Mountain City Nursing & Rehabilitation Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, review of select facility incident reports and clinical records, and staff interview, it was determined that the facility failed to provide adequate supervision and maintain an environment free of accident hazards to prevent a minor injury (a cut to the thumb) sustained by one of 11 sampled residents (Resident 65). Findings include: A review of clinical record revealed that Resident 65 was admitted to the facility on [DATE], with diagnoses which included chronic alcoholism and hypertension. A review of the resident's Quarterly Minimum Data Set Assessment (MDS - a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated June 10, 2024, indicated the resident was moderately cognitively impaired with a BIMS (brief screener that aids in detecting cognitive impairment) score of 8 (a score of 8-12 indicates moderate cognitive impairment). A review of the resident's current care plan revealed that the resident did have a self-care deficit and required…

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

Based on review of select facility policy and staff interview, it was determined the facility failed to ensure that nursing staff possessed the appropriate competencies and skill sets to conduct a thorough resident assessment of residents following an incident of sexual abuse involving two out of 11 residents reviewed (Resident 16 and Resident 91) Findings include: A review of the facility's policy entitled Pennsylvania Resident Abuse last reviewed by the facility August 2023, indicated that after an allegation of sexual abuse The resident's attending physician should be notified if an incident has occurred requiring physician involvement. If appropriate, the facility should send the resident to the hospital for an examination. The facility will contact the police for any allegation of misappropriation of resident property. Administrator or designee will notify police when the facility receives a complaint of, or suspect sexual abuse, serious bodily injury or suspicious death in Allegations of Sexual Abuse every effort will be made to preserve evidence on both the resident and the…

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

Based on review of the facility's plan of correction from the survey of April 19, 2024, and the findings of the survey ending July 10, 2024, it was determined that the facility's Quality Assurance Performance Improvement (QAPI) committee failed to develop and implement corrective action plans to prevent a continued quality deficiency related to abuse prohibition to ensure that plans designed to improve the delivery of care and services were consistently implemented to effectively deter future quality deficiencies. Findings include: During a standard survey completed at the facility on April 19, 2024, deficient facility practice was identified under the requirement for residents to be free from abuse and neglect. In response to this quality deficiency the facility developed a plan of correction, to include a quality assurance monitoring component to ensure that solutions were sustained. This plan was to be completed by May 14, 2024. In response to the quality of care deficiency cited during the survey of April 19, 2024, related to the facility's failure to prevent resident abuse 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 a review of clinical records, select facility policies, investigate reports, and employee job descriptions it was determined the facility's administration failed to effectively use its resources to promote resident safety by failing to implement established procedures to monitor resident whereabouts and prevent an elopement for one out of 16 sampled residents (Resident 181 ). Findings include: Based on review of clinical records and select facility policy, observations, and staff and resident interviews it was determined that the facility failed to provide necessary supervision and effective safety measures to monitor a resident's whereabouts and prevent an elopement by one resident (Resident 181) out of 14 sampled residents, placing the 65 residents out of 238 residents residing in the facility, identified at risk for elopement, including Resident 142, in immediate jeopardy to their health and safety. A review of the job description for the Administrator of the facility revealed that the Administrator leads and directs the overall operations of the facility in accordance…

