Greene Health & Rehab Center

Based on clinical record reviews and staff interviews, it was determined that the facility failed to follow recommendations from the optometrist for a follow-up appointment for one of 14 residents reviewed (Resident 5).Findings include:A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 5, dated December 31, 2025, revealed that the resident was cognitively intact and required maximum assistance for daily care needs.An optometry (a profession that specializes in caring for your eyes) consult for Resident 5, dated March 21, 2025, revealed that the resident presented for a diabetic eye exam and an evaluation of bilateral cataracts (a progressive eye condition that causes blurred vision) and recommended that the resident returned in six months for a follow up examination. There was no documented evidence that the optometrist recommendation for Resident 5 to return in six months was completed or that the resident's physician disagreed with the optometrist's plan of care.Interview with the Nursing Home Administrator…

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

Based on a review of facility policy and clinical records, observations, and staff interviews, it was determined that the facility failed to ensure that a device for fall prevention was in place as care planned for one of 14 residents reviewed (Resident 10).Findings include:The facility's policy regarding fall prevention and management, dated April 20, 2026, indicated if risks are identified, preventive measures will be put in place as care planned.A comprehensive Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 10, dated January 29, 2026, revealed that the resident had severe cognitive impairment, was sometimes understood, rarely/never understand, and had diagnoses that included dementia. Resident 10's care plan, dated March 5, 2026, indicated that the resident utilized a chair alarm while she is in her chair, and for staff to ensure the alarm is always working.Observations of Resident 10 on April 21, 2026, at 11:56 a.m. revealed that she was sitting in her Broda chair (specialized wheel chair) and that there was chair…

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

Based on review of facility policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that residents were provided with proper colostomy care for two of 14 residents reviewed (Residents 3, 10). Findings include:The facility's policy regarding colostomy care (care for an artificial opening in the bowel), dated April 20, 2026, indicated that when colostomy care was provided and the drainage bag was replaced, staff were to measure the stoma (surgically created opening that connects the intestines to the outside) size using the measuring guide and trace the pattern of the size of the opening on the wafer (adhesive component that attaches to the skin around the stoma) backing and cut the opening to size.A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 3, dated February 24, 2026, indicated that the resident was cognitively impaired, required assistance from staff for daily care needs, and had an ostomy (a surgically created opening in the…

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

Based on a review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that a resident's dignity was maintained for two of five residents reviewed (Resident 2 and 4). Findings include: The facility's policy regarding call lights, dated October 28, 2025, indicated that staff members who are alerted of an activated call light are responsible for responding promptly to promote a secure atmosphere for residents. A quarterly Minimum Data Set (MDS) assessment (a federally-mandated assessment of a resident's abilities and care needs) for Resident 2, dated January 9, 2025, revealed that the resident was alert and oriented, able to make his needs known, required assistance from staff for daily care needs including toileting, hygiene, and transfers and had medical diagnosis that included multiple sclerosis (disease affects the nerves in the brain and spinal cord). Interview with Resident 2 on February 28, 2023, at 1:56 p.m. revealed that he had to wait for an extended period of time for staff to respond to his call bell.…

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 records, and shower schedules, as well as staff interviews, it was determined that the facility failed to ensure that residents were provided with showers per their preferences and plan of care for one of five residents reviewed (Resident 5).Findings include: The facility policy for bathing and showering, dated October 28, 2025, indicated that residents will be bathed or showered according to their preferences in order to maintain healthy hygiene and skin conditions. The charge nurse will speak with the resident who refuses to ascertain why they are refusing and to determine if alternative arrangements that suit the resident can be made. If the resident continues to refuse the Charge nurse will document the resident's refusal in the medical record. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 5, dated December 4, 2025, revealed that the resident is cognitively impaired, required assistance from staff for daily care needs including bathing, and had diagnosis…

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, observations, and staff interviews, it was determined that the facility failed to ensure that medications were properly stored and labeled for two of five residents reviewed (Residents 1, 3). Findings include: The facility's policy for medication administration dated October 28, 2025, indicated that facility staff should not leave medications or chemicals unattended.A quarterly Minimum Data Set (MDS) for Resident 1, dated December 17, 2025, indicated that the resident was cognitively intact, requires assistance with daily care needs, and has diagnosis that included heart failure, anxiety, depression. Observation of Resident 1 on February 3, 2026, at 9:14 a.m. revealed that the resident was lying in her bed in her room. An unsupervised medicine cup with twelve unlabeled pills in it was sitting on her overbed table. An interview with Resident 1 at that time revealed that she did know the pills were on her table and that nurses will frequently leave her pills sitting there. An interview with Licensed Practical Nurse 1 on February 3, 2026, at 9:16…

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

Based on clinical record reviews and staff interviews, it was determined that the facility failed to notify the resident representative and ombudsman, in writing, regarding the reason for hospitalization, and failed to notify the resident about the facility's bed-hold policy at the time of transfer for three of 42 residents reviewed (Residents 2, 29, 105), and failed to provide a reconciliation of all pre-discharge medications with the resident's post-discharge medications for two of 42 residents reviewed (Resident 103 and 105).Findings include: A nursing note for Resident 2, dated January 30, 2025, at 12:21 a.m. revealed that the resident was transferred to the hospital for evaluation after a fall due to a radius (a bone in the lower arm) fracture. There was no documented evidence that a written notice of Resident 2's transfer to the hospital was provided to the emergency contact or the long-term ombudsman regarding the reason for transfer or was notified about the facility's bed-hold policy at the time of transfer. A nursing note for Resident 29, dated September 30, 2025, at 6:26…

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

Based on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to respond to a pharmacy recommendation for five of 42 residents reviewed (Residents 11, 29, 37, 57, 71).Findings include:A facility policy related to medication regimen review, March 26, 2025, revealed that when the pharmacist identifies a time-sensitive medication related concern the issue will be escalated to the medical director for immediate action by facility staff, and the Medication regimen review will be addressed by the attending physician in a timely manner. A Quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 11, dated September 4, 2025, revealed that the resident was cognitively impaired, required partial assistance for care from staff, and had diagnosis of hypertension (high blood pressure), coronary heart disease, and anemia (low iron levels). A pharmacy consultant note for Resident 11, dated August 15, 2025, revealed that the pharmacist recommended 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.

Based on review of clinical records, as well as staff interviews, it was determined that the facility failed to inform the resident or resident representative in advance of the risks and benefits of a psychotropic medication (medications that affect the persons mental state, emotions and behavior) and the treatment alternatives prior to initiating the administration of the medication for two of 42 residents reviewed (Residents 37 and 57).Findings include:A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 37, dated August 14, 2025, indicated the resident was cognitively intact, was understood, took antidepressant medications, and had diagnoses that included depression and anxiety.A nursing noted dated October 7, 2025, for Resident 37 indicated that she was evaluated by psychological consult because she reported feelings of anxiety, sadness, anger, and increased sleep disturbances. A psychological consult for Resident 37, dated October 7, 2025, indicated that the resident has gone three days without sleeping and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility documents and clinical records, as well as staff interviews, it was determined that the facility failed to accommodate the resident's needs by failing to provide a bariatric broda chair for one of 42 residents reviewed (Resident 96). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 96, dated September 17, 2025, indicated that the resident was cognitively intact, was not ambulatory and was dependent for mobility in a wheelchair, was dependent for transfers, and had a diagnosis of morbid obesity. Observations of Resident 96 on November 3, 2025, at 12:47 p.m. revealed the resident was lying in a bariatric bed. An interview with the resident at that time revealed that she wanted to get out of bed. She indicated that they did not have a chair big enough. She stated that she was able to get up before and now she does not because they said she was not safe in her chair. An occupational therapy…

