Haida Nursing And Rehab

Based on a review of facility policies and clinical records as well as staff interviews, it was determined that the facility failed to ensure that residents medication regime was free from unnecessary psychotropic medication (drugs that affect a person's mental state, emotions, and behavior) for two of 5 residents reviewed (Residents 1 and 5). Findings Include: The facility policy related to the use of psychotropic medications, dated April 23, 2025, indicated that residents will only receive psychotropic medications when other nonpharmacological interventions are clinically contraindicated. Additionally, these medications should only be used to treat the resident's medical symptoms and not used for discipline or staff convenience, which would deem it a chemical restraint. Nonpharmacological approaches must be attempted, unless clinically contraindicated, to minimize the need for psychotropic medications, use the lowest possible dose, or discontinue the medications. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for…

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

Based on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to inform the resident representative in advance of the risks and benefits of a psychotropic medication (medications that affect the persons mental state, emotions and behavior) use and the treatment alternatives prior to initiating the administration of the medication for two of 5 residents reviewed (Resident 1 and 5).Findings Include: The facility's policy related to the use of psychotropic medications, dated April 23, 2025, indicated that prior to initiating or increasing a psychotropic medication, the resident, family, and/or resident representative must be informed of the benefits, risks, and alternatives for the medications, including any black box warnings for antipsychotic medications, in advance of such initiation or increase. The facility will document that the resident or resident representative was informed in advance of the risks and benefits of the proposed care, the treatment alternatives or other options and the preferred option to accept…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 the resident's representative/interested family member was notified timely about the need to alter treatment/changes in physician's orders for one of seven residents reviewed (Resident 7). Findings include: The facility's policy regarding charting and documentation, dated July 25, 2024, indicated that documentation of procedures and treatments will include care-specific details, including notification of family, physician, or other staff, if indicated. A quarterly Minimum Data Set (MDS) assessment (a federally-mandated assessment of a resident's abilities and care needs) for Resident 7, dated December 2, 2024, revealed that the resident was understood, understands with a Brief Interview for Mental Status score (BIMs - intended to determine the resident's attention, orientation and ability to register and recall new information and whether the resident has signs and symptoms of delirium) of 10, indicating that the resident was moderately impaired,…

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

Based on review of clinical records, as well as staff interviews, it was determined that the facility failed to ensure that residents received care and treatment in accordance with professional standards of practice, by failing to ensure that physician's orders were followed for one of seven residents reviewed (Resident 2). Findings include: A quarterly Minimum Data Set (MDS) assessment (a federally-mandated assessment of a resident's abilities and care needs) for Resident 2, dated November 20, 2024, revealed that the resident was understood, could understand others, and had a Crohn's disease (a chronic inflammatory bowel disease that causes inflammation in the digestive tract), diabetes (a chronic disease that occurs when the body can not produce or use insulin properly, resulting in high blood sugar levels), and hemiplegia (a neurological condition that causes paralysis or weakness on one side of the body). The resident's clinical record revealed that Resident Family Member 2 (son) and Resident Family Member 3 (daughter-in-law) were the resident's emergency contacts and 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 review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that clinical records were complete and accurately documented for one of seven residents reviewed (Resident 2). Findings Include: The facility's policy regarding charting and documentation, dated July 25, 2024, indicated that documentation in the medical record will be objective, complete, and accurate. A quarterly Minimum Data Set (MDS) assessment (a federally-mandated assessment of a resident's abilities and care needs) for Resident 2, dated November 20, 2024, revealed that the resident was understood, could understand others, and had Crohn's disease (a chronic inflammatory bowel disease that causes inflammation in the digestive tract), diabetes (a chronic disease that occurs when the body can not produce or use insulin properly, resulting in high blood sugar levels), and hemiplegia (a neurological condition that causes paralysis or weakness on one side of the body). The resident's clinical record revealed that Resident Family Member 2 (son)…

