Pavilion At St Luke Village, The

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of clinical records, resident council meeting minutes, grievances filed with the facility, and resident and staff interviews, it was determined the facility failed to provide care in a manner that promotes each resident's quality of life by failing to respond timely to residents' requests for assistance, including experiences reported by two residents out of 21 sampled (Residents 25 and 74) and experiences reported by five out of the nine residents during a resident group interview (Residents 24, 28, 31, 55, and 57). Findings include: A review of Resident Council meeting minutes dated October 2, 2024, revealed that residents in attendance had concerns regarding call bell response wait times. The meeting minutes contained no further documentation regarding the residents' concerns. A grievance dated October 2, 2024, revealed residents had concerns regarding call bells not answered timely. The document indicated individual concerns would be addressed as needed and reviewed during resident council.…

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 investigative reports, observation and resident and staff interview it was determined the facility failed to consistently provide care and services to prevent the development of a pressure sore for two residents out of 21 sampled (Residents 19 and 26). Findings include: A review of facility policy titled Unavoidable Pressure Injury, last reviewed by the facility on June 6, 2024, revealed it is the facility's policy that a resident who enters the facility without pressure injuries does not develop pressure injuries unless the individual's risk factors demonstrate they were unavoidable. A clinical record review revealed Resident 19 was admitted to the facility on [DATE], with diagnoses that included chronic obstructive pulmonary disease (COPD is a condition caused by damage to the airways or other parts of the lung that blocks airflow and makes it hard to breathe). A review of a quarterly Minimum Data Set assessment (MDS - a federally mandated standardized…

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, select facility policy, and resident and staff interviews, it was determined the facility failed to ensure residents receive appropriate services and assistance to maintain or improve mobility with the maximum practicable independence for one out of 21 residents sampled (Resident 74). Findings include: A review of the facility policy titled Restorative Nursing Services, last reviewed by the facility on June 6, 2024, revealed the facility provides restorative nursing to encourage and enable residents to be as independent as possible based on their individual condition and goals. A clinical record review revealed Resident 74 was admitted to the facility on [DATE], with diagnoses that included chronic kidney disease (gradual loss of kidney function) and pulmonary embolism (a condition in which one or more arteries in the lungs become blocked by a blood clot). A review of an annual Minimum Data Set assessment (MDS - a federally mandated standardized assessment process conducted…

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, select facility policies, and staff interviews it was determined the facility failed to assess and implement individualized measures to meet the toileting needs of one resident out of 21 sampled residents. (Residents 26). Findings included: A facility policy entitled Bladder and Bowel Evaluation last reviewed by the facility June 6, 2024, indicated that residents are evaluated for continence on admission/readmission, quarterly, and with a significant change in status. Residents who are determined to be incontinent without a documented irreversible cause are to be further evaluated for potential bowel and/or bladder management and will have a Bowel and Bladder Evaluation completed and a Bowel and Bladder Elimination Pattern Evaluation completed. Based on the data collected from the patterning evaluation, residents are to be provided an individualized continence management program, a scheduled toileting program, a re-training program, or routine incontinence care which is to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of clinical records, select facility policy, and staff interview, it was determined the facility failed to provide pharmaceutical services in acquiring medication to meet the needs of one resident out of 21 sampled (Resident 9). Findings include: A review of facility policy titled, 4.1 New Orders for Controlled Substances, last reviewed by the facility on June 6, 2024, revealed it is the facility's policy that all controlled substance orders should be communicated to the pharmacy. If the medication is needed before the next scheduled delivery, facility staff should indicate the exact time by which the medication is needed. If the controlled substance is needed before the pharmacy can make arrangements for a timely delivery, then the facility should fax a request to remove a controlled substance from the emergency medication supply to the pharmacy. A clinical record review revealed Resident 9 was admitted to the facility on [DATE], with diagnoses that included neuropathy (a nerve condition 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 clinical record review and staff interviews, it was determined the facility failed to ensure the presence of physician documentation of the clinical rationale for the continued administration of an antipsychotic medication for one resident out of five sampled residents for unnecessary medication use. (Resident 96). Findings included: A clinical record review revealed Resident 96 was admitted to the facility on [DATE], with diagnoses that included Alzheimer's disease (a brain disorder that slowly destroys memory and thinking skills and, eventually, the ability to carry out the simplest tasks) and generalized anxiety disorder (a mental health disorder characterized by the presence of excessive anxiety and worry about a variety of topics, events, or activities). A review of a quarterly Minimum Data Set assessment (MDS-a federally mandated standardized assessment process conducted periodically to plan resident care) dated November 20, 2024, revealed Resident 96 is severely cognitively impaired with a BIMS…