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

Based on clinical record reviews and staff interviews, it was determined that the facility failed to provide the required notice to the resident or the resident's representative following the end of their Medicare coverage for two of 42 residents reviewed (Resident 40 and 106). Findings include:A Skilled Nursing Facility Beneficiary Protection Notification Review form, completed by the facility and dated October 15, 2025, revealed that Medicare coverage for Resident 40 started on September 27, 2025, and that her last covered day was October 10, 2025. The form indicated that the facility initiated discontinuation from Medicare Part A coverage, and that the resident's benefit days were not exhausted. The Advanced Beneficiary Notice of Non-coverage for Resident 40 was not issued.A Skilled Nursing Facility Beneficiary Protection Notification Review form, completed by the facility and dated June 6, 2025, revealed that Medicare coverage for Resident 106 started on June 2, 2025, and that her last covered day was June 6, 2025. The form indicated that the facility initiated discontinuation…

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, owners manual, as well as observations and staff interviews, it was determined that the facility failed to provide a clean and homelike environment in one of three pantries reviewed (300/400 hall pantry).Findings include:The facility's policy regarding homelike environment, dated July 22, 2025, indicated that the facility staff and management were to the extent possible, maintain a facility that reflected a personalized homelike setting including a clean and sanitary environment.Observations of the 300/400 hall pantry on November 3, 2025, at 1:39 p.m. revealed that there was a moderate to large amount of brownish/black removable substance on the inside ceiling of the cooking cavity of the microwave. In addition, there were three areas on the inside frame of the microwave that ranged from one half inch to six inches in length where the paint was worn off and metal was exposed. The [NAME] Beach microwave oven owners manual for Model No.P11O43ALH-WTB indicated that the…

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

Based on review of policies, clinical records, and investigation documents, as well as staff interviews, it was determined that the facility failed to ensure that residents were free from abuse or neglect for one of 42 residents reviewed (Resident 7). Findings include:The facility's abuse policy, dated July 22, 2025, indicated that it is the facility's policy to investigate all allegations, suspicions and incidents of abuse, neglect, involuntary seclusion, intimidation, exploitation of residents, misappropriation of resident property and injuries of an unknown source. An annual Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 8, dated August 7, 2025, revealed that the resident was severely cognitively impaired. Resident 7's care plan, dated August 6, 2025, indicated that the resident had an overall decline in status with activities of daily living related to deconditioning and weakness and will be monitored for signs and symptoms of skin and/or wound infections. Nurse Aide Documentation for October 11, 2025, revealed…

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

Based on review of policies, investigative reports, and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that allegations of possible abuse were reported timely to the Nursing Home Administrator for one of 42 residents reviewed (Resident 7).Findings include:The facility's abuse policy dated July 22, 2025 indicated that staff were to report all allegations of abuse, neglect, involuntary seclusion, injuries of unknown source, and misappropriation resident property must be reported immediately to their direct supervision, the resident's responsible party and attending physician, if appropriate, will be notified. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 7, dated September 17, 2024, revealed that the resident was cognitively impaired and was dependent on staff for all daily care needs. Nurse Aide documentation for Resident 7 dated October 11, 2025, revealed that she had a bruise of unknown origin on her right wrist and forearm. However, as of November 4,…

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

Based on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that a resident's care plan was updated/revised to reflect the resident's specific care needs for three of 42 residents reviewed (Residents 2, 7 and 68).Findings include: The facility's policy regarding care plans, dated July 22, 2025, indicated that a resident care plan conference is scheduled at least weekly to disucss each resident, review the previous care plan and to finalize the development of the current care plan. Adjustments are made by the interdisciplinary team to ensure that all programs and identified category of needs are addressed and that the plan is orientewd toward preventing a decline in functioning. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 2, dated October 9, 2025, revealed that the resident was cognitively impaired and was dependent on staff for care needs. Review of the care plan for Resident 2 dated December 12, 2024, indicated that the…

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

Based on clinical record review and interviews with staff, it was determined that the facility failed to complete ambulation and transfer programs as ordered for one of 42 residents reviewed (Resident 10).Findings include:A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 10, dated October 22, 2025, revealed that the resident was cognitively impaired and was dependent on staff for transfers and ambulation. Physician's orders for Resident 10, dated October 16, 2025, included orders for the resident to walk in the corridor for 50 feet with a rollator (a walker with wheels) and one assist twice a day, and to stand and pivot with one assist from bed to wheelchair twice a day up to 15 minutes. A restorative care plan, dated October 24, 2025, indicated that Resident 10 was to stand and pivot twice a day for 15 minutes each time and walk in the corridor 50 ft with the rollator and gait belt twice a day for 15 minutes. There was no documented evidence in Resident 10's clinical record to indicate that the resident was…

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

Based on review of facility policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that residents received proper care for indwelling urinary catheters for one of 42 residents reviewed who had an indwelling urinary catheter (Resident 100).Findings include:The facility's policy regarding indwelling urinary catheter (a flexible catheter used to drain urine from the bladder into a drainage collection bag) care procedure, dated July 22, 2025, indicated that the urinary drainage bag must be placed below the bladder level but not on the floor.An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 100, dated October 21, 2025, revealed that the resident was cognitively intact, had an indwelling urinary catheter, and had a diagnosis of obstructive uropathy (blockage of the urinary tract). A care plan for the resident, dated July 23, 2025, and revised October 28, 2025, revealed that the resident had an indwelling urinary catheter with an intervention…

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

Based on review of facility policies and clinical records, as well as resident and staff interviews, it was determined that the facility failed to ensure that residents were assessed and received trauma-informed care to eliminate or mitigate triggers for residents with the diagnosis of Post Traumatic Stress Disorder (PTSD - a mental and behavioral disorder that develops related to a terrifying event) for one of 42 residents reviewed (Resident 81).Findings include:The facility's policy related to social services, dated July 22, 2025, indicated that social services would assist in implementing interventions for resident ' s needs by developing and maintaining care plans which are individualized, realistic, with measurable goals, including but not limited to trauma/PTSD. Social Services is responsible for assessing and ensuring residents who are trauma survivors receive culturally competent, trauma-informed care/approaches including identifying triggers and implementing approaches/interventions to help reduce the risk of re-traumatization.An admission Minimum Data Set (MDS) assessment…

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

Based on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to maintain accountability for controlled medications (drugs with the potential to be abused) for two of 42 residents reviewed (Resident 37 and 73). Findings include:The facility's policy regarding medication administration, dated July 22, 2025, indicated that after medication administration, the facility staff should take all measures required by facility policy and applicable law, including but not limited to documenting necessary medication administration/treatment information (when the medication was given, prn/as needed medications) on appropriate forms. Document the administration of controlled substances in accordance with applicable law.A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 37, dated August 14, 2025, indicated the resident was cognitively intact, was understood, had pain, took opioid medications, and had diagnoses that included heart failure.Physician's orders…

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

Based on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that residents were free from unnecessary psychotropic medications (medications that affect the mind, emotions and behavior), by failing to ensure that non-pharmacological (non-medication) behavioral interventions (individualized, non-pharmacological approaches to care), were attempted prior to the administration of as needed antianxiety medications (psychotropic medication used to treat anxiety) for one of 42 residents reviewed (Resident 81).Findings include:The facility's policy regarding psychotropic gradual dose reduction, dated July 22, 2025, indicated that the facility will use psychotropic medications only when necessary and beneficial, ensuring appropriate use, evaluation and monitoring. A plan of care will be developed to include specific non-pharmacological interventions. The non-pharmacological interventions will also be placed on the Resident Care Card.An admission Minimum Data Set (MDS) assessment (a mandated assessment of a…