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 clinical records, and resident and staff interview it was determined that the facility failed to provide care in a manner and environment, which promotes each resident's quality of life by failing to respond timely to residents' requests for assistance as reported by two residents out of 14 residents sampled (Residents 14 and Anonymous Resident 1). Findings include: During interview On May 31, 2024, at 11:40 AM with Anonymous Resident 1 ( resident who preferred to remain anonymous for fear of retaliation), the cognitively intact resident stated that over the past weekend on the second shift he/she waited an hour for staff to answer the call bell to be answered and his/her brief to be changed. The resident stated that wait times seem to be longer when agency staff are working. Clinical record review revealed that Resident 14 was admitted to the facility on [DATE], with diagnoses which included diabetes and hypertension. The resident was cognitively intact. During interview on May 31, 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of clinical records and select incident reports, observation, and staff interview, it was determined that the facility failed to provide dependent residents with the necessary feeding assistance to promote safe swallowing for one of 14 residents sampled (Resident 196). Findings include: Review of Resident 196's clinical record revealed that the resident was admitted to the facility on [DATE], with diagnoses to have included dysphagia (difficulty swallowing). Review of Resident 196's care plan initiated March 5, 2024, revealed the problem of self-care deficit with an intervention for staff assistance of one person for eating. The resident had a physician order dated March 27, 2024, for a pureed texture diet, nectar consistency liquids. Review of an incident revealed that the resident was coughing during the dinner meal on April 21, 2024, and the resident coughed up a small piece of shrimp. The incident report included employee witness statements, and none of the employees interviewed as…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of clinical records and select facility policy, and resident and staff interview, it was determined that the facility failed to ensure the provision of a nourishing (satisfying to the resident) evening snack for one resident out of 14 sampled (Resident 14). Findings include: Review of the facility Nourishment and Supplement Policy last reviewed August 21, 2023, indicated that the facility will assure a supply of nourishments such as snacks between meals, and supplements that have been ordered are available. Clinical record review revealed that Resident 14 was admitted to the facility on [DATE], with diagnoses which included diabetes and hypertension. During an interview with Resident 14 on May 31, 2024, at 12:00 PM the resident stated that he has diabetes and feels that a bedtime snack would be beneficial to help control his blood sugars and to keep him from getting too hungry between supper and breakfast the next day. Resident 14 stated that he had requested a bedtime snack over the last four…

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

Based on observation and staff interview, it was determined that the facility failed to maintain acceptable practices for the storage and service of food to prevent the potential for contamination and microbial growth in food, which increased the risk of food-borne illness in the food and nutrition services department and one of five resident pantries. Findings include: Food safety and inspection standards for safe food handling indicate that everything that comes in contact with food must be kept clean and food that is mishandled can lead to foodborne illness. Safe steps in food handling, cooking, and storage are essential in preventing foodborne illness. You cannot always see, smell, or taste harmful bacteria that may cause illness according to the USDA (The United States Department of Agriculture, also known as the Agriculture Department, is the U.S. federal executive department responsible for developing and executing federal laws related to food). Review of the facility policy titled Food Brought in from Outside the Facility last reviewed by the facility January 16, 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and staff interview, it was determined that the facility failed to maintain a clean and orderly environment on four of five resident units (Nursing Unit 2, 3, 4, 5 in the blue and white buildings) Findings include: Observations on April 16, 2024, at approximately 11:15 AM of the Unit 4 second floor of the blue building revealed the following: The closet door handles were broken off and the door was unable to open or close properly with several items on the floor inside the closet of resident room [ROOM NUMBER]. There were two large bags observed on the floor that contained several personal items that included food. The bathroom had a strong urine smell. In the hallway exiting this room there was a strong odor of feces. A ceiling block was missing directly above an occupied resident bed in resident room [ROOM NUMBER]. There was an unattended wheeled cart, a toolbox, tools and the ceiling block with dirt and debris covering the floor in this room room [ROOM NUMBER] was noted to have two large…

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 select facility policy and staff interviews, it was determined that the facility failed to make information and forms accessible regarding the facility's grievance/complaint process and the residents' rights to file a grievance anonymously in prominent locations on four of seven floors in the facility (blue and white buildings). Findings include: Review of the facility's policy titled Concern Resolution and Grievance Procedure last reviewed by the facility on January 16, 2024, indicated that each resident has the right to file grievances orally (spoken) or in writing, and the right to file grievances anonymously. If choosing to report anonymously, residents can fill out a Concern/Grievance Form located on each floor in each lobby. Once the form is completed, residents can place it in the black boxes located on each floor on each lobby. Observation of the Blue building first-floor nursing unit on April 19, 2024, at 10:10 AM revealed there were no postings to indicate the location of grievance forms, the process of filing a grievance, the expectation…

