Willow Grove Post Acute

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy and review of clinical record, it was determined that the facility failed to ensure timely and accurate medication administration for two of five residents reviewed (Resident R1, and Resident R6)Review of facility policy 'Administering medications,' revised April 2019, indicates that medications are to be administered in a safe and timely manner as prescribed. Further review of policy indicates that medications are administered in accordance with prescriber orders, including any required time frames. Review of Resident R1's electronic medication administration report (e-MAR), dated September 21, 2025, revealed an order for Carbidopa Levodopa, extended release 70-280 milligrams (mg), scheduled to be administered at 9:00 am for Parkinson's disease (progressive disease of the central nervous system). Further review of the e-MAR revealed that the medication was not administered until 3:49 pm. Continued review of the e-MAR revealed the medication Keppra, 500 mg, was scheduled to be…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility provided documentation, it was determined that the facility failed to address residents' concerns related to late call bell response time three of six residents reviewed. (Resident R3, R4, R5) Findings include:During interview with Resident R3, on Monday, December 1, 2025 at 11:10 am, room [ROOM NUMBER]-A, he reported waiting excessively long time for response from nursing staff during overnight shifts, 11 pm to 7 am.Review of facility provided grievance reports for month of November 2025 revealed care concern was submitted on November 2, 2025 regarding Resident R4, and untimely hygiene care; unidentified shift.Further review of grievance reports revealed care concern was submitted on November 2, 2025, regarding Resident R5 and call bell response time; unidentified shift.Further review of facility report submitted to the State Survey Agency, dated November 18, 2025, revealed Resident R5's concern related to waiting long periods for care, and not cleaned properly after being soiled;…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility provided documentation, interview with residents and observations, it was determined that facility did not ensure that call bells were properly functioning for one of six residents reviewed. (Resident R2) Findings include: Review of facility current policy 'Answering the Call Light,' indicates that purpose of this procedure is to ensure timely responses to the resident's requests and needs.Further review of policy indicates that staff are to ensure that the call light is plugged in and functioning at all times, and report all defective call lights promptly.During interview with Resident R2 on Monday, December 1, 2025 at 11:30 am, room [ROOM NUMBER]-B, the resident reported that his call bell had not function for a while and did not bother reporting it since (his/her) other concerns were unaddressed as well.Further observation of Resident R2's environment revealed non-functioning call bell system. 28 Pa Code 211.12(d)(1)(5) Nursing services

Based on observations, resident interviews, and staff interviews, it was determined that the facility failed to post the State Survey Agency and the State Long-Term Care Ombudsman program phone number and contact information readily accessible on the two of two nursing floors. (1st Floor, and 2nd Nursing Units) Findings include: During an observation of First Floor nursing units on May 13, 2025 at 11:44 a.m. revealed there was no posting for the required Department of Health contact information or required postings for the State Long-Term Care Ombudsman. A tour of the lobby area revealed there was a standard size page for the contact information for the State Long-Term Ombudsman in the entry way between the two glass entry doorways. Resident Council meeting was held on May 14, 2025, at 10:15 a.m. held on the second floor with four alert and oriented residents reported that they were not aware how to contact the State Department of Health or Ombudsman Office and have not seen any postings in the building. (R17, R58, R61, R77) Observations during a tour with the Director of Social…

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 interview with staff, it was determined that the facility did not ensure that care plans were revised in a timely manner related to hopsice services, enternal feeding, and intravenous device for three of nineteen records reviewed (Resident R18, R36, and R80). Findings include: Review of facility policy titled, Care Plans, Comprehensive Person-Centered revised March 2022 states, Policy Statement- 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. 12. The interdisciplinary team reviews and updates the care plan: a. when there has been a significant change in the resident's condition; b. when the desired outcome is not met; c. when the resident has been readmitted to the facility from a hospital stay; and d. at least quarterly, in conjunction with the required quarterly MDS statement. Review of Resident R18's clinical record…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record reviews, interviews with residents and staff and reviews of policies and procedures and hospital records, it was determined that the facility failed to ensure that residents with bowel and bladder incontinence received care to maintain, restore or improve bowel and bladder function for two of five residents reviewed. (Residents R8 and R41) Findings include: Review of the facility policy titled urinary continence and incontinence assessment and management dated August 2022 revealed that it was the responsibility of the staff to screen for management of individuals with urinay incontinence. The policy indicated that staff will provide appropriate services and treatment to ensure residents restore or improve bladder function and prevent urinary tract infections to the extent possible. Hosptal record review indicated that Resident R41 was admitted to the hospital on [DATE] and was treated for nephrolitiasis (kidney stones). Clinical record review for Resident R41 revealed an admission…