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

Based on review of policies, as well as observations and staff interviews, it was determined that the facility failed to ensure that medications were properly secured in the medication cart.Findings include:The facility's policy regarding medication administration, dated March 26, 2025, indicated that the purpose was to provide a method for the safe, accurate administration of oral medications to residents. Observations of the top drawer of the 300 hall medication cart on November 3, 2025, at 10:55 a.m. revealed an undated/unmarked medication cup that contained two white oval tablets, one oval yellow tablet, one oval beige tablet, one white pearl shaped capsule, one white oblong tablet and one white small round tablet.Interview with Registered Nurse 4 at that time, confirmed that an undated/unmarked medication cup that contained medications was in the top drawer of the 300 hall medication cart, and it should not have been.Interview with the Interim Director of Nursing on November 3, 2023, at 11:08 a.m. confirmed that an undated/unmarked medication cup that contained medications…

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

Based on a review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to maintain clinical records that were complete and accurately documented for two of 42 residents reviewed (Residents 37 and 73).Findings include:The facility's policy regarding medication administration, dated July 22, 2025, indicated that after medication administration, the facility staff should take all measures required by facility policy and applicable law, including but not limited to documenting necessary medication administration/treatment information (when the medication was given, prn/as needed medications) on appropriate forms. Document the administration of controlled substances in accordance with applicable law.A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 37, dated August 14, 2025, indicated the resident was cognitively intact, required assistance, was understood, had pain, took opioid medications, and had diagnoses that included heart failure.Physician'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 the facility's plans of correction for previous surveys, and the results of the current survey, it was determined that the facility's Quality Assurance Performance Improvement (QAPI) committee failed to correct quality deficiencies and ensure that plans to improve the delivery of care and services effectively addressed recurring deficiencies.Findings include:The facility's deficiencies and plans of corrections for State Survey and Certification (Department of Health) survey ending October 31, 2024, revealed that the facility developed plans of correction that included quality assurance systems to ensure that the facility maintained compliance with cited nursing home regulations. The results of the current survey, ending November 6, 2025, identified repeated deficiencies regarding maintaining a homelike environment, providing transfer notices and bed hold policies, care plan timing and revision, failure to provide proper catheter care, and the inability to ensure the proper storage of drugs and biologicals.The facility's plan of correction for a deficiency…

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

Based on review of policies and attendance records for the facility's Quality Assurance Committee, as well as staff interviews, it was determined that the facility failed to ensure that all required members of the Quality Assurance Committee attended quarterly meetings.Findings include:The facility's policy for Quality Assurance and Performance Improvement, dated March 12, 2025, revealed that meetings would be held at least quarterly and would include the Nursing Home Administrator, Director of Nursing, Medical Director, direct care staff, staff from ancillary departments and a designated Infection Preventionist.Review of the attendance records for the facility's Quality Assurance Committee meetings revealed that the Infection Preventionist did not attend any meetings that were held during the first and fourth quarters of 2024-2025.Interview with the Director of Nursing on November 5, 2025, at 11:30 a.m. confirmed that the Infection Preventionist did not attend meetings of the Quality Assurance Committee that were held during the first and fourth quarters of 2024-2025.28 Pa code…

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

Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to follow recommendations from a wound consultation for one of 14 residents reviewed (Resident 6).Findings include:The facility's pressure injury prevention and treatment policy, dated July 22, 2025, revealed that identified pressure injuries would be documented on and orders obtained from providers for treatment.An admission MDS for Resident 6, dated September 11, 2025, revealed that the resident was cognitively intact, required assistance for daily care needs, and was at risk for developing pressure ulcers. A care plan for Resident 6, dated September 15, 2025, revealed that the treatments to the sacral wound were to be applied per physician orders.A wound consultation for Resident 6, dated September 12, 2025, revealed that the resident had an unstageable pressure ulcer (non-stageable due to coverage of wound bed by slough and/or eschar) to her sacral area (lower tailbone) that measured 5.7 x 5.5 centimeters (cm). Physician's orders for Resident 6, dated…

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

Based on review of clinical records, observations, and staff interviews, it was determined that the facility failed to ensure that staff provided assistive devices to eat as ordered by the physician for one of 14 residents reviewed (Resident 12). Findings include: An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 12, dated September 4, 2025, indicated that the resident was cognitively intact, required set-up assistance from staff with eating, and had diagnoses that included hemiplegia and hemiparesis following cerebral infarction (paralysis or weakness to one side of the body due to brain injury). An occupational therapy note for Resident 12, dated September 19, 2025, indicated that the resident was to continue the use of a divided plate (plate that allows easier access to food) with dycem (a non-slip mat used to keep items in place) underneath and left angled black ridged non weighted utensils (designed to assist individuals with limited mobility, hand tremors, or dexterity issues). A dietary slip was…

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

Based on review of policies and observations, as well as staff interviews, it was determined that the facility failed to serve palatable food that was at appropriate temperatures. Findings include:The facility's policy regarding food temperatures, dated February 5, 2025, revealed that hot foods would be plated at 135 degrees Fahrenheit (F) when plated and should be palatable at the point of delivery. Cold foods were to be served at a temperature of 41 degrees F or below.Review of the posted menus for the lunch meal on Friday, September 5, 2025, revealed that residents were to receive potato encrusted fish, rice pilaf, creamy coleslaw, sliced carrots (alternative), a citrus banana cup, and milk.A test tray for the lunch meal on the 200 nursing unit on September 5, 2025, revealed that the cart left the kitchen at 12:26 p.m., arrived on the nursing unit at 12:27 p.m., and the last resident was served at 12:53 p.m. The test tray was tasted at 12:54 p.m. and the potato encrusted fish was 121.1 degrees F, the sliced carrots were 120.4 degrees F, the creamy coleslaw was 67.7 degrees F, the…

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

Based on review of policies, as well as observations and staff interviews, it was determined that the facility failed to store and prepare food under sanitary conditions.Findings include:The facility's policy for storage of refrigerated foods, dated February 5, 2025, revealed that refrigerated foods would be marked to indicate the date the food would be consumed or discarded.A deep cleaning calendar, dated August 2025, revealed that staff were to clean an area of the kitchen each day of the week. On Sundays the morning dietary aide was to clean the outside of the dish machine and wipe all walls around the machine; however there was no documented evidence that this was completed each Sunday during the month. There were only two days of the month that staff signed off on the calendar that the cleaning was completed.Observations in the main kitchen on September 5, 2025, at 8:50 a.m. revealed that in the walk-in refrigerator there were cartons of macaroni salad and potato salad, and a container of pasta salad that were not labeled or dated; the convection oven had a build up of food 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 Pennsylvania's Nursing Practice Act and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that a professional (registered) nurse assessed a resident after a change in condition for one of eight residents reviewed (Resident 4).Findings include:The Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.11 (a)(1)(2)(4) indicated that the registered nurse was to collect complete and ongoing data to determine nursing care needs, analyze the health status of individuals and compare the data with the norm when determining nursing care needs, and carry out nursing care actions that promote, maintain, and restore the well-being of individuals.The facility's Registered Nurse Charge Nurse job description, undated, revealed the primary purpose of the job was to assess resident's needs. An essential function of the position was to notify the physician, responsible parties, or other necessary parties with changes in condition.The facility's policy regarding pain management, dated July 22,…

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 records, and shower schedules, as well as staff interviews, it was determined that the facility failed to ensure that residents were provided with showers as scheduled for one of eight residents reviewed (Resident 5). Findings include: The facility policy for bathing and showering, dated July 22, 2025, indicated that residents will be bathed or showered according to their preferences. Each resident will be scheduled to receive bathing a minimum of two times per week unless they prefer less frequently. If the bath/shower cannot be given or the resident refuses, the nursing assistant will promptly report this to the charge nurse. The charge nurse will speak to the resident who refuses to ascertain why they are refusing and to determine if alternative arrangements that suit the resident can be made. If the resident continues to refuse, the charge nurse will document the resident's refusal in the medical record. An admission Minimum Data Set (MDS) assessment (a mandatory assessment of a resident's abilities and care needs) for Resident 5,…

