titled, Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating, which states, The individual conducting the investigation as a minimum: a. reviews the documentation and evidence; b. reviews the resident's medical record to determine the resident's physical and cognitive status at the time of the incident and since the incident; c. observes the alleged victim, including his or her interactions with staff and other residents; d. interviews the person(s) reporting the incident; e. interviews any witnesses to the incident; f. interviews the resident (as medically appropriate) or the resident's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and interviews with staff, it was determined the facility failed to ensure a resident was provided necessary care and services related to follow up care including neurological assessment after an unwitnessed fall with head injury for one of four resident records reviewed (Resident R1). Findings include: Review of facility policy, titled, Falls - Clinical Protocol, revised March 2018, revealed the nurse shall assess and document/report the following: a. Vital signs; b. Recent injury, especially fracture or head injury; c. Musculoskeletal function, observing for change in normal range of motion, weight bearing, etc.; d. Change in cognition or level of consciousness; e. Neurological status; f. Pain; Review of Resident R1's admission assessment revealed he/she was admitted on [DATE], with diagnosis of Dementia (group of symptoms affecting memory, thinking and social abilities). Review of the Brief Interview for Mental Status completed on April 14, 2025 revealed a score of 5, which…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, observations, interviews with residents and staff, it was determined that the facility did not ensure a clean, comfortable, and homelike environment in resident care areas for two of two nursing units observed (First Floor and Second Floor). Findings Include: Review of the facility policy titled, Homelike Environment revised February 2021 states, Residents are provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible. Further review of the policy revealed 2. The facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include: a. clean, sanitary and orderly environment; .e. clean bed and bath linens that are in good condition; f. pleasant, neutral scents. An initial tour was taken on May 28, 2025 at of the second-floor nursing unit at 9:21 a.m A tour was taken initially of the locked…

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, interviews with staff and hospital staff, reviews of hospital records, electronic communication records and facility policies and procedures, it was determined that the facility failed to permit one of one resident reviewed to return to the facility after hospitalization. (Resident R12) Findings include: Review of the policy titled Bed Holds and Returns revised March 2022 revealed that Residents and/or representatives are informed (in writing) of the facility and state (if applicable) bed-hold politicizes. All residents/representatives are provided written information regarding the facility bed-hold policies, which address holding or reserving a resident's bed during periods of absence (hospitalization ortherapeutic leave). Residents are provided written information about these policies at least twice: a. well in advance of any transfer (e.g., in the admission packet); and b. at the time of transfer (or, if the transfer was an emergency, within 24 hours). 2. Reissuance 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 observations, and resident and staff interviews, it was determined that the facility failed to honor resident food and drink preferences by providing food that was requested by and acceptable to the residents for 3 of 13 residents reviewed (Residents R10, R8, R13). Findings include: On May 28, 2025, at 9:20 a.m. during the initial tour of the 1st floor Pavilion nursing unit, it was observed that residents did not receive their coffee beverage. Residents' trays had juice on their trays, but there were no hot beverages. During a random room tour, it was observed that breakfast trays remained on bedside tray tables in Rooms 124 through 138. However, there was no evidence of hot beverage cups containing hot beverages on any of the trays. On May 28, 2025, at 9:33 a.m., an interview was conducted with Resident R13, who reported that her egg omelet was burned and that she was still hungry. She also stated that she prefers coffee as her morning hot beverage, but no coffee was provided on her breakfast tray. At the surveyor's request, the resident pressed the call bell. In response,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, observations, and staff interviews, it was determined that the facility failed to implement enhanced barrier precautions for one of two residents reviewed who had a peripherally inserted central catheter (PICC) line. (Resident R12). Findings Include: Review of facility policy Isolation- Categories of Transmission -Based Precautions revised October 2018, revealed transmission-based precautions are initiated when a resident develops signs and symptoms of a transmissible infection; arrives for admission with symptoms of an infection; pr has a laboratory confirmed infection; and is at risk of transmitting the infection to other residents. Under bulletin #5. When a resident is placed on transmission-base precautions, appropriate notification is plced on the room entrance door and on the front of the chart so that personnel and visitors are aware of the need for and the type of precautions. The signage informs the staff of the type of CDC precautions, instruction for use of PPE,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, observations, resident and staff interviews, review of the pest control logs and the pest control reports and documentation, it was determined that the facility failed to maintain an effective pest control program for one of two nursing units and the kitchen area. (Second Floor Nursing Unit and Kitchen Area) Findings Include: A tour was taken on May 28, 2025 at 9:21 a.m. of Resident R2's room and the resident was visualed sleeping in bed. Observation was made of two bed side dressers for the resident. The resident had a small nightstand dresser to the right of his bed that had a broken bottom drawer. Upon opening the drawer there was a plastic bag with opened food including cookies and nuts. A review of Resident R2's clinical record revealed the resident was admitted to the facility on Feburary 4, 2025 with the following diagnsoses; Dementia with agitation, Anxiety Disorder, and Major Depressive Disorder. Further review of Resident R2's clinical record revealed a MDS (Minimum…

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, resident and staff interviews, and a review of facility documentation, it was determined that the facility has failed to provide meals at regular times each day. Findings include: Interview with Administrator (NHA) on May 6, 2025, at 9:05 a.m. revealed that there was a sewage backup in the kitchen which caused the County Health Department to shut the kitchen down in the middle of preparing for lunch and all the food had to be discarded. This did cause the meal to be late until facility staff could arrange meals to purchase. Interview with the Food Service Director (FSD), Employee E11, on May 6, 2025, at 9:15 a.m. confirmed that the County Health Department made them destroy all the food that was to be served for lunch when the kitchen was contaminated with a sewage backup and that the lunch meal was hoagies from a local fast food place which was not delivered until at 3:45 p.m. Interview with Resident R11 at 10:30 a.m. on May 6, 2025, revealed that she was still waiting for breakfast, and that yesterday they waited all afternoon until 4 p.m. for lunch when…

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, family and staff interview, it was determined that the facility failed to ensure that the resident's representative was notified timely about a residents fall with injury for one of 18 residents reviewed (Residents R4). Findings include: A review of clinical records revealed that Resident R4 was admitted to the facility on [DATE], for short time rehabilitation after a fall at an assisted living facility. Further review revealed a nursing note written by licensed nurse, Employee E16, stating that on April 18, 2025, Resident R4 was found on the floor. The Hoyer lift (mechanical lift) was used along with two nurse aides to help the resident to bed. The registered nurse supervisor informed Employee E16 that she would make the follow up contact to the physician and the resident's responsible party. An interview with the Director of Nursing (DON) on May 7, 2025, at 11:20 a.m. confirmed that the nursing notes did not indicate that the daughter, who is Resident R4's responsible…

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 and resident and staff interviews, it was determined that the facility failed to maintain the facility in a clean, safe, comfortable and homelike condition in two of nursing floors (1st and 2nd floor). Findings include: Observations on May 6, 2025, at 9:50 a.m., on the first floor main near the nurse's station and room [ROOM NUMBER] revealed a strong odor of urine. Interview with the Director of Nursing (DON) on May 6, 2025, at 9:54 a.m., on the first floor main near the nurse's station confirmed that she smelled the heavy odor of urine. Interview with the Administrator (NHA) on May 6, 2025, at 10:05 a.m., during a tour of the first floor confirmed the smell of urine near the nurse station and room [ROOM NUMBER], and the door handle on the inside of the door to the stairwell was missing and the opening was sharp and the only way to open the door from the inside of the stairwell was to reach into the hole to hold the door. Observations on May 6, 2025, at 10:53 a.m., in the bathroom in room…