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 reviews of the facility assessment, staff training and competency skill sets to provide care and services to assure residents' safety and ensure that each resident attained or maintained their highest practicable well-being, it was determined that for two of two licensed nursing staff reviewed, the facility failed to have records of training and competencies available for review. (Employees E5 and E27) Findings include: A review of the facility assessment indicated that the residents at this facility were at risk for falls, required increased help with activities of daily living, had behavioral health needs, dementia and memory care needs, were prescribed psychoactive medications, had skin integrity issues, required tube feedings and pressure ulcer care. Employee E26, a registered nurse was hired on September 8, 2016. There was no annual training and competencies available for review for the resident care areas of medication administration, tube feeding administration and care, wound care assessment, monitoring and treatment and safe transfers during care. Employee E27, a…

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

Based on review of facility provided documentation and interview with staff, it was determined that facility did not ensure annual performance evaluations were completed for four of four nurse aides reviewed (Employees E24, E25 E26, and E27) Findings include: On May 14, 2025, annual performance reviews were requested from Staff Development, Employee E6 for Employees E24, E25, E26, E27. The facility did not provide the annual performance reviews requested for Employees E24, E25, E26, and E27 on May 16, 2025. Interview on May 16, 2025 at 11:26 a.m. with Staff Development, Employee E6 revealed that the facility had not completed any performance reviews for any staff for the current year (2025). Employee E6 stated that there were no record from the past year (2024), including Employees E24, E25, E26 and E27. Employee E6 stated that the old company took all of those records. When asked if the Staff Development, Employee E6 had completed any performance evaluations for the year of 2025, Employee E6 stated, No, they are not due till June so they told me to hold off on completing them.…

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, review of employee files, and staff interviews, it was determined that the facility failed to provide training upon hire on activities that constitute abuse, neglect, exploitation, and misappropriation of resident property, procedures for reporting incidents of abuse, neglect, exploitation, or the misappropriation of resident property and prevention of resident abuse for thirteen of forty employees reviewed (E11, E12, E15, E16, E17, E18, E19, E20, E21, E31, E32, E33, E34) Findings Include: Review of facility policy titled, Abuse, Neglect, Exploitation and Misappropriation Prevention Program revised April 2021 states, Policy Interpretation and Implementation- The resident abuse, neglect and exploitation prevention program consists of a facility-wide commitment and resource allocation to support the following objectives: 1. Protect residents from abuse, neglect, exploitation or misappropriation of property by anyone including, but not necessarily limited to: a. facility staff; b. other residents; c. consultants; d. volunteers; e. staff from other…

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 reviews of staff training and competency sets for nursing assistants, reviews of the facility assessment and interviews with staff, it was determined that, the facility failed to ensure that nursing assistants retained a required minimum of 12 hours of nursing training annually for two of four nurse aides record reviewed. (Employees E24 and E25). Findings include: A review of the facility assessment revealed that the residents at this facility were at risk for falls, required increased help with activities of daily living, had behavioral health needs, dementia and memory care needs, were prescribed psychoactive medications, had skin integrity issues, required tube feedings and pressure ulcer care. Employee E24, nursing assistant was hired on March 12, 2024. Annual training and competencies based on the needs of the residents (dementia care of the cognitively impaired, abuse prevention, accident prevention, restorative nursing techiques, emergency preparedness, resident rights, cultural competency) were not documented and available for review for this nursing assistant.…

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, hospital records,and facility policies and procedures, interviews with staff and residents and review of facility provided incident reports, it was determined that facility failed to ensure a complete evaluation of change in condition to address pain levels for one of 19 residents reviewed (Resident R62). Findings include: Review of facility policy 'Change in a Resident's Condition or Status,' revised February 2021, indicates that the nurse will notify the resident's attending physician or physician on call when there has been an accident or incident involving the resident; adverse reaction to medication; significant change in the resident's physical/emotional/ mental condition. The policy also indicated that a significant change in a resident's physicial, mental or psychosocial status was a deterioration in health, mental or psychocial status with clinical complications. The nursing staff and other professional staff were responsible to notify the physician with all…

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

Based on a review of facility policy and procedures, resident group interview, staff interview, and observations it was determined that the facility failed to ensure that the grievance forms were available and accessible to residents on two of two nursing units reviewed. (First Floor and Second Floor Units) Findings include: A review of facility policy titled Grievances/Complaints, Filing dated April 2017 states, Policy Statemen-Residents and their representatives have the right to file grievances, either orally or in writing, to the facility staff or to the agency designated to hear grievances (e.g., the State Ombudsman). 5. Grievances and/or complaints may be submitted orally or in writing and may be filed anonymously. 7. The administrator is the facility grievance officer. During a resident council meeting on May 14, 2025, at 10:15 a.m. held on the second floor with four alert and oriented residents reported that they were not aware how to file a grievance or where to find a grievance form at the facility. (Residents R17, R58, R61, R77) A review of a Grievance/Concern Form…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of clinical records and staff interviews, it was determined the facility failed to conduct a significant change assessment for one of nineteen residents reviewed (Resident R28). Findings include: According to the Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which provides guidance and instructions for the completion of Minimum Data Set (MDS - a federally mandated standardized assessment process conducted at specific intervals to plan resident care) assessments dated October 2023, the facility must conduct a comprehensive assessment of a resident within 14 days after the facility determines or should have determined that there has been a significant change in the resident's physical or mental condition. The RAI Manual indicates a significant change is a major decline or improvement in a resident's status that: 1. Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions, the decline is not…