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, as well as staff interviews, it was determined that the facility failed to follow physician's orders for one of eight residents reviewed (Resident 5).Findings include: An admission Minimum Data Set (MDS) assessment (a mandatory assessment of a resident's abilities and care needs) for Resident 5, dated July 7, 2025, revealed that the resident was cognitively impaired, required partial/moderate assistance with care needs, and received routine pain medication. Physician's orders for Resident 5, dated July 1, 2025, included an order for the resident to receive 500 milligrams (mg) of Naproxen (a non-steroidal anti-inflammatory pain medication) twice a day with meals. A review of Resident 5's Medication Administration Record (MAR) for August 2025 revealed no documented evidence that the resident received the Naproxen on August 6, 2025 at 6:00 p.m.; August 9, 2025 at 6:00 p.m.; August 21, 2025 at 9:00 a.m. and 6:00 p.m.; August 25 at 9:00 a.m. and 6:00 p.m.; and August 27 at 9:00 a.m. Interview with the Director of Nursing on September 5, 2025, at 5:23…

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

Based on review of facility policies, and residents' clinical records, as well as staff interviews, it was determined that the facility failed to provide pain management for one of eight residents reviewed (Resident 4).Findings include:The facility's policy regarding pain management, dated July 22, 2025, indicated that acute pain was usually a sudden onset and time-limited with a duration of less than one month, and often caused by injury, trauma, or medical treatments. A pain evaluation would occur with any onset of new pain. The physician or provider would be notified of a new onset of pain, or a significant increase in pain, as appropriateA quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 4, dated June 25, 2025, revealed that the resident was cognitively intact, was usually understood, and could usually understand, and required assistance from staff for daily care needs.Physician orders for Resident 4 dated November 20, 2024, included an order for her to receive 650 milligrams (mg) Pharbetol (Tylenol, an…

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

Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that care plans were updated to reflect changes in residents' care needs for one of eight residents reviewed (Resident 7). Findings include:The facility's policy regarding care plans, dated July 22, 2025, indicated that the facility will develop a comprehensive person-centered care plan for each resident. The care plan is reviewed on an ongoing basis and revised as indicated by the resident's needs, wishes, or a change in condition. At a minimum, this will occur with each comprehensive and quarterly assessment in accordance with the Resident Assessment Instrument (RAI - a standardized, comprehensive process used in nursing facilities to assess residents' needs and develop individualized care plans) requirements. A quarterly Minimum Data Set (MDS) assessment (a federally mandated assessment of a resident's abilities and care needs) for Resident 7, dated April 30, 2025, revealed that the resident was understood, could understand others, and had a…

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

Based on review of policies, clinical records, and investigation documents, as well as staff interviews, it was determined that the facility failed to ensure that residents were free from abuse for one of eight residents reviewed (Resident 6). Findings include: The facility's abuse policy, dated September 26, 2024, indicated that the facility would not tolerate abuse, neglect, mistreatment, exploitation of residents and misappropriation of resident property by anyone. Facility staff must immediately report all such allegations to the administrator/abuse coordinator. An investigation would begin immediately and all applicable local and state agencies would be notified in accordance with the procedures in this policy. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 6, dated December 12, 2024, revealed that the resident was understood and could usually understand others, was dependent on staff for transfers, had no behaviors, and had a diagnosis of dementia. A nursing note for Resident 6, dated March 12, 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.

Based on clinical record reviews, as well as staff interviews, it was determined that the facility failed to follow physician's orders for one of eight residents reviewed (Resident 2). Findings include: An admission Minimum Data Set (MDS) assessment (a mandatory assessment of a resident's abilities and care needs) for Resident 2, dated April 11, 2025, revealed that the resident was cognitively intact, needed assistance from staff for daily care needs, and had diagnoses that included paraplegia (no feeling below the abdomen), wound infection, and a Stage 4 pressure ulcer (wound that exposes bone, tendon or muscle). Physician's orders for Resident 2, dated April 5, 2025, included an order for the resident to receive 4.5 grams of Piperacillin-tazobactam (antibiotic) intravenously (IV-administered through the vein) every eight hours. A review of Resident 2's Medication Administration Record for April 2025 revealed no documented evidence that the resident received the Piperacillin-tazobactam per physician's orders on April 6, 2025, at 12:00 a.m., 8:00 a.m., and 4:00 p.m. A nursing note…

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

Based on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to maintain accountability for controlled medications (drugs with the potential to be abused) for three of five residents reviewed (Residents 3, 4, 5). Findings include: The facility's policy for medication administration, dated September 26, 2024, indicated to document the administration of controlled substances in accordance with applicable law and to document necessary medication administration/treatment information (e.g., when medications are given and as needed medications) on appropriate forms. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 3, dated February 4, 2025, revealed that the resident was cognitively intact, required assistance with care needs, had pain frequently rated a 10 of 10 on a pain scale of 0-10, was receiving an opioid (narcotic pain medication that can lead to addiction) for pain, and had diagnoses that included a fracture to the right lower leg.…

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

Based on a review of clinical records, as well as resident and staff interviews, it was determined that the facility failed to maintain clinical records that were complete and accurately documented for five of five residents reviewed (Residents 1, 2, 3, 4, 5). Findings include: The facility's policy for medication administration, dated September 26, 2024, indicated to document the administration of controlled substances (drugs with the potential to be abused) in accordance with applicable law and to document necessary medication administration/treatment information (e.g., when medications are given and as needed medications) on appropriate forms. An annual Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated April 9, 2025, revealed that the resident was cognitively intact, required assistance with care needs, was receiving a scheduled opioid (narcotic pain medication that can lead to addiction) for pain, and had diagnoses that included multiple sclerosis (MS-chronic disease that affects nerves in 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.

Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to notify the physician/provider regarding behaviors for one of seven residents reviewed (Resident 3). Findings include: The facility's policy regarding notification, dated September 26, 2024, indicated that any changes in a resident's condition would be reported to the physician/provider when necessary. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 3, dated February 12, 2025, indicated that the resident was severely cognitively impaired and required assistance from staff for daily care needs. The resident's care plan, dated January 20, 2025, indicated that a Gradual Dose Reduction (GDR) would be attempted unless clinically contraindicated. A nursing note for Resident 3, dated January 16, 2025, revealed that the resident was admitted from the hospital on this date. A nursing note for Resident 3, dated January 17, 2025, revealed that the resident was combative with staff and was refusing…

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

Based on clinical record reviews and staff interviews, it was determined that the facility failed to review and revise care plans for one of seven residents reviewed (Resident 3). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 3, dated February 12, 2025, indicated that the resident was severely cognitively impaired and required assistance from staff for daily care needs. The resident's care plan, dated January 20, 2025, indicated that the resident was to receive a psychiatric consult. A nursing note for Resident 3, dated January 16, 2025, revealed that the resident was admitted from the hospital on this date. A nursing note for Resident 3, dated January 17, 2025, revealed that the resident was combative with staff and refusing care and medications. A nursing note for Resident 3, dated January 27, 2025, revealed that the resident was verbally aggressive towards staff and yelling out for help. A nursing note for Resident 3, dated January 31, 2025, revealed that he continued to have…

