Hanover Hall For Nursing And Rehabilitation

Based on clinical record review and staff interview, it was determined that the facility failed to ensure a urinalysis and urine culture and sensitivity were completed timely for one of two resident records reviewed (Resident 4).Findings include:Review of Resident 4 clinical record revealed diagnoses that included history of urinary tract infection.Review of Resident 4's physician orders included: obtain UA (urinalysis) C&S (culture and sensitivity) one time only for 2 Days, started October 7, 2025, at 5:30 PM.Review of the Medication Administration Record documented 15 (resident refused and requested the urine be collected on day shift) on December 7th, 2025.Further review of the physician orders included obtain UA/ C&S discontinue once completed, started October 13th, 2025, at 3:00 PM, and discontinued October 13th, 2025, at 4:39 PM.Review of the urinalysis report dated October 13, 2025, at 6:20 PM, revealed the specimen was taken October 13th, 2025, at 10:19 AM, was received at 3:57 PM, and the result was available at 4:22 PM. The results revealed urine appeared turbid, trace…

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

Based on observations, clinical record review, as well as resident and staff interviews, it was determined that the facility failed to ensure that a comprehensive, person-centered care plan was developed for each resident for two of 28 residents reviewed (Residents 63 and 99). Findings include: Review of Resident 63's clinical record revealed diagnoses that included quadriplegia (partial or total loss of use of all four limbs) and muscle weakness. Observation of Resident 63 on February 24, 2025, at 12:20 PM, revealed that contractures (permanent shortening and tightening of muscle fibers that reduces flexibility and makes movement difficult) were present in both of his hands. Resident 63 was observed wearing a splinting device on his right hand. During an immediate interview with Resident 63, he confirmed he had contractures and utilized splinting devices to prevent further functional loss. Review of Resident 63's physician orders revealed an order to cleanse both hands and check placement of cushion pad/brace that is worn at all times for contractures each shift, effective June 1,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, policy review, and staff and resident interviews, it was determined that the facility failed to ensure residents unable to carry out activities of daily living receive the necessary services to maintain good grooming and personal hygiene for four of 28 residents reviewed (Residents 3, 15, 17, and 93). Findings Include: Activities of Daily Living (ADLs) refer to basic self-care tasks that people typically perform daily. A review of the facility's policy, titled Activities of Daily Living (ADL's), revised March 2018, read, in part, Appropriate care and services will be provided for residents who are unable to carry out ADLs, including appropriate support and assistance with hygiene [bathing, dressing, grooming and oral care]. A review of Resident 3's clinical record revealed diagnoses that included hypertension (elevated blood pressure) and quadriplegia (a condition characterized by the complete or partial loss of motor and sensory function in all four limbs [arms and legs]). An observation of Resident 3, on February 24, 2025, at 1:10 PM, revealed facial hair…

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

Based on clinical record review, and interviews with staff and residents, it was determined that the facility failed to provide care and services as ordered by the physician for two of 28 residents reviewed (Residents 6 and 99). Findings Include: Review of the clinical record for Resident 6 revealed diagnoses that included lymphedema (swelling in the legs caused by lymphatic system blockage) and peripheral vascular disease (circulatory condition which narrowed blood vessels reduce blood flow to the limbs). During an interview with Resident 6 on February 24, 2024, at 11:14 AM, the Resident was asked about his lymphedema pumps (pumps that use compressed air to apply pressure to the affected limb to force excess fluid out of the limb) that were lying in his room. Resident 6 stated that the pumps are to be applied twice a day but they are never done twice a day and sometimes goes a week without it being done. Review of Resident 6's physician orders dated February 2025, stated, lymphedema pumps to bilateral lower extremities: cover legs with pillowcases before putting boots on. 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 facility policy review, clinical record review, and staff interviews, it was determined that the facility failed to ensure that residents who required dialysis services received such services consistent with professional standards of practice for two of two residents reviewed for dialysis (Residents 80 and 99). Findings include: A review of facility policy, End-Stage Renal Disease, Care of a Resident with, revised September 2010, revealed, Agreements between this facility and the contracted ESRD [End Stage Renal Disease] facility include all aspects of how the resident's care will be managed and may include: how information will be exchanged between the facilities. A review of Resident 80's clinical record revealed diagnoses that included hypertension (elevated blood pressure) and chronic end-stage or end-stage kidney (a severe and irreversible condition where the kidneys lose their ability to function). A review of Resident 80's physician orders revealed an order for dialysis treatments every Monday, Wednesday, and Friday. A review of Resident 80's dialysis communication…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 resident and staff interviews, clinical record review, and policy review, it was determined that the facility failed to provide sufficient nursing staff to provide nursing and related services for two of 26 residents reviewed (Residents 15 and 93). Review of the facility assessment and documentation determined that the facility failed to meet the staffing needs of their residents. Findings Include: Review of the facility's document, titled Facility Assessment, approved August 9, 2024, revealed its purpose is to determine what resources are necessary to care for our residents competently during both day-to-day operations (including nights and weekends) and emergencies. The document continued, This assessment addresses . The care required by the resident population using evidence-based, data driven methods that consider the types of diseases, conditions, physical and behavioral health needs, cognitive disabilities, overall acuity, and other pertinent facts that are present within that population, consistend with and informed by individual resident assessments. Also, The…