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

Based on clinical record reviews and staff interviews, it was determined that the facility failed to notify the resident, the responsible party, and long-term care ombudsman in writing regarding the reason for hospitalization for seven of 35 residents reviewed (Residents 1, 19, 22, 27, 29, 53, 64). Findings include: A nursing note for Resident 1, dated September 27, 2024, at 12:52 a.m. revealed that the resident was admitted to the hospital with congestive heart failure (a medical condition where the heart is unable to pump enough blood to meet the body's needs). There was no documented evidence that a written notice of Resident 1's transfer to the hospital was provided to the emergency contact or the long-term care ombudsman regarding the reason for transfer. A nursing note for Resident 19, dated September 24, 2024, at 1:07 a.m., revealed that the resident was admitted to the hospital with urinary tract infection and possible pneumonia. There was no documented evidence that a written notice of Resident 19's transfer to the hospital was provided to the resident's emergency contact…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 provide a written notice of the facility's bed-hold policy to the resident and/or the resident's representative at the time of a transfer for five of 35 residents reviewed (Residents 1, 22, 27, 29, 53). Findings include: A nursing note for Resident 1, dated September 27, 2024, at 12:52 a.m. revealed that the resident was admitted to the hospital with congestive heart failure (a medical condition where the heart is unable to pump enough blood to meet the body's needs). There was no documented evidence that the resident and/or the responsible party was notified about the facility's bed-hold policy at the time of the above transfer to the hospital for Resident 1. A nursing note for Resident 22, dated September 27, 2024, at 1:21 a.m., revealed that the resident was admitted to the hospital with hypoosmolarity hyperglycemic state (high blood sugar). There was no documented evidence that the resident and/or the responsible party was notified about 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of clinical records and staff interviews, it was determined that the facility failed to maintain clinical records that were accurately documented for two of 35 residents reviewed (Residents 24, 45). Findings include: Based on review of clinical records, as well as 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 24). A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 24, dated July 5, 2024, indicated that the resident was cognitively impaired, was dependent on staff assistance for daily care needs, had a diagnosis of depression. Physician's orders for Resident 24, dated October 22, 2024, included orders for the resident to receive 0.5 mg of 2mg/ml Lorazepam (a medication to treat anxiety) every four hours as needed. Review of Resident 24's Medication Administration Record (MAR) for October 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 review of policies and personnel files, as well as staff interviews, it was determined that the facility failed to complete a professional licensure check prior to hire for one of one licensed practical nurse reviewed (Licensed Practical Nurse 1). Findings include: The facility's abuse policy, dated August 27, 2024, indicated that the facility will not employ individuals that had a disciplinary action in effect against his or her professional license by a state licensure body as a result of a finding of abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property. Review of personnel file for Licensed Practical Nurse 1 revealed that she was hired on September 3, 2024, and the Pennsylvania Professional Licensure check was not verified until November 4, 2024, two months after she was hired. Interview with Director of Human Resources on November 5, 2024, at 11:05 a.m. confirmed that the license check for Licensed Practical Nurse 1 was not done timely. She stated that she accidently ran the check on her graduate license and not her permanent…

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

Based on review of the Resident Assessment Instrument (RAI) User's Manual and clinical records, as well as staff interviews, it was determined that the facility failed to complete accurate Minimum Data Set (MDS) assessments for three of 35 residents reviewed (Residents 3, 9, 29). Findings include: The Resident Assessment Instrument User's Manual, which gives instructions for completing Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2023, revealed that Section N0350 Insulin (medication used to lower blood sugar) was to be coded if the resident received insulin during the seven-day look-back period. Section N0350A was to be coded with the number of days the resident received insulin injections during the look-back period. Physician's orders for Resident 3, dated September 11, 2024, included an order for the resident to receive 1.8 milligrams (mg) of Victoza (non-insulin medication used to treat diabetes) subcutaneously (beneath the skin) one time a day. Review of the Medication Administration Record (MAR) for Resident…

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

Based on review of facility policy and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that a resident's care plan was created to reflect the resident's specific care needs for two of 35 residents reviewed (Residents 19, 82). A facility policy regarding care plans, dated August 27, 2024, revealed that care plans shall incorporate goals and objectives that lead to the resident's highest obtainable level of independence. Care plan goals and objectives were derived from information contained in the resident's comprehensive assessment. A facility policy regarding tobacco-free policy, dated October 29, 2024, revealed that the facility was tobacco free, and the facility prohibits the possession and/or storage of all smoking/smokeless tobacco materials. However, any resident admitted to the facility prior to the effective date of this policy would be Grandfathered into the prior policy and procedure. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 19, dated…