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 resident and staff interviews, it was determined that the facility failed to ensure that wound care was performed per physician orders for one of 18 residents reviewed (Resident R3). Findings include: Review of Resident R3's clinical records revealed that the resident was admitted on [DATE], with diagnosis including generalized weakness and abnormalities of gait and mobility (when a person walks differently due to injuries, conditions, or issues with the legs or feet). An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident R3, dated April 1, 2025, revealed that the resident was understood and could understand. Review of Resident R3's physician order revealed a December 23, 2024, order to cleanse right and left buttock with Dyna-Hex4, apply triamcinolone cream to 6x6 foam dressing and apply to wound bed. And a December 23, 2024, order to cleanse groin with Dyna-Hex4, and a July 9, 2024, order to apply…

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 staff, it was determined that the facility failed to ensure that a safe environment was maintained related to exposed sharp edges, tripping hazards and a syringe being left unattended on a medication cart on two of four nursing units. (First floor and Second floor) Findings include: Review of the Administering Medications policy revised April 2019, revealed that during administration the cart must be closed and locked when out of sight of the medication nurse, and that no medications are kept on the top of the cart. Interview with the Administrator (NHA) on May 6, 2025, at 10:05 a.m., during a tour of the first floor confirmed that the door handle on the inside of the door to the stairwell was missing and the opening was sharp and the only way to open the door from the inside of the stairwell was to reach into the hole to hold the door, a potentially dangerous situation. Interview on May 6, 2025, at 10:58 a.m., with Employee F10, Environmental…

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, interviews with staff, and a review of facility procedures, it was determined that the facility failed to store food in accordance with professional standards for food service safety. Facility Policy: The review of the facility's policy titled Food Receiving and Storage, undated reported under bulletin #7. Dry foods that are stored in bins will be removed from original packaging, labeled and dated (use by date). Such foods will be rotated using a first in-first out system. On April 7, 2025, at 9:25 a.m., a kitchen tour was conducted with the Dietary Director, Employee E6, who confirmed the observation of three large bags of hamburger buns, 44 loaves of bread, and two bags of hot dog buns-all of which were unlabeled. Employee E6 reported that the facility received a shipment on Saturday, April 5, 2025, and that the weekend staff had failed to label the items. During the tour of the main walk-in refrigerator, a large salad bowl was observed containing lettuce with visibly discolored, pink edges and was also unlabeled. Additionally, cut vegetables such 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and interviews with staff, it was determined that the facility failed to ensure that a care environment was maintained for one of eight residents reviewed that provided her with the privacy and dignity that she was entitled to. (resident R2) Findings include: An observation tour was conducted of the nursing care unit located on the second floor of the facility. During the tour Resident R2 was visited in her assigned room. Resident R2 is a female patient admitted to the facility on [DATE], for skilled nursing care. It was observed that Resident R2 shared a bathroom with the occupants of the adjacent room. The residents occupying the other room were both males. The entry doors on the bathrrom did not have a locking mechanism to ensure privacy. During interview at the time of the observation Licensed nurse, Employee E5 confirmed that the a common bathroom was shared by Resident R2, a female patient, and residents R4 & R5, two male patients. An interview was conducted with the facility…

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,and interviews with residents and staff, it was determined that the facility did not ensure to provide adequate overbed lighting for one of eight residents. (Resident R2) Findings include: Observations on March 27, 2025, on the nursing care unit located on the second floor of the facility revealed that the overbed light in room [ROOM NUMBER], above the bed occupied by Resident R2 was not functioning. An interview was conducted with Licensed nurse, Employee E5, on March 27, 2025, at 11:00 a.m. confirmed that the overbed light above the bed occupied by Resident R2 was not operational. 28 Pa Code 201.18(a) Management 28 Pa Code 201.18(b)(1) Management 28 Pa Code 201.18(b)(3) Management 28 Pa Code 201.18(d) Management 28 Pa Code 201.29(a) Resident Rights

Based on environmental observations of the food and nutriton services department, interviews with residents and staff and reviews of the consulting pest control operator's reports, it was determined that the facility was not maintaining an effective pest control program. Findings include: During a resident council meeting on March 4, 2025, at 10:30 a.m. with 19 residents, (Residents R14, R32, R75, R51, R79, R48, R50, R102, R63, R10, R57, R87, R90, R2, R12, R64, R18, R27, R101) who were identified as being alert and oriented, reported that they are seeing mice in the facility and are reporting to staff for the pest control documentation and treatment. Reviews of the pest control operator's reports for the months of November and December, 2024, January and February, 2025 revealed that the main kitchen and certain resident rooms were being treated for common household pests and rodents. It was noted that the pest control operator was mentioning and documenting voids that need to be filled/addressed in the main kitchen and adjacent hallways and corridors, outside the main kitchen, 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 observation and an interview with staff, it was determined that the facility failed to ensure that the most recent Department of Health Survey results were in a place readily accessible to residents and visitors for two or two nursing units. (First floor, Second Floor) Findings Include: Observations conducted on March 4, 2025, at 11:33 a.m. with the Nursing Home Administrator, Employee E1 to observe where the Department of Health Survey binder was in the facility. Upon observing the front lobby facilities, it was noted that the Department of Health survey results binder was placed behind the desk in the main lobby, making it inaccessible to residents and visitors without asking. A review of the binder showed that the information was outdated, with the last survey results recorded on September 1, 2022. The second-floor binder contained results from April 17, 2023, while the dining room binder, where residents gather for meals and activities, was last updated on April 26, 2023. The Administrator confirmed that this was an area they had identified for improvement but had 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 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 19 of 21 residents (Residents R14, R32, R75, R51, R79, R48, R50, R102, R63, R10, R57, R87, R90, R2, R12, R64, R18, R27, R101) Findings include: A review of facility policy titled Grievances/Complaints, Filing revised April 2017 stated residents and their representatives have the right to file grievances, either orally or in writing, to the facility staff or to the agency designated to hear grievances. It further stated under bulletin #5 Grievances and/or complaints may be submitted orally or in writing and may be filed anonymously. During a resident council meeting on March 4, 2025, at 10:30 a.m. with 19 residents, (Residents R14, R32, R75, R51, R79, R48, R50, R102, R63, R10, R57, R87, R90, R2, R12, R64, R18, R27, R101) who were identified as being alert and oriented, revealed that the residents were unaware of where 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 observations, review of clinical records, and interviews with facility staff, it was determined that the facility failed to ensure that it was free of medication error rate of five percent or greater for one of four residents observed during medication administration (Residents R1, R68, R37 and R100). Findings include: On March 4, 2025, at 9:02 a.m., observed that Employee E7, a Licensed Nurse, administered to Resident R1, the medicine, Fluticasone Propionate HFA Inhalation Aerosol 110 MCG/ACT, two puffs to inhale orally, and it was noticed that R1 did not rinse his mouth after inhaling Fluticasone Propionate HFA Inhalation Aerosol 110 MCG/ACT. Review of physician order for Resident R1, revealed an order, dated January 29, 2025, to administer Fluticasone Propionate HFA Inhalation Aerosol 110 MCG/ACT, inhale one puff orally every 12 hours for Allergies, and rinse mouth with water, after use to reduce aftertaste. The Licensed Nurse, E7, did not follow the physician order to administer Fluticasone Propionate HFA Inhalation Aerosol 110 MCG/ACT, one puff inhale orally 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 documentation and interviews with staff, it was determined that the facility failed to maintain an effective, comprehensive, data-driven quality assurance and performance improvement program (QAPI) that focuses on indicators of the outcomes of care and quality of life as required. Findings include: Review facility policy on Quality Assurance and Performance Improvement, (QAPI) last revised on February 2020 reveal that This facility shall develop, implement and maintain and ongoing, facility-wide, data- driven QAPI program that is focused on indicators of the outcomes of care and quality of life for our residents. It furthers reveals under implementation section 2. The QAPI plan described the process for identifying and correction quality deficiencies. Key components of this process include tracking and measuring performance, establishing goals and threshold for performances measures, identifying and prioritizing quality deficiencies, systematically analyzing underlying causes of systemic quality deficiencies, developing and implementing corrective action…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of clinical records and staff interview, it was determined that the facility failed to offer and/or provide the influenza and pneumococcal immunization to four of five residents reviewed. (Residents R77, R100, R31, and R78) Findings include: Review of Resident R77's admission Minimum Data Set (MDS- a federal mandated assessment for all residents) dated December 27, 2024, revealed that this resident was admitted to the facility on [DATE], with diagnosis including heart failure and asthma (chronic condition that effects the lungs). Review of Resident R77's immunization record revealed no evidence that this resident received influenza or pneumococcal vaccine or that the facility offered the influenza vaccine or pneumococcal vaccine. Review of Resident R100 admission MDS dated [DATE], revealed that this resident was admitted into the facility on December 6, 2024 with diagnosis' including malnutrition (nutritional deficiency), cerebral vascular incident (stroke, lack of blood flow to the brain), and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of clinical records, observation, review of facility policy and resident and staff interviews, it was determined that the facility failed to maintain resident dignity related to appropriately sized gowns and linens being available for three of 21 residents reviewed. (Resident R 77, R31, R78) Findings: Review of facility assessment last reviewed February 28, 2025 revealed that the resident's physical environment has supplies readily available to this facility including bed frames, mattresses, specialty mattresses, bariatric equipment, housekeeping equipment, as well as non-medical supplies such as bed and bath linens. Review a facility policy titled Resident Rights dated February 2021, revealed Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's rights to a dignified existence, to be treated with respect, kindness, and dignity to be free from abuse neglect misappropriation of property and exploitation. Review of facility…

