Oak Hill Rehabilitation & Healthcare Center

Based on review of the facility's plans of correction for previous surveys, and the results of the current survey, it was determined that the facility's Quality Assurance Performance Improvement (QAPI) committee failed to correct quality deficiencies and ensure that plans to improve the delivery of care and services effectively addressed recurring deficiencies. Findings include: The facility's deficiencies and plans of corrections for State Survey and Certification (Department of Health) surveys ending June 13, 2024; October 22, 2024; and April 21, 2025, revealed that the facility developed plans of correction that included quality assurance systems to ensure that the facility maintained compliance with cited nursing home regulations. The results of the current survey, ending June 18, 2025, identified repeated deficiencies related to a failure to notify residents' of a change in Medicare coverage, to provide services provided to meet professional standards, to prevent accident hazards, to prevent issues with oxygen therapy, that nurse aide performance evaluations were completed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 routinely conduct care plan meetings and invite the resident or interested family member to attend for two of 26 residents reviewed (Residents 3, 20). Findings include: The facility's policy regarding care plan conferences, dated February 19, 2025, indicated that the intent was to promote a care plan conference which ensured that the resident and/or responsible party would have the opportunity to review and participate in the development of the care plan. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 3, dated May 28, 2025, indicated that the resident was understood and understands, required assistance with activities of daily living, and had diagnoses that included Parkinson's. Interview with Resident 3, dated June 17, 2025, at 1:27 p.m., revealed that the resident stated the facility does not conduct care plan meetings with her or invite her responsible party. There was no…

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

Based on a review of facility policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to maintain the dignity of one of 26 residents reviewed (Resident 45) who had an indwelling urinary catheter (a flexible tube inserted into the bladder to drain urine). Findings include: A facility policy for Quality of Life - Dignity, dated February 19, 2025, indicated that residents shall be treated with dignity and respect at all times. Demeaning practices and standards of care that compromise dignity are prohibited. Staff shall promote dignity and assist residents as needed by helping the resident to keep urinary catheter bags covered. An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 45, dated May 26, 2025, indicated that the resident had moderate cognitive impairment, had an indwelling urinary catheter, and had diagnoses that included neurogenic bladder (lack of bladder control due to brain, spinal cord or nerve problems). Observations of Resident 45 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 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 one of 26 residents reviewed (Resident 44). Findings include: A Skilled Nursing Facility Beneficiary Protection Notification Review form, completed by the facility and dated February 10, 2025, revealed that Medicare coverage for Resident 44 started on January 11, 2025, and that her last covered day was February 12, 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 44 was not issued. Interview with the Nursing Home Administrator on June 18, 2025, at 12:37 p.m. confirmed that Resident 44 was not provided with an Advanced Beneficiary Notice of Non-coverage as required when their Medicare coverage ended. 28 Pa. Code 201.18(e)(1) Management.

Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to notify the resident and the resident's representative, in writing regarding the reason for transfer to the hospital and to ensure that a bed-hold notice was provided to the resident's responsible party for two of 26 residents reviewed (Residents 29, 36). Findings include: The facility's policy regarding bed-holds and returns, dated February 19, 2025, indicated that residents and/or representatives are informed (in writing) of the facility and state (if applicable) bed-hold policies. Residents, regardless of payer source are provided written notice about these policies at least twice: notice one well in advance of any transfer (for example, in the admission packet); and notice two at the time of transfer (or if the transfer was an emergency, within 24 hours). An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 29, dated March 25, 2025, indicated that the resident had moderate cognitive…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 develop individualized care plans for four of 26 residents reviewed (Residents 13, 20, 36, 45). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 13, dated May 2, 2025, indicated that the resident was cognitively intact and was frequently incontinent of bowel and bladder. Physician's orders for Resident 13, dated April 21, 2025, included an order for the resident to receive Methenamine Hippurate (an antibiotic) two times a day for preventative measures. A Certified Registered Nurse Practitioner's note, dated April 22, 2025, indicated that Resident 13 had chronic urinary tract infections and was to continue suppressive therapy with Methenamine Hippurate. However, there was no documented evidence that a care plan was developed to address Resident 13's long term antibiotic use. An interview with the Director of Nursing on June 17, 2025, at 1:53 p.m. confirmed that there was no 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 the Pennsylvania Nurse Practice Act, facility policies, and clinical records, as well as staff interviews, it was determined that the facility failed to obtain a physician's orders for a medication for one of 26 residents reviewed (Resident 13). This deficiency was cited as past non-compliance. 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 policy regarding medication administration, dated February 19, 2025, indicated that medications were to be administered in accordance with the prescriber's orders, including any required time frame. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs)…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 bathing records, as well as staff interviews, it was determined that the facility failed to ensure that residents were provided with showers/baths as scheduled for one of 24 residents reviewed (Resident 5). Findings include: The facility's policy regarding baths/showers, dated February 19, 2025, revealed that staff were to document the date and time that the resident's shower was provided. Staff were to notify the charge nurse or supervisor if the resident refused the shower or bath. An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 5, dated May 26, 2025, revealed that the resident was cognitively intact and was dependent on staff for showers/baths. The resident's care plan, dated June 1, 2025, revealed that staff were to assist her to bathe/shower as needed. Interview with Resident 5 on June 16, 2025, at 10:30 a.m. revealed that she was upset that she was not getting her showers as scheduled. Current bathing records indicated that Resident 5 was to receive 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 facility policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that the resident environment remained as free from accident hazards as possible by failing to complete an air mattress safety assessment to identify potential safety hazards for two of 26 residents reviewed (Residents 20, 36). Findings include: The facility's policy regarding air mattresses, dated February 19, 2025, indicated that support surfaces will be utilized in accordance with manufacturer recommendations (including considerations for contraindications) a schedule for inspection and replacement will be established accordingly. An annual Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 20, dated March 7, 2025, indicated that the resident was understood and understands, required assistance from staff for her daily care needs, and had medical diagnoses that included dementia. Physician's orders for Resident 20, dated June 1, 2025, 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 policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that long-term intravenous catheters were flushed as ordered by the physician for one of 26 residents reviewed (Resident 36). Findings include: The facility's policy regarding flushing intravenous (IV) catheters (a thin tube inserted into a vein and used long-term for the administration of fluids and/or medications), dated February 19, 2025, indicated that the catheter was to be flushed with 10 milliliters of saline (sterile salt water solution) before and after medication administration. A nursing note for Resident 36, dated May 2, 2025, at 4:54 p.m. revealed that he was readmitted to the facility and required IV therapy. Physician's orders, dated May 3, 2025, included an order for the resident to receive 2 grams of IV Meropenem solution (an antibiotic) one time a day on Tuesdays, Thursdays and Saturdays after dialysis for ESBL (Extended-Spectrum Beta-Lactamase- refers to enzymes produced by certain bacteria that make them resistant to many common…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 ensure that a resident who needed respiratory care was provided such care consistent with professional standards of practice and the resident's person-centered care plan for one of 26 residents reviewed (Resident 2). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 2, dated March 7, 2025, revealed that the resident was understood/understands, required assistance with daily care tasks, had diagnoses that included heart failure and high blood pressure, and required supplemental oxygen. Physician's orders, dated August 29, 2023, included an order for the resident to receive continuous oxygen at a flow rate of 3 liters per minute by nasal cannula (tubes that deliver oxygen into the nostrils). Physician's orders, dated August 29, 2023, included orders to change oxygen tubing and canister every Tuesday night and as needed. Observations on June 15, 2025, at 10:15 a.m. and June 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 review of policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that a safety assessment was completed for side rail/enabler use for one of 26 residents reviewed (Resident 29). Findings include: The facility's policy regarding bed safety, dated February 19, 2025, indicated that the resident's sleeping environment shall be assessed by the interdisciplinary team, considering the resident's safety, medical conditions, comfort, and freedom of movement, as well as input from the resident and family regarding previous sleeping habits and bed environment. To try to prevent deaths/injuries from the beds and related equipment, the facility shall promote the inspection of all beds and related equipment as part of the regular bed safety program to identify risks and problems including potential entrapment risks. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 29, dated March 25, 2025, indicated that the resident was moderately…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 nurse aides' dates of hire and their most recent performance review dates, it was determined that the facility failed to complete an annual nurse aide performance evaluation for one of three nurse aides reviewed (Nurse Aide 4). Findings include: A list of nurse aides provided by the facility revealed that based on their months and days of hire, an annual performance evaluation was due in March 2025 for Nurse Aide 4. However, there was no documented evidence that an annual performance evaluation was completed as required for Nurse Aide 4. Interview with the Human Resource director on June 18, 2025, at 1:41 confirmed that she could provide no evidence that an annual performance evaluation was completed as required for Nurse Aide 4. 28 Pa. Code 201.18(e)(1) Management.