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

Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that pressure ulcer treatments were provided to prevent infection for one of 35 residents reviewed (Resident 19). Findings include: A facility policy regarding pressure ulcer/skin breakdown clinical protocol policy, dated August 27, 2024, revealed that the physician would authorize pertinent orders related to wound treatments, including wound cleansing and debridement approaches, dressings, and applications of topical agents, if indicated for type of skin alteration. A facility policy regarding handwashing/hand hygiene policy, dated August 27, 2024, revealed that staff were to use alcohol-based hand rub containing at least 62 percent alcohol or, alternatively, soap and water after handling clean or soiled dressings and gauze pads. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 19, dated October 2, 2024, revealed that the resident was cognitively intact, was clearly understood…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 observations and staff interviews, it was determined that the facility failed to ensure that physician-ordered contracture management interventions were provided as care planned for one of 35 residents reviewed (Resident 65). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 65, dated August 2, 2024, revealed that the resident was cognitively impaired, required extensive assist assistance from staff for personal hygiene, and had diagnosis that included hemiplegia/hemiparalysis (a medical condition that causes weakness or paralysis on one side of the body). Resident 65's care plan, dated March 5, 2024, indicated that the resident was to always have a rolled towel in her left hand, except during a.m. and p.m. care, and it was to be checked for placement and integrity. Physician's orders for Resident 65, dated June 5, 2024, revealed the resident was to always have a rolled towel in her left hand, and it was to be checked every shift for placement…

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

Based on review of clinical records and facility investigation reports, as well as staff interviews, it was determined that the facility failed to complete safety assessments for one of 35 residents reviewed (Resident 47) who used an air mattress. Findings include: A facility policy regarding support surface guidelines, dated August 27, 2024, indicated that the facility would follow the guidelines for the assessment of appropriate pressure-reducing and relieving devices for residents at risk for skin break down. Support surfaces were critical to pressure ulcer prevention and general safety include pressured redistribution, moisture control, shear reduction, and life expectancy. A significant change Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 47, dated June 29, 2024, revealed that the resident was usually understood, could usually understand others, was cognitively impaired, required assistance from staff for care needs, had a Stage 3 pressure ulcer (full thickness skin loss into the lower layers of skin) 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 facility 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 and arm circumference was measured as ordered for one of 35 residents reviewed (Resident 82). Findings include: The facility's policy regarding flushing central and midline catheters (a tube placed in a vein that can be used to deliver fluids and/or medications), dated August 27, 2024, revealed that when a resident was ordered intravenous medication, a 10 milliliter (ml) saline flush (a method used to clean a catheter of blood or medication) was to be administered before each medication was infused. Physician's orders for Resident 82, dated November 1, 2024, included an order for the peripherally-inserted central catheter (PICC line - a type of catheter that is inserted through a peripheral vein and used long-term to administer medications and/or fluids) be flushed with a minimum of 10 cubic centimeters (cc's) of 0.9 percent sodium chloride (sterile salt water solution) every shift, before and…

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

Based on clinical record reviews and staff interviews, it was determined that the facility failed to ensure that the physician wrote a progress note for each visit for one of 35 residents reviewed (Resident 15). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 15, dated August 16, 2024, indicated that the resident was cognitively intact and required maximum assistance from staff for care. A nurse's note for Resident 15, dated March 5, 2024, at 3:30 p.m., revealed that the resident was seen by the physician regarding her increased behaviors in the evening and increased meanness towards her family and spoke with the physician at length; however, there was no documented evidence of a provider's progress note in the clinical record. A nurse's note for Resident 15, dated March 14, 2024, at 2:09 p.m., revealed that the resident was examined by the physician at bedside; however, there was no documented evidence of a provider's progress note in the clinical record. A nurse's note for Resident 15,…