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 select facility policy and clinical records, observations, and staff interview it was determined that the facility failed to consistently administer oxygen as ordered and maintain sanitary oxygen delivery systems for six out of 35 sampled residents (Resident 8, 26, 48, 59, 64 and 124). Findings included: According to the American Thoracic Society, O2 is a medication that requires a prescription from a healthcare provider. The provider will prescribe your O2 at a specific flow rate and a specific number of hours per day. It is very important that O2 is used as prescribed. Using too little O2 may put a strain on the heart and brain, causing heart failure, fatigue, or memory loss. Using too much O2 can also be a problem. For some patients, using too much O2 can cause them to slow their breathing to dangerously low levels. It is important to wear O2 as your provider ordered it. If the patient starts to experience headaches, confusion, or increased sleepiness after using supplemental O2, the patient may 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 observations, a review of clinical records and facility investigations, and staff interview, it was determined that the facility failed to provide sufficient staff, providing direct services to residents, who possess the necessary competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident as evidenced by three residents out of 35 sampled (Residents 213, 214, and 188). Findings include: Review of clinical record of Resident 213 revealed that the resident was admitted to the facility on [DATE], with diagnoses including dementia. A 5-Day/admission Minimum Data Set assessment (MDS- a federally mandated standardized assessment process completed at specific intervals to plan resident care) dated February 14, 2024, indicated that Resident 213 was severely cognitively impaired with had a BIMS (brief screener that aids in detecting cognitive impairment) score of 1.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, a review of select facility policy, clinical records and reports, and staff interviews, it was determined that the facility failed to develop and/or implement individualized plans to manage residents' dementia-related behavioral symptoms to promote resident safety and highest practicable physical and mental well-being for four residents out of 35 sampled (Residents 138, 213, 221 and 225). Findings include: Review of a facility policy entitled Dementia Care Services Policy with a review date of January 16, 2024, indicated that residents who are diagnosed with forms of dementia will receive the appropriate treatment and services to attain or maintain their highest practicable physical/mental/psychosocial wellbeing. Staff will demonstrate competencies and skills to support residents through the implementation of individualized approaches to care (including direct care and activities) that are focused on understanding, preventing, relieving and or accommodating a resident's distress or loss 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 staff interviews and a review of the facility's assessment and the medical, psychiatric, and mental health conditions of the resident census it was determined that the facility failed to conduct and document a facility wide assessment, which identified the specific resources necessary to care for its specific resident population. Findings include: At the time of the survey ending April 19, 2024, the facility had completed a facility assessment to determine the specific and unique needs of its resident population. Following surveyor inquiry, the facility provided a Facility Assessment document last reviewed January 9, 2024, which identified that the facility's average daily census was 232 residents. The number/average or range of residents with behavioral health needs was 20 to 30. A review of facility documentation as of the date of the survey ending April 19, 2024, revealed that there were 73 residents with Alzheimer's disease/dementia and 54 residents with a mental disorder, intellectual disability, or related condition. Review of facility documentation 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 review of clinical records and staff and resident interview, it was determined that the facility failed to incorporate preferred resident schedules into the residents' daily routine and to allow resident to make choices about aspects of their life that were important to them as evidenced by three of 35 sampled residents (Resident 19, 26 and 64). Findings include: Review of Resident 19's clinical record revealed that the resident was admitted to the facility on [DATE], with diagnoses of hemiplegia (paralysis of one side of the body) unspecified side and chronic obstructive pulmonary disease ([COPD]a respiratory disease characterized by persistent respiratory symptoms like progressive breathlessness and cough). An annual Minimum Data Set ([MDS] - a federally mandated assessment of a resident's abilities and care needs) dated August 20, 2023, at 12:03 PM revealed that it was somewhat important to the resident to go outside to get fresh air when the weather is good. Review of Resident 19's current care plan…