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

Based on observation, staff interviews, and Infection Control Preventionist (ICP) credential review, it was determined that in addition to the role of the Director of Nursing (DON), the DON was also the ICP and worked on the unit caring for residents as the nursing supervisor. Findings include: Review of facilty staffing information revealed that the DON was serving as the ICP. Observation during the full health survey revealed four residents that required personal protective equipment (PPE) and signage for enhanced barrier precautions (EBP) due to wounds, dialysis, colostomy and catheter, no PPE or signage was present at the time of screening process. Additionally, two staff were observed entering a Resident's room who had signage designating contact precautions, and no PPE was worn while direct care was being provided. During an interview with the DON on February 25, 2025, at 1:00 PM, the DON confirmed that she should be functioning as the DON on a full-time basis. The DON has been doing the role of DON, ICP, and, on multiple occasions, covering as house supervisor with direct…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, facility policy review, clinical record review, and staff interviews, it was determined that the facility failed to ensure staff implemented infection control policies and practices to prevent the spread of infection by using PPE (personal protective equipment) for four of 26 residents reviewed (Residents 32, 63, 96, and 99). Findings Include: Review of facility policy, titled Isolation- Multi Route Transmission-Based Precautions, last revised October 2018, revealed that staff and visitors will wear clean, disposable gloves and a disposable gown when entering the room of a resident on contact precautions. Review of Resident 96's clinical record revealed diagnoses that included clostridium difficile (bacterium that causes an infection of the colon) and chronic kidney disease (condition where the kidneys stop filtering waste from the blood). Observation on February 24, 2025, at 10:29 AM, revealed Employee 3 (Licensed Practical Nurse [LPN]) and Employee 2 entering Resident 96's room to help…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 that the facility failed to ensure that the resident assessment accurately reflected the resident's status for three of 28 residents reviewed (Residents 6, 41, and 99). Findings include: Review of the clinical record for Resident 6 revealed diagnoses that included lymphedema (swelling in the legs caused by lymphatic system blockage) and peripheral vascular disease (circulatory condition which narrowed blood vessels reduce blood flow to the limbs). Review of Resident 6's physician orders revealed an order for Oxycodone 10 mg (opioid medication) twice a day for severe pain that was initiated July 14, 2023. Review of Resident 6's December 6, 2024, quarterly MDS (Minimum Data Set - an assessment tool to review all care areas specific to the resident such as a resident's physical, mental or psychosocial needs) revealed that the assessment was not coded to indicate that he received an opiod medication. During an interview with the Nursing Home…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff interview, it was determined that the facility failed to develop and implement a baseline care plan for each resident within 48 hours of the resident's admission for one of 28 residents reviewed (Resident 99). Findings include: Review of Resident 99's clinical record revealed diagnoses that included end stage renal disease (condition where one's kidneys are functioning below 10 percent of their normal function) and dependence on renal dialysis (treatment that removes extra fluid and waste products from the blood when the kidneys are not able to function properly). Further review of Resident 99's clinical record revealed that he was admitted to the facility on [DATE], was discharged home on October 3, 2024, then was readmitted to the facility on [DATE]. Review of Resident 99's order summary revealed an order for dialysis services three times per week, effective September 26, 2024. A second order for dialysis services three times per week was written upon his second…

