Hempfield Manor

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility documents, resident and staff interviews, observation, and clinical record review, it was determined that the facility failed to obtain routine services from an eye care professional and failed to accurately document the need for vision care for one of five residents (Resident R12).Findings include: Review of the Facility Assessment dated 10/22/25, indicated the facility will provide vision care for vision loss, cataracts, glaucoma, and macular degeneration. Review of the clinical record revealed Resident R12 was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS - periodic assessment of resident care needs) dated 3/5/26, included diagnoses of Parkinsonism (group of neurological disorders characterized by tremors, stiffness, slowness of movement, and difficulty maintaining balance), Alzheimer's disease (a type of brain disorder that causes problems with memory, thinking and behavior), and a seizure disorder. Section B: Hearing, Speech, and Vision indicated that…

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

Based on review of facility documents and staff interview, it was determined that the facility failed to provide training on the prevention of abuse, neglect, and exploitation for five of ten staff members (Employees E2, E3, E5, E6, and E7).Findings Include: Review of the facility policy, Inservice Education dated 12/2/25, indicated, The inservice education program is planned and conducted for the development and improvement of skills and personnel. Included in the list of topics was Abuse, Neglect, and Misappropriation and Reporting Crimes Pursuant to the Elder Justice Act.Review of Registered Nurse Employee E2's facility provided staff list indicated she was hired on 2/14/23. Review of RN Employee E2's training record for 2/14/25, through 2/14/26, did not include training on the prevention of abuse, neglect, and exploitation.Review of Licensed Practical Nurse Employee E3's facility provided staff list indicated she was hired on 2/12/19. Review of RN Employee E3's training record for 2/12/25, through 2/12/26, did not include training on the prevention of abuse, neglect, 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 facility documents and staff interview, it was determined that the facility failed to provide training on infection control for four of ten staff members (Employees E2, E5, E6, and E7).Findings include: Review of the facility policy, Inservice Education dated 12/2/25, indicated, The inservice education program is planned and conducted for the development and improvement of skills and personnel. Included in the list of topics was Prevention and Control of Infections / Standard Precautions. Review of Registered Nurse Employee E2's facility provided staff list indicated she was hired on 2/14/23. Review of RN Employee E2's training record for 2/14/25, through 2/14/26, did not include training on infection control. Review of the Activity Employee E5's facility provided staff list indicated she was hired on 1/6/06. Review of Activity Employee E5's training record for 1/6/25, through 1/6/26, did not include training on infection control. Review of Nurse Aide (NA) Employee E6's facility provided staff list indicated she was hired on 1/9/24. Review of NA Employee E6's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy, document review, resident interviews, observation, and staff interviews, it was determined that the facility failed to provide prompt assistance to meet residents care needs for ten of twenty residents who require care (Residents R1, R2, R3, R4, R5, R6, R7, R8, R9, and R10). Based on facility policy, document review, resident interviews, observation, and staff interviews, it was determined that the facility failed to provide prompt assistance to meet residents care needs for ten of twenty residents who require care (Residents R1, R2, R3, R4, R5, R6, R7, R8, R9, and R10). Findings included: Review of facility policy Resident Rights last reviewed 12/4/24, indicated in part The resident has a right to a dignified existence, self-determination, and communication with and access to person and services inside and outside the Manor. The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which provides instructions and guidelines for completing the required Minimum Data…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy review, clinical and facility record review, facility submitted documents, and staff interviews, it was determined that the facility failed to provide adequate supervision to prevent elopement for one of nine residents (Resident R1). Review of the facility Missing Resident Policy dated 12/4/24, indicated the facility will complete all necessary steps to locate any resident that is missing from a community. Review of the clinical record revealed Resident R1 was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS - periodic assessment of resident care needs) dated 4/1/24, included diagnoses of diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time), high blood pressure, and dementia (a group of symptoms that affects memory, thinking and interferes with daily life). Review of an Elopement Risk Assessment completed on 3/19/25, indicated Resident R1 was at risk for elopement. Review of the physician's order dated 2/18/25,…