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, observation, interview with staff, it was determined the facility failed to ensure that resident's confidentiality was protected related to staff using personal device to access resident protective health information (PHI ) for one of two nursing units (First floor nursing unit). Findings include: Review of facility policy titled Protected Health Information(PHI) safeguarding Electronic dated February 2014, revealed Electronic protected health information (e-PHI) is safeguarded by administrative, technical and physical means to prevent unauthorized access to protected health information. All business associates are required to comply with security standards established by our business associate agreement relative to e-PHILA cultural of society awareness and protection of PHI is reinforced among employees and staff through initial training, periodic training and information system security. Review of facility policy titled Protective Health Information (PHI) Common Management and Protection of dated April 2014 revealed the protected health…

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 residents were free of neglect related to the provision of incontinence care for one of 21 residents reviewed. (Resident R31) Findings include: Observation on March 3, 2025, at 10:35 a.m. revealed nursing aide, Employee E15 completing routine care of Resident R31 in the resident's bed. This observation revealed that the resident was lying in saturated linens. All bed linens were soaked trough with urine and needed to be changed. Interview with Resident R31 at time of the observation revealed, the overnight aides never provide care, and this resident was left is urine-soaked briefs. Interview with nursing aide, Employee E 15 at time of above observation revealed that she was completing her morning tasks and found the resident was lying in urine-soaked lines from the previous evening. Employee E15 stated that the overnight aides are supposed to provide care through the night and in the morning before the end of shift. Interview with the Director of Nursing Employee E2, in resident 31's…

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

Based on review of clinical records, interview with staff and review of facility policy, it was revealed that the facility did not ensure revision were made to the PASRR (Pre-admission Screening and Resident Review) application to include mental health diagnoses for 3 out of 21 residents reviewed. (Resident R42 R37) Findings include: Review of the facility policy titled admission Criteria policy last revised March 2019 revealed under bulletin 9 All new admissions and readmissions are screened for mental disorders (MD), intellectual disability (ID) or related disorders (RD) per the Medicaid Pre-admission Screening and Resident Review (PASSARR). The facility a Level 1 PASARR screen for all potential admissions, regardless of payer sources, to determine if the individual meets the criteria for a MD, ID, or RD. Review of Resident R42's PASRR completed on October 15, 2019, indicated that Resident R62 did not have a mental health condition or suspected mental health condition. Review of R42's clinical record revealed admission date October 15, 2019. Clinical record review for Resident R42…

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, and staff interviews, it was determined that the facility failed to develop a comprehensive person-centered care plan for two of 21 Residents reviewed (R1, R84) . Findings include: Review of Resident R1's clinical record revealed that the resident was admitted to the facility on [DATE], with diagnoses that included Cerebral Palsy (a group of movement disorders that affect a person's ability to control their muscles, balance, and posture. It is caused by damage to the brain during or before birth or in the early years of life), Acute Respiratory Failure With Hypoxia (a condition where the lungs cannot effectively exchange oxygen and carbon dioxide, leading to a buildup of carbon dioxide and a deficiency of oxygen in the blood. Hypoxia specifically refers to a state where the body or a specific tissue does not have enough oxygen), and Chronic Obstructive Pulmonary Disease (a group of lung diseases that cause ongoing breathing problems.…

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 staff and resident interviews, it was determined that the facility failed to provide necessary services to maintain adequate grooming for dependent residents for two of 21 residents reviewed (Resident R70, and R95) Findings include: A review of the Activities of Daily Living (ADL), Supporting) policy last updated May, 2018, indicated Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. Review of admission record indicated Resident R70 was admitted to the facility on [DATE], with a diagnosis of cerebral infarction due to embolism of left middle cerebral artery (stroke), open wound, right knee, muscle weakness, injury of right lower leg, and need for assistance…

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 residents clinical records, observation and interview with staff, it was determined that facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice related to physician orders of medication administration and weekly weights for two of 21 residents observed. (Resident 45 and Resident 100) Findings include: Resident R45 was admitted to the facility on [DATE], with the following diagnoses of atherosclerotic heart disease of native coronary artery with unstable angina pectoris (limit or blocks blood flow to various parts of your body, including your heart and brain), dementia, and epilepsy. Review of Resident R49's clinical record revealed a physician order for the Resident R45 to obtain weekly weights x 4 every day shift every Tuesday on January 28, 2025. A review of clinical record further revealed that weekly weights were taken on January 28, 2025, February 1,4,11, 2025. There were no weekly weights 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations of care and services, clinical record reviews, interviews with staff and reviews of policies and procedures, it was determined that the facility failed to assess and monitor one of two residents reviewed for sensory and communication needs, to ensure that treatment and assistive devices to maintain hearing abilities provided to each resident. (Resident R95) Findings include: A review of the facility policy titled sensory impairments dated March, 2018 revealed that it was the responsibility of the staff and physician to identify residents with hearing impairment. The policy indicated that the physician was responsible for ordering consultation with an audiologist to define causes and treatment options to address complications of the sensory impairment. Clinical record review revealed an admission comprehensive assessment dated [DATE] that indicated Resident R95 was cognitively intact. Observations of Resident R95 throughout all days of the survey ( March 3, 4, 5, and 6, 2025) 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 record review, and staff interview, it was determined that the facility failed to implement treatment and services for incontinence management for one of 21 residents reviewed.(Resident R1). Findings include: Review of physician order for Resident R1, dated January 29, 2025, indicated an order for Supra Pubic Catheter with size 16FR (french)/10 CC Balloon. On March 4, 2025, at 9:14 a.m., it was observed that Resident R1 had a Supra Pubic Catheter of 22 FR/10 CC Balloon, instead of 16FR/10 CC Balloon. At the time of the finding, confirmed the same with a Licensed Nurse, Employee E7. 28 Pa Code 211.12(d)(1) Nursing services 28 Pa Code 211.12(d)(5) Nursing services

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 care and services for one of 21 residents reviewed (R1). Findings include: Review of Resident R1's clinical record revealed that the resident was admitted to the facility on [DATE], with diagnoses that included Cerebral Palsy (a group of movement disorders that affect a person's ability to control their muscles, balance, and posture. It is caused by damage to the brain during or before birth or in the early years of life), Acute Respiratory Failure With Hypoxia (a condition where the lungs cannot effectively exchange oxygen and carbon dioxide, leading to a buildup of carbon dioxide and a deficiency of oxygen in the blood. Hypoxia specifically refers to a state where the body or a specific tissue does not have enough oxygen), and Chronic Obstructive Pulmonary Disease (a group of lung diseases that cause ongoing breathing problems. It is…