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

Based on review of facility policies, clinical records, and pharmacy labels for medications, as well as observations and staff interviews, it was determined that the facility failed to ensure that medications were properly labeled and dated for one of 35 residents reviewed (Resident 19). Findings include: A facility policy regarding medication ordering and receiving from pharmacy policy, dated August 27, 2024, revealed that improper and inaccurate labeled medications were rejected and returned to the dispensing pharmacy. Medication labels were not to be altered, modified, or marked in any way by nursing personnel. If the physician's directions for use change or the label was inaccurate, the nurse may place a change or order - check chart label on the container indicating there is a change in directions for use, taking care not to cover important label information. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 19, dated October 2, 2024, revealed that the resident was cognitively intact, was clearly…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 maintain compliance with nursing home regulations and ensure that plans to improve the delivery of care and services effectively addressed recurring deficiencies. Findings include: The facility's deficiencies and plan of correction for a State Survey and Certification (Department of Health) survey ending December 7, 2023, revealed that the facility developed plans of correction that included quality assurance systems to ensure that the facility maintained compliance with cited nursing home regulations. The results of the current survey, ending November 7, 2024, identified repeated deficiencies related to a failure to ensure that Minimum Data Sets (MDS, a mandated assessment of a resident's abilities and care needs) assessments were accurate upon submission, develop individualized care plans, and properly store and label medications. The facility's 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 of established infection control guidelines, facility policies, and clinical records, as well as observations and staff interviews, 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 during a COVID-19 outbreak and failed to follow infection control guidelines from CMS and the CDC for residents requiring Enhanced Barrier Precautions (EBP) for six of seven residents reviewed (Residents 1, 2, 3, 5, 6, 7). Findings include: The facility's policy regarding COVID-19 management, dated August 27, 2024, indicated that the facility follows current guidelines and recommendations for managing COVID-19 in the facility. This included ensuring the facility has all the necessary supplies, including personal protective equipment (PPE). The CDC recommends a 10-day isolation period for residents with suspected or confirmed COVID infection, and the door should be kept closed if safe to do so. CDC…

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

Based on review of facility policies, clinical records, and facility investigative documents, as well as staff interviews, it was determined that the facility failed to ensure that each resident received adequate supervision by failing to ensure that care-planned interventions were in place for one of four residents reviewed (Resident 2). Findings include: A quarterly Minimum Data Set (MDS) assessment (a federally-mandated assessment of a resident's abilities and care needs) for Resident 2, dated March 21, 2024, indicated that the resident could usually understand, was usually understood, was cognitively intact, and required extensive assistance from staff for daily care. Resident 2's care plan, dated June 14, 2023, revealed that she was to have an extensive assist of two when providing care. A witness statement from Nurse Aide 1, dated March 27, 2024, revealed that she provided incontinence care to Resident 2 by herself around 12:00 a.m A witness statement from Licensed Practical Nurse 2, dated March 27, 2024, revealed that Tylenol was administered to Resident 2 at 1:00 a.m. due 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 facility policy, clinical record reviews, and staff interviews, it was determined that the facility failed to ensure that resident-centered care plans were developed and implemented for four of 32 residents reviewed (Residents 12, 37, 60, 69). Findings include: A facility policy regarding comprehensive, person-centered care plans, dated December 21, 2022, indicated that the care plan would include measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs and be developed and implemented for each resident. The care plan will identify problem areas and their causes that are meaningful to the resident. The care plan shall be reviewed and updated when there has been a significant change in the resident's condition. An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 12, dated October 19, 2023, indicated that the resident was severely cognitively impaired, required partial to moderate…

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

Based on review of personnel files and 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 three nurse aides reviewed (Nurse Aides 3, 4, 5). Findings include: A list of nurse aides provided by the facility revealed that based on their months and dates of hire, annual performance evaluations were due during the 2023 calendar year for Nurse Aides 3, 4 and 5. The date of hire for Nurse Aide 3 was March 27, 2017; Nurse Aide 4 was June 15, 2021; and Nurse Aide 5 was June 15, 2021. As of December 7, 2023, there was no documented evidence that annual performance evaluations were completed for 2023 as required for Nurse Aides 3, 4 or 5. Interview with the Nursing Home Administrator on December 7, 2023, at 2:33 p.m. confirmed that annual performance evaluations were not completed as required for Nurse Aides 3, 4 and 5. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(1)(3)(e)(1) Management. 28 Pa. Code 201.20(a)(c) Staff development.