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 interview, it was determined that the facility failed to develop and implement an individualized person-centered plan to render trauma informed care to a resident with a diagnosis of Post-Traumatic Stress Disorder for one out of 35 residents reviewed (Resident 29). Findings include: A review of the clinical record revealed that Resident 29 was admitted to the facility on [DATE], with diagnoses that included Post Traumatic Stress Disorder (PTSD). The resident's current care plan, in effect at the time of review on April 19, 2024, did not identify the resident's PTSD symptoms or triggers related to this diagnosis and resident specific interventions to meet the resident's needs for minimizing triggers and/or re-traumatization. The facility failed to develop and implement an individualized person-centered plan to address, this resident's diagnosis of PTSD according to standards of practice to promote the resident's emotional well-being and safety. Interview 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 a review of clinical records and staff interviews it was determined that the facility failed to ensure that residents were free from significant medication errors for one resident out of (Resident 103) out of 35 sampled. Findings included: A review of the clinical record review revealed that Resident 103 was admitted to the facility on [DATE], with diagnoses of unspecified psychosis, and dementia (a condition characterized by progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change, resulting from organic disease of the brain) with agitation. Resident 103 had a physician order, initially dated February 22, 2024, for risperidone (antipsychotic drug) tablet 0.25 mg give one tablet in the evening, and a physician order, initially dated March 14, 2024, for Asenapine (antipsychotic drug) transdermal patch 3.8 mg/24 hours, apply one patch transdermal at bedtime when available; discontinue the risperidone. A review…

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 clinical records, select facility policies, investigate reports, and employee job descriptions it was determined the facility's administration failed to effectively use its resources to promote resident safety by failing to implement established procedures to prevent physical abuse of six out of 41 sampled residents (Residents 212, 93, 203, 178, 487, and 213). Findings include: A review of a facility policy entitled Pennsylvania Resident Abuse: Abuse, Neglect, and Exploitation, dated August 30, 2023, revealed that it is the policy of the facility to not tolerate abuse, neglect, mistreatment, exploitation of residents, or misappropriation of resident property by anyone. The policy defines abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. A review of facility reports and clinical records between…

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 clinical records, facility provided documentation, grievances lodged with the facility, and the minutes from Resident Council meetings, and resident and staff interviews it was determined that the facility failed to provide care in a manner and environment, which promotes each resident's quality of life by failing to respond timely to residents' requests for assistance as reported by 15 residents out of 33 interviewed (Residents 6, 17, 24, 27, 43, 53, 54, 58, 72, 77, 112, 113,117, 141 and 163). Findings include: A review of the minutes from the Resident Council meeting dated January 23, 2024, revealed that the residents in attendance voiced concerns that staff do not answer their requests for assistance, via the nurse the call bell system, in a timely manner. A review of grievances lodged with the facility revealed a grievance filed on January 23, 2024, on behalf of a resident, indicating that the resident's call bell was on for an extended period of time with no response from staff. A grievance was lodged with the facility on January 30, 2024, indicating that 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 observations and staff interviews, it was determined that the facility failed to provide housekeeping and maintenance services to maintain a clean and orderly environment in resident areas on four of five nursing units (Blue Building Unit 200, 300, [NAME] Building Unit 100 and 200). Findings included: An observation of resident lounge area on the third floor of the Blue Building on March 20, 2024, at 12:51 PM, revealed a dried brown fecal-like substance on the seat cushion of a teal-colored dining chair, that had a foul odor. An observation of resident dining area on the second floor of the Blue Building on March 20, 2024, at 12:55 PM, revealed a large soiled area from an unknown substance on the seat cushion of a teal-colored dining chair. An observation of resident sitting area on the second floor of the Blue Building on March 20, 2024, at 12:56 PM, revealed multiple brown and white stained areas of from an unknown substance on the seat cushion of a teal-colored chair. An observation of resident sitting area on the second floor of the [NAME] Building on March 20, 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 a review of grievances lodged with the facility and the minutes from Residents' Council meetings and resident and staff interviews, it was determined that the facility failed to provide care in a manner and environment that promotes each resident's quality of life by failing to respond timely to residents' requests for assistance, including experiences reported by five alert and oriented residents out of 16 sampled (Residents 1, 2, 11, 16, and 17). Findings include: A review of the minutes from the Resident Council meeting August 22, 2023, revealed that the residents in attendance voiced concerns about waiting over two hours for staff to respond to their call bells when assistance is needed. A review of a grievance filed with the facility dated September 7, 2023, revealed that a resident complained that he rang the call bell to get staff assistance to be changed, and staff responded initially, but never returned to provide the needed care. A review of Resident Council meeting minutes dated September 18, 2023, revealed that the residents in attendance raised concerns about…