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, interviews with staff and residents and reviews of policies and procedures, it was determined that the facility failed to ensure that treatment and services were attain for two of eleven resident reviewed related to mood, behavior and the use of psychotropic medications. (Residents R37 and R48) Findings include: A review of the facility's policies titled behavioral health service and behavioral assessment, intervention and monitoring dated February and March 2019, revealed that it was the facility's responsibility to provide each resident with behavioral health services as needed to attain or maintain their highest practicable physical, mental and psychosocial well-being. The policies indicated that the behavioral health services were to be provided by staff who were qualified and competent in behavioral health and trauma informed care. The policies said that the interdisciplinary team would evaluate the new or changing behavior to identify underlying causes and address the factors that are causing physical, emotional or functional impairments 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, review of clinical records, observation, and interviews with staff it was determined that the facility did not ensure that insulin was provided timely to a resident as needed, and did not ensure accurate narcotic reconciliation was completed for one of three residents reviewed. ( Resident R 37) Findings include: Review all facility policy Administering Medications dated April 2019 revealed only persons license or permitted by the state to prepare administer and document the administration of medications may do so. Director of nursing services supervises and directs all personnel who administer medications and have related functions. Insulin pens are clearly labeled with the resident's name or other identifying information prior to administrating insulin with an insulin pen the nurse verifies the correct pen is used for the resident. A drug that is withheld ,refused or given at a time other than the scheduled time the individual administrating the medication shall initial encircle the MAR space provided. Review of facility policy titled Storage 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 observation and staff interview, it was determined that the facility failed to ensure all drugs and biologicals used in the facility were labeled in accordance with professional standards, and to discard expired medications in accordance with professional standards, for one of three medication carts observed and reviewed (Medication cart of Second Floor, Front Hall). Findings include: Observation of the Medication Cart at the Second Floor, Front Hall, on March 6, 2025, at 10:57 a.m., revealed; an opened one Vial of Humalog Insulin Lispro, Injection, 100 Units per ML, with expiration date as September 30, 2027, which was opened, but with no opened date marked; and an opened one Vial of Insulin Aspart, Injection,100 Units per ML, with expiration date as April 30, 2027, which was opened, but with no opened date marked. Interview with a Licensed Nurse, Employee E17, at the time of the finding, confirmed that the insulin vials should have been discarded. 28 Pa Code 211.9(g)(h) Pharmacy services 28 Pa Code 211.12(c) Nursing services

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, pertinent dental documents, interviews with staff and reviews of policies and procedures, it was determined that the the facility failed to ensure that routine dental services were provided promptly to one of four residents reviewed for dental and nutritonal care. (Resident R38) Findings include: A review of the facility's policy titled dental examination, dated December, 2013 revealed that it was the facility's responsibility to ensure that each resident would be examined and assessed by a dentist. The policy also indicated that each resident would be given dental services as needed and any resident needing dental services will be promply assessed by a dentist. Clinical record review for Resident R38 revealed a quarterly assessment MDS (an assessment of care needs) dated January 7, 2025 that indicated that this resident was admitted to the facility on [DATE]. The assessment also indicated that this resident was cognitively intact. Clinical record documentation for Resident R38…

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, interviews with staff, and review of facility policy, it was determined that the facility failed to ensure safe and sanitary storage and handling of personal food products brought in from outside sources for three of 21 residents. (R42, R80, R64). Findings Include: Review of Facility Policy: Foods Brought by Family/Visitors revised March 2021 states Food brought to the facility by visitors and family is permitted. Facility staff will strive to balance resident choice and homelike environment with the nutritional and safely needs or residents. Family members and visitors are requested to inform nursing staff or their desire to bring foods into the facility. Nursing staff will provide family/visitor who wish to bring foods to the facility with a copy of this policy. It further explains under bulletin 7 Food brought by family/visitors that is left with the resident to consume later will be labeled and stored in a manner that is a clearly distinguishable from facility-prepared food On March 3, 2025, at 11:16 a.m. observation revealed Resident R42 had two Ziplock…

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, review of facility documentation, and staff interview, it was determined that the facility failed report the results of abuse, neglect, and misappropriation investigations within 5 working days to the State Survey Agency, as required, for four of four residents reviewed (Resident R1, R2, R7, and R8). Findings Include: Review of facility policy Abuse and Neglect - Clinical Protocol, revised March 2018, revealed the management and staff, with physician support, will address situations of suspected or identified abuse and report them in a timely manner to appropriate agencies, consistent with applicable laws and regulations. Review of documentation submitted by the facility on September 30, 2024, to the State Survey Agency via the Event Reporting System (electronic database that collects reports of resident events from healthcare facilities), revealed on September 27, 2024, Resident R7 reported to facility staff that money was taken from his personal bag that was hanging on his wheelchair. The facility subsequently initiated an internal investigation…

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, and resident and staff interviews, it was determined that the facility failed to maintain a safe, functional, sanitary, and comfortable environment for residents and staff for three of four nursing units toured (1 Pavilion, 2 Pavilion, and 2 Main). Findings Include: During an interview on January 28, 2025, at 9:25 a.m. with Resident R3 and R4, the residents reported the sink next door (room [ROOM NUMBER]) was clogged causing the sink to overflow and subsequently flood into their room (room [ROOM NUMBER]). Resident R3 and R4 reported it has happened 4-5 times over the last few weeks. Observations revealed rooms [ROOM NUMBERS] were conjoined by a shared bathroom. room [ROOM NUMBER] and room [ROOM NUMBER] were each equipped with its own sink in the room. Observations on January 28, 2025, at 9:30 a.m. confirmed the sink in room [ROOM NUMBER] was clogged. When surveyor turned on the sink in room [ROOM NUMBER], the sink quickly began to fill up with water. Observations of the clogged sink 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, review of clinical records, and staff interview, it was determined that the facility failed to provide evidence of a Level 1 pre-screening for mental disorders/intellectual disabilities for one of two residents reviewed (Resident R1). Findings Include: Review of facility policy admission Criteria, revised March 2019, revealed the facility only allows admissions of residents who's medical and nursing care needs can be met. Continued review of facility policy admission Criteria revealed all new admissions and readmissions are screened for mental disorders (MD), intellectual disabilities (ID) or related disorders (RD) per the Medicaid Pre-admission Screening and Resident Review (PASARR) process. The facility conducts a Level I PASARR screen for all potential admissions, regardless of payer source, to determine if the individual meets the criteria for a MD, ID or RD. Review of Resident R1's quarterly Minimum Data Set (MDS - federally mandated resident assessment and 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 facility documentation, review of clinical records, and resident and staff interviews, it was determined that the facility failed to maintain agreements pertaining to services furnished by outside resources. Findings Include: Review of Resident R1's quarterly Minimum Data Set (MDS - federally mandated resident assessment and care screening) dated January 5, 2025, revealed the resident was admitted to the facility on [DATE], and was cognitively intact. Further review of the MDS revealed Resident R1 had diagnoses of post-traumatic stress disorder (PTSD - a mental and behavioral disorder that develops from experiencing a traumatic event), schizophrenia (mental disorder characterized by delusions, hallucinations, disorganized thoughts, speech and behavior), and depression (a mood disorder that causes persistent feelings of sadness). Interview on January 25, 2025, at 9:35 a.m. Nursing Home Administrator, Employee E1, and Assistant Nursing Home Administrator, Employee E3, revealed that the facility…

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, and interview with residents and staff, it was determined that facility did not ensure to provide safe and comfortable temperature levels for 19 out of 55 rooms observed (Rooms 110, 109, 135, 136, 138, 102, 103, 116, 117, 119, 118, 120, 132, 135, 133, 136, 137, 238, and 225) Findings include: Review of facility policy 'Homelike Environment,' revised February 2021, indicates that the facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include: comfortable and safe temperatures (71F - 81F) Review of facility policy 'Emergency Generator or Alternate Energy Source,' revised April 2019, indicates that temperature regulation for resident health, safety and comfort (between 71- and 81-degrees Fahrenheit), as well as to protect supplies and subsistence needs, will be maintained by the alternate power source. Observations of first floor unit, room [ROOM NUMBER], on January 21, 2025,…