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

Based on observation, policy review, staff interviews, and record review, it was determined that the facility failed to ensure that a resident with a pressure ulcer received care consistent with professional standards of practice for one of three Residents reviewed for pressure ulcers (Resident 8). Findings include: A review of the facility wound care policy, titled Dry/Clean Dressings, last reviewed July 2024, read, in part, 17. Apply the ordered dressing and secure with tape or bordered dressing per order. Review of Resident 8's clinical record revealed diagnoses that included unstageable pressure ulcer of left buttock (type of sore that occurs due to prolonged pressure on a specific area) and chronic kidney disease, stage 3 (moderate level of kidney damage where the kidney are not filtering waste effectively). Review of Resident 8's physician orders included an order to cleanse the left buttock wound with normal sterile saline and apply a hydrocolloid dressing (moisture retentive dressing) three times a week (Monday, Wednesday, Friday) on day shift and PRN (as needed).…

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

Based on observation, clinical record review, and resident and staff interviews, it was determined that the facility failed to ensure that residents with limited mobility received appropriate services, equipment, and assistance to maintain or improve mobility for one of three residents reviewed for mobility (Resident 63). Findings Include: Review of Resident 63's clinical record revealed diagnoses that included quadriplegia (partial or total loss of use of all four limbs) and muscle weakness. Review of Resident 63's physician orders revealed an order to cleanse both hands and check placement of cushion pad/brace that is worn at all times for contractures each shift, effective June 1, 2023. Observation of Resident 63 on February 24, 2025, at 12:20 PM, revealed that contractures (permanent shortening and tightening of muscle fibers that reduces flexibility and makes movement difficult) were present in both of his hands. Resident 63 was observed wearing a splinting device on his right hand. During an immediate interview with Resident 63, he confirmed he had contractures and utilized…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, policy review, and staff interview, it was determined that the facility failed to ensure the resident environment remains free of accident hazards and that each resident receives adequate supervision and assessment for two of three residents reviewed for use of enabler bars (Residents 3 and 39). Findings Include: A review of the facility's policy, titled Use of Bed Rails, revised September 2022, read, in part, Facility staff, in conjunction with the Attending Physician, will assess and document the resident's risk for injury due to neurological disorders or other medical conditions. Also, The resident will be checked periodically for safety relative to bed rail use. According to the policy, examples of bed rails included, Grab bars and assist bars. A review of Resident 3's clinical record revealed diagnoses that included hypertension (elevated blood pressure) and quadriplegia (a condition characterized by the complete or partial loss of motor and sensory function in all four limbs [arms and legs]). A review of Resident 3's interdisciplinary plan 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 observations, policy review, and resident and staff interviews, it was determined that the facility failed to provide respiratory services for one of 28 residents reviewed (Resident 90). Findings include: Review of facility provided policy, titled Oxygen Administration, last revised October 2010, revealed in a step called Preparation, 1. Verify that there is a physician's order for the procedure. Review the physician's orders or facility protocol for oxygen administration. Review of Resident 90's clinical record revealed diagnoses that included obstructive sleep apnea (a sleep disorder characterized by recurrent episodes of complete or partial blockage of the upper airway during sleep, leading to reduced or absent breathing) and diabetes mellitus (a group of diseases that result in too much sugar in the blood [high blood glucose]). Observation of Resident 90 on February 24, 2025, at 11:57 AM, revealed the Resident sitting in their bed. On the side of the bed was an oxygen concentrator and the oxygen concentrator, providing the Resident supplemental oxygen at 2 liters…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 facility policy review, clinical record reviews, and staff interview, it was determined that the facility failed to act upon the licensed pharmacist's report of a medication irregularity for two of five residents reviewed for unnecessary medications (Residents 8 and 41). Findings Include: Review of facility policy, titled Antipsychotic Medication Use, last reviewed July 2024, read, in part, Antipsychotic medication will be prescribed at the lowest possible dosage for the shortest period of time and are subject to gradual dose reduction and re-review .18. The physician shall respond appropriately by changing or stopping problematic doses or medications, or clearly documenting (based on assessing the situation) why the benefits of the medication outweigh the risks or suspected or confirmed adverse consequences. Review of Resident 8's clinical record revealed diagnoses that included dementia (decline in cognitive abilities that interferes with daily life) and anxiety disorder (excessive and persistent worry, fear, and nervousness that significantly interferes with daily life).…