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 resident and staff interviews, it was determined that the facility failed to consistently implement a resident's plan of care to assure the use of the necessary level of staff assistance and assistance device to perform safe transfers of one resident out of 20 sampled (Resident 11). Findings include: A clinical record review revealed that Resident 11 was admitted to the facility on [DATE], with diagnoses to include radiculopathy (an injury or damage to nerve roots in the area where they leave the spine). A nursing progress note dated October 12, 2023, at 3:50 PM, indicated that the resident requires two staff for transfers. The Minimum Data Set assessment (MDS - a federally mandated standardized assessment process conducted periodically to plan resident care) dated October 18, 2023, revealed that Resident 11 is cognitively intact with a BIMS score of 13 (Brief Interview for Mental Status- a tool to assess cognitive function; a score of 13-15 indicates cognition is…

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, select facility policy, and facility investigative reports, and staff interview, it was determined that the facility failed to ensure that one resident out of the eight sampled residents was free from physical abuse (Resident 2). Findings including: A review of a facility policy entitled Pennsylvania Resident Abuse: Abuse, Neglect, and Exploitation, dated August 30, 2023, revealed that it is the policy of the facility to not tolerate abuse, neglect, mistreatment, exploitation of residents, or misappropriation of resident property by anyone. The policy defines abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. A clinical record review revealed that Resident 1 was admitted to the facility on [DATE], with diagnosis…

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 interview it was determined that the facility failed to permit a resident to remain in the facility and not discharge the resident except for defined necessary reasons and failed to ensure the presence of necessary documentation supporting the specific reasons for discharge of one resident out of three residents reviewed (Resident 2) Findings include: A review of the clinical record revealed that Resident 2 was transferred to the emergency room on September 16, 2023, due to aggressive behavior. Review of the resident's Discharge summary dated [DATE], revealed that the resident's discharge date from the facility was September 16, 2023. The reason for the resident's discharge was the resident's aggressive behavior. The resident's clinical record contained no physician documentation of the specific reasons why the resident could not be treated at the facility and documented evidence of the facility's attempts to meet this resident's needs. There was no documentation…

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 facility staff it was determined that the facility failed to develop and implement a policy and procedure to ensure that a resident transferred from the facility with the expectation of returning to the facility was permitted to return or met the specific requirements for a facility initiated discharge for one out of three discharged residents reviewed (Resident 2). Findings included: A review of the clinical record revealed that Resident 2 was transferred to the emergency room on September 16, 2023, due to aggressive behavior. Review of the resident's Discharge summary dated [DATE], noted that the resident's discharge date from the facility was September 16, 2023. The reason for discharge was noted to be due to the resident's aggressive behavior. The hospital attempted to discharge the resident back to the facility, and facility would not open the doors and let the resident back in. The resident's clinical record contained no physician documentation of the…

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

Based on observation and staff interview, it was determined that the facility failed to store resident care equipment and supplies in a sanitary and orderly manner. Findings include: An observation of the facility's central supply area, located across from the main entrance to the facility, September 6, 2023 at 10 AM. revealed that the exterior door was door open to the outside. On the wooden shelving unit to the left of the door was an opened cardboard box of facial tissues, one opened box of facial tissues, a can of wasp insect spray, a can of WD40 lubricant spray, mechanical tools, a roll of plastic and an unbagged resident CPAP machine. On the next shelving unit there were multiple open boxes of resident incontinence briefs. Loose single briefs were observed out of their original packaging strewn about on the shelf and the floor. There were additional opened cardboard boxes containing resident supplies with a broom placed on top of these boxes of resident care supplies. Opened boxes and containers of resident care supplies were observed throughout the entire room, with multiple…