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 Review of facility's police, clinical record review and interview with staff, it was determined that the facility failed to folow professional standards of quality related to ensuring that medications were given according to physician's instructions for one of 10 residents reviewed. (Resident R1) Findings include: Review of facility's policy on Administering Medications revealed that under section Policy Statement, medications administered or administered in the state and family matter and as prescribed under section Policy Interpretation and implementation #1. #2. The Director of Receiving Services supervises and directs all personnel who administer medications and or have related functions. #3 Staffing schedules are arranged to ensure that medications are administered without unnecessary interruption. #4 Medications are administered in accordance with the Prescribers Order, including any required time frame. #5 Medication administration times are determined by resident needs and benefits, not staff…

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 a police report and interview with staff, it was determined that the facility failed to report to the State Survey Agency an elopment incident for one of two residents reviewed. (Resident R1) Findings include: Review of Resident R1's clinical record revealed that the resident was admitted to the facility on [DATE] with the diagnoses of schizophrenia, (A mental disorder characterized by delusions, hallucinations, disorganized thoughts, speech and behavior), paranoid personality disorder (characterized by paranoia, mistrust and suspiciousness of others) and unspecified psychosis (a condition of the mind,where there is a loss of reality) not due to a substance or known physiological condition. Review of a police report received on July 29, 2024, revealed at 3:34 a.m. Resident R1 was observed sitting on the sidewalk at an intersection near the facility. Resident R1 told police she was from the facility. The police attempted to call the facility to confirm this but no one at the facility answered…

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 police file, review of clinical records, review of facility policy, review of Pennsylvania Code Title 49, Professional and Vocational Standards Department of State and staff interview, it was determined that the facility failed to ensure one of two residents (Resident R1) received care and services in accordance with professional standards related to assessing a resident after an elopment and notifying the resident's physician of the elopment. Findings include: Pennsylvania Code Title 49, Professional and Vocational Standards Department of State, Chapter 21 State Board of Nursing, Chapter 21.11 Functions of the RN (Registered Nurse) requires the following: The registered nurse assesses human responses and plans, implements and evaluates nursing care for individuals or families for whom the nurse is responsible. 21.18 A registered nurse shall undertake a specific practice only if the registered nurse has the necessary knowledge, preparation, experience and competency to properly execute the…

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

Based on review of clinical records, and interview with resident and staff, it was determined that facility failed to administer medications timely for one of two residents reviewed (Resident R1) Findings include: Review of facility policy Administering Medications, revised April 2019, revealed that medications are administered in accordance with prescriber orders, including any required time frame, and Medications are administered within one hour of their prescribed time, unless otherwise specified. During interview with Resident R1 on July 16, 2024 at 1:00 p.m., resident expressed concern regarding her medications not being administered timely. Resident R1 received her anti-anxiety medication Buspar up to two hours after scheduled time and her medication for non-small-cell lung carcinoma. Medication Osimertinib (Tagrisso) was also administered more than an hour after scheduled time. Per Resident R1's statement, resident becomes stressed when she does not receive her ant-anxiety medication on time and is concerned that stress is contributing to her already deteriorating…

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, review of facility policy, review of clinical record and staff interview, it was determined that the facility failed to ensure that resident's privacy regarding the public exhibition of photographs was protected for seven of eleven residents observed. (Residents R1, R2, R3, R4, R5, R6, and R7) Findings include: Review facility policy regarding confidentiality of information and personal privacy the most recent revision date of October 2017, reveal that under section Policy Statement: The facility will protect and safeguard resident confidentiality and personal privacy. Under section Policy Interpretation and Implementation: #1. The facility will safeguard the personal privacy and confidentiality of all resident personal and medical records. #7. Release of information including video, audio or computer stored information will be handled in accordance with resident rights and privacy policies. #8. Residents may initiate a request to release information contained in the record and charge to themselves or anyone they wish. Such requests will be honored only upon…

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 interviews, it was determined that the facility failed to ensure that snacks were served at safe and appetizing temperatures for residents on one of four nursing units observed. (First floor) Findings include: During observation on May 8, 2024 at 9:30 a.m. on the first floor nursing station desk that sits next to the facility's main entrance was, a brown tray with 4 vanilla flavored Mighty Shakes (nutritional shakes made from dairy products); 1 sandwich labeled PBJ (peanut butter and jelly), and 2nd sandwich labeled deli sandwich made with a lunch meat and a piece of lettuce on top of it. In addition, there were 4-4 ounce containers of magic cups (an ice cream-like frozen dessert with a pudding consistency when thawed that is oftentimes provided to individuals with difficulty swallowing and/or individuals who may need additional calories and protein due to weight loss), and a bag of animal crackers. The food and beverage items had a label that included the resident's name, along with May 8, 2024 and the time, 10:00 a.m. All items described above 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 observations of the food and nutrition department, reviews of policies and procedures and the loading and receiving area, it was determined that the facility was not disposing of garbage and refuse properly. Findings include: The undated facility policy titled waste disposal indicated that garbage was to be disposed of as needed throughout the day. The policy indicated that priroe to disposal all waste was to be kept in leak-proof, non-absorbant, fire proof covered containers. The policy also said that all trash bags were to be sealed prior to removing them from the facility and placing them into the dumpster unit, located on the premises, for pick-up by an outside trash removal company. The policy indicated that each container (dumpster unit) was to be cleaned as needed by the maintenance department. Observations of the outdoor loading and receiving dock with the registered dietitian, Employee E23 and director of dietary services, Employee E26 at 11:10 a.m., on May 7, 2024 revealed that the garbage and refuse containing was not in good condition. The container was leaking…

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

Based on review of facility documents and interviews with staff, it was determined that the facility failed to conduct a facility-wide assessment that included the facility's resident population, the care required by the resident population, staff competencies that are necessary to provide the level and types of care needed for the resident population, physical environment and equipment that are necessary to provide care required by the resident population, cultural factors, the facility's resources, equipment, services provided, all personnel including education, training and competency requirements, contracts with third parties and health information technology resources, as required. Findings include: Review of the facility assessment, dated April 8, 2024, revealed that the facility's census and acuity was listed, as well as general statements regarding the facility's religious denominations, recreation, social services and physical, occupational and speech therapy services. Continued review of the facility assessment revealed that there was no evidence of assessment of staff…

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 department, interviews with staff and reviews of the chemical manufacturers specifications, it was determined that the facility failed to ensure that essential mechanical dietary equipment was in safe operating condition. Findings include: Observations of the food service department at 11:00 a.m., on May 7, 2024 revealed that the plumbing inside the main kitchen was not functioning properly; since the essential dietary equipment (grease traps) located in the dish room were not fully functioning. The grease traps were not not filtering fat, grease, oil and solids during the dishwashing process. The grease traps were not allowing the disposal of the fat, oil, grease and solids in the collection tanks and receptacles. The floor draining inside the dish room area was spewing the unfiltered and not entrapped oil, grease, fat and solids onto the floor. Large volumes of rancid sewage and water were covering the floor in the main kitchen as the dietary staff were washing the dishes with the dish machine and three compartment sink. A rancid…

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 of the food and nutrition department and the first floor nursing unit, interviews with staff and reviews of the pest control operator's service reports, it was determined that the facility failed to maintain an effective pest control program. Findings include: Observations of the food and nutrition department on May 7 and May 8, 2024 revealed that the door sweep of the door leading directly onto the loading dock and outdoor delivery area was not sealed completely. There was a one inch gap located at the threshold of the door upon closing, allowing easy access to the building for common household pests and rodents. The dumpster unit stored at the facility's delivery and loading dock area contained a malordous leaking trash and refuse container. An infestation of household flies and other flying inserts were present at the loading dock area. The flying insect light used to zap and eliminate pests was not functioning. The dish room inside the food and nutrition department contained a grease,…