Based on review of facility policies, observations, and staff interviews, it was determined that the facility failed to provide a separately-locked, permanently-affixed compartment in the refrigerator for the storage of controlled drugs in one of one medication rooms reviewed. Findings include: The facility's policy regarding controlled substances, dated February 19, 2025, indicated that that controlled substances are separately locked in permanently affixed compartments. Observations in the facility's medication room on the French unit on June 18, 2025, at 7:36 a.m. revealed one locked compartment in the medication refrigerator that was not secured to a shelf and was able to be removed from the refrigerator. This unsecured, locked compartment contained one unopened bottle of liquid Ativan (a controlled medication used to treat anxiety). Interview with Registered Nurse 3 at the time of the observation confirmed that the locked compartment box that contained Ativan was not permanently affixed to the refrigerator. Interview with the Nursing Home Administrator on June 18, 2025, at…

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

Based on review of policies and residents' clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that proper hand washing/hand hygiene was completed during wound care and it was determined that the facility failed to follow infection control guidelines from the Centers for Medicare/Medicaid Services (CMS) and the Centers for Disease Control (CDC) to reduce the spread of infections and prevent cross-contamination for one of 26 residents reviewed (Resident 20). Findings include: The facility's policy regarding hand hygiene, dated February 19, 2025, revealed that hand hygiene was to be performed whether or not gloves were worn when/after touching inanimate objects that were likely to be contaminated with microorganisms, and after contact with blood, body fluids, mucous membranes, secretions, or excretions. CDC guidance on isolation precautions and Implementation of Personal Protective Equipment (PPE) use in Nursing Homes to Prevent Spread of Multidrug-Resistant Organisms (MDRO's - bacteria that have become resistant to…

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

Based on review of 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 sanitization, dated February 19, 2025, revealed that the food service area was to be maintained in a clean and sanitary manner. All kitchens, kitchen areas, and dining areas were to be kept clean, free from garbage and debris, and protected from rodents and insects. All utensils, counters, shelves, and equipment were to be kept clean, maintained in good repair and free from breaks, corrosions, open seams, cracks, and chipped areas that may affect their use or proper cleaning. Observations in the main kitchen on April 21, 2025, at 9:20 a.m. revealed that two meal serving carts had a build up of food and debris on the lower metal edge in between the bumpers, a large black box (grease trap) located under the three-compartment sink had a large build up of food and debris on the top of the box, and a wall-mounted fan in the corner near the food prep area had a build up 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 policies, clinical records, and facility grievance/complaint logs, as well as staff interviews, it was determined that the facility failed to ensure that a written copy of the grievance/complaint decision was provided to the resident and/or resident representative for one of four residents reviewed (Resident 1). Findings include: The facility's policy regarding grievances/complaints, dated June 7, 2024, revealed that the resident, or the person filing the grievance and/or complaint on behalf of the resident, will be informed (verbally and in writing) of the findings of the investigation and the actions that will be taken to correct any identified problems. The administrator or designee will make such reports orally within five working days of the filing of the grievance or complaint with the facility. A written summary of the investigation will also be provided to the resident, and a copy will be filed in the business office. The facility's grievance/complaint logs, dated July through October 22, 2024, revealed that Resident 1 filed a verbal grievance/complaint…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 Nurse Practice Act and clinical records, as well as staff interviews, it was determined that the facility failed to clarify a questionable physician's order for one of four residents reviewed (Resident 1). 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. Physician's orders for Resident 1, dated August 25, 2024, included an order for the resident to receive the Restorative Nursing (a person-centered program that helps residents in long-term care facilities improve or maintain their ability to live independently and safely) Range of Motion (ROM - the distance and direction a joint can move between its fully extended and flexed positions) program 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 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 four residents reviewed (Resident 1). Findings include: Physician's orders for Resident 1, dated August 25, 2024, included an order for the resident to receive the Restorative Nursing (a person-centered program that helps residents in long-term care facilities improve or maintain their ability to live independently and safely) Range of Motion (ROM - the distance and direction a joint can move between its fully extended and flexed positions) program to maintain her current upper extremity strength through use of a weighted dowel rod. Restorative Nursing documentation for Resident 1, dated August, September, and October 2024, revealed that staff documented N/A during the 2:00 p.m. to 10:00 p.m. shift on August 27, 2024; documented as N/A during the 6:00 a.m. to 2:00 p.m. shift on September 1, 3, 5, 6, 22, and 29, 2024, and during the 2:00 p.m. to 10:00 p.m. shift on September 2, 3, 6, 9, 14,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, observations, and staff interviews, it was determined that the facility failed to ensure that food was served under sanitary conditions, in accordance with professional standards for food service safety. Findings include: The facility's policy regarding sanitization, dated June 7, 2024, indicated that the food service area is maintained in a clean sanitary manner. All kitchen areas are kept clean and free from debris. All utensils, counters, shelves and equipment are kept clean and maintained. Observations in the main kitchen on June 13, 2024, at 9:23 a.m. revealed that there was a black, removable substance on the wall near the dishwasher; kitchen shelves, where clean pots and serving pans were kept, had dust and debris on them; and the dish warmer tray had a thick, removable substance on it. Interview with the Dietary Manager on June 13, 2024, at 9:23 a.m. confirmed that the kitchen, the shelving, and kitchen equipment should be clean and free of debris and was not. 28 Pa. Code 211.6(f) Dietary Services.