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

Based on review of facility policy, observations, and resident and staff interviews, it was determined that the facility failed to make accessible grievance boxes to residents on two of two nursing unit resident lounge areas (East and [NAME] Wings). Findings include: A review of the facility policy Grievances reviewed 1/6/25, all persons will be provided with an opportunity to present these complaints through a formal grievance procedure. During an observation on 3/4/25, at 11:25 a.m. revealed the grievance box and forms were not accessible on the East and [NAME] nursing unit resident lounge areas. The grievance boxes had been placed on a shelf, out of the reach of residents in wheelchairs. During an interview on 3/4/25, at 11:40 a.m. The Activity Director Employee E1 confirmed the facility failed to make accessible grievance boxes to residents on two of two nursing units resident lounge areas (East and [NAME] Wings). During an interview on 3/5/25, at 2:45 p.m. The Nursing Home Administrator confirmed the facility failed to make accessible grievance boxes to residents on two of two…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, resident interviews, observation, and staff interviews, it was determined that the facility failed to provide prompt assistance to meet residents care needs for two of ten residents who require care (Residents R14 and R49). Findings included: Review of facility policy Resident Rights last reviewed 1/06/25, indicated the facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident. 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 a BIMS (Brief Interview of Mental Status) is a brief screener that aids in detecting…