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 documentation and interviews with staff, it was determined that the facility failed to develop, implement, and maintain an effective training program, for five of five personnel files reviewed related to annual training records (Employees E34, E35, E36, E37 and E38). Findings include: Review of annual training records revealed the following: Employee E34 completed trainings related to: safe resident handling, hand hygiene, nail care, identification bracelets, customer service, personal protective equipment, antibiotic stewardship, range of motion, accidents/supervision, blood borne pathogens and environment. Employee E35 completed trainings related to: safe resident handling, hand hygiene, nail care, identification bracelets, customer service, personal protective equipment, antibiotic stewardship, range of motion, accidents/supervision, blood borne pathogens, environment, infection control linen handling and weights. Employee E36 completed trainings related to: safe resident handling, preventing workplace injuries, identification bracelets, antibiotic…

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, clinical record reviews and interviews with residents and staff, it was determined that the facility failed to develop and implement comprehensive person-centered care plans related to weight loss, discharge planning, foot care, pain management, wounds, anticoagulant medications and immunocompromised status for six of 29 residents reviewed (Residents R27, R38, R34, R108, R70 and R48). Findings include: Clinical record review revealed a comprehensive quarterly MDS (an assessment of care needs) dated April 8, 2024 for Resident R34 that revealed this resident was cognitively intact, had a diagnosis of a hip fracture, was 67 inches tall and was not on a physician-prescribed weight loss regimen. The resident's medication included diuretic therapy. Clinical record review for Resident R34 revealed that this resident experienced a significant weight loss over five months and three months. Resident R34's weights were recorded as follows: January, 2024 the weight was recorded at 264 pounds,…

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 policies, clinical record reviews and interviews with residents and staff, it was determined that the facility failed to clarify physician orders related to medications for six of 29 residents reviewed (Residents R63, R107, R105, R40, R107 and R117). Findings include: Review of the facility policy, Administering Medications, with a revised date of April 2019, indicated that medications are administered in accordance with prescribers orders, including any required time frame. The policy also indicated that if a dosage is believed to be inappropriate or excessive for a resident, or a medication has been identified as having potential adverse consequences for the resident or is suspected of being associated with adverse consequences, the person preparing or administering the medication will contact the prescriber, the resident's attending physician or the facility's medical director to discuss the concerns. Review of the facility policy also indicated that medications are administered in accordance with prescribers orders, including any…

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, clinical record reviews and interviews with residents and staff, it was determined that the facility failed to ensure that appropriate wound care was provided for two of three residents with wounds reviewed (Residents R12 and R70). Findings include: Interview on May 7, 2024, at 10:34 a.m. Resident R70 stated that he has a large wound on his leg and that staff were not consistently changing his dressings. Review of wound consultant notes for Resident R70 revealed a note, dated May 7, 2024, which indicated that the resident has wounds on his left distal shin, left dorsal (top) foot, right shin and left calf. The wound consultant recommended skin prep to the resident's left dorsal foot; calcium alginate with ABD pad and gauze roll dressings to the resident's left calf and left distal shin, and recommended calcium alginate with ABD pad to the resident's right shin. Review of Treatment Administration Records (TARs) for May 2024 for Resident R70 revealed that the following wound treatments were signed out as being administered: Collagen cream apply topically daily;…

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 and interviews with staff, it was determined that the facility failed to ensure that skills competencies reviews were completed for four of five newly hired employees reviewed (Employees E19, E20, E32 and E33). Findings include: Review of the facility's job description for nurse aides revealed that duties include: transporting residents, assisting residents with dental and mouth care, bathing, hair care, nail care, shaving, bed linens, bowel and bladder functions, giving enemas, collecting specimens, lifting, turning, moving, positioning, restorative and rehabilitative procedures, changing dressings, bandages and binders, weigh, measure and record temperature, pulse and respirations, provide indwelling catheter care, range of motion exercises, serve meals and assist with feeding. Review of the facility's job description for staff nurse revealed that duties include: provide direct care to residents as needed, administer medications, oxygen, perform wound care, foley catheter care and changes, feeding tube care, colostomy care, intravenous 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 personnel file and interviews with staff, it was determined that the facility failed to conduct performance evaluations as required for three of three nurse aides reviewed (Employees E34, E35 and E36). Findings include: Review of facility documentation, Employee Roster revealed that Employee E34 was hired by the facility as a nurse aide on June 15, 2021; Employee E35 was hired by the facility as a nurse aide on August 15, 2019; and Employee E36 was hired by the facility as a nurse aide on June 1, 1998. Review of personnel files and training records for Employees E34, E34 and E36 revealed that no documentation was available for review at the time of the survey of any annual performance evaluations. Interview on May 13, 2024, at 1:42 p.m. Employee E17, Human Resources, stated that the facility does performance reviews verbally and that there was nothing available in writing for review for Employees E34, E34 and E36. Employee E17, Human Resources, provided a blank job description for nurse aides and stated that this was the template that the facility would use 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 observations and interviews with residents, it was determined that the facility failed to ensure that residents dignity was maintained related to dining for one of three residents observed in the Main dining room (Residenr R98). Findings include: Observation, on May 7, 2024, at 12:24 p.m. revealed three residents sitting at a table in the Main dining room, including Residents R8 and R98 and a third resident who did not want to identify himself. Resident R8 and the unidentified resident were both eating their meals, consisting of a chicken breast, mashed potatoes and steamed vegetable blend. Resident R8 stated that the chicken was hard and difficult to eat. Resident R98 was upset because he was hungry, but had not been served yet. Continued observation, at 12:39 p.m. Resident R8 and the unidentified resident had both finished eating their meals. Resident R98 became increasing upset because he still had not been served his meal. Resident R8 called out loudly to staff, in attempt to assist Resident R98. A dietary staff person approached the table; Resident R98 stated that he…

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 and residents, it was determined that the facility did not ensure that a resident was allowed to participate in decisions regarding his care and treatment for one of 23 records reviewed (Resident R48). Findings include: Review of Resident R48's clinical record review revealed that Resident R48 was admitted to the facility on [DATE], with diagnoses of hidradenitis suppurativa (HS; a chronic skin condition in which lesions develop as a result of inflammation and infection of sweat glands; the pea- to marble-sized lumps under the skin can be painful and tend to enlarge and drain pus), generalized muscle weakness, and need for assistance with personal care. Review of clinical documentation revealed orders for care for his HS, which included the following: Chlorhexidine Gluconate External Liquid 4% .Apply to affected areas topically every day shift for skin cleanser to groin buttock perianal areas unsupervised self-administration .apply wash and rinse in shower…

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 interviews with residents and staff, it was determined that the facility failed to ensure that residents participated in their care planning process, including expected goals and outcomes of care, for one of two residents reviewed for care conferences (Resident R27). Findings include: Interview on May 7, 2024, at 11:09 a.m. Resident R27 stated that he was trying to leave the facility because he wanted to be closer to his family, but that there were no staff at the facility to assist him or get anything done. Resident R27 expressed that he was frustrated because he had been at the facility for over a year and missed his family. During a follow-up interview on May 8, 2024, at 11:39 a.m. Resident R27 stated that he wants to transfer to another nursing facility and provided the name of the facility that he wanted to go to. Review of Resident R27's Quarterly MDS (Minimum Data Set - a mandatory periodic resident assessment tool), dated February 12, 2024, revealed that 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and interview with staff and residents, it was determined that the facility did not ensure that a resident was appropriately assessed for ability to self-administer medications for one of residents reviewed for one of 23 records reviewed (Resident R48). Findings include: Resident R48 was admitted to the facility on [DATE], with diagnoses of hidradenitis suppurativa (HS; a chronic skin condition in which lesions develop as a result of inflammation and infection of sweat glands; the pea- to marble-sized lumps under the skin can be painful and tend to enlarge and drain pus), generalized muscle weakness, and need for assistance with personal care. Review of clinical documentation revealed orders for care for his HS, which included the following: Chlorhexidine Gluconate External Liquid 4% .Apply to affected areas topically every day shift for skin cleanser to groin buttock perianal areas unsupervised self-administration .apply wash and rinse in shower ordered on August 5, 2023.…