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 during a tour of the dietary department equipment storage area and staff interview, it was determined that the facility failed to maintain acceptable food services sanitation practices for the preparation and service of food. Findings include: Food safety and inspection standards for safe food handling indicate that everything that comes in contact with food must be kept clean and food that is mishandled can lead to foodborne illness. Safe steps in food handling, cooking, and storage are essential in preventing foodborne illness. You cannot always see, smell, or taste harmful bacteria that may cause illness according to the USDA (The United States Department of Agriculture, also known as the Agriculture Department, is the U.S. federal executive department responsible for developing and executing federal laws related to food). During a tour of the dietary department equipment storage area on September 6, 2023, at approximately, 10:30 a.m., with the Nursing Home Administrator, the following sanitation issues, with the potential to introduce contaminants into food…

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

Based on observation and staff interview it was determined that the facility failed to store drugs and pharmacy supplies in a safe and sanitary manner. Findings include: An observation September 6, 2023, of the facility central supply area revealed two metal cabinets containing over the counter non prescription medications. The doors to the central supply area was unlocked and opened and both cabinets were observed to be open and unlocked. The the floor of central supply area, in which this cabinet of OTC drugs were stored, was observed to be coated with a build-up of direct and accummulation of cobwebs. Paper and plastic debris was observed on the floor surrounding the cabinet. Dirt and debris was observed on the bottom shelf of the cabinet, in front of, and underneath the cabinet. Brown stains were observed on multiple ceiling tiles located above the cabinet of medications. During an interview at the time of the observation, the Nursing Home Administrator confirmed the observation and stated the maintenance department stated that there had been several roof leaks above the…

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

Based on observation and staff interview, it was determined that the facility failed to maintain acceptable practices for the storage and service of food to prevent the potential for contamination and microbial growth in food, which increased the risk of food-borne illness in the food and nutrition services department and two of three resident pantries. Findings include: Food safety and inspection standards for safe food handling indicate that everything that comes in contact with food must be kept clean and food that is mishandled can lead to foodborne illness. Safe steps in food handling, cooking, and storage are essential in preventing foodborne illness. You cannot always see, smell, or taste harmful bacteria that may cause illness according to the USDA (The United States Department of Agriculture, also known as the Agriculture Department, is the U.S. federal executive department responsible for developing and executing federal laws related to food). The initial tour of the kitchen was conducted with the facility's Dietary Managers and Registered Dietitian (RD) on May 9, 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 minutes from Resident Council meetings and resident and staff interviews, it was determined that the facility failed to demonstrate sufficient efforts to promptly resolve continued resident complaints and grievances expressed during Resident Council meetings, including those voiced by five (5) of seven (7) residents (Residents 98, 104, 121, 128, 174, 189, and 208). Findings include: A review of the minutes from the Resident Council meetings held from May 2022 through April 2023 revealed that residents in attendance at those resident group meetings voiced their concerns regarding resident care and facility services during the meetings. During the September 13, 2022, Resident Council meeting, the residents raised concerns with the timeliness of staff response to their requests for assistance via the nurse call bell system. During the January 10, 2023, Resident Council meeting, the residents again voiced concerns with the timeliness of staff response to their requests for assistance via the nurse call bell system. During the March 21, 2023, Resident Council meeting,…