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

Based on review of facility policy, observations and staff interviews it was determined that the facility failed to maintain a homelike environment throughout the facility (resident rooms) for three of four nursing units. (A, C, and D nursing units). Findings include: A review of the facility policy Environment Policy dated 1/6/25, indicated the facility will provide a safe, clean, comfortable, and homelike environment. During an observation of the facility on 3/7/25, at 1:00 p.m., the following was revealed: A Wing resident rooms 5W, 2W, 13W, and 14W (window) air condition/heating unit had dusty debris on the unit. C Wing resident rooms 33W, 43W, 45W, and 47W (window) air condition/heating unit had dusty debris on the unit. D Wing resident rooms 54W, 55W, 58W, and 59W (window) air condition/heating unit had dusty debris on the unit. During an interview on 3/7/25, at 1:30 p.m., the Nursing Home Administrator confirmed that the facility failed to maintain the facility in a homelike environment on three of four nursing units. Pa Code: 207.2 (a) Administrator's responsibility.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of facility policy, clinical records, and staff interview, it was determined that the facility failed to develop care plans that included instructions to provide person centered care for two of five residents (Residents R4 and R86). Findings include: Review of facility's policy Comprehensive Care Plan dated 12/4/24, indicated the facility will develop a comprehensive care plan for each resident that includes measurable objectives and timetables to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. Review of the clinical record revealed that Resident R4 was admitted to the facility on [DATE]. Review of Resident R4's Minimum Data Set (MDS - periodic assessment of resident care needs) dated 12/18/24, indicated diagnoses of dementia. Review of Resident R4's current care plan dated 9/12/24, failed to reveal a care plan with goals and interventions for dementia. Review of the clinical record revealed that Resident R86 was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical records, and staff interview, it was determined the facility failed to update a care plan for one of five residents (Resident R4) to accurately reflect the current status of the resident and care needs. Findings include: Review of the facility policy Comprehensive Care Plans dated 1/6/25 indicated the facility will develop a comprehensive care plan for each resident that describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial wellbeing. Review of the admission record indicated Resident R4 admitted to the facility on [DATE]. Review of Resident R4's Minimum Data Set (MDS - a periodic assessment of care needs) dated 12/18/24, indicated the diagnoses of dementia, depression, anxiety, and bipolar disorder (a mental condition marked by alternating periods of elation and depression), the resident is alert and oriented and able to make needs known. Review of Resident R4's physician order 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 job description, resident record review, and staff interviews, it was determined that the facility failed to follow professional standards of practice for one of four residents observed (Resident R57). Review of the facility Registered Nurse (RN) job description, revised 2/07, indicated the RN must function within the scope of practice according to the State Board of Nursing. Administers medication and treatments as prescribed by the physician. Assumes responsibility for his/her own professional competence. Review of the clinical record indicated that Resident R57 was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS - periodic assessment of resident care needs) dated 1/10/25, included diagnoses of dysphagia (difficulty swallowing) and orthostatic hypotension (decrease in blood pressure after rising from laying or sitting). During an observation on 3/3/25 at approximately 11:29 a.m. RN Employee E2 administered medication to Resident R57 while Resident 57 was in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy and clinical records, and staff interview, it was determined that facility staff failed to maintain ongoing communication with the hemodialysis (a machine filters wastes, salts and fluid from your blood when your kidneys are no longer healthy enough to do this work adequately) center for one of two residents reviewed (Resident R59). Findings include: A review of the facility policy Dialysis Care Policy reviewed 1/6/25, indicated residents ordered dialysis will have ongoing communication and collaboration with the dialysis facility regarding dialysis care and services. Qualified trained staff will communicate via written format with a dialysis communication form. A review of the clinical record indicated Resident R59 was re-admitted to the facility on [DATE], with diagnoses that included chronic renal disease (ESRD - the kidneys permanently fail to work) and high blood pressure. A review of the Minimum Data Set (MDS - periodic assessment of care needs) dated 12/27/24, indicated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff interview, it was determined the facility failed to ensure resident was free from unnecessary medication for one of twenty-four residents reviewed (Resident 39). Findings include: A review of the facility policy Medication Administration General Guidelines reviewed 1/6/25, indicated medications are administered according to written orders of the attending physician. When PRN (as needed) medications are administered, documentation of complaints or symptoms for which medication was given is to be provided. A review of the clinical record indicated Resident R39 was admitted to the facility on [DATE], diagnoses included pain in left knee and pain in right hip. A review of the Minimum Data Set (MDS - periodic assessment of care needs) dated 2/4/25, indicated the diagnoses remain current. Review of Resident 39's physician order dated December 6, 2024, revealed an order for Tramadol HCI (A medication used to treat severe pain) 50 mg Give one tablet by mouth every 6 hours as…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policies and clinical records and staff interview, it was determined that the facility failed to make certain that medical records on each resident are complete and accurately documented for two of four residents (Residents R4 and R168) A review of the facility policy Documentation Policy dated 1/6/25, indicated the facility will provide an account of the resident's care and treatment and information will be appropriate. The resident's medical record shall be complete, accurate, and timely. A review of the clinical record on 3/7/25, indicated that Resident R4 was admitted to the facility on [DATE]. Diagnoses included anxiety and bipolar disorder (a mental condition marked by alternating periods of elation and depression). A review of the MDS (minimum data set - resident assessment and care screening) dated 12/18/24, indicated the diagnoses remained current and the resident can make needs known. A review of physician orders dated 3/4/25, indicated Resident R4 received psychoactive…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, documents and staff interviews it was determined that the facility failed to conduct a through investigation three of three allegations of possible abuse and neglect. (5/20/24, 6/11/24, and 6/26/24) Findings include: A review of facility Abuse, Neglect, Exploitation and Misappropriation of Resident Property policy date 12/23/23, revealed that abuse, neglect, exploitation and misappropriation of resident property will not be tolerated. An investigation of the allegations will be conducted. A review of grievance form dated 5/20/24. revealed Resident R4 alleged that Licensed Practical Nurse (LPN)Employee E1 refused to provide treatment on 5/18/24. A statement written date 5/18/24, by LPN Employee E1 confirmed that she refused to complete the treatment as she was unaware of the physician order. A review of Resident R4's May Electronic Treatment Administration Record (ETAR) revealed that LPN Employee E1 signed off on completing the treatment on 5/16/24, and 5/17/24. A review of grievance form dated 6/11/24, Resident R5 alleged that a staff member…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, resident medical records, facility provided documents, staff statements and staff interviews, it was determined that the facility failed to provide a dignified living experience for one of three residents (Resident R4). Findings include: A review of facility Resident Rights policy dated 12/13/23, indicated that the residents have the right to a dignified existence, self determination, communication with access to persons and services within and outside the facility. A review of facility grievance form dated 5/20/24, revealed that Resident R4 filed a grievance on 5/18/24, Licensed Practical Nurse (LPN) E1 called the resident by her non preferred name. Review of a handwritten employee statement submitted on 5/18/24, by LPN Employee E1 confirmed that she had called the resident by her non preferred name. LPN Employee E1's statement indicated that LPN Employee E1 and Resident R4 were discussing a treatment for the resident when LPN Employee E1 stated she said * (resident's non preferred name) I have to go look at the computer. The resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of select facility documents, clinical record review as well as resident and staff interviews, it was determined that the facility failed to ensure sufficient staffing to meet resident need for one of three residents (Resident R1). Findings include: Review of the facility, Nursing Services Policy dated 12/8/23, indicated the facility will have sufficient nursing staff to provide nursing and related services to attain or maintain the highest physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care. Review of the clinical record indicated Resident R1 was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS - periodic assessment of care needs) dated 3/27/24, included the diagnoses of chronic obstructive pulmonary disease (COPD - a group of progressive lung disorders characterized by increasing breathlessness), chronic respiratory failure with hypoxia (inadequate respiration resulting in low levels of oxygen…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical records, and staff interviews, it was determined that the facility failed to make certain that residents were monitored, assessed, and received the necessary services to prevent pressure ulcers from developing or worsening for one of three residents (Resident R1). Findings include: Review of facility policy Pressure Ulcer Policy dated 12/13/23, indicated a resident who enters the facility without a pressure ulcer will not develop a pressure ulcer unless the individual's clinical condition demonstrates they are unavoidable. All residents will be assessed for pressure ulcer risk on admission, monitored weekly and reviewed quarterly and as needed. Review of the clinical record indicated Resident R1 was admitted to the facility on [DATE]. Review of Resident R1's Minimum Data Set (MDS - a periodic assessment of care needs) dated 2/3/24, indicated diagnoses of high blood pressure, diabetes (high blood sugar levels), and anemia (too little iron in the blood). Section M: Skin…