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 policies, clinical record reviews and interviews with residents and staff, it was determined that the facility failed to ensure that residents were offered the opportunity to formulate an advanced directive for one of 29 residents reviewed (Resident R268). Findings include: Review of facility policy, admission Assessment and Follow Up: Role of the Nurse dated revised September 2012, revealed, The purpose of this procedure is to gather information about the resident ' s physical, emotional, cognitive, and psychosocial condition upon admission for the purposes of managing the resident, initiating the care plan, and completing required assessment instruments. Continued review revealed, Determine if the resident has existing advance directives. If so, initiate the process of obtaining a copy for the medical record. If not, provide the resident with information on his/her rights to have advance directives and initiate the process of establishing them. Observation on May 7,…

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 and interviews with residents and staff, it was determined that the facility failed to maintain a safe, clean and homelike environment for three of four nursing units observed (1 Pavilion, 1 Main and 2 Main units). Findings include: Interview on May 7, 2024, at 10:34 a.m. Resident R108 stated that there was always trash under the beds and that the floor was always sticky in his room. Resident R70 stated that he was also worried about mice because the room was not kept clean. Resident R70 stated that he was blind and unable to clean or take out his trash. Observation, at the time of the interview, revealed that room [ROOM NUMBER] on the 1 Main unit was dirty, with trash under the beds, trash cans overflowing with garbage and sticky floors throughout the room. Observation on May 7, 2024, at 1:41 p.m. of room [ROOM NUMBER] on the 1 Main unit revealed that there were wires sticking out of the wall above the B bed. There was no light fixture above the bed and the wires were sticking out from…

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, it was determined that the faciltiy failed to document that a resident was provided with sufficient preparation for ensure an orderly and safe environememt for one of five closed records reviewed (Resident R115) Findings include: Review of Resident R115's clinical record revealed that this resident was discharged from the facility on February 15, 2024. The clinical record indicated that this resident was transferred to a veterans hospital located two hours away from the facility. There was no documented evidence to indicate that a safe and orderly discharge had transpired for Resident R115. There was no clinical record documentation to indicate what type of transportation the resident used to travel a distance of 100 miles to the transferring hospital destination. The was no clinical record documentation to indicate if the receiving facility received Resident R115, his medications and medical information for the continuum of health care for this resident. 28 Pa. Code 211.5( f)(iii)(vii)(xi) Medical records

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record reviews, interviews with staff and observations of residents, it was determined that for one of 23 residents reviewed, it was determined that the facility failed to conduct an accurate comprehensive assessment. (Resident R3) Findings include: Clinical record review revealed a quarterly assessment MDS ( a minimum data set, which was part of the U.S. federally mandated process for clinical assessment of all residents in Medicare or Medicaid-certified nursing homes) dated April 24, 2024 that indicated Resident R3 was receiving dialysis care while at the facility. Clinical record review for Resident R3 revealed that this resident did not have orders from the physician to receive dialysis care. There was no documentation available for review to indicate that Resident R3 was receiving dialysis care. Interview with the registered nurse, Employee E24, at 10:30 a.m., on May 13, 2024 confirmed that Resident R3 had diagnoses of hypertension, peripheral vascular disease, dementia with senile…

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, clinical record reviews and interviews with residents and staff, it was determined that the facility failed to develop a baseline care plan within 48 hours of admission that includes the instructions needed to provide effective and person-centered care, related to behaviors, elopement risk and mental health needs, for one of 29 residents reviewed (Resident R268). Findings include: Observation on May 7, 2024, at 1:41 p.m. revealed Resident R268 sitting on his bedside with his hands on his head. Resident R268 appeared visibly upset, tearful and shaking. Upon interview, Resident R268 stated that he was mentally ill then began crying and was unable to continue the interview. Continued observation, on May 8, 2024, at 11:29 a.m. revealed that Resident R268 was again sitting on his bedside. Resident R268 stated that he wasn't supposed to be at the facility, that the hospital lied and that he wanted to go home. Interview, at the time of the observation, Employee E30, nurse aide, revealed that she…

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 interviews with residents and staff, it was determined that the facility failed to implement an effective discharge planning process that focuses on the residents' goals for two of 29 residents reviewed (Residents R38 and R108). Findings include: Interview on May 7, 2024, at 11:09 a.m. Resident R38 stated that he was discharged from therapy a month ago, that he wanted to go home and that no one has assisted him with discharge planning. Review of Resident R38's admission MDS, dated [DATE], revealed that he was admitted to the facility on [DATE], and that he received physical and occupational therapies. Review of Resident R38's admission Social Services Assessment, dated March 13, 2024, revealed that the resident was admitted to the facility for short-term rehabilitation services and that the resident's overall goal was to discharge to the community. Review of Resident R38's care conference note, dated March 19, 2024, revealed that the resident's expectation was to return home…

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 interviews with staff, it was determined that the facility failed to ensure that discharge summaries provided all the necessary information, including a recapitulation of stay, a summary of the residents' status, medication reconciliation and a post-discharge plan of care, for one of five closed records reviewed (Resident R117). Findings include: Review of Resident R117's Annual MDS (Minimum Data Set - a mandatory periodic resident assessment tool), dated February 5, 2024, revealed that the resident was admitted to the facility on [DATE], and had diagnoses including diabetes (ability to produce or respond to the hormone insulin is impaired, resulting in abnormal metabolism of carbohydrates and elevated levels of glucose), renal failure (a condition in which the kidneys lose the ability to remove waste and balance fluids) and leg amputations. Review of Resident R117's care plan, dated initiated February 22, 2023, revealed that the resident has limited physical mobility related…

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

Based on observations, staff interviews, review of facility policy and the review of the clinical record, it was determined that the facility failed to ensure that residents were provided with appropriate care and services related to nail care for one out of 29 residents reviewed (Resident R63). Findings include: Review of the facility policy, Activities of Daily Living (ADL), Supporting, with a revision date of March 2018, indicated that residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. Review of the policy also indicated that appropriate care and services will be provided for residents who are unable to carry out ADLs such as bathing, toileting, grooming and oral care. Review of the May 2024 physician orders for Resident R63 included the following diagnoses: quadriplegia (a paralysis of all four limbs and the torso, usually caused by a spinal cord injury in the neck), paraplegia (paralysis of the legs and lower body, and the need for assistance with…

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

Based on clinical record review, review of facility policy and staff interviews, it was determined that the facility failed to ensure that weights, nutritional assessments and notification to the physician of a signifcant weight loss were completed in a timely manner for one of 23 clinical record reviewed. (Resident R69) Findings include: Review of the facility policy, Weight Assessment and Intervention, with a revision date of March 2022 indicated that residents are weighed upon admission and intervals established by the interdisciplinary team. The policy also indicated that any weight change of 5% or more since the last weight assessment is retaken the next day for confirmation and if verified, nursing will immediately notify the dietician in writing of the weight change. Review of Resident R69's clinical record revealed a nursing note date February 7, 2024, at 9:23 p.m. which noted that the resident was sent out to the hospital for a change in condition and was admitted with RSV (Respiratory syncytial virus-common respiratory virus that usually causes mild, cold-like symptoms)…