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 resident and staff interviews, it was determined the facility failed to provide services to maintain a clean and homelike environment for one of nine residents sampled (Resident 76). Findings include: During an interview on October 16, 2024, at 11:35 AM, Resident 76 indicated the facility is not taking her soiled clothing to the laundry. She explained there have been dirty clothes in the bottom of her closet, and this continues to occur. An observation on October 16, 2024, at 11:35 AM revealed Resident 76's closet had several dirty clothing articles crumpled up on the bottom shelf of her closet. During an interview on October 16, 2024, at 11:40 AM, Employee 1, Licensed Practical Nurse (LPN), indicated the facility washes Resident 76's clothing. She confirmed that worn, soiled, or dirty clothing should be placed in a laundry receptacle and sent to the laundry for cleaning. Employee 1, LPN, confirmed there was dirty clothing in Resident 76's closet and removed the dirty clothing. During an interview on October 16, 2024, at approximately 12:30 PM, the Nursing…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and resident interview, it was determined that the facility failed to provide nursing services consistent with professional standards of practice by failing to ensure physician ordered medication, an antibiotic, was timely obtained and administered to treat cellulitis for one resident (Resident 75). Findings include: A review of the facility policy titled Notification of Change in Condition, last reviewed by the facility on May 9, 2024, revealed that the facility will promptly notify the resident, the attending physician, and the resident representative when there is a change in the resident's status or condition. The policy indicates the nurse will notify the attending physician and resident representative when there is a need to alter treatment significantly. Also, the policy states the nurse will contact the physician. In the event that the attending physician does not respond in a reasonable amount of time, the medical director may be contacted. A clinical record 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of clinical records, select facility policies, and staff interview, it was determined that the facility failed to ensure that the resident's drug regimen was free of unnecessary antibiotic drugs for one out of nine residents sampled (Resident 76). Findings included: A review of the facility policy titled Antibiotic Stewardship, last reviewed by the facility on May 9, 2024, revealed that antibiotics are to be prescribed and administered to residents under the guidance of the facility's antibiotic stewardship program. The policy states that staff orientation, training, and education will emphasize the importance of antibiotic stewardship and include how the inappropriate use of antibiotics affects individual residents and the overall community. The training and education will focus on the relationship between antibiotic use and gastrointestinal disease, opportunistic infections, medication interactions, and the evolution of drug-resistant pathogens. A clinical record review revealed that Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of select facility policy and clinical records and staff interviews it was determined that the facility failed to provide nursing services consistent with professional standards of quality to ensure that licensed nurses accurately and fully evaluated and documented the results of those evaluations and assessments to demonstrate that the resident received timely and necessary care to promote the health of one resident (Resident 94) out of 24 residents reviewed. Findings included: According to the Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.11 (a)(1)(2)(4) indicates that the registered nurse was to collect complete ongoing data to determine nursing care needs, analyze the health status of individuals and compare the data with the norm when determining nursing care needs, and carry out nursing care actions that promote, maintain, and restore the well-being of individuals. The Pennsylvania Code, Title 49, Professional and Vocational Standards, State…