Based on observations and staff interviews, it was determined that the facility failed to provide a clean and homelike environment for four of 28 residents reviewed (Residents 4, 8, 9, 29). Findings include: Observations of Resident 4's wheelchair on June 10, at 11:42 a.m.; June 11, 2024, at 12:18 p.m.; and June 12, 2024, at 9:00 a.m. revealed that the resident was resting his hand/arm on an oversized right armrest that had a moderate accumulation of removable, dried-on debris. Observations of Resident 8's wheelchair on June 10, 2024, at 11:47 a.m.; June 11, 2024, at 2:16 p.m.; and June 12, 2024, at 11:12 a.m. revealed that the resident's cushioned wheelchair had a moderate to large amount of thick, removable dust/debris on the metal supports under the seat and an accumulation of dirt and sticky debris that caused the seat cushion to stick to the wheelchair seat. Observations of Resident 9's wheelchair on June 10, 2024, at 11:38 a.m.; June 11, 2024, at 1:20 p.m.; and June 12, 2024, at 1:32 p.m. revealed that there was a large amount of removable dust/debris on the wheels and 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 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 three of five nurse aides reviewed (Nurse Aides 6, 7, 8). Findings include: The facility's policy regarding performance evaluations, dated June 7, 2024, indicated that job performances of each employee shall be reviewed and evaluated at least annually. A list of nurse aides provided by the facility revealed that Nurse Aide 6 was hired on March 28, 2023, and that she was due for her annual performance evaluation in March 2024. Nurse Aide 7 was hired February 26, 2023, and was due for her annual performance evaluation in February 2024. Nurse Aide 8 was hired April 16, 2023, and was due for her annual performance evaluation in April 2024. There was no documented evidence that the annual performance evaluations were completed as required for Nurse Aides 6, 7, and 8. Interview with the Nursing Home Administrator on June 12, 2024, at 2:40 p.m. confirmed that she could not provide…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 record reviews, as well as staff interviews, it was determined that the facility failed to ensure the accountability of controlled medications (drugs with the potential to be abused) for three of 28 residents reviewed (Residents 2, 11, 20). Findings include: A facility policy regarding administration of pain medication, dated June 7, 2024, indicated that facility staff were to administer pain medication as ordered and to document in the resident's medical record the results of the pain assessment, medication, dose, route of administration, and the result of the medication. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 2, dated May 6, 2024, revealed that the resident was understood and could understand others and was receiving palliative care. Physician's orders for Resident 2, dated January 17, 2024, included an order for the resident to receive 30 milligrams (mg) of MS Contin (Morphine Sulfate - a controlled narcotic) by mouth three times a day related…