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

Based on review of facility provided documentation and review of clinical record, it was determined facility did not ensure to maintain nutrition status according to professional standards of practice for a resident receiving total parenteral nutrition one of 19 residents reviewed. (Resident R71) Findings include: Review of facility policy 'Administering Medications,' revised April 2019, indicates that the individual administering medications verifies the resident's identity before giving the resident his/her medications. Methods of identifying the resident include: a. Checking identification band; b. Checking photograph attached to medical record; and c. If necessary, verifying resident identification with other facility personnel Review of Resident R71's clinical record revealed that the resident, was awake alert and oriented x 3 (people, place and time), with medical history of hypokalemia (disorder of low potassium), cardiac arrest, hypomagnesemia, tracheostomy (tube inserted through the neck to assist with breathing) status, diabetes type 2 (failure of the body to produce…

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, review of facility policy and interviews with staff, it was determined that the facility failed to maintain effective communication with a dialysis provider for one of two residents reviewed. (Residents R74) Findings Include: Review of facility policy titled End-Stage Renal Disease, Care of a Resident with with a revision date of September 2010 states, 4. Agreements between this facility and the contracted ESRD facility include all aspects of how the resident's care will be managed, including: a. how the care plan will be developed and implemented: b. how information will be exchanged between the facilities. Review of Resident R74's quarterly MDS (Minimum Data Set - a mandatory periodic resident assessment tool) revealed that the resident was admitted to the facility on [DATE], with the diagnosis of End Stage Renal Disease. On May 15, 2025 at 2:02 p.m., Resident R74's dialysis communication with the facility was requested. A binder containing communication sheets with 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and interviews with staff, it was determined that the facility did not ensure that a physician assessment was completed related to unplanned weight loss for one of nineteen residents reviewed (Resident R28). Findings include: Review of clinical documentation for Resident R28 revealed that she was re-admitted to the facility on [DATE] and had diagnoses of; Muscle Wasting and Atrophy, Dysphagia, and Dementia. Review of the resident's weight documentation revealed that on August 9, 2024, the resident weighed 175.4 pounds on November 19, 2024. The resident was weighed again on January 7, 2025, and weighed 171. The resident was weighed again a week later on January 14, 2025, and the resident weighed 155 pounds. Review of Resident R28's Weight Change Note from January 15, 2025 states, Resident now triggered for significant weight change. History of Dementia and confusion noted. Resident with poor intake and refuses some food and drinks. Her intakes are poor to fair per 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.

Based on reviews of policies and procedures, observations of the outdoor loading and receiving area and interviews with staff, it was determined that the facility was not disposing of garbage and refuse properly. Findings include: A review of the policy titled cleaning and sanitizing of the food service areas, it was indicated that the food service director was responsible for devising a comprehensive cleaning schedule for dietary staff to complete daily. The director of dietary services was to determine all cleaning and sanitation tasks needed for the operation of the food and nutrition services department. frequency of cleaning as necessary. The director of dietary services was responsible for posting a cleaning schedule for all cleaning tasks, and staff will initial the tasks as completed. The policy indicated that staff will be held accountable for cleaning assignments. A review of the cleaning schedules and responsibilitites of the dietary staff to include the proper disposal of the kitchen garbage and trash revealed that there was no comprehensive cleaning schedule developed…