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 and resident interviews it was determined that the facility failed to ensure that physician ordered intravenous (IV- medication is administered through needle or tube inserted into a vein) medications, an antibiotic, were administered as prescribed for one resident out of 24 sampled (Resident 148). Findings include: Review of a facility policy titled Administering Medications last reviewed by the facility on May 9, 2024, indicated that medications are administered in a safe and timely manner. It indicated that medications are administered in accordance with prescriber orders, including any required time frame. Medication errors are documented, reported, and reviewed by the QAPI committee to inform process changes and/or the need for additional staffing. Prescribed medications are to be administered within one hour of their prescribed time, unless otherwise specified. Review of Resident 148's clinical record revealed that the resident was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff interview, it was determined that the facility failed to attempt non-pharmacological interventions to alleviate pain prior to the administration of an opioid pain medication prescribed on an as needed basis and failed to ensure that the physician orders for administration of pain medication were followed for two residents (Resident 8 and 20) of 24 residents reviewed. Findings include: A review of the clinical record revealed that Resident 8 was admitted to the facility on [DATE], with diagnoses to include fibromyalgia. The resident had a current physician order initially dated November 16, 2023, for oxycodone ( an opioid pain medication) 5 mg tablet give 2.5 mg by mouth, every 8 hours, as needed, for pain rating 4 to 10 (on a scale of 1-10, with 1 being the least pain and 10 being the most severe pain). A review of the resident's May 2024 Medication Administration Record (MAR) revealed that staff administered the prn opioid pain medication to the resident on May 11, 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 observation, a review of clinical records, a review of nurse staffing, and grievances filed with the facility, and interviews with staff and residents, it was determined that the facility failed to provide sufficient nursing staff to provide timely and quality care to each resident including eight residents out of 24 sampled (Residents 19, 20, 21, 48, 151, 38, 30 and 85), including concerns expressed in grievances filed with the facility (Resident 85). Findings included: A grievance lodged with the facility dated April 3, 2024, indicated that Resident 48 reported that she was continuously dissatisfied with nursing staff's untimely call bell response time. The facility noted that the grievance is not resolved to the resident's liking, despite facility improvements in staff's call bell response. A grievance filed with the facility dated April 29, 2024, indicated that Resident 85 expressed concerns that staff initially responded to his call bell but left and never came back to get him out of bed 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 review of clinical records and staff interview it was determined that the facility failed to provide pharmacy services to assure timely receiving of a prescribed antibiotic medication for one resident out of 24 residents reviewed (Resident 148). Findings include: Review of clinical record revealed that Resident 148, was admitted to the facility on [DATE], with diagnoses to include septic (infected with bacteria) left knee and diabetes. An admission physician order was noted for Daptomycin (an antibiotic medication) 750 mg intravenously (IV- medication is administered through needle or tube inserted into a vein) in the morning daily with end date August 12, 2024, for septic left knee. Review of Resident 148's Medication Administration Record dated July 12, 2024, through July 14, 2024, revealed the physician ordered intravenous antibiotic medication, Daptomycin, was not administered on July 12, 2024 July 13, 2024, and July 14, 2024. Interview with the Nursing Home Administer (NHA) on July 19, 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 a staff interview, it was determined that the facility failed to demonstrate that the pharmacist identified and reported irregularities in the drug regimen of residents and that the physician acted upon the identified irregularities in the drug regimens of four of the 24 residents sampled (Residents 78, 20, 52, and 17). Findings include: A review of the clinical record revealed that Resident 78 was admitted to the facility on [DATE], and had diagnoses that included type 2 diabetes, depression, and anxiety. A review of a pharmacy consultant note revealed that on February 4, 2024, the pharmacist completed a medication regimen review and noted to see the report for any noted irregularities. A review of a pharmacy consultant note revealed that on May 28, 2024, the pharmacist completed a medication regimen review and noted to see the report for any noted irregularities. A review of the clinical record revealed that Resident 20 was admitted to the facility on [DATE], and had…