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

Based on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to document the opportunity to formulate advance directives and failed to document the resident's decision to accept or decline assistance to formulate advance directives for four of 28 residents reviewed (Residents 6, 26, 34, 41). Findings include: The facility's policy regarding advance directives (instructions regarding the provision of health care and life sustaining measures when the resident is incapacitated), dated June 7, 2024, indicated that upon admission, the resident will be provided with written information concerning the right to refuse or accept medical or surgical treatment and to formulate an advance directive if he or she chooses to do so. Information about whether or not the resident has executed an advance directive shall be displayed prominently in the medical record. If the resident indicated that he or she has not established advance directives, the facility staff will offer assistance in establishing advance directives. 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 notices of Medicare non-coverage were issued timely for two of three discharged residents reviewed (Residents 44, 45). Findings included: The facility's policy regarding notices of Medicare non-coverage, dated June 7, 2024, indicated that Skilled Nursing Facility Beneficiary Notices will be issued following the Medicare Claims Processing Manual Chapter 30 Section 260 with the purpose to inform beneficiaries on the Medicare covered services ending and how to request an appeal. A nursing note for Resident 44, dated May 1, 2024, at 11:20 a.m. revealed that she was discharged home. There was no documented evidence that Resident 44 was issued a notice of Medicare non-coverage prior to the end her of Medicare coverage. A nursing note for Resident 45, dated February 28, 2024, at 7:16 p.m. revealed that she was discharged . There was no documented evidence that Resident 45 was issued a notice of Medicare non-coverage prior to the end her 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 policies and personnel files, as well as staff interviews, it was determined that the facility failed to ensure that the status of nursing licenses was checked with the State Board of Nursing for one of two nurses reviewed (Registered Nurse 4) and failed to complete a Nurse Aide Registry verification for one of three nurse aides reviewed (Nurse Aide 5). Findings include: The facility's policy regarding abuse prevention program, dated June 7, 2024, indicated that the facility would conduct employee background checks and would not knowingly employ or otherwise engage any individuals who have had a finding entered into the State Nurse Aide Registry concerning abuse, neglect, exploitation, mistreatment of residents or misappropriation of their property; or have a disciplinary action in effect against his or her professional license by a state licensure body as a result finding of abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property. The personnel file for Registered Nurse 4 revealed a start date of March 12, 2024. However,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 resident, the resident's representative, and the state long-term care ombudsman in writing regarding the reason for transfer to the hospital for two of 28 residents reviewed (Residents 6, 26). Findings include: The facility's policy regarding transfer or discharge, dated June 7, 2024, indicated that the facility would provide written notification to inform residents, residents' representatives, and the state long-term care ombudsman of hospitalization. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 6, dated May 30, 2024, indicated that the resident was cognitively intact, required extensive assistance from staff for daily care needs, and had a diagnosis of chronic congestive heart failure. Nursing notes for Resident 6, dated February 21, 2024, indicated that the resident was transferred to the hospital on that date. There was no documented evidence that written notification…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 a bed-hold notice was provided to the resident's responsible party for two of 28 residents reviewed (Residents 6, 26) who were transferred to the hospital. Findings include: The facility's policy regarding bed-hold notices, dated June 7, 2024, indicated that the facility would provide notification to inform residents and/or the resident's representative of their rights regarding holding the resident's current bed in the facility when a resident must be hospitalized or temporarily leaves the facility for medical or therapeutic reasons. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 6, dated May 30, 2024, indicated that the resident was cognitively intact, required extensive assistance from staff for daily care needs, and had a diagnosis of chronic congestive heart failure. Nursing notes for Resident 6, dated February 21, 2024, indicated that the resident was transferred 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 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 baseline care plan was developed that included resident-specific information necessary to properly care for one of 28 residents reviewed (Resident 242). Findings include: The facility's policy for baseline care plans (includes the minimum healthcare information necessary to properly care for a resident), dated June 7, 2024, indicated that a baseline care plan would be developed within 48 hours of the resident's admission. The baseline care plan would be used until the staff conducts the comprehensive assessment and develops an interdisciplinary person-centered care plan. An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 242, dated June 7, 2024, revealed that the resident was admitted on [DATE], was understood, was able to understand others, required assistance with care needs, was taking an…

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

Based on review of clinical records, as well as staff interviews, it was determined that the facility failed to ensure that physician's orders were followed for one of 28 residents reviewed (Resident 41). Findings include: An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 41, dated June 10, 2024, revealed that the resident was understood, understands, and required assistance from staff for daily care needs. Physician's orders for Resident 41, dated June 5, 2024, included an order to cleanse the right shin with normal saline, pat dry with ABD (a gauze pad used to treat large wounds), and wrap with rolled gauze. Observations on June 10, 2024, at 11:15 a.m. and June 11, 2024, at 1:15 p.m. revealed that Resident 41 did not have a wrap on her right leg. Resident 41 stated that she did not think the wraps had been discontinued. Review of Resident 41's Treatment Administration Record (TAR) for June 2024 revealed that the order for the leg wrap was still an active order and that the wrap was signed off 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.