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

Based on clinical record reviews and staff interviews, it was determined that the facility failed to monitor, assess and analyze, and attempt new interventions for a resident's increased verbal, physically-aggressive behaviors, and sexual behaviors for one of seven residents reviewed (Resident 3). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 3, dated February 12, 2025, indicated that the resident was severely cognitively impaired, required assistance from staff for daily care needs, and had physical and verbal behaviors towards others. A nursing note for Resident 3, dated January 16, 2025, revealed that the resident was admitted from the hospital on this date. A nursing note for Resident 3, dated January 17, 2025, revealed that the resident was combative with staff and refusing care and medications. A nursing note for Resident 3, dated January 27, 2025, revealed that the resident was verbally aggressive towards staff and yelling out for help. A nursing note for Resident 3, dated January…

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 records, and shower schedules, as well as staff interviews, it was determined that the facility failed to ensure that residents were provided with showers per their preferences and plan of care for three of seven residents reviewed (Residents 5, 6, 7). Findings include: The facility policy for bathing and showering, dated September 26, 2024, indicated that residents will be bathed or showered according to their preferences in order to maintain healthy hygiene and skin conditions. The charge nurse will speak with the resident who refuses to ascertain why they are refusing and to determine if alternative arrangements that suit the resident can be made. If the resident continues to refuse, the charge nurse will document the resident's refusal in the medical record. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 5, dated January 23, 2025, revealed that the resident was cognitively impaired, required assistance from staff for daily care needs including bathing, 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 clinical record reviews and staff interviews, it was determined that the facility failed to follow recommendations from a wound consultation for one of seven residents reviewed (Resident 6). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 6, dated December 17, 2024, revealed that the resident was cognitively intact, required substantial assistance with care needs including bathing and toileting hygiene, was incontinent of bowel and bladder, had an unstageable deep tissue injury (pressure injury that affects the underlying soft tissues and may not be visible until advanced), received pressure ulcer treatment, and had diagnoses including peripheral vascular disease (disease reducing blood flow to the legs) and diabetes. A wound consultation note for Resident 6, dated March 17, 2025, revealed that the resident had an unstageable pressure injury to his right heel measuring 1.4 centimeters (cm) length x 1.9 cm width with no measurable depth, with an area of 2.66 square cm. A subsequent…

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, as well as staff interviews, it was determined that the facility failed to follow physician's orders for one of five residents reviewed (Resident 1). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandatory assessment of a resident's abilities and care needs) for Resident 1, dated October 1, 2024, revealed that the resident was cognitively intact, was independent with personal care needs, and had a diagnosis of chronic kidney disease. Physician's orders for Resident 1, dated July 12, 2024, included for the resident to receive 10 milligrams (mg) of metoclopramide before meals three times a day. Review of mealtime deliveries provided by the facility revealed that 300 hall breakfast trays were delivered daily at 7:10 a.m. Observations of Resident 1 on December 17, 2024, at 8:40 a.m. revealed the resident lying in his bed with his eyes closed and a medicine cup with two white pills in it sitting unsupervised on his bedside table. There was no breakfast on his table. Interview with Licensed Practical Nurse 1 on December 17, 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 review of the Resident Assessment Instrument User's Manual and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that comprehensive admission Minimum Data Set assessments were completed in the required time frame for seven of 51 residents reviewed (Residents 48, 70, 98, 203, 204, 205, 206) and annual Minimum Data Set assessments were completed in the required timeframe for one of 51 residents reviewed (Resident 36). Findings include: The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which provides instructions and guidelines for completing required Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2023, indicated that an admission MDS assessment was to be completed no later than 14 days following admission (admission date + 13 calendar days), and that an annual comprehensive MDS assessment was to be completed no later than the assessment reference date (ARD -…

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

Based on review of the Resident Assessment Instrument Manual and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that quarterly Minimum Data Set assessments were completed within the required timeframe for four of 51 residents reviewed (Residents 27, 45, 55, 63). Findings include: The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which provides instructions and guidelines for completing Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2023, indicated that the assessment reference date (ARD - the last day of the assessment's look-back period) of a quarterly MDS assessment must be no more than 92 days after the ARD of the most recent assessment of any type, and the assessment was to be completed no later than the ARD plus 14 calendar days. A quarterly MDS assessment for Resident 27, with an ARD of May 4, 2024, was due to be completed by May 18, 2024, but was not signed as completed until August 7, 2024, which was 96 days from the ARD until…

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 the Resident Assessment Instrument User's Manual and clinical records, as well as staff interviews, it was determined that the facility failed to complete accurate Minimum Data Set assessments for seven of 51 residents reviewed (Residents 20, 22, 34, 38, 49, 87, 92). Findings include: The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which provides guidance and instructions for the completion of Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2023, indicated that Section N0415I1 was to be checked if the resident received an anti-platelet medication during the seven-day assessment period, Section N0415G1 was to be coded if the resident received a diuretic pill (a medication used to help remove extra fluid) during the seven day assessment period, and Section N0450D Antipsychotic Medication - physician documented gradual dose reduction (GDR) as clinically contraindicated was to be coded (0) no, if a GDR has not been documented by a physician as clinically contraindicated…

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

Based on clinical record reviews, observations, and staff interviews, it was determined that the facility failed to provide adequate ongoing activities designed to meet the needs of five of 51 residents reviewed (Residents 30, 53, 63, 67, 74) who had wandering behaviors and/or dementia, and resided on the facility's Memory Impaired Unit (secured unit). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 30, dated August 14, 2024, revealed that the resident was severely cognitively impaired, was rarely able to understand others, was sometimes understood by others, and had diagnoses that included dementia. The resident's care plan, dated February 27, 2024, revealed that the resident enjoyed socializing with other residents, was an elopement risk, and required a secure, locked unit for her safety. An annual MDS assessment for Resident 53, dated August 14, 2024, revealed that the resident was sometimes understood and could sometimes understand others, was severely cognitively impaired, had…

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

Based on clinical record reviews and observations, as well as resident and staff interviews, it was determined that the facility failed to ensure that drink preferences were honored for six of 51 residents reviewed (Residents 6, 23, 36, 75, 79, 96). Findings include: Interview with a group of residents on October 29, 2024, at 10:00 a.m. revealed that they wanted to have soda as a drink choice, either for meals or for a snack. They stated that they previously had soda available with their meals or with a snack, but that this is no longer the case. The residents stated that they were told that they could purchase their own soda from the activity room or the snack wagon located at the entrance to the facility. They could also have someone bring in soda for them, but it would no longer be supplied. Interview with the Dietary Manager on October 30, 2024, at 10:56 a.m. revealed that the facility has some soda (ginger ale) that is available if a resident is ill. However, she does not order any other soda for the residents on a regular basis. Interview with the Activities Manager on October…

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 residents' clinical records, as well as staff interviews, it was determined that the facility failed to ensure that each resident received pneumococcal immunizations for four of 51 residents reviewed (Residents 20, 42, 49, 55). Findings include: The facility's vaccination policy, dated September 26, 2024, indicated that residents and/or their responsible party would be asked about prior vaccinations at admission. Prior doses of influenza, pneumococcal, COVID-19, and other vaccines would be documented in the immunization portal in the electronic health record. A quarterly Minimum Data Set (MDS) assessments (a mandated assessment of a resident's abilities and care needs) for Resident 20, dated September 4, 2024, revealed that the resident was admitted to the facility on [DATE]. The sections of the MDS assessment related to the resident's pneumococcal vaccination revealed that the resident's pneumococcal vaccination was not up to date and was not offered. There was no documented evidence that the…