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 select facility policies and the facility's infection monitoring and surveillance system, and staff interviews, it was determined that the facility failed to maintain and implement a comprehensive program to monitor and prevent infections in the facility for two out the eight months reviewed (June 2024 and July 2024). Findings include: A review of the facility policy titled Policies and Practices: Infection Control, reviewed last by the facility on May 9, 2024, revealed that this facility's infection control policies and practices are intended to facilitate maintaining a safe, sanitary, and comfortable environment and to help prevent and manage the transmission of diseases and infections. The objectives of the infection control policies and practices are to prevent, detect, investigate, and control infections in the facility and maintain records of incidents and corrective actions related to infections. The policy also indicates that surveillance tools are used for recognizing the occurrence of infections, recording their number and frequency, detecting…

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, review of clinical records and the minutes from Residents' Council meetings, and staff and resident interviews, it was determined that the facility failed to afford residents the right to make choices about aspects of their life in the facility that are significant to them for two out of 24 sampled residents (Residents 21 and 72). Findings include: Clinical record review revealed Resident 21 was admitted to the facility on [DATE], with diagnoses that included chronic obstructive pulmonary disease (COPD is a condition caused by damage to the airways or other parts of the lung that blocks airflow and makes it hard to breathe) and heart failure (a condition that develops when the heart doesn't pump enough blood to meet the body's needs). A quarterly Minimum Data Set assessment (MDS - a federally mandated standardized assessment process conducted periodically to plan resident care) dated April 24, 2024, revealed that Resident 21 is cognitively intact with a BIMS score of 15 (Brief Interview 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 review of clinical records, select facility incident reports, and select facility grievance reports, and staff interview, it was determined that the facility failed to timely notify the resident representative of an allegation of physical abuse of one resident out of 24 sampled (Resident 35). Findings include: A review of the clinical record revealed that Resident 35 was admitted to the facility on [DATE], with diagnoses which included spinal stenosis (the space around the spinal cord becomes too narrow which puts pressure on the spinal cord and nerves) and hypertension. A review of Resident 87's clinical record revealed that the resident was admitted to the facility on [DATE], with diagnoses, which included Alzheimer's disease. Review of a facility incident report dated July 9, 2024, at 4:30 PM revealed that Resident 35 reported to a staff member that Resident 87 was in her room uninvited and slapped her in the face, when Resident 35 told Resident 87 to put down her orange. Review of a facility…

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

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 provide a comfortable environment for one resident out of the 24 sampled (Residents 89). Findings include: Clinical record review revealed Resident 89 was admitted to the facility on [DATE], with diagnoses that included spinal stenosis ( a condition where the spaces in the spine narrow and create pressure on the spinal cord and nerve roots that may cause pain or weakness). A review of an admission Minimum Data Set assessment (MDS - a federally mandated standardized assessment process conducted periodically to plan resident care) dated June 21, 2024, revealed that Resident 89 is cognitively intact with a BIMS score of 15 (Brief Interview for Mental Status- a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 13-15 indicates cognition is intact). During an interview on July 16, 2024, at 1:55 PM,…

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, the facility's abuse prohibition policy and select investigative reports, and resident and staff interviews, it was determined that the facility failed to ensure that one resident was free was free from physical abuse and mental anguish out of 11 residents sampled (Resident 35). Findings include: The facility's Abuse, Neglect, Exploitation, and Misappropriation Policy, last reviewed on May 9, 2024, revealed Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Physical abuse includes but is not limited to hitting, slapping, punching, biting, and kicking. Acts of abuse directed against residents are absolutely prohibited. Prevention includes having sufficient numbers of staff to meet the needs of residents, monitoring of residents who may be at risk is the responsibility of all facility staff. The abuse coordinator or designee will investigate all reports of allegation of abuse,…