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

Based on review of facility policies, review of Centers for Disease Control (CDC) guidelines for Legionella (bacterium that causes Legionnaires Disease found in pipes and heating systems) Control, the facility's infection control tracking logs for water management and staff interview, it was determined that the facility failed to implement a comprehensive program for water management to monitor the potential development and spread of Legionella within the facility, failed to exercise proper infection control techniques and dispose of contaminated PPE (personal protective equipment) during a dressing change to prevent the potential of spread of infection for one of three residents (Resident R59). Review of the facility Legionella Policy-Environmental reviewed 12/13/23, indicated that the facility will implement control measures to reduce the potential for the growth and spread of Legionella by quarterly testing of chlorine levels. The facility indicated that the Weekly Water Temperature Inspection logs are used to track the testing of the water temperatures and the chlorine levels.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy, observation and staff interview, it was determined that the facility failed to ensure that care was provided in a manner which maintained resident dignity for one of three residents (Residents R59). Findings include: Review of facility policy Resident Rights dated 12/13/23, indicated the Resident has a right to a dignified existence. The facility must treat each Resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life. Review of the clinical record indicated that Resident R59 was admitted to the facility on [DATE], with diagnoses that included malnutrition, falls, heart disease and peripheral vascular disease. A review of the Minimum Data Set (MDS-a periodic assessment of resident care needs) dated 12/27/23, indicated the diagnoses remained current. Review of the facility provided pressure ulcer list indicated Resident R59 developed pressure ulcers of his right and left heels on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy, clinical record, facility provided documents and staff interview it was determined that the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice and the residents' choices for one of two residents (Resident R21). Review of the facility policy Physician Services, last reviewed on 12/13/23, indicated that all medications and treatments administered to the resident must be ordered by the physician. Review of the clinical record indicated that Resident R21 was admitted to the facility on [DATE], with diagnoses which included Type 2 Diabetes Mellitus, Parkinsons (a disorder of the nervous system that affects movement), anxiety, and cognitive disorder. Review of the Physician Orders Audit Report indicated that on 12/2/23, Resident R21 was ordered the Freestyle Libre 2 Sensor for glucose monitoring (device that requires no finger sticks). Resident R21's family member (FM1) requested due to Resident R21's inability to tolerate…

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

Based on observations and staff interview it was determined that the facility failed to maintain an environment free of potential accident hazards when the salon was unsecured containing hazardous items in two unsecured cabinets (Beauty Salon). Findings include: During an observation on 2/13/24, at 10:50 a.m., the main hallway between the two nursing unit halls, the beauty salon door was unsecured with a hoyer lift placed inside and one upper cabinet with a bottle of eye wash, a bottle of Tylenol with tablets inside, and the lower cabinet had a bottle of sledge hammer all purpose cleaner. During an interview on 2/13/24, at 10:53 a.m., the Nursing Home Administrator (NHA) stated that the salon door should have been locked. The NHA confirmed that the cabinets should have been secured and that the facility failed to maintain the environment free from potential hazards. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code: 201.18 (e)(1) Management. 28 Pa. Code 207.2(a) Administrator's responsibility. 28 Pa. Code: 211.10(d) Resident care policies.

Based on a review of facility policy, observations and staff interviews, it was determined that the facility failed to provide a functional resident call bell system for the beauty salon (Beauty Salon). Findings include: Review of the facility provided checklists of Environmental Services monthly review indicated that the nurses call system of all call lights and bulbs are functioning is identified. During an observation on 2/13/24, at 10:50 a.m., of the hair salon, the emergency call bell alarm was triggered however, the light above the door and the alert sound were not in functioning order. During an interview on 2/13/24, at 10:50 a.m., Nurse Aide Employee E2 indicated that the light above the door should illuminate and a sound should be present to alert staff of the need for assistance. During an interview on 2/13/24, at 10:53 a.m., the Nursing Home Administrator and Maintenance Director Employee E3 confirmed that the facility failed to provide a functional call bell system for the hair salon to alert staff if assistance is needed. 28 Pa. Code: 205.28 (c) (1) Nurse's station. 28…

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