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 an environmental tour and observations of the food and nutrition services department, interviews with staff and reviews of equipment purchase orders, it was determined that the facility was not maintaining essential equipment for the dietary services department in safe operating condition. Findings include: Observations of the ice machine located in the food and nutrition department revealed that it was not functioning. Interviews with the maintenance director, Employee E26, at 10:30 a.m., on May 13, 2025 revealed that the ice machine inside the main kitchen of the food and nutrition services department had been out of service since, January, 2025. Interview with the director of dietary services, Employee E36 confirmed that the essential equipment (industrial-sized ice maker machine) had not been operational for months. A work order was placed in January, 2025 to repair the ice machine. The director of dietary services said that the dietary staff were forced to use the second floor nursing units' ice machine or have ice delivered in bags from an outside vender. A review 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations of the food and nutrition department, reviews of policies and procedures and interviews with staff, it was determined that the facility failed to maintain an an effective pest control program in the dietary department. Findings include: A review of the undated facility policy titled pest control revealed that it was the responsibility of food service director to take appropriate action to eliminate pests in the main kitchen. The policy indicated that a pest control contractor would be contacted to complete preventative treatments at appointed times. The pest control operator would be contacted to visit the facility. The pest control contractor will document all visits along with actions taken. Pest traps and chemical treatments will be done by the certified pest control operator. Observations of the main kitchen at 10:00 a.m., on May 13, 2025 were made with Employee E37, the director of dietary services. The main kitchen of the food and nutrition service department was considered 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 resident interviews and review of facility policy, it was deteremined that the facility failed to ensure that there was a routine process to ensure that the call bells systems was fincition and that call bells were answered in a timely manner during the weekends on two two nursing floors. (1st and 2nd Floor) Findings include: Review of facility's policy 'Call Lights,' revised on 06/01/2021, states that .patients will have a call light or alternative communication device within their reach at all times when unattended. Staff will respond to call lights and communication devices promptly. Interview with Residents R2 and R3 on Monday, December 9, 2024 at 10:00AM, on second floor unit, revealed complaints related to late responses from nursing staff when using call bells. Review of facility provided grievance log for months of November 2024 and December 2024 revealed a concern, dated November 11, 2024, related to long call bell wait times. Concern dated December 6, 2024 was related to call bells were on but nursing staff were on their phones. Review of facility provided call…

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 record and review of facility provided documentation, and interview with staff, it was determined facility failed to ensure complete documentation related to treatment administration for one of three clinical records reviewed. (Resident R1) Findings include: Review of faciltiy's policy 'Treatments,' revised on 06/01/2021, indicates that a licensed nurse or medical technician will perform treatment as ordered, and document administration on 'Treatment Administration Record' (TAR), patient's response, patient's refusal of treatment, and notification of physician. Review of Resident R1's clinical record revealed a physician order obtained on July 11, 2024 for Hydrocortisone External Cream 2% to be applied to upper chest and back topically two times a day for rash with start date of 07/11/2024 at 11:00 PM and discontinued date of 07/18/2024 at 10:18 AM. Review of Resident R1's TAR revealed no documented evidence of the administration of Hydrocortisone cream on July 12, 2024 morning and evening shift, July 13, 2024 evening shift, July 14, 2024 evening shift,…

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, review of facility policy, observation, and staff and resident interview, it was determined that the facility failed to ensure that all drugs and biologicals were safely stored for three of three residents reviewed (Resident R3, R4 and Resident R5). Findings include: Observation of the Resident R3's room conducted on September 9, 2024, at 10:49 a.m. during the tour revealed Fluticasone nasal spray on resident's bed side table. Review of clinical record for Resident R3 revealed no evidence that the facility conducted an assessment for Resident R3 for safe self administration of medication or care planned to store medication in his room. Observation of the Resident R4 room conducted on September 9, 2024, at 11:00 a.m. during the tour revealed 1 bottle of Nystatin antifungal powder and 2 Albuterol inhaler on resident's bed side table. Review of clinical record for Resident R4 revealed no evidence that the facility conducted an assessment for Resident R4 for safe self-administration of medication or care planned to store medication in her room.…

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 observation and interviews with staff, it was determined that the facility failed to equip corridors with safe handrails on each side, for two of two nursing units observed (First and Second floor nursing units). Findings include: Observation of the corridor handrail revealed the following findings: There was loose/missing/broken handrail in the corridor next to room [ROOM NUMBER] (missing end piece). There were loose/broken handrail next to resident room [ROOM NUMBER], 219, 216, 213, 224, 221, 223, 228, 227, 116, 122, 123, 124 and first shower room. Interview on September 9, 2024, at 12:00 p.m. the Nursing Home Administrator confirmed that handrails were broken or missing, and she would have the maintenance correct the issue. 28 Pa Code 201.14(a) Responsibility of licensee

Based on review of facility policy, clinical records reviewed, and staff interview, it was determined that the facility failed to inform a resident's representative in advance of the proposed care, including the risk and benefits of the prescribed medication for one out of three sampled residents (Resident R1). Findings include: Review of Resident R1's MDS assessment (MDS-Minimum Data Set assessment: periodic assessment of resident care needs) dated August 21, 2024, indicated the diagnose of cognitive impairment (a condition impacting decision making and memory), and dementia (a decline in cognitive abilities that can impact a person's ability to perform everyday tasks). Further review of the MDS indicated that the resident BIMS (Brief Interview for Mental Status) assessment was not completed due to poor cognitive status. Review of Resident R1's care plans dated August 15, 2024, indicated impaired/decline in cognitive function or impaired thought processes related to a condition other than delirium: Dementia. Review of physician progress note dated August 15, 2024, revealed that…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, and resident and staff interviews, it was determined that the facility failed to maintain a safe, clean, homelike environment on two of two nursing units (First floor and Second floor). Findings include: An initial tour of the facility on September 9, 2024, 10:00 a.m. revealed the following observations. Observation of facility room [ROOM NUMBER] revealed there were strong odor of urine in the room, the commode was not emptied and cleaned, there were urine, feces, and bathroom tissue in the commode. Interview with the Resident R2 at the time of the observation stated it was from the night before. Observation of facility room [ROOM NUMBER] revealed there were trash on the floor, under the bed such as used medicine cups, alcohol wipes, gauze and tape with blood dripping to the floor, there was yellow stain on the sheet near the foot of the bed, used PICC line dressing cleaning materials, old foam coffee cup with dried stain outside appeared from the day before. Interview with the Employee…