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

Based on review of policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to determine if residents were safe to self-administer medications for one of 51 residents reviewed (Resident 107). Findings include: The facility's self administration of medications policy, dated September 26, 2024, indicated that the interdisciplinary team would assess and determine, with respect to each resident, whether self administration of medications was safe and clinically appropriate based on the resident's functionality and health condition. A nursing note, dated October 9, 2024, at 4:01 p.m. revealed that Resident 107 was alert and oriented, and admitted to the facility on this day. Physician's orders for Resident 107, dated October 22, 2024, included orders for the resident to receive 6.25 milligrams (mg) of Carvedilol (used to treat high blood pressure) twice a day, 550 mg of Xifaxan (antibiotic) twice a day, and 30 milliliters (mL) of Lactulose (used to treat constipation) twice a day. Observations during a tour of the facility 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 review of policies, as well as observations and staff interviews, it was determined that the facility failed to ensure that residents' wheelchairs were clean for one of 51 residents reviewed (Resident 30), and failed to provide a clean and homelike environment in residents' rooms for one of 51 residents reviewed (Resident 31). Findings included: The facility's policy titled General/Routine Environmental Cleaning and Disinfection, dated September 26, 2024, revealed that the policy objective was to provide a safe, clean environment and equipment for residents. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 30, dated August 14, 2024, revealed that the resident was severely cognitively impaired, required assistance with most daily care needs, and had diagnoses that included dementia and hypertension. Observation of Resident 30 lying on the bed in her room on October 28, 2024, at 11:15 p.m. with her wheelchair beside the bed revealed that there was a heavy accumulation of removable dust/debris on 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 clinical record reviews and staff interviews, it was determined that the facility failed to notify the resident and legal guardian in writing regarding the reason for hospitalization for two of 51 residents reviewed (Residents 22, 32). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 22, dated August 19, 2024, revealed that the resident was cognitively impaired, required assistance with daily care needs, and had diagnosis that included atherosclerosis (thickening or hardening of the arteries). A nursing note for Resident 22, dated August 6, 2024, at 2:03 a.m., revealed that the resident was observed on the floor, could not move her leg, and had severe pain in her left hip. The resident was transferred to the emergency room for evaluation. A nursing note for Resident 22, dated August 6, 2024, at 6:10 a.m., reveled that the resident was admitted to the hospital with a left femur fracture. There was no documented evidence that a written notice of Resident 22's transfer to the hospital…

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

Based on review of the Resident Assessment Instrument User's Manual and clinical records, as well as staff interviews, it was determined that the facility failed to complete a significant change Minimum Data Set assessment for one of 51 residents reviewed (Resident 22). Findings include: Review of the Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which provides guidance and instructions for the completion of Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs) revealed that the facility must conduct a comprehensive assessment of a resident within 14 days after the facility determines, or should have determined that there has been a significant change in the resident's physical or mental condition. The RAI Manual revealed that staff should complete a significant change MDS when a resident has a decline that will not normally resolve itself without interventions by staff, impacts more than one area of the resident's health status, and requires interdisciplinary review and/or revision of the resident's 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 policies, clinical records, and information submitted by the facility, as well as staff interviews, it was determined that the facility failed to review and revise care plans to reflect changes in residents' care needs for two of 51 residents reviewed (Residents 5, 31). Findings include: The facility's policy regarding care plans, dated September 26, 2024, revealed that an interdisciplinary plan of care will be established for every resident and updated in accordance with state and federal regulatory requirements and on an as needed basis. The comprehensive care plan is reviewed and updated at least every 90 days by the interdisciplinary team. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's care needs and abilities) for Resident 5, dated August 15, 2024, indicated that the resident was cognitively impaired, was dependent on staff for daily care needs, and had diagnoses that included dementia. Physician's orders for Resident 5, dated July 29, 2024, included for the resident to receive 5 milligrams (mg) of Zyprexa (antipsychotic…

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

Based on clinical record reviews and staff interviews, it was determined that the facility failed to ensure that a discharge summary, including a recapitulation of the resident's stay, was completed for one of three discharged residents reviewed (Resident 102). Findings include: A nursing note for Resident 102, dated September 11, 2024, at 9:28 a.m. revealed that the resident was discharged from the hospital directly to home. As of October 31, 2024, there was no documented evidence that a discharge summary that included a recapitulation of the resident's stay was completed for Resident 102. Interview with the Assistant Director of Nursing on October 31, 2024, at 2:51 p.m. confirmed that there was no documented evidence that a discharge summary was completed for Resident 102. 28 Pa. Code 211.5(d) Clinical Records.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that assistance devices to prevent accidents or injury were in place for two of 51 residents reviewed (Residents 22, 74) Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 22, dated August 19, 2024, revealed that the resident was cognitively impaired, required assistance with daily care needs, and had diagnosis that included atherosclerosis (thickening or hardening of the arteries). The resident's care plan, dated August 8, 2023, indicated that the resident was at risk for falling and was to have a bolster overlay (a mattress cover with foam bolsters around the edge of the bed to help prevent residents from falling out) on her mattress. An intervention that was added on September 10, 2024, indicated that the resident was to have a reacher (device that enables a person to pick up objects…

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

Based on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to obtain physician's orders for the size of indwelling urinary catheters for one of of 51 residents reviewed (Resident 42). Findings include: The facility's policy regarding urinary catheters, dated September 26, 2024, revealed that staff would catheterize the resident per the provider's order. An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's care needs and abilities) for Resident 42, dated October 8, 2024, revealed that the resident was understood and could understand, required staff assistance for care, had pressure ulcers, and had an indwelling urinary catheter (a tube inserted and held in the bladder to drain urine). A care plan, dated October 28, 2024, indicated that the resident was to have an indwelling urinary catheter per orders. A nursing note for resident 42, dated September 25, 2024, at 3:18 p.m., revealed that a urinary catheter was placed per orders. Physician's orders for Resident 42, dated October 2,…

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

Based on review of clinical records, as well as staff interviews, it was determined that the facility failed to ensure that residents were free from unnecessary drugs for one of 51 residents reviewed (Resident 34). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 34, dated August 7, 2024, revealed that the resident was cognitively intact, required assistance from staff for daily care needs, and had diagnoses that included diabetes. A nurse's note for Resident 34, dated October 10, 2024, at 10:56 a.m., revealed that the resident was seen by the Certified Registered Nurse Practitioner for shortness of breath and congestion and was to be administered azithromycin for five days, two 10 mg tablets of prednisone for three days, then one 10 mg tablet of prednisone for three days. Physician's orders for Resident 34, dated October 10, 2024, included orders for the resident to receive two 250 milligram (mg) tablets of azithromycin one time on October 10, 2024, then one 250 mg tablet of azithromycin 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 review of clinical records and staff interviews, it was determined that the facility failed to provide medication as ordered by the physician, resulting in significant medication errors for one of 51 residents reviewed (Resident 34). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 34, dated August 7, 2024, revealed that the resident was cognitively intact, required assistance from staff for daily care needs, and had diagnoses that included diabetes. Physician's orders for Resident 34, dated October 4, 2024, included an order for the resident to receive 10 units of insulin lispro (used to lower blood sugar levels) twice a day, to be held for a blood sugar less than 100 milligrams/deciliter (mg/dL). A review of the Medication Administration Record (MAR) for Resident 35, dated October 2024, revealed that on October 7 at 8:00 a.m. the resident's blood sugar was 95 mg/dL and 10 units of insulin lispro was administered; on October 9 at 8:00 a.m. the resident's blood sugar was 82 mg/dL…

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

Based on review of policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that medications were properly stored and labeled for one of 51 residents reviewed (Resident 107). Findings include: The facility's medication administration policy, dated September 26, 2024, indicated that facility staff were not to leave medications or chemicals unattended. A nursing note, dated October 9, 2024, at 4:01 p.m. revealed that Resident 107 was alert and oriented, and admitted to the facility on that day. Physician's orders for Resident 107, dated October 22, 2024, included orders for the resident to receive 6.25 milligrams (mg) of Carvedilol (used to treat high blood pressure) twice a day, 550 mg of Xifaxan (antibiotic) twice a day, and 30 milliliters (mL) of lactulose (used to treat constipation) twice a day Observations during a tour of the facility on October 28, 2024, at 11:31 a.m. revealed that a plastic cup containing two white pills and a plastic cup containing 30 mL of a green liquid were sitting on 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.