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, the facility's abuse prohibition policy, and select facility incident reports, and resident and staff interview, it was determined that the facility failed to investigate an injury of unknown source to rule out abuse, neglect, or mistreatment for one resident (Resident 24) and failed to thoroughly investigate an allegation of physical abuse of one resident (Resident 35) out of 24 residents sampled. Findings include: The facility's Abuse, Neglect, Exploitation, and Misappropriation Policy, last reviewed on May 9, 2024, revealed that it is the facility policy that any employee who has knowledge of an injury of an unknown source is obligated to report such information immediately, but no later than two hours or no later than 24 hours if the events do not result in serious bodily injury to the administrator and to other officials in accordance with state law. Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical…

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 the Resident Assessment Instrument and staff interview, it was determined that the facility failed to ensure that the Minimum Data Set Assessments (MDS - a federally mandated standardized assessment conducted at specific intervals to plan resident care) accurately reflected the status of one resident out of 24 sampled (Residents 96). Findings included: A review of Resident 96's clinical record revealed that the resident was admitted to the facility on [DATE], and discharged from the facility on June 18, 2024. A review of Resident 96's Discharge MDS assessment dated [DATE], revealed in Section A2105 Discharge Status that Resident 96 was discharged to a short term general hospital. A review of the resident's Discharge Plan and Instructions revealed the resident was discharged home, and the June 18, 2024, discharge MDS was inaccurate. Interview with the Nursing Home Administrator on July 19, 2024, at approximately 9:20 AM, confirmed the aforementioned MDS Assessment was…

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 resident and staff interviews, it was determined that the facility failed to thoroughly assess and evaluate bowel and bladder function, to identify factors for decline, and implement individualized interventions, including timely toileting assistance, to improve bladder and bowel function to the extent possible for one out of 24 sampled residents (Residents 38). Findings include: Review of the facility Bowel and Bladder Evaluation Policy last reviewed May 9, 2024, indicated that residents are evaluated for continence on admission/readmission, quarterly, and with significant change in status. Residents without a documented reversible cause for bowel and bladder incontinence are to have a Bowel and Bladder evaluation completed and Bowel and Bladder Elimination Pattern evaluation completed. Based on data collected from the patterning evaluation residents to be provided an individualized continence management program. Review of Resident 38's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of clinical records and select incident reports, and resident and staff interview, it was determined that the facility failed to develop and implement individualized plans to manage residents' dementia-related behavioral symptoms to promote resident safety and highest practicable physical and mental well-being residents including one resident out of 24 sampled (Resident 87). Findings include: A review of Resident 87's clinical record revealed that the resident was admitted to the facility on [DATE], with diagnoses which included Alzheimer's disease and was severely cognitively impaired. Review of a facility incident report dated July 9, 2024, at 4:30 PM revealed that Resident 35 reported to a staff member that Resident 87 was in her room uninvited and slapped her in the face when she told Resident 87 to put down her orange. Interview with Employee 7 (RN Supervisor) on July 18, 2024, at 1:30 PM revealed that a nurse, she cannot recall which aide, initially notified her of the incident 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 review of clinical records and staff interviews, it was determined that the facility failed to ensure that the physician was promptly notified of abnormal x-ray results for one of 24 residents reviewed (Resident 94). Findings include: A review of the clinical record of Resident 94 revealed admission to the facility on June 28, 2024, with diagnoses, which included Type 2 diabetes, pressure ulcer to the right heel, non-pressure ulcer to the right lower leg, and non-pressure ulcer to the left lower leg. A review of a wound consult note dated July 10, 2024, revealed the wound consultant noted that the resident's right heel appears boggy (soft and spongy) with foul odor and soft eschar (dead tissue). The wound consultant recommended an X-ray of the right heel be obtained due to its deterioration. A nursing progress note dated July 11, 2024, at 12:00 PM revealed that the facility's contracted mobile x-ray company was in the facility and completed the x-ray of Resident 94's right heel. A review of a Radiology…