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 interviews with residents and staff, it was determined that the facility failed to ensure that pain management was provided that was consistent with professional standards of practice, for one of 29 residents reviewed (R108). Findings include: Review of facility policy, Administering Medications dated revised April 2019, revealed, Medications are administered with one (1) hour of their prescribed time. Interview on May 13, 2024, at 10:50 a.m. Resident R108 stated that his pain medications were recently changed, that he had not received them yet that morning and that he was in a lot of pain. Resident R108 was loud, irritable and yelling, I'm in so much pain right now. Review of Resident R108's admission MDS, dated [DATE], revealed that he was admitted to the facility on [DATE], with diagnoses including left toes amputation, sepsis (infection) and mood disorder. Review of progress notes for Resident R108 revealed a physician note, dated May 8, 2024, 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, clinical record reviews and interviews with residents and staff, it was determined that the facility failed to ensure that residents who display or are diagnosed with a mental disorder receive appropriate treatment and services for one of 29 residents reviewed (Resident R268). Findings include: Observation on May 7, 2024, at 1:41 p.m. revealed Resident R268 sitting on his bedside with his hands on his head. Resident R268 appeared visibly upset, tearful and shaking. Upon interview, Resident R268 stated that he was mentally ill then began crying and was unable to continue the interview. Continued observation, on May 8, 2024, at 11:29 a.m. revealed that Resident R268 was again sitting on his bedside. Resident R268 stated that he wasn't supposed to be at the facility, that the hospital lied and that he wanted to go home. Interview, at the time of the observation, Employee E30, nurse aide, revealed that she was assigned to provide one-to-one (1:1) supervision for Resident R268 due 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policies, clinical record reviews and interviews with staff, it was determined that the facility failed to ensure that medically-related social services were provided as required for two of 29 residents reviewed (Residents R27 and R268). Findings include: Review of facility policy, admission Assessment and Follow Up: Role of the Nurse dated revised September 2012, revealed, The purpose of this procedure is to gather information about the resident's physical, emotional, cognitive, and psychosocial condition upon admission for the purposes of managing the resident, initiating the care plan, and completing required assessment instruments. Continued review revealed, Notify other disciplines and departments of the resident's admission, including . Social Services. Interview on May 7, 2024, at 11:09 a.m. Resident R27 stated that he was trying to leave the facility because he wanted to be closer to his family, but that there were no staff at the facility to assist him or get anything done.…

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 staff interviews and the review of clinical records, it was determined that the facility failed to ensure that medications were obtained by pharmacy as ordered by the physician for two out of 29 residents reviewed (Resident R88 and R48). Findings include: Review of Resident R48's clinical record revealed that the resident was admitted to the facility on [DATE], with diagnoses of hidradenitis suppurativa (HS; a chronic skin condition in which lesions develop as a result of inflammation and infection of sweat glands; the pea- to marble-sized lumps under the skin can be painful and tend to enlarge and drain pus), generalized muscle weakness, and need for assistance with personal care. Review of clinical documentation revealed orders for care for his HS, which included the following: Chlorhexidine Gluconate External Liquid 4% .Apply to affected areas topically every day shift for skin cleanser to groin buttock perianal areas unsupervised self-administration .apply wash and rinse in shower, ordered on August…

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

Based on review of facility policies, clinical record reviews and interviews with staff, it was determined that the facility failed to ensure that drug regime reviews were reviewed by the physician in a timely manner as required for one of five residents reviewed (Residents R70). Findings include: Review of facility policy, Pharmacy Services - Role of the Consultant Pharmacist dated revised April 2019, revealed, The consultant pharmacist will provide specific activities related to medication regimen review including: a documented review of the medication regimen of each resident at least monthly, . providing the facility with written or electronic reports and recommendation related to all aspects of medication and pharmaceutical services review. Review of progress notes for Resident R70 revealed that the consultant pharmacist conducted a medication review on February 21, 2024, April 10, 2024, and May 6, 2024. Review of the consultant pharmacist's report to the physician, dated February 21, 2024, for Resident R70 revealed that the pharmacist requested that the physician review 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 observations and interviews with residents and staff, review of facility menus, resident council meeting minutes and policies and procedures, it was determined that the facility failed to ensure that menus were followed to meet the daily nutritional needs and preferences of the residents routinely and during an emergency. Findings include: Review of the facility policy titled emergency menu, dated 2029 it was indicated that it was the responsibility of the facility to have a seven day supply of foods and fluids inaccordance with an emergency menu planned by the registered dietitian for all therapeutic and regular diets. The policy also said that food and beverages was to be stored in an area not likely to be affected by an emergency in the building and also in an area separate from the regular menus. Interview on May 7, 2024, at 10:28 a.m. Resident R107 stated that the facility often serves bologna and cheese sandwiches for dinner and that the facility has not been serving foods as per the posted menus. Interview on May 7, 2024, at 10:34 a.m. Resident R108 stated 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of clinical records, facility documentation and interviews with residents and staff, it was determined that the Nursing Home Administrator and the Director of Nursing failed to effectively manage the facility related to failing to ensure that two of 23 residents reviewed were protected from sexual abuse, and a failure to appropriately investigate the abuse. This failure resulted in an Immediate Jeopardy situation. (Residents R5 and R36) Findings include: Review of the job description for the Nursing Home Administrator revealed, 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 long-term care facilities. To follow all facility policies and apply them uniformly to all employees. To ensure the highest degree of quality care is provided to our residents at all times. Review of the job description for the Director of Nursing revealed, To plan, organize, develop and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record reviews, interviews with staff and residents and reviews of policies and procedures, it was determined that the facility failed to ensure that professional services were furnished and arranged at an outside resource, in a timely manner, for one of 23 residents, to meet orthopedic needs. (Residents R34) Findings include: Review of the facility policy dated December, 2009 titled consults indicated that it was the responsibility of the facility to assure that specific services not furnished by the facility were provided to the residents in accordance with professional standards of practice were provided for the residents. The personal providing these services would be employed on a consulting basis. The policy said that written signed and dated agreements were maintained for each consultant. The agreement indicated that the consultant was responsible for providing written documents of the consultation visit for the facility. The consultation reports contained the recommendations by 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 clinical record reviews, interviews with staff and review of facility policy, it was determined that the facility failed to ensure complete and accurate documentation related to weight loss, tuberculosis screening, admission notes and diagnoses,vaping and safe smoking practices for four of 29 residents reviewed (Residents R34, R67, R48, R91, R115, and R268). Findings include: Review of the facility policy, Weight Assessment and Intervention, with a revision date of March 2022 indicated that residents are weighed upon admission and intervals established by the interdisciplinary team. The policy also indicated that any weight change of 5% or more since the last weight assessment is retaken the next day for confirmation and if verified, nursing will immediately notify the dietician in writing of the weight change. Clinical record review revealed that Resident R34 experienced a significant and continuous weight loss. Weights were recorded as January 8, 2024 a weight of 264 pounds, February 1, 2024 a weight…

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 policies and interviews with staff, it was determined that the facility failed to maintain proper infection control practices related to wound care for one of three residents reviewed for wounds (Resident R12). Findings include: Review of facility policy, Handwashing/Hand Hygiene dated revised August 2019, revealed that alcohol-based handrub or handwashing with soap and water shall be used: before handling clean or soiled dressings, gauze pads, etc.; before moving from a contaminated body site to a clean body site during resident care; after contact with blood or bodily fluids; after handling used dressings, contaminated equipment, etc.; after removing gloves. Review of wound consultant notes for Resident R12 revealed a note, dated May 2, 2024, which indicated that the resident has wounds on his right heel, right buttock, sacrum, right dorsal (top) foot, left dorsal foot and right ischium. The wound consultant recommended calcium alginate and foam silicone border dressings to the resident's right buttock, right ischium and sacral wounds. 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 staff, it was determined that the facility failed to maintain an environment free from hazards related to an unlocked syringe side box on the medication cart for one of two nursing units. (Pavilion 1) Findings include: On April 17, 2024, at 10:52 a.m. observations were made at the Pavilion 1's medication cart which was assigned to License nurse, Employee E4. This employee was also observed giving out medication and then left her cart. The medication cart syringe side box was observed left unlocked. On April 17, 2024, at 11:02 a.m. observation was made at the Pavilion 1's medication cart with the Director Of Nursing, Employee E2, who confirmed that the syringe side box was unlocked. Interview was held with the License nurse, Employee E4 on April 17, 2024, at 11:12 a.m. who reported that she did not check if the syringes side box if it was locked when she/he received the cart from the nurse that she/he was relieving. Interview was held with License nurse, Employee E3, on April 17, 2024, at 12:40 p.m. who also reported that she does not check…

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.