Based on clinical record reviews and staff interviews, it was determined that the facility failed to obtain a physician's order for an invasive procedure to collect a specimen for a laboratory test for one of 51 residents reviewed (Resident 8). Findings include: An annual Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 8, dated July 10, 2024, revealed that the resident was rarely/never understood, could rarely/never understand others, was always incontinent (lack of voluntary control) of urine, and had diagnoses that included dementia. Physician's orders for Resident 8, dated October 7, 2024, included an order for staff to obtain a urine culture and sensitivity (C&S - to test for specific bacteria) after the completion of her antibiotics. A nursing note for Resident 8, dated October 10, 2024, revealed that a urine sample was collected via straight catheterization (insertion of a plastic tube into the bladder to obtain urine) and labeled and placed into the specimen refrigerator. The Registered Nurse Supervisor was made…

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

Based on review of policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that proper infection control practices were followed during medication administration for one of 51 residents reviewed (Resident 77). Findings include: The facility's policy regarding medication administration, dated September 26, 2024, indicated that staff were to avoid touching the medication with their bare hands when opening a bottle or unit dose package. Observations during medication administration on October 31, 2024, at 8:23 a.m. revealed that Licensed Practical Nurse 9 was preparing medications to administer to Resident 77 when she knocked over the medication cup and two pink pills landed on the medication cart. With her bare hands, the nurse picked up the pills and placed them into a plastic medication cup, entered the resident's room, and the resident took the medications by mouth. Interview with Licensed Practical Nurse 9 on October 31, 2024, at 8:45 a.m. confirmed that she should not have touched the pills with her bare…

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

Based on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to maintain accountability for controlled medications (drugs with the potential to be abused) for two of 13 residents reviewed (Residents 11, 13). Findings include: The facility's policy for medication administration, dated August 29, 2023, revealed that facility staff should take all measures required by facility policy and applicable law, including documenting necessary medication information on appropriate forms. Each dose of a medication shall be initialed on the Medication Administration Record (MAR). A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 11, dated August 31, 2024, revealed that the resident was cognitively intact, required assistance with personal care needs, and had diagnoses that included chronic pain syndrome and chronic obstructive pulmonary disease (lung disease). Physician's orders for Resident 11, dated July 1, 2024, included an order for the resident 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 observations and staff interviews, it was determined that the facility failed to ensure that dishes used for residents' meals were dried in a sanitary method after manual dishwashing. Findings include: Observations in the main kitchen area on September 26, 2024, at 9:14 a.m. revealed staff removing dishes from the sanitization solution and placing them on a rack to dry. An industrial fan was blowing on the dishes as they sat in the rack. Observations of that fan revealed an accumulation of dirt or dust on the air intake side of the fan. The grate at the front of the fan, where the air blew out, had dirt and dust on it. Dust could also be seen in the interior walls of the fan when looking inside it. Interview with the certified Dietary Manager on September 26, 2024, at 9:25 a.m. confirmed that the fan blowing on the dishes had an accumulation of dirt or dust on it and should not have been used to blow air on the clean dishes. Interview with the Maintenance Director on September 26, 2024, at 11:33 a.m. confirmed that the fan that was blowing on the dishes in the kitchen had…

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

Based on review of policies, clinical records, and grievance/complaint investigation documents, as well as staff interviews, it was determined that the facility failed to ensure that residents were free from abuse for one of four residents reviewed (Resident 1). Findings include: The facility's policy regarding abuse, dated August 29, 2023, indicated that the facility would not tolerate abuse, neglect, mistreatment, exploitation of residents, and misappropriation of resident property. The facility would investigate all alleged, suspicions, and incidents of abuse, neglect, involuntary seclusion, intimidation, exploitation of residents, misappropriation of resident property, and injuries of unknown source. Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Mental abuse includes, but is not…

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

Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to thoroughly investigate potential abuse for one of four residents reviewed (Resident 1). Findings include: The facility's policy regarding abuse, dated August 29, 2023, indicated that the facility would not tolerate abuse, neglect, mistreatment, exploitation of residents, and misappropriation of resident property. The facility would investigate all alleged, suspicions, and incidents of abuse, neglect, involuntary seclusion, intimidation, exploitation of residents, misappropriation of resident property, and injuries of unknown source. Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Mental abuse includes, but is not limited to, humiliation, harassment, and threats of…

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

Based on review of clinical records, as well as staff interviews, it was determined that the facility failed to ensure that the resident and/or the responsible party was notified about the facility's bed-hold policy upon transfer to the hospital for one of 39 residents reviewed (Resident 81). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 81, dated November 3, 2023, revealed that the resident was cognitively intact, required set up and supervision with daily care needs, and had diagnoses that included acute cholecystitis (inflammation of the gallbladder) and clostridium difficile infection (infection of the colon). A progress note for Resident 81, dated October 11, 2023, revealed that the resident was sent to the hospital on September 29, 2023, with vomiting and was admitted with a diagnosis of acute cholecystitis and had a cholecystostomy tube placed (to allow for drainage from the gallbladder). There was no documented evidence that the resident and/or the responsible party was notified…

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

Based on review of policies and clinical records, observations, and staff interviews, it was determined that the facility failed to ensure that care plans were updated to reflect changes in resident's care needs for three of 39 residents reviewed (Residents 34, 54, 81). Findings include: The facility's policy for care planning, dated August 29, 2023, indicated that the care planning coordinator will add minor changes in the resident's status to the existing care plans on a daily basis. An annual Minimum Data Set (MDS) assessment (a federally-mandated assessment of a resident's abilities and care needs) for Resident 34, dated September 5, 2023, revealed that the resident was cognitively intact, required extensive assistance from staff with her daily care needs, was not ambulatory, and was dependent for transfers with the use of a full-body lift. The resident's care plan, edited on November 29, 2023, revealed that the resident was ordered oxygen and an anticoagulant (blood thinning medication) for short-term use. A review of Resident 34's Medication Administration Record (MAR), dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policies, clinical records, and shower schedules, as well as staff interviews, it was determined that the facility failed to ensure that residents were provided with showers as scheduled for two of 39 residents reviewed (Residents 15, 83). Findings include: The facility policy for bathing and showering, dated August 28, 2023, indicated that every resident will be asked about his/her bathing preferences upon admission. Each resident will be scheduled to receive bathing a minimum of two days per week unless they prefer less frequent baths. When the bath or shower is complete, the nursing assistant will document the activity on the shower sheet or in the point-of-care section of the electronic record. The charge nurse will speak to the resident who refuses to ascertain why they are refusing and to determine if alternative arrangements that would suit the resident could be made. If the resident continues to refuse, the charge nurse will document the resident's refusal in the medical…

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

Based on review of clinical records, as well as staff interviews, it was determined that the facility failed to ensure that physician's orders for medications were followed for one of 39 residents reviewed (Resident 29). Findings include: The facility's policy regarding medication administration, dated August 29, 2023, revealed that medications shall be administered in a safe and timely manner, and as prescribed. Vital signs must be checked/verified for each resident prior to administering medications. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 29 dated November 27, 2023, revealed that the resident was cognitively impaired, requires assistance for daily care needs, and had diagnoses that included high blood pressure. Physician's order for Resident 29, dated November 22, 2023, included an order for the resident to receive 25 milligrams of Metoprolol (a medication for high blood pressure) two times a day and to hold medication if blood pressure systolic is less than 110 mmHg and diastolic is less than 60…

