Holland Center For Rehabilitation And Nursing

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy and review of clinical records, it was determined that the facility failed to develop and implement a baseline care plan for one of two clinical records reviewed (Resident R140). Findings Include: Review of facility policy, Care Plan, Comprehensive Person-Centered revised March 2022, revealed, A comprehensive, personal -centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Review of Resident 140's clinical record revealed the resident was admitted to the facility on [DATE], and had a diagnosis of severe protein-calorie malnutrition, anorexia (eating disorder that involves severe calorie restriction), depression (loss of interest in pleasurable activities), muscle weakness. On May 13, 2025, at 12:13 p.m. an interview was held with Resident 140 who reported I lost a lot of weight. Review of Resident R140's clinical record revealed no documented…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, review of clinical records, observations, and staff interviews, it was determined that the facility failed to develop a comprehensive person-centered care plan for three of twelve residents reviewed (Residents R29, R4 and R188 ). Findings include: Review of facility policy, Care Plan, Comprehensive Person-Centered revised March 2022, revealed, a comprehensive, personal -centered care plan that includes measurable objectives and timetables to [NAME] the resident's physical, psychosocial and functional needs is developed and implemented for each resident and services not provided due to the resident exercising their right to refuse treatment. A review of the clinical record for Resident R4 revealed an admission date of November 02, 2023, with diagnoses including chronic pulmonary disease (disease process that causes decreased ability of the lungs toperform), respiratory failure with hypoxia (low levels of oxygen). Review of Resident R4's physician orders dated May 11, 2025, 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 observation, clinical record review, review of facility policy and staff interview, it was determined that the facility failed to provide appropriate respiratory care and services for two of 12 residents reviewed (Residents R4, R29). Findings include: Review of the Facility Policy and Guidelines for implementation of Oxygen administration indicated that the nurse should review and follow the physician's orders while administering Oxygen via nasal canula. Review of Resident R29's clinical record revealed that the resident was admitted to the facility on [DATE], with diagnoses that included Parkinson's Disease (Parkinson's disease is a progressive neurological disorder characterized by the degeneration of brain cells that produce dopamine, a neurotransmitter essential for motor control. This leads to a variety of motor symptoms, including tremors, stiffness, slowness of movement, and balance problems. Additionally, non-motor symptoms like depression, anxiety, and sleep disturbances can also occur), and…

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

Based on a review of employee personnel records and staff interviews, it was determined that the facility failed to complete performance reviews for nurse aides in one out of the two employee personnel records reviewed. (Employee E12) Findings include: Record review of personnel file for Employee E12 revealed that employee was hired by the facility on March 23, 2024 as a nurse aide. There was no further documentation available in the record to demonstrate that a skills evaluation or post orientation performance evaluation had been completed. Interview on May 16, 2025 at 10:44 a.m. with the Director of Nursing revealed that the facility does not complete competencies or performance reviews on staff and confirmed that Employee E12 does not have a completed performance review on file. Continued interview with the Director of Nursing revealed that the facility does not have a policy or procedure related to staff competencies or performance reviews and stated that none of the nurse aides have annual performance reviews completed. 28 Pa. Code 201.19 Personnel policies and procedures

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interview and review of facility policy, it was determined that the facility failed to to ensure that nursing staff was informed of a resident with a diagnosis of PTSD (Post traumatic Stress Disorder) to ensure treatment and services for one of one resident review with PTSD. (Resident R4) Findings include: A review of the facility policy titled, Trauma-Informed Care undated, reveals This policy establishes guidelines for implementing trauma-informed care (TIC) in the long-term care facility to support residents and staff who may have experienced trauma. The goal is to provide care that is safe, respectful, and responsive to the effects of trauma while fostering a supportive environment. Rreview of Resident R4's clinical record revealed that the resident was admitted to the facility on [DATE]. Continued review of the resident's clinical record revealed a psychological notes completed by Nurse Practitioner , Employee E7 on March 27, 2025, and May 1, 2025, which documented…

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 interviews with staff, it was determined the facility failed to acquire, receive and administer medications to a newly admitted resident for one of 12 resident records reviewed (Resident 190). Findings include: Review of Resident R190's nursing note revealed that the resident was admitted to the facility on [DATE], at 11:52 a.m. from the hospital, with a diagnosis of traumatic subdural hematoma due to a fall prior to admission. Resident R190 was alert and oriented, capable of making their own decisions. Continued review of nursing notes indicated Writer reviewed and provided a copy of all of physician orders including medication administration and treatment administration records to resident. Resident reviewed and is agreeable with and received a copy of baseline and discharge plan of care. On March 1, 2025 the electronic medication administration record (EMAR) noted Heparin Sodium (Porcine) Injection Solution 5000 UNIT/ML instructed to inject 50000 unit subcutaneously two…

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 clinical records, and interviews with facility staff, and facility policy it was determined that the facility failed to ensure that it was free of medication error rate of five percent or greater for one of four residents observed during medication administration (Residents R29), and failed to administer medications in a timely manner, and as ordered by the physician for one of 12 resident records reviewed (Resident R188). Findings include: Review of the facility's policy titled, Administering Medications revised on April 2020 states medications are administered in a safe and timely manner, and as prescribed. Medications are administered in accordance with prescriber orders, including any required time frame. Medication administration times are determined by resident need and benefit not staff convenience. Medications are administered within one hour of prescribed time, if a dosage is believed to be inappropriate or excessive for a resident the person preparing or administering the medication will contact the prescriber. Resident R188 was initially…

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, clinical record review, and interviews with staff, it was determined that the facility did not maintain complete and accurate medical records for four of four records reviewed related to catheter care and urinary continence. (Residents R1, R2, R4, and R5). Findings include: Review of clinical documentation revealed that Resident R1 was admitted to the facility on [DATE], and had diagnoses of fracture of right tibia, fracture of left tibia, fracture of left fibula, and morbid obesity. Review of the resident's clinical record revealed that she utilized an indwelling urinary catheter (a tube inserted into the bladder through the urethra in order to assist in emptying it of urine, and which stays in place for an extended period of time). Review of Nurse Aide documentation of bladder function for the time period of September 13, 2024, through September 24, 2024, revealed that available options for documenting the resident's urinary continence included Continent (having sufficient voluntary…

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

Based on clinical record reviews, interviews with staff and review of policies and procedures and review of emergency medications and review of Pennsylvania Professional Nurse Practice Act., it was determined that the facility failed to meet professional standards of practice related to providing routine and emergency pain medication to meet the needs of one of seven residents reviewed. (Resident R1) Findings include: According to the Pennsylvania Code Title 49, Professional and Vocational Standards Department of State, Chapter 21 State Board of Nursing, Chapter 21.145 Functions of the LPN (Licensed Practical Nurse) requires the following: (a) The LPN is prepared to function as a member of the health care team by exercising sound nursing judgement based on preparations, knowledge, skills, understandings, and past experiences in nursing situations. The LPN participates in the planning, implementation, and evaluation of nursing