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 resident and staff interview it was determined that the facility failed to maintain an environment free of potential accident hazards in one resident's room (Resident 70) and failed to timely and adequately address factors contributing to repeated falls for one resident (Resident 182) out of 35 sampled residents. Findings include: Review of Resident 70's clinical record revealed that the resident was initially admitted to the facility on [DATE], and most recently readmitted to the facility on [DATE], with diagnoses to have included dementia without behavioral disturbances, acute fracture of the patella, and anxiety. Review of the resident's care plan dated April 5, 2021, and revised on April 6, 2023, identified that the resident was non-compliant with care and that she pocketed disposable gloves in her mouth. It was noted that Resident 70 spoke Romanian and had a diagnosis of dementia and the planned interventions were to offer the resident activities to meet her needs…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of clinical records and select facility policy and staff interviews, it was determined that the facility failed to demonstrate timely and consistent monitoring of nutritional paramaters, resident weights, and timely assessment of resident's nutritional status and needs to ensure prompt implementation of measures to prevent continued weight loss for two residents out of four sampled with significant weight loss (Resident 41 and 211) Findings include: A review of facility policy entitled Weights Policy that was last reviewed by the facility on January 17, 2023, indicated that upon admission/readmission, the resident will be weighed as soon as practicably possible, but no later than 24-hours after admission/readmission. After admission weight is obtained, the individual will be weighed for 4-weeks, or more often as per provider order. All weekly weights will be obtained the same day of each week and the facility will designate a specific day of the week for weekly weights (can vary for each unit).…

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, a review of clinical records and interviews with staff it was determined that the facility failed to ensure that staff consistently provided a functional communication system to maintain the resident's ability to communicate for two residents out of 35 sampled (Residents 140 and 70). Findings included: A review of clinical record revealed that Resident 140 was admitted to the facility on [DATE], with diagnoses to include dementia, schizophrenia, and depression. An Annual Minimum Data Set assessment (MDS - a federally mandated standardized assessment process conducted at specific intervals to plan a resident's care) dated March 16, 2023, revealed that Resident 140 was severely cognitively impaired with a BIMS score of 00 (Brief Interview for Mental Status - a tool to assess cognitive function - a score of 0-7 indicates severely cognitively impaired). The assessment noted that the resident's preferred language was Spanish, and that the resident needed an interpreter to communicate with 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of clinical records and select facility investigations and staff interview, it was determined that the facility failed to thoroughly assess and evaluate a resident's bladder and bowel habits and toileting needs to develop individualized approaches to maintain continence and meet the resident's needs for toileting assistance to the extent possible for one resident (Resident 182) out of 35 sampled residents. Findings include: A review of the clinical record revealed that Resident 182 was admitted to the facility on [DATE], with diagnoses to include chronic obstructive pulmonary disease, diabetes, and dementia. A review of Resident 182's Evaluation for continence and retraining/ scheduled toileting dated April 5, 2023, revealed that the resident required the use of a cane for physical functioning and was placed on a 72-hour bowel and bladder tracking to evaluate voiding pattern. However, there was no documented evidence that the 72-hour tracker was fully completed. Resident 182's care plan initiated…

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, clinical record review and staff interviews, it was determined that the facility failed to ensure each resident received the necessary behavioral health care in a timely manner to attain or maintain the highest practicable mental and psychosocial well-being for one of 12 residents sampled (Resident 40). Findings include: Review of clinical record of Resident 51 revealed that the resident was admitted to the facility on [DATE], with diagnoses including bipolar disorder (a mental health condition that causes extreme mood swings that include emotional highs (mania or hypomania) and lows (depression), and dementia (the loss of cognitive functioning - thinking, remembering, and reasoning - to such an extent that it interferes with a person's daily life and activities). Further review of Resident 51's clinical record revealed that the resident exhibited multiple behaviors, including resident to resident altercations, crying, verbal behaviors towards staff, urinating in hallway, and sexually…

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 interview, it was determined that the facility failed to develop and implement an individualized person-centered plan to address a resident's dementia-related behavioral symptoms for one out of five residents (Resident 36) Findings include: A review of the clinical record revealed that Resident 36 was admitted to the facility on [DATE], with diagnoses to include depression and anxiety. Review of clinical record revealed resident was newly diagnosed, March 7, 2023, with dementia (a chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning). A review of the resident's current care plan in effect at the time of the survey ending May 12, 2023, revealed no documented evidence that the facility had developed an individualized person-centered plan for the resident's dementia care, which maximized the resident's dignity, autonomy, privacy, socialization, independence,…

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.