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, review of facility policies, clinical record reviews and interviews with residents and staff, it was determined that the facility failed to provide care and assessments consistent with professional standards of practice related to intravenous therapy for three of four residents reviewed for intravenous therapy (Residents R5, R58 and R265). Findings include: Review of facility policy, Assessment of the Patient Receiving IV Therapy [intravenous therapy - therapy that delivers liquid substances directly into a vein] dated September 2022, revealed, Assess vascular access device function by aspirating for a blood return and flushing prior to each intermittent use (intermittent medication administration) and as clinically indicated with continuous infusions. Assess the catheter insertion site and surrounding area for redness, tenderness, swelling, and drainage by visual inspection and palpation through the intact dressing. Recommended minimum assessment of midlines and central venous access…

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, review of the Pennsylvania Nurse Practice Act, clinical record reviews, review of personnel files and interviews with residents and staff, it was determined that the facility failed to assure that nursing staff possess the competencies and skill sets necessary to provide nursing and related services to meet the residents' needs for five of five personnel files reviewed for competency evaluations (Employees E11, E12, E13, E14 and E15) and for four of four residents reviewed for intravenous therapy (Residents R5, R58, R265 and R266.) Findings include: Review of the Pennsylvania Nurse Practice Act for Registered Nurses (RNs), 49 Pa Code 21.12, revealed that, Performing venipuncture and administering and withdrawing intravenous fluids are functions regulated by this section, and these functions may not be performed unless: . (3) The registered nurse who administers parental fluids, drugs or blood has had instruction and supervised practice in administering parental fluids, blood or medications into the vein. Review of the Pennsylvania Nurse Practice Act 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of clinical records, review of facility policy and facility documentation, and staff interviews, it was determined the facility failed to implement a complete drug regimen review process for three of three residents reviewed (Resident R16, R5 and R270). Findings Include: Review of the facility policy, Medication Monitoring, Medication Regimen Review (MRR) and Reporting revealed that the Drug Regimen Review is a thorough evaluation of the medication regiment of a resident. And that the resident-specific MRR recommendations and findings are documented and acted upon by the nursing care center and/or physician. Review of Resident R16's clinical record revealed that resident was admitted on [DATE], with diagnoses including glaucoma (condition where the eye's optic nerve, which provides information to the brain, is damaged with or without raised intraocular pressure. If untreated, this will cause gradual vision loss). A review of the July 31, 2024, pharmacy recommendation for Resident R16 revealed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, review of facility policies, review of facility documentation, clinical record reviews and interviews with residents and staff, it was determined that the facility failed to maintain an effective infection control program related to infection surveillance for three of five residents reviewed with infections (Residents R5, R16 and R56), infection data reporting and infection committee meetings as required. Findings include: Review of facility policy, Infection Control Outcome and Process Surveillance and Reporting, dated revised March 1, 2024, revealed, The Infection Preventionist will conduct regular outcome surveillance which consists of collecting/documenting data on individual cases and comparing collective data to standard, written definitions of infection. Observation, on August 12, 2024, at 11:15 a.m. revealed that Resident R5 had a PICC line (peripherally inserted central catheter - a thin soft tube inserted in a vein in the arm with the tip of the tube positioned in a large vein…

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, review of facility policies, review of facility documentation, clinical record reviews and interviews with residents and staff, it was determined that the facility failed to maintain an effective antibiotic stewardship program for five of five of residents reviewed for antibiotics (Residents R5, R16, R56, R266 and R265). Findings include: Review of facility policy, Antibiotic Stewardship dated July 1, 2024, revealed, Centers will implement an Antibiotic Stewardship Program that include antibiotic use protocols and systems for monitoring antibiotic use. Observation, on August 12, 2024, at 11:15 a.m. revealed that Resident R5 had a PICC line (peripherally inserted central catheter - a thin soft tube inserted in a vein in the arm with the tip of the tube positioned in a large vein that carries blood to the heart) in his right upper arm. Interview, at the time of the observation, Resident R5 stated that he received antibiotic therapy daily through his PICC line. Review of Resident R5'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 with staff, it was determined that the facility failed to notify the Office of the State Long-Term Care Ombudsman of facility-initiated emergency transfers and discharges as required. Findings include: Documentation of notification to the Office of the State Long-Term Care Ombudsman of facility-initiated emergency transfers and discharges for the past three months was requested on August 15, 2024, at 12:45 p.m. from Employee E1, Nursing Home Administrator (NHA). Interview with NHA on August 15, 2024, at 1:50 p.m. confirmed that the facility did not send the notification to the Office of the State Long-Term Care Ombudsman of facility-initiated emergency transfers and discharges for the past three months. She indicated that this function will be done by the new social worker going forward. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(2) Management