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

Based on observation, facility policy review, product packaging review, and staff interview, it was determined that the facility failed to store medication in accordance with manufacture guidelines for one of three medication carts reviewed (D-2 medication cart). Findings Include: Review of facility provided policy, titled Medication Storage in the Facility, most recently reviewed July 2024, revealed, Medications requiring 'refrigeration' or 'temperatures between 2ºC (36ºF) and 8ºC (46ºF)' are kept in a refrigerator with a thermometer to allow temperature monitoring. Medications requiring storage 'in a cool place' are refrigerated unless otherwise directed on the label. And, Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from stock, disposed of according to procedures for medication disposal and reordered from the pharmacy, if a current order exists. Observation of the C-2 medication cart on February 26, 2025, at 10:17 AM, revealed two Tresiba (insulin) pen unopened and not…

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

Based on document review, policy review, and resident and staff interviews, it was determined that the facility failed to ensure sufficient nursing staff to provided nursing and related services to assure resident safety and maintain the highest practicable physical, mental, and psychosocial well-being of each resident as determined by individual plans of care for one of four residents reviewed (Resident 4). Findings Include: A review of the facility's policy, titled Care Plans-Comprehensive Person-Centered, revised September 2022, read, in part, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Review of the facility's policy, titled Resident Rights, revised October 2022, read, in part, Employees shall treat all residents with kindness, dignity and respect. The policy continued, residents have the right to have the facility respond to his or her grievances. Review of Resident 4's interdisciplinary plan of care revealed 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 clinical record review, policy and document review, and staff interview, it was determined that the facility failed to implement policies and procedures to ensure that each resident is offered the COVID-19 vaccine, when available, and if the vaccination requires multiple doses, the resident and/or representative has the opportunity to accept or refuse the COVID-19 vaccine for one of four residents reviewed (Resident 2). Findings Include: A review of the facility's policy, titled Coronavirus (COVID-19) and COVID-19 Vaccine Policy, revised on February 18, 2022, read, in part, The vaccine will be offered and administered to residents per the most current Manufacturers', CDC [Centers for Disease Control], Federal, State, and/or local guidance. The policy continued, If a vaccine requires multiple doses, or an additional 3rd dose or more, or booster, educational information and consents will be completed for each dose administered. And Documentation of vaccination for residents: Acceptance or refusal of the vaccine. A review of electronic mail correspondence from the facility'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 record review and staff interviews, the facility failed to get a resident out of bed when requested for one of four residents reviewed (Resident 2). Findings included: A review of the clinical record for Resident 2 revealed diagnoses that included diabetes mellitus (a form of diabetes that is characterized by high blood sugar, insulin resistance, and relative lack of insulin) and congestive obstructive pulmonary disease (COPD - disease process that causes decreased ability of the lungs to perform). A review of the care plan for Resident 2 dated July 2024, revealed that Resident 2 requires 2-person assist and his walker for transfers. Resident 2's care plan also had an intervention to keep Resident 2's routine consistent to decrease confusion due to Resident's fluctuating BIMs score (brief interview of mental status). A review of the nursing note for Resident 2 dated July 13, 2024, at 1:37 PM, stated, resident was unable to get out of bed before breakfast and was offered breakfast in bed but refused. Resident 2's wife (also his roommate) called a family member to complain,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 staffing schedules, facility documentation, and staff interview, it was determined that the facility failed to ensure sufficient nursing staff to assure residents attain or maintain the highest practicable physical, mental, and psychosocial well-being for one of four residents reviewed (Residents 2). Findings include: A review of the clinical record for Resident 2 on July 30, 2024, revealed a nursing note that there was only one Nurse Aide (NA) working on Resident 2's unit, and when Resident 2 rang the call bell to get out of bed for breakfast, the Resident was offered to eat breakfast in bed because there was not a second NA working to assist in getting the Resident out of bed. Resident 2 requires 2-person assist with his walker for transfers. The spouse of Resident 2 had to call a family member in to the facility to dress and assist the Resident out of bed for the lunch meal. During an interview with the Nursing Home Administrator (NHA) on August 1, 2024, at 9:00 AM, the NHA confirmed the accuracy of the low staffing levels. 