Based on clinical record reviews, observations, and staff interviews, it was determined that the facility failed to ensure that pressure-relieving interventions were in place as care planned for one of 28 residents reviewed (Resident 4) who was at risk for pressure ulcers. Findings include: The facility's policy regarding mobility and skin integrity, dated June 7, 2024, indicated that any protective device should be provided as established by the physician. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 4, dated May 9, 2024, indicated that the resident was severely cognitively impaired, dependent on staff for care, had limited range of motion of the upper and lower extremities on both sides, and had diagnoses that included cerebral palsy (a disorder of muscle tone and exaggerated reflexes) with right hand and leg contractures. Physician's orders, dated April 30, 2024, included an order for the resident to have a right palm guard splint (a type of cushioned barrier between the fingers and the palm to prevent…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 complete safety assessments for one of 28 residents reviewed (Resident 11) and failed to provide safe transport in a wheelchair for one of 28 residents reviewed (Resident 26). Findings include: The facility's policy for bed safety, dated June 7, 2024, indicated that the resident's sleeping environment shall be assessed by the interdisciplinary team considering the resident's safety, medical conditions, comfort and freedom of movement to try to prevent deaths or injuries from the beds and related equipment (including mattress). A significant change Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 11, dated May 23, 2024, revealed that the resident was cognitively impaired, required assistance from staff for his daily care needs, and had a Stage 4 pressure ulcer (pressure wound with full thickness tissue loss with exposed bone, tendon or muscle). Physician's orders 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 policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that residents received oxygen as ordered by the physician for one of 28 residents reviewed (Resident 2). Findings include: The facility's policy regarding oxygen therapy, dated June 7, 2024, indicated that oxygen was to be administered in accordance with physician's orders. A quarterly Minimum data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 2, dated May 6, 2024, revealed that the resident was cognitively intact and had diagnoses that included atrial fibrillation (an irregular heart rate causing poor blood flow) and heart failure (a condition in which the heart does not pump blood as well as it should). Resident 2's care plan, dated May 20, 2024, indicated that she had difficulty breathing related to cardiac disease. Physician's orders for Resident 2, dated August 29, 2023, included an order for the resident to receive continuous oxygen at a flow rate of 3 liters per minute via…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 staff interview, 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 28 residents reviewed (Resident 2). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 2, dated May, 2024, indicated that the resident was cognitively intact, required assistance from staff for daily care needs, and had diagnoses that included schizophrenia and post-traumatic stress disorder (PTSD). A review of Resident 2's care plan, revised on May 20, 2024, indicated that the resident had PTSD and anxiety. There was no documented evidence the facility identified Resident 2's specific triggers that could re-traumatize the resident or implement measures as to how facility staff could prevent or minimize triggers from occurring.…

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

Based on a review of facility policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to label multi-dose containers of medications with the date they were opened in one of one medication carts observed (Colonial Wing). Findings include: The facility's policy regarding medication labeling and storage, dated June 7, 2024, revealed that multi-dose medications that have been opened or accessed are to be dated and discarded within 28 days unless the manufacturer specifies a shorter or longer date for the open medication. Observations of the Colonial Wing medication cart on June 10, 2024, at 12:24 p.m. revealed one opened and undated vial of Levemir insulin, one opened and undated vial of glargine insulin, and one opened and undated bottle of .005 percent Latanoprost solution eye drops. Interview with Registered Nurse 3 on June 10, 2024, at 12:30 p.m. confirmed that the insulin vials and bottle of eye drops should have been dated with the date they were opened. Interview with the Nursing Home Administrator on June 10, 2024,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 employ a full-time qualified dietitian. Findings include: Interview with the facility's Dietary Manager on June 10, 2024, at 9:14 a.m. revealed that the facility did not have a qualified dietician on staff as of May 20, 2024, when the previous dietician's employment ended. Interview with the Nursing Home Administrator on June 13, 2024, at 10:45 a.m. confirmed that the facility did not have a dietician or a dietician consultant employed as of June 13, 2024. 28 Pa Code 201.18(e)(1)(6) Management. 28 Pa. Code 211.6(c)(d) Dietary Services.

Based on clinical record reviews and staff interviews, it was determined that the facility failed to ensure that clinical records were complete and accurately documented for one of 28 residents reviewed (Resident 2). Findings include: The facility policy, dated June 7, 2024, indicated that documentation would be complete and accurate. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 2, dated May 6, 2024, revealed that the resident was cognitively intact, required the extensive assistance of two staff for daily care tasks, and had diagnoses that included heart failure and diabetes. Physician's orders for Resident 2, dated November 7, 2023, included an order to clean the reddened area on the right lower back with wound cleanser, pat dry, and apply a hydrocolloid (breathable) dressing every third day and every shift as needed. Observations on June 13, 2024, at 2:10 p.m. of Resident 2's right lower back revealed that there was no reddened area or dressing noted. Review of the June 2024 Treatment Administration…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 the required information from the contracted hospice provider for one of one hospice residents reviewed (Resident 11). Findings include: The facility's policy regarding the hospice program, dated June 7, 2024, indicated that facility was responsible for obtaining the hospice election of benefits form (a form signed to indicate that the individual waives all rights to traditional Medicare Part A payments for treatment related to the terminal illness) and the certification of terminal illness form (to certify a person's terminal diagnosis and life expectancy of six months or less) from the hospice provider (provider of end-of-life services) A significant change Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 11, dated May 23, 2024, revealed that the resident was cognitively impaired, required assistance from staff for his daily care needs, and was receiving hospice services.…