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 investigative reports and staff interview, it was determined that the facility failed to maintain accurate and complete clinical records, according to professional standards of practice for two of 24 sampled residents (Residents 35 and 87). Findings include: According to the American Nurses Association Principles for Nursing Documentation, nurses document their work and outcomes and provide an integrated, real-time method of informing the health care team about the patient status. Timely documentation of the following types of information should be made and maintained in a patient record to support the ability of the health care team to ensure informed decisions and high quality care in the continuity of patient care: Assessments, Clinical problems, Communications with other health care professionals regarding the patient, Communication with and education of the patient, family, and the patient's designated support person and other third parties. According to 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 and staff interviews it was determined the facility failed to ensure coordination of care and services between the facility and the Hospice Agency for one resident out of 24 sampled residents (Resident 84). Findings include: A review of Resident 84's clinical record revealed admission to the facility on January 8, 2024, with a diagnosis of include malignant neoplasm (cancer) of the liver and bile duct. A physician order was noted February 5, 2024, for the resident to be admitted into hospice services at the facility. A review of the resident's care plan conducted during the survey ending July 19, 2024, revealed that the resident's care plan failed to reflect coordination of services between the facility and the Hospice agency in meeting the resident's daily care needs and specific needs related to care and services provided for the resident's terminal diagnosis. An interview with the Nursing Home Administrator on July 19, 2024, at approximately 1:45 PM, confirmed the resident's care plan was not coordinated with hospice services. 28 Pa. Code…

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 select facility policy and clinical records, and staff interview, it was determined that the facility failed to implement a system to assure timely disposition of resident medications (the process of returning and/or destroying unused medications) to prevent loss and potential drug diversion. Finding include: Review of facility policy entitled, Disposal/Destruction of Expired or Discontinued Mediation, date revised [DATE], revealed that facility staff should destroy and dispose of medications in accordance with Facility policy and Applicable Law, and applicable environmental regulations. Facility should place all discontinued or outdated medications in a designated, secure location which is solely for discontinued medications or marked to identify the medications are discontinued and subject to destruction. In Pennsylvania, discontinued and unused medications and medications of discharged or deceased residents shall be immediately removed from the medication cart and brought to…

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

Based on observation and staff interviews it was determined that the facility failed to ensure the consistent implementation of infection control procedures designed to prevent the spread of infection in one out of two medication rooms (3 rd floor medication room). Findings include: Observation of the facility's third floor medication room on April 9, 2024, at approximately 9:28 AM accompanied by Employee 1 (Licensed Practical Nurse - LPN) revealed a small, dormitory size medication refrigerator located on the floor. Inside the refrigerator observations revealed resident medications were stored along with Observed two plastic, one-gallon containers of iced tea and on the door of the refrigerator were six {6}, 16 fluid oz. bottles of salad dressings. Interview with Employee 1, LPN, on April 9, 2024, at approximately 9:40 AM, confirmed that the food and beverages stored in the medication refrigerator belonged to staff. Interview with the Director of Nursing (DON) on April 9, 2024, at approximately 10:20 AM, confirmed the facility failed to store medication medications under sanitary…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff interview, it was determined that the facility failed to accommodate one resident's needs for assistive positioning devices during wheelchair transport of one of three resident reviewed (Resident 74). Findings include: Review of clinical records revealed Resident 74 was admitted to the facility on [DATE], with diagnoses to include aneurysm of carotid artery (a bulge in one of the arteries supplying blood to the brain), muscle weakness and need for assistance with personal care. An admission Minimum Data Set assessment (MDS- a federally mandated standardized assessment process conducted periodically to plan resident care) dated May 22, 2023, indicated that the resident required total dependence of two+ persons physical assist for transfers. Review of the resident's Occupational Therapy Evaluation dated May 16, 2023, revealed that the resident was unable to sit unsupported, and was dependent (requires 100% assist, or 2 or more helpers) for repositioning in a standard…

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.