28 Pa Code 211.12 (d)(4) Nursing…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 interviews, it was determined that the facility failed to ensure that resident assessments accurately reflected the resident's status for three of 25 residents reviewed (Residents 53, 107, and 358). Finding include: Review of Resident 53's clinical record on March 12, 2024, at 11:47 AM, revealed diagnoses that included vascular dementia (decline in thinking skills caused by conditions that block or reduce blood flow to various regions of the brain) and heart failure (condition where the heart can't pump enough blood to meet the body's needs). Review of Resident 53's physician orders revealed Resident 53 was admitted to hospice services on February 27, 2023. Review of Resident 53's minimum data set (MDS - assessment tool utilized to identify a residents' physical, mental, and psychosocial needs), section O0110 special treatments, procedures, and programs, subsection K1 hospice, revealed the facility failed to indicate that Resident 53 was receiving hospice services while…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 record review, and staff interviews, it was determined the facility failed to develop and implement a comprehensive person-centered care plan to attain or maintain the highest practicable level of physical and mental well-being for one of 25 residents reviewed (Resident 49). Findings include: Review of facility policy, titled Care Plans, Comprehensive Person-Centered, last revised September 2022, read, in part, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the residents physical, psychosocial, and functional needs, is developed and implemented for each resident. The services provided or arranged by the facility, as per the comprehensive care plan, must be culturally-competent and trauma-informed .Trauma-informed Care is an approach to delivering care that involves understanding, recognizing, and responding to the effects of all types of trauma. A trauma-informed approach to care delivery recognizes the widespread…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 resident and staff interviews, it was determined that the facility failed to ensure each resident received proper treatment to maintain vision for one of 25 residents reviewed (Resident 90). Findings include: Review of Resident 90's clinical record revealed diagnoses that included adult failure to thrive (syndrome of weight loss, decreased appetite, depressive symptoms, and impaired immune function), hemiplegia (paralysis of one side of the body) following stroke effecting left dominant side, diabetes mellitus (the body's ability to produce or respond to the hormone insulin is impaired, resulting in abnormal metabolism of carbohydrates and elevated levels of glucose in the blood and urine), chronic kidney disease (CKD - the kidneys don't function as they should), and depressed mood. During an interview with Resident 90 on March 11, 2024, at 11:31 AM, it was revealed that he hasn't seen an eye doctor to get shots in his right eye for at least two months and that, according to the facility, this was due to the eye doctor not accepting his insurance.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 facility policy review, clinical record review, and staff interviews, it was determined the facility failed to ensure the monthly pharmacy medication regimen review recommendations were acted upon in a timely manner for two of 25 residents reviewed (Residents 37 and 49). Findings include: Review of facility policy, titled Medication Monitoring and Management, not dated, read, in part The consultant pharmacist reviews written record to determine that: 'Stop order' policies, where utilized, are observed .'Standing orders,' where utilized, are implemented appropriately. Review of Resident 37's clinical record revealed diagnoses that included pain in left knee, hypertension (high blood pressure), and osteoarthritis (a type of arthritis that affects the joints in your body). Review of Resident 37's monthly pharmacy medication regimen review recommendations revealed a recommendation from July 9, 2023, that stated Please add 'Do not exceed 3 grams in 24 hours from all sources' to the PRN [PRN- as needed] Acetaminophen order(s). Thank you. Review of Resident 37's monthly pharmacy…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, facility policy review, and staff interview, it was determined that the facility failed to ensure controlled substances were contained in a permanently affixed locked compartment for two of two medication rooms observed (A1/B1 hall and C2/D2 hall); failed to ensure adherence to medication expiration dates for one of two medication storage rooms observed (A1/B1 hall); and failed to ensure appropriate labeling of medication when opened for one of two medication storage rooms observed (A1/B1 hall). Findings include: Review of facility policy, titled Medication Storage in the Facility, last reviewed August 24, 2023, stated, Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. Further review of the policy revealed a section titled Procedures subsection I stated, Controlled medications are stored separately from other medications…