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, review of facility policies, clinical record review and interviews with residents and staff, it was determined that the facility failed to develop a baseline care plan that includes the instructions needed to provide effective and person-centered care within 48 hours of admission for two of four residents reviewed for intravenous therapy (therapy that delivers liquid substances directly into a vein) (Residents R5 and R58). Findings include: Review of facility policy, Person-Centered Care Plan dated last revised October 24, 2022, revealed, A baseline care plan must be developed within 48 hours and include the minimum healthcare information necessary to properly care for a patient. Observation, on August 12, 2024, at 11:15 a.m. revealed that Resident R5 had a PICC line (peripherally inserted central catheter - a thin soft tube inserted in a vein in the arm with the tip of the tube positioned in a large vein that carries blood to the heart) in his right upper arm. Interview, at the time 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of clinical records, facility policies and documentation, and interviews with staff, it was determined that the facility failed to develop and implement comprehensive person-centered plans of care in a timely manner, for two of 21resident records reviewed (Residents R16 and R27). Findings include: Review of facilities policy, Person Centered Care Plan, revised October 24, 2022, revealed that a comprehensive, individualized care plan will be developed within seven days after completion of the comprehensive assessment (admission, annual or significant change) and review and revise the care plan after each assessment. Review of Resident R16's clinical record revealed that resident was admitted on [DATE]. Further review of Resident R16's admission MDS (Minimum Data Set- assessment of resident's needs) dated July 31, 2024, section title Health Conditions, revealed that Resident R16 had shortness of breath or trouble breathing when lying flat. Observation Resident R16 conducted on August 12, 2024, at…

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

Based on staff interviews, review of facility policy and the review of clinical records, it was determined that the facility failed to ensure that activities of daily living related to bathing was provided for one out of 26 residents reviewed (Resident R48). Findings include: Review of the facility policy, Activities of Daily Living, with a revision date of May 1, 2023, indicated that when patients are assessed upon admission, quarterly and with a significant change to identify their status of activities of daily living, their inability to perform activities of daily living, their risk of decline in any activity of daily living and the resident's ability to improve in the identified activity of daily living (e.g. bathing, showering, toileting, eating, walking, transferring). The policy also indicated that adl (activities of daily living) care will be recorded in the resident's medical record, is reflective of the care provided by nursing staff, will be documented as close to the time that the care was provided and documented on every shift by thee nursing assistant. Review 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, review of facility policies, clinical record review and interviews with staff, it was determined that the facility failed to obtain and follow physician orders related to diet, urinary catheters and wound care for two of 26 residents reviewed (Residents R168 and R265). Findings include: Observation on August 12, 2024, at 10:17 a.m. revealed that Resident R265 had a dressing on her right knee; the dressing was dated August 9, 2024, at 8 p.m. Review of Resident R265's admission Assessment, dated August 7, 2024, at 3:00 p.m. revealed that the resident was admitted to the facility on [DATE], with a diagnosis of right knee septic arthritis (infection of the knee). Review of physician's orders for Resident R265, revealed an order, dated August 9, 2024, to cleanse right knee surgical incision with normal saline, pat dry, then apply clean dry dressing daily; monitor for any signs or symptoms of infection or drainage from suture site. Continued observation and interview on August 12, 2024, at 10:51…

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 staff interviews and the review of clinical records, it was determined that the facility failed to maintain complete and accurate records related to dialysis communication for one of one dialysis residents reviewed (Resident R48). Findings include: Review of Resident R48's clinical record revealed that the resident was admitted to the facility on [DATE], and that Resident R48 had diagnoses of End-Stage Renal Disease (a medical condition in which a person's kidneys cease functioning on a permanent basis leading to the need for a regular course of long-term dialysis or a kidney transplant to maintain life). Review of Resident R48's physician order, dated July 26, 2024, revealed that Resident R48 received dialysis treatment at an outpatient dialysis facility on Mondays, Wednesdays, and Fridays on 7/29/24; 8/5/24; and 8/7/24. Review of Resident R48's Hemodialysis Communication Record revealed that on July 29, 2024, and on August 5, 2024, it was lacking all the information to be completed by licensed nurse…