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

Based on clinical record reviews, observations, and staff interviews, it was determined that the facility failed to complete safety assessments for five of 39 residents reviewed (Residents 3, 15, 34, 40, 67) who used an air mattress, and failed to implement new interventions for fall/injury prevention for one of 39 residents reviewed (Resident 49). Findings include: The facility's policy for bed identification and safety inspection, dated August 29, 2023, indicated that beds, rails and mattresses (including air mattresses) will be inspected for safe operation and any potential adverse events and are to be completed annually and as needed. An annual Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 3, dated October 31, 2023, revealed that the resident was cognitively impaired, required substantial to total assistance from staff for his daily care needs, was at risk for developing a pressure ulcer, and had diagnoses that included dementia and diabetes. Physician's orders, dated June 28, 2023, included an order for the…

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

Based on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that residents maintained acceptable parameters of nutritional status, by failing to ensure timely intervention for weight loss and failing to notify the responsible party of weight loss for one of 39 residents reviewed (Resident 77). Findings include: The facility's policy for weights, dated August 29, 2023, indicated that any resident with a new significant weight change of five percent or more in one month, seven and a half percent or more in three months, or ten percent or more in six months would be weighed weekly until stable or unless the provider orders otherwise. All significant weight changes must be communicated to the resident, if appropriate, the attending physician and responsible party. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 77, dated November 14, 2023, revealed that the resident was cognitively impaired, required moderate assistance for personal…

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

Based on review of personnel files, as well as staff interviews, it was determined that the facility failed to ensure that nurse aide performance evaluations were completed annually based on hire dates for four of five nurse aides reviewed (Nurse Aides 1, 2, 3, 4). Findings include: A list of nurse aides provided by the facility revealed that based on their months and days of hire, annual performance evaluations for Nurse Aides 1, 2, 3 and 4 were due between April 18 and August 2, 2023. As of December 14, 2023, there was no documented evidence that annual performance evaluations were completed as required for Nurse Aides 1, 2, 3 and 4. Interview with the Director of Nursing on December 14, 2023, at 9:07 a.m. confirmed that she did not have performance reviews for the staff. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(1)(3)(e)(1) Management. 28 Pa. Code 201.20(a)(c) Staff development.

Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to maintain accountability for controlled medications (drugs with the potential to be abused) for one of 39 residents reviewed (Resident 53). Findings include: The facility's policy regarding the administration of oral medications, dated August 29, 2023, indicated that the nurse will document on the Medication Administration Record (MAR) with their initials at the appropriate date and time for the medication administered after witnessing the ingestion of the medication. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 53, dated November 1, 2023, revealed that the resident was cognitively intact, required assistance from staff for daily care needs, and had diagnoses that included heart failure, high blood pressure, and chronic pain syndrome. Physician's orders for Resident 53, dated August 21, 2023, included an order for the resident to receive 5-325 milligrams (mg) of Hydrocodone (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 facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to respond timely to a pharmacy recommendation for two of 39 residents reviewed (Residents 16, 49), and failed to ensure that the pharmacist completed monthly medication regimen reviews for one of 39 residents reviewed (Resident 83). Findings include: The facility's policy for medication regimen reviews (MRR), dated August 29, 2023, revealed that the facility should encourage the physician who is receiving a MRR and the Director of Nursing (DON) to act upon the recommendations contained in the MRR, and that the attending physician should document in the resident's health record that the identified irregularity has been reviewed and what, if any, action has been taken to address it. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 16, dated November 14, 2023, revealed that the resident was cognitively…

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

Based on review of policies, as well as observations and staff interviews, it was determined that the facility failed to store food in accordance with professional standards of food service safety, by failing to properly date frozen foods. Findings include: The facility's policy regarding food storage, dated August 29, 2023, revealed that all foods stored in the freezer should have a use by date once the food is opened. Observations in the walk-in freezer on December 11, 2023, at 10:00 a.m. revealed that there were opened bags of sliced garlic bread and omelets that were not labeled with a use by date. Observations in the kitchen's free-standing freezer on December 11, 2023, at 10:07 a.m. revealed that there was an opened bag of hamburger patties and an opened bag of veggie burgers that were not labeled with a use by date. Interview with the Dietary Manager on December 11, 2023, at 10:30 a.m. confirmed that all food in the freezers should be labeled with a use by date when they are opened and that the garlic bread, omelets, hamburger patties, and veggie burgers were not. 28 Pa. Code…

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

Based on review of the facility's plans of correction for previous surveys, and the results of the current survey, it was determined that the facility's Quality Assurance Performance Improvement (QAPI) committee failed to correct quality deficiencies and ensure that plans to improve the delivery of care and services effectively addressed recurring deficiencies. Findings include: The facility's deficiencies and plans of correction for State Survey and Certification (Department of Health) surveys ending January 26, 2023, and September 14, 2023, revealed that the facility developed plans of correction that included quality assurance systems with audits to ensure that the facility maintained compliance with cited nursing home regulations. The results of the audits were to be reported to the QAPI committee for review. The results of the current survey, ending December 14, 2023, identified repeated deficiencies regarding care plan timing and revision, quality of care, accident hazards, nutrition/hydration maintenance, pharmacy services and food procurement, storing, preparing and serving…

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, as well as staff interviews, it was determined that the facility failed to ensure that the resident's physician was notified timely about the unavailability of a medication for four of six residents reviewed (Residents 1, 3, 4, 6). This deficiency was cited as past non-compliance. Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated August 9, 2023, revealed that the resident was cognitively intact, required limited assistance from staff for personal care needs, and had diagnosis that included kidney disease. Physician's orders for Resident 1, dated July 3, 2023, included for the resident to receive 81 milligrams (mg) of aspirin daily. Review of the Medication Administration Record (MAR) for Resident 1, dated July 2023, revealed that 81 mg of aspirin was not available for administration on July 4 and July 5. There was no documented evidence that the physician was notified regarding the aspirin being unavailable on these dates. A quarterly MDS 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 clinical records, as well as staff interviews, it was determined that the facility failed to ensure that physician's orders for medications were followed for one of six residents reviewed (Residents 4). This deficiency was cited as past non-compliance. Findings include: A Quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 4, dated August 9, 2023, revealed that the resident was understood, could understand, required extensive assistance from staff for his daily care tasks, and had a diagnosis of diabetes. Physician's orders for Resident 4, dated June 28, 2023, included an order for the resident to receive 20 units of Levemir (a long-acting Insulin) at bedtime. Review of the Medication Administration Records (MAR) for Resident 4, dated July 2023, revealed no documented evidence that the resident received 20 units of Levemir at bedtime on July 9 and 11, 2023. Interview with the Assistant Director of Nursing on September 14, 2023, at 1:22 p.m. confirmed that there was no documented evidence 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 clinical record reviews and staff interviews, it was determined that the facility failed to ensure that residents' clinical records were complete and accurately documented for one of six residents reviewed (Resident 6). This was cited as past non-compliance. Findings include: Physician's orders for Resident 6, dated July 28, 2023, included an order for the resident to receive four drops of Debrox 6.5 percent (used to treat earwax buildup) once a day. Review of the Medication Administration Records (MAR) for Resident 6, dated July and August 2023, revealed that staff documented the four drops of Debrox 6.5 percent as being administered on July 29, 2023. However, on July 30 and 31, 2023, and August 2, and 3, 2023, staff documented that the four drops of Debrox 6.5 percent was not administered due to not being available. Interview with the Director of Nursing on September 14, 2023, at 1:22 p.m. confirmed that the Debrox 6.5 percent was not available for staff to administer to Resident 6 on July 29, 2023, and that staff should not have documented the Debrox 6.5 percent as being…

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.