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

Based on review of select facility documentation, observations, and staff interview, it was determined that the facility failed to follow appropriate portion sizes for residents prescribed double portions for three of five residents observed (Residents 5, 7, and 32); and failed to provide therapeutic diet restrictions (a meal plan that controls the intake of certain foods or nutrients) for five of five residents observed on the carbohydrate controlled diet restriction (Residents 28, 58, 70, 83, and 409) during one of one tray line meal service observed. Findings include: Review of Document titled Carbohydrate Controlled Diet not dated, read, in part, Food Group: Desserts .Foods Allowed: Half portion of regular desserts. Review of the meal extension sheets revealed that residents on the carbohydrate controlled diet restriction should be served half of a 2 x 3 inch square of the chocolate chip brownie bar. Observation of lunch meal tray line service on March 13, 2024, between 11:10 AM and 12:07 PM, revealed Residents 28, 58, 70, 83, and 409's, tray tickets had notation that they were…

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

Based on facility policy review, observations, and staff interviews, it was determined that the facility failed to store food and beverages in accordance with professional standards for food service safety in the main kitchen and four of four nourishment areas. Findings include: Review of facility policy, titled Policy: Storage Areas, not dated, read, in part, Food should be dated as it is placed on the shelves. Date marking to indicate the date or day by which are ready to eat .Leftover food is stored in covered containers or wrapped carefully and securely. Each item is clearly labeled and dated before being refrigerated. Leftover food is used within 3 days or discarded .All foods should be covered, labeled, and dated. All foods will be checked to assure that foods (including leftovers) will be consumed by their safe use by dates, or frozen (where applicable) or discarded. Review of facility policy, titled Policy: Food from outside Sources, last revised July 2023, revealed, Visitors/family members will label food and beverages with the resident's name, room number, and date…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 aide in-service records and staff interview, it was determined that the facility failed to ensure that all nurse aide staff received a minimum of 12 hours of in-service education training each year for five of five direct care staff members reviewed (Employees 8, 9, 10, 11, and 12). Findings include: Review of the facility's yearly mandatory in-service training failed to reveal documented evidence that Employees 8, 9, 10, 11, and 12 (Nurse Aides) met the yearly regulatory minimum training requirements. The following were documented hours of training for each employee: Employee 8 had 7 hours; Employee 9 had 6 hours; Employee 10 had 7 hours; Employee 11 had 7 hours; and Employee 12 had 7 hours. During an interview with the Nursing Home Administrator (NHA) on March 14, 2024, at 10:55 AM, it was revealed that the facility scheduled in-person training lasting one hour in duration each month and covered a different topic. It was further revealed that all staff are expected to attend one of the two training sessions offered each month; no make-up sessions were…

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

Based on facility policy review, observations, record review, and staff interviews, it was determined that the facility failed to provide respiratory care consistent with professional standards of practice for one of 25 residents reviewed (Resident 49). Findings include: Review of facility policy, titled Equipment Management, last revised February 27, 2019, read, in part, All equipment must be wiped down between patient use with a disinfectant cleaning solution/wipe that is rated: bactericidal, fungicidal, virucidal, tuberculocidal or as per manufacturer instructions .CPAP Machine filters: Non disposable filters should be washed monthly. Disposable filters should be changed out monthly .Humidifier chambers: Recommend to use distilled water only. Water should be changed daily. Review of Resident 49's clinical record revealed diagnoses that included Obstructive Sleep Apnea (a common disorder that causes repeated breathing interruptions during sleep), Post-Traumatic Stress Disorder (PTSD - a mental and behavioral disorder that develops from experiencing a traumatic event, such as…