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

Based on a review of facility documentation and interviews with staff, it was determined that the facility failed to complete performance reviews for three of three nurse aides personnel files reviewed related to performance reviews as required (Employees E16, E17 and E18). Findings include: Review of facility documentation pertaining to current employees, revealed that Employee E16 was hired by the facility as a nurse aide on July 8, 2002; Employee E17 was hired as a nurse aide on April 19, 2022; and Employee E18 was hired as a nurse aide on December 30, 2019. On August 13, 2024, at 11:54 a.m. annual performance reviews for Employees E16, E17 and E18 were requested from the Nursing Home Administrator and Director of Nursing. Interview on August 14, 2024, 10:06 a.m. the Nursing Home Administrator revealed that the facility had not completed any performance reviews for any staff, including Employees E16, E17 and E18. 28 Pa. Code 201.19(2) Personnel policies and procedures

Based on observations, review of clinical records, and interviews with facility staff, it was determined that the facility failed to ensure that it was free of medication error rate of five percent or greater for one of three residents observed during medication administration. (Resident R220) Findings include: Observations conducted of medication administration on August 12, 2024, 9:20 a.m., with Registered Nurse , Employee E9, revealed that Resident R220 ordered Metoprolol Tartrate Oral Tablet 25 MG (Metoprolol Tartrate), Give 1 tablet by mouth two times a day for Tachycardia; Rosuvastatin Calcium Oral Tablet 20 MG (Rosuvastatin Calcium), Give 1 tablet by mouth one time a day for HLD; Sertraline HCl Oral Tablet 100 MG (Sertraline HCl), Give 1 tablet by mouth one time a day for depression. Registered Nurse , Employee E9, did not administered the medications listed above to Resident R220. Employee E9 stated that the Metoprolol Tartrate Oral Tablet 25 MG, Rosuvastatin Calcium Oral Tablet 20 MG, and Sertraline HCl Oral Tablet 100 MG were not available at that time. (Metoprolol…

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 reviews and interviews with staff, it was determined that the facility failed to offer pneumococcal vaccines for two of five residents reviewed for vaccinations (Residents R46 and R37). Findings include: Facility polices for influenza and pneumococcal vaccines were requested from facility administrative staff on August 12, 2024, at 10:00 a.m. The policies were requested again on August 12, 2024, at 2:23 p.m.; August 13, 2024, at 12:21 p.m. and August 14, 2024, at 2:43 p.m. The policies were not provided for review at any the time during the survey. Clinical record review for Resident R46 revealed that the resident was admitted to the facility on [DATE]. Continued review revealed that there was no indication in Resident R46's clinical record that the resident was offered the pneumococcal vaccine. Review of hospital records, dated August 15, 2024, revealed that the resident was due for a pneumococcal vaccine but has never received one. Clinical record review for Resident R37 revealed that…

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

Based on observations and staff interviews, it was determined that the facility failed to ensure that resident bathrooms were equipped with the appropriate call bell system for 3 out of 25 residents reviewed (Rooms 100,102 and 104) Findings include: During interview with the maintenance assistance, Employee E24 and the Nursing Home Administrator (NHA) on August 14, 2023 at 3:54 p.m. it was reported that the call bell system has been broken for the following rooms: 116, 100 102, 104, and 104. Rooms 100, 102 and 104 were confirmed to be currently occupied by residents. Continued interview with the maintenance assistance and the NHA revealed that all three residents were provided with a handheld call bell system with a lanyard attached so that they can wear it around their neck. During an observation in rooms 100 (Resident 315), 102 (Resident 26) and 104 (Resident R51) on August 14, 2024, at 11:00 a.m. the above referenced rooms were toured and the call bell system in the bathroom of each room also did not work to ensure that when the residents are utilizing that bathroom, they have a…

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

Based on review of personnel files, facility documentation and interviews with staff, it was determined that the facility failed to ensure that an effective training program was maintained as required for five of ten staff reviewed related to training (Employees E20, E18, E11, E14 and E15). Findings include: Review of the Facility Assessment, dated reviewed July 1, 2024, revealed that, Staff training/education and competencies are necessary to provide support and care needed for the facility's short term resident population. Continued review revealed that required training topics include: effective communications; resident's rights; abuse, neglect and exploitation; infection control; and identification of resident changes in condition. Review of facility documentation pertaining to current employees, revealed that Employee E20 was hired by the facility as a licensed practical nurse on May 28, 2019, Employee E18 was hired as a nurse aide on December 30, 2019, Employee E11 was hired as a nurse aide on July 16, 2024, Employee E14 was hired as a nurse aide on July 2, 2024, and Employee…