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

Based on review of 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 a State Survey and Certification (Department of Health) survey ending August 30, 2023, revealed that the facility developed plans of correction that included development and implementation of abuse and neglect polices, quality of care, and pharmacy services. The results of the current survey, ending June 13, 2024, identified repeated deficiencies related development and implementation of abuse and neglect polices, quality of care, and pharmacy services. The facility's plan of correction for a deficiency regarding development and implementation of abuse and neglect policies, cited during the survey ending August 30, 2023, revealed that the facility…

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

Based on review of a list of nurse aides currently employed by the facility, including their hire dates and training hours, as well as staff interviews, it was determined that the facility failed to ensure that nurse aides had 12 hours of in-service training annually for two of three nurse aides reviewed (Nurse Aide 6, Nurse Aide 7), and failed to ensure that nurse aides received annual in-service training regarding abuse and dementia for one of three nurse aides reviewed (Nurse Aide 6). Findings include: The facility's policy regarding in-services, dated June 7, 2024, indicated that the facility was mandated to ensure that all employees receive training hours required within state and federal guidelines. A list of nurse aides provided by the facility revealed that based on their months and days of hire: Nurse Aide 6 should have received at least 12 hours of in-service training between March 28, 2023, and March 28, 2024. However, there was no documented evidence that she received at least 12 hours of in-service training as required. Nurse Aide 7 should have received at least 12…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 facility grievance forms, as well as staff interviews, it was determined that the facility had no documented evidence of the steps taken to investigate the grievance, a summary of the pertinent findings or conclusion regarding the resident's concerns, or any corrective action taken or to be taken by the facility as a result of the grievance for one of five residents reviewed (Resident 1). Findings include: The facility's grievance policy, dated December 18, 2023, indicated that all grievances and complaints filed with the facility would be investigated and corrective actions would be taken to resolve the grievance(s). The investigation and report would include, as applicable: the date and time of the alleged incident; the circumstances surrounding the alleged incident; the location of the alleged incident; the names of any witnesses and their accounts of the alleged incident; the resident's account of the alleged incident; the employee's account of the alleged incident; accounts of any other individuals involved; and recommendations…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 an intravenous line was flushed in accordance with professional standards for three of 25 residents reviewed (Residents 24, 27, 39) and failed to ensure that physician's orders were followed for intravenous line care for one of 25 residents reviewed (Resident 39). Findings include: The facility's policy regarding flushing of central venous (a thin, flexible tube (catheter) that is placed into the large vein above the heart for the administration of fluids and/or medications) and midline (catheter inserted in the upper arm for the administration of fluids and/or medications) catheters, dated December 21, 2022, revealed that staff were to flush catheters at regular intervals to maintain patency and before and after the following: administration of intermittent solutions, administration of medications, administration of blood or blood products, obtaining blood samples, and/or converting from continuous to intermittent therapies. The diagnosis record…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 maintain a complete and accurate accounting of controlled medications (medications with the potential to be abused) for two of 25 residents reviewed (Residents 24, 35). Findings include: The facility's policy for controlled medications, dated December 21, 2023, indicated that when a controlled medication is administered, the licensed nurse administering the medication immediately enters the date and time of administration, amount administered, and the signature of the nurse administering the dose after the medication is actually administered. A diagnosis record for Resident 24, dated June 22, 2023, had diagnoses that included neuropathy (weakness numbness and pain from nerve damage), pneumonia, fracture of the upper left arm, pain disorder with psychological factors, depression and anxiety. A significant change Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 24, dated July 5, 2023, revealed that she was alert 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 a review of facility policies, as well as interviews with residents and a meal test tray, it was determined that the facility failed to serve food items that were palatable and at proper temperatures. Findings include: The facility's policy for food preparation and service, dated December 21, 2022, indicated that fresh, frozen or canned foods are cooked to a holding temperature of 135 degrees Fahrenheit and the proper hot and cold temperatures are to maintained during food distribution. An interview with a group of residents on August 28, 2023 at 3:00 p.m. revealed a concern about food being cold when served in the dining room and that it is not always good. Observations on August 30, 2023, at 11:57 a.m. in the dietary department revealed that the broccoli was in a vented steam table pan with another pan underneath it that had water in it and the container was sitting on the stove griddle area. The stove temperature controls were noted to be in the off position. The last resident was served their lunch meal at 12:09 p.m. in the dining room. Temperatures of the test tray 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 the facility's admission packet, as well as observations and staff interviews, it was determined that the facility failed to ensure that the results of all recent surveys conducted by state surveyors (Department of Health) were made accessible for residents to review without asking for staff assistance. Findings Include: A facility policy regarding examination of survey results, dated December 21, 2022, revealed that a copy of the most recent survey, including any subsequent extended surveys, follow-up revisits reports, along with state approved plans of correction of noted deficiencies, would be maintained in a three-ring binder located in an area frequented by most residents, such as the main lobby or resident activity room. An interview with a group of residents on August 28, 2023, at 3:00 p.m. indicated that the results of the state inspection surveys were available in the lobby. However the lobby door was locked, and the results were not accessible to residents to read without asking for facility staff assistance to open the door. Observations during 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 personnel files, as well as staff interviews, it was determined that the facility failed to complete a nurse aide registry verification upon hire for one of two nurse aides reviewed (Nurse Aide 1) and failed to complete a licensed practical nurse (LPN) license check prior to hire for one of one licensed practical nurses reviewed (LPN 2). Findings include: The facility's policy regarding background screening investigations, dated December 21, 2022, revealed that the purpose of the policy was to ensure the Director of Personnel, or designee, would conduct background checks, reference checks, and criminal conviction checks on all potential direct access employees and contractors. Background and criminal checks were to be initiated within two days of an offer of employment or contract agreement and completed prior to employment. Applicants for a position of nurse assistant would have the state nurse aide registry contacted to determine any findings of abuse, neglect, mistreatment of individuals, and/or theft of property, and the check would be entered…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 two of 25 residents reviewed (Residents 8, 27). Findings include: The facility's policy regarding care plans, dated December 21, 2022, indicated that the facility was responsible for the development of an individualized comprehensive care plan for each resident. A significant change comprehensive Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 8, dated August 6, 2023, revealed that the resident was understood and could understand, was cognitively intact, required extensive assistance from staff for her daily care tasks, and had a diagnoses that included respiratory failure, chronic obstructive pulmonary disease (COPD - impaired air flow in lungs), and used oxygen therapy. A care plan for Resident 8, dated April 30, 2021, revealed that the resident had respiratory impairment and staff was to provide oxygen at 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.

Based on the review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that the physician order for daily weights was followed for one of the 25 residents reviewed (Resident 8) and failed to ensure medications were provided as ordered for one of the 25 residents reviewed (Resident 24). Findings include: The facility policy for documentation of medication orders, dated December 21, 2022, indicated that when recording treatment orders, specify the treatment, frequency, and duration of the treatment. A significant change Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 8, dated August 6, 2023, revealed that the resident was understood and understands, was cognitively intact, required extensive assistance from staff for her daily care tasks, and had a diagnosis which included respiratory failure, chronic obstructive pulmonary disease (COPD - impaired air flow in lungs), and congestive heart failure. Physician's orders for Resident 8, dated August 18,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 were followed for an indwelling urinary catheter for one of 25 residents reviewed (Resident 25) who had a indwelling urinary catheter. Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 27, dated June 5, 2023, revealed that the resident usually understood, usually understands, required extensive assistance from staff for his daily care tasks, and had an indwelling urinary catheter. Physician's orders for Resident 27, dated June 12, 2023, included an order for staff to check the patency and output from the resident's left nephroureteral catheter (a tube inserted directly into the kidney. The tube then drains urine from the kidney into a collection bag outside of the body) every shift. Resident 27's Treatment Administration Record, dated June, July, and August 2023, revealed that there was no documented evidence that the resident's nephroureteral tube'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 Pennsylvania's Nursing Practice Act, facility policies, and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that an assessment was completed by a professional (registered) nurse after a fall occurred for one of seven residents reviewed (Resident 5). 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 policy for change in condition, dated December 21, 2022, indicated that the nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a 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 review of policies, clinical records, and facility investigation reports, 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 as care planned for one of seven residents reviewed (Resident 7) who was at risk for falls. Findings include: The facility's policy regarding managing falls and fall risks, dated December 21, 2022, indicated that in conjunction with the attending physician, staff will identify and implement relevant interventions to try to minimize serious consequences of falling. A quarterly MDS assessment for Resident 7, dated May 12, 2023, indicated that the resident was cognitively impaired, required extensive assistance from staff with daily care tasks, and had diagnoses that included schizophrenia (disorder that affects a person's ability to think, feel, and behave clearly). A care plan for Resident 7, dated March 27, 2023, revealed that the resident was at risk for falls due to medication side effects, a history of falls, and weakness. Review of a facility fall…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 maintain clinical records that were complete and accurately documented for one of seven residents reviewed (Resident 6). Findings include: The facility policy for change in condition, dated December 21, 2022, indicated that the nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs)for Resident 7, dated May 26, 2023, revealed that the resident was cognitively intact, required limited assistance from staff for personal care needs, and had diagnoses that included Multiple Sclerosis (disease that affects the central nervous system). A review of a facility incident report investigation (which is not part of the clinical record) for Resident 6, dated July 14, 2023, at 2:00 p.m. revealed that the resident had a fall in her bathroom. There was no…

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