Based on review of facility policy and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that a resident's care plan was updated/revised to reflect the resident's specific care needs for one of 31 residents reviewed (Resident 38). Findings include: A facility policy for care planning, dated November 16, 2023, revealed that assessments of residents were ongoing and care plans were revised as information about the residents' conditions change. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 38, dated August 8, 2023, revealed that the resident was understood and could understand others, had a cognitive impairment, and was dependent on staff for daily care needs. A care plan for Resident 38, updated August 8, 2023, revealed that the resident was receiving a diuretic medication (water pill). Current physician's orders for Resident 38 revealed that the resident was not receiving a diuretic medication. Interview with Director of Nursing on December 8, 2023, at 08:43…

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

Based on clinical record reviews, as well as observations and staff interviews, it was determined that the facility failed to ensure that a dialysis emergency kit was at the resident's bedside for one of 32 residents reviewed (Resident 25). The findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 25, dated September 5, 2023, indicated that the resident was cognitively intact and required hemodialysis (a process of cleaning the blood of toxins and returning it into the body). Physician's orders, dated September 6, 2023, included an order for the resident to have a dialysis emergency kit containing a tourniquet, sterile gauze, gloves, etc. at the resident's bedside in order to stop bleeding in case the resident's dialysis catheter pulls out or breaks off. Observation of Resident 25 on December 7, 2023, at 9:09 a.m. revealed that she was lying in bed and had a fistula to her left arm. There was no emergency equipment at her bed side. Interview with Licensed Practical Nurse 2 on December 7, 2023, 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 clinical records, as well as staff interviews, it was determined that the facility failed to maintain accountability for controlled medications (drugs with the potential to be abused) for three of 32 residents reviewed (Residents 31, 34, 54). Findings include: The facility's policy regarding medication administration, dated November 16, 2023, indicated that staff were to document on the appropriate line of the resident's Medication Administration Record (MAR) that the medication was given. An annual Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 31, dated November 8, 2023, revealed that the resident is alert, able to make needs known, and requires assistance with all care. Physician's orders for Resident R31, dated May 12, 2023, included an order for the resident to receive one 5/325 milligrams (mg) tablet of Norco (a controlled narcotic pain medication) every six hours as needed for moderate to severe pain. Resident R31's controlled drug records for September and October 2023 indicated…

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

Based on review of facility policy and clinical records reviews, as well as observations and staff interviews, it was determined that the facility failed to label medications with the date they were opened for one of three bottles in the medication refrigerator. Findings include: The facility's policy on medication labeling and storage, dated November 16, 2023, revealed that multi-dose vials that have been opened or accessed (needle punctured) are to be dated and discarded within 28 days. Observations in the facility's medication room refrigerator on December 7, 2023, at 1:01 p.m. revealed one opened and undated bottle of Tubersol Tuberculin injection for Mantoux TB skin test (to test for tuberculosis). Interview with Registered Nurse 8 on December 7, 2023, at 1:01 p.m. confirmed that the bottle of Tubersol was not dated when it was opened, and that it should have been. Interview with the Director of Nursing on December 7, 2023, at 1:34 p.m. confirmed that the opened vial of Tubersol should have been dated when opened. 28 Pa. Code 211.9(a)(1)(h) Pharmacy services.

Based on clinical record reviews and staff interviews, it was determined that the facility failed to follow recommendations from a wound consultation for two of seven residents reviewed (Residents 1, 2). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated August 2, 2023, revealed that the resident was cognitively impaired, required extensive assistance with daily care activities, including bed mobility, was dependent for transfers, could not walk, was incontinent of bowel and bladder, had a Stage 3 pressure ulcer (full thickness tissue loss, subcutaneous fat may be visible but bone, tendon or muscle is not exposed), and had a Stage 4 pressure ulcer (full thickness tissue loss with exposed bone, tendon or muscle). The resident's care plan, dated September 19, 2022, included that the resident had pressure ulcers, and treatments were to be completed as ordered by the physician. Physician's orders for Resident 1, dated June 2, 2023, included an order for 0.25 percent acetic acid (inhibits…

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