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 interviews, review of clinical records and review of resident grievances, it was determined that the facility failed to provide a summary of the pertinent findings or conclusions regarding the resident's concerns(s), a statement as to whether the grievance was confirmed or not confirmed, any corrective action taken or to be taken by the facility as a result of the grievance, the date the written decision was issued; and evidence that the resident was notified of the outcome of their grievance for 1 out of 3 residents reviewed (Resident R1): Findings include: Review of the facility policy, Grievance/Concern, with a revision date of January 8, 2024, indicated that the Nursing Home Administrator (NHA) will serve as the Grievance Officer who is responsible for overseeing the grievance process, receiving and tracking grievances through to their conclusion, leading any necessary investigations by the facility, and maintaining the confidentiality of all information associated with grievances. The policy also indicated that the NHA was responsible for issuing written grievance…

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 interviews with staff, it was determined that the facility failed to ensure a safe and orderly discharge planning process for five of seven discharge records reviewed. (Resident R1, R2, R3, R4 and R5) Findings include: Clinical record review for Resident R1 revealed that this resident was admitted to the facility on [DATE], from an acute care hospital for treatment and rehabilitation after recovering from pneumonia and respiratory failure. Review of Resident R1's electronic medical record revealed an April 18, 2024, progress note written by Licensed nurse, Employee E8, at 10:51 p.m. indicating that Resident R1 was discharged . Further review revealed a note written on April 19, 2024, at 5:15 p.m., a day after the resident was discharged , by Employee E9, Respiratory Therapist (RT), indicating that she spoke to the durable medical equipment (DME) supplier who informed me that they did not receive the original order for trach set up supplies other then her spare trach, inner…

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 reviews of policies and procedures, interviews with staff, review of clinical records and reviewss of hospital records, it was determined that for one of two residents reviewed for weight loss, the facility failed to ensure that each resident maintained acceptable parameters of nutritional status for usual body weight. (Resident R1) Findings include: A review of the facility's policies and procedures titled weights and heights dated June 15, 2022, it was revealed that each resident would be weighed by the nursing staff upon admission to the facility. The nursing staff were also responsible for obtaining weekly weights after the resident was admitted to the facility for one month. The weights were to be documented in each resident's clinical record. Clinical record review for Resident R1 indicated that this resident was admitted to the facility on [DATE]. There was no documentation to indicate that the nursing staff obtained a weight upon admission for Resident R1. Clinical record review 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, interviews with staff, reviews of the pharmacy delivery schedule, hospital record and policy and procedure reviews, it was determined that the facility failed to acquire and dispense medications as ordered by the physician for one of three residents reviewed. (Resident R1) Findings include: A review of the policies titled Pharmacy Services dated Janaury 1, 2022 it was detailed that the licensed nurse receives orders for medications and treatments from the physician. The licensed nurse was responsible for verifying the orders for medications and treatments with the physician. The licensed nurse was responsible for reconciling orders for medications and treatments with the physician upon admission of the resident to the facility. Upon admission/readmission to the facility the licensed nurse was to communicate by sending the electronic prescriptions for medication and treatments to the pharmacy services. The policy also indicated that some complex orders such as titration orders, infusion therapy orders, wound care orders or alternating dosing orders…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of clinical records and interview with staff, it was determined that the facility failed to provide resident with measures to prevent the development of or worsening of pressure injury for one of 25 residents reviewed (Resident R59) Findings include: Review of clinical record revealed that Resident R59 was admitted to the facility on [DATE], with diagnoses of Cerebral Infarction, CVA (Cerebrovascular Accident) with left facial droop and left sided weakness upper and lower extremity. COPD (Chronic Obstructive Pulmonary Disease), Muscle Weakness and Cognitive Communication Deficit. Resident R59 was discharged to home on September 13, 2023. Review of nursing admission progress note dated August 22, 2023, revealed that Resident R59 was extensive assist with turning, bed mobility, and repositioning. Further, Resident R59 was incontinent of bowels had Foley indwelling cath. 18 French with a 10cc balloon that was intact and draining hematuria (blood in the urine). Review of Resident R59's admission MDS…

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 poilicy, review of United States Food and Drug Administration (FDA) policy and interview with staff, it was determined that the facility failed to ensure the proper sanitation of the kitchen related to a staff members pet confined into a office within the kitchen. Findings include: Review of the facility's policy titled Animal Visitation/Animal Facilitated Treatment revised August 7, 2023 revealed that the purpose was to provide a safe and organized animal visitation and/ or animal facilitated program. The policy states 2.6.1 Be prohibited from being present in food preparation or serving areas clean linen storage spaces. Review of the united Stated Food and Drug Administration Food Code Policy, U.S. Public Health Service dated 2017, Chapter 2-403, page 54 states (A) Except as specified in ¶ (B) of this section, food employees may not care for or handle animals that may be present such as patrol dogs, service animals, or pets that are allowed as specified in Subparagraphs 6-501.115(B)(2)-(5). Pf. Interview with Dietary Director, Employee E4 on August 25, 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.