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

Based on completion of a test tray and resident and staff interviews, it was determined that the facility failed to provide foods that were at an appetizing temperature for one of one meals tested. Findings include: An interview with Resident 408 on March 11, 2024, at 11:17 AM, revealed his food is not always served hot during meals. During the resident group interview completed on March 12, 2024, at 10:00 AM, multiple residents voiced concerns with the temperature of the food served during meal service. During an interview with Employee 3 on March 13, 2024, at 12:20 PM, he revealed that he conducts test trays monthly, and hot foods should be served at or above 135 degrees and chilled foods should be served at or below 40 degrees. A test tray was completed on March 13, 2024, at 12:26 PM, utilizing a lunch tray served from tray line in the main kitchen. A test tray was served and placed in a closed food cart for approximately two minutes prior to being delivered to the C1 unit (other trays for room service were being delivered here also at this time). The test tray included: 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 facility record review, facility policy review, and staff interviews, it was determined that the facility failed to provide education regarding the benefits and risks of the influenza and pneumococcal vaccines for three of five residents reviewed for vaccination status (Residents 61, 90, and 92). Findings include: Review of facility policy, titled Influenza Vaccine, last reviewed August, 2023, revealed the policy statement included, The facility shall provide pertinent information about the significant risks and benefits of vaccines to staff and residents (or residents' legal representatives); for example, risk factors that have been identified for specific age groups or individuals with risk factors such as allergies or pregnancy. Review of subsection 4 of the policy revealed it stated, Prior to the vaccination, the resident (or residents' legal representative) or employee will be provided information and education regarding the benefits and potential side effects of the influenza vaccine. (See current vaccine information statements at [Centers for Disease Control'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 facility documentation, and interviews it was determined that the facility failed to ensure that direct care nursing staff completed training/demonstrated competency upon hire and annually thereafter related to resident rights for two of five direct care staff members reviewed (Employees 8 and 9). Findings include: Review of the annual Staff Education Reports for five direct care staff members revealed that Employees 8 and 9 (Nurse Aides) failed to complete annual training for resident rights in the past year. During an interview with the Nursing Home Administrator (NHA) on March 14, 2024, at 10:55 AM it was revealed that the facility scheduled in-person training lasting one hour in duration each month and covered a different topic. It was further revealed that all staff were expected to attend one of the two training sessions offered each month. The NHA acknowledged that at times a staff member doesn't attend the required monthly training, and the facility doesn't provide make-up sessions. 28 Pa. Code 201.18(b)(1)(3)(e)(1) Management. 28 Pa. Code 201.20(a)(d)…

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

Based on observation as well as resident and staff interview it was determined that the facility failed to ensure each resident the right to a clean and comfortable homelike environment for two of three residents reviewed (Residents 3 and 4). Findings Include: An observation of Resident 3, on March 4, 2024, at 10:15 AM revealed him to be sitting in his wheelchair resting. A closer observation of Resident 3's wheelchair revealed multiple areas of dried liquid on the seat, as well as debris resembling crumbs and other materials located on the seat, arm rests and back of the wheelchair. An immediate interview with Resident 3 revealed he did not know how the stains or debris were deposited on his wheelchair but assumed them to be remnants of his meals. An observation of Resident 4, on March 4, 2024, at 10:18 AM revealed him to be resting in a geri-chair (a larger and padded, reclining chair to help seniors with limited mobility). A closer observation of the geri-chair revealed a significant amount of crumbs on the seat and stains on the linen placed under Resident 4. An interview with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, facility policy review, and staff interviews, it was determined that the facility failed to ensure residents received appropriate treatment and services to prevent urinary tract infections and complications related to the use of a catheter (thin tube that can be inserted through the urethra and into the bladder, allowing urine to drain) by catheterizing more times than required and improper placement of a foley catheter, for one of three residents reviewed for use of a catheter (Resident 1). Findings Include: Review of facility policy, titled Catheterization, Intermittent, Female Resident, revised October 2010, revealed, Verify that there is a physician's order for this procedure. Review of Resident 1's clinical record revealed diagnoses that included obstructive and reflux uropathy (disorder where urine cannot flow through the urinary tract due to an obstruction) and retention of urine (condition where one is unable to empty urine from the bladder, which can cause urine to back…

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

Based on observation, clinical record review, and resident and staff interviews, it was determined that the facility failed to ensure sufficient staff to meet resident needs on two of four nursing units (A1 and C2/D2). Findings include: Review of Resident 16's clinical record revealed diagnoses that included dementia (loss of memory, language, problem-solving, and other thinking abilities that are severe enough to interfere with daily life) and muscle weakness. Resident 16 resides on the A1 nursing unit. Review of Resident 16's care plan indicated she is at risk for falls and that staff are to provide a prompt response to all requests for assistance. Review of Resident 16's nursing progress notes dated September 16, 2023, revealed, Writer was notified by resident daughter via verbal that her mom was on the floor, writer walker [walked] to resident room, and found resident was on floor with supine position at 2045. Resident stated that she was sitting on her recliner, and she wanted to see something on her rollator walker pouch during that time she lost her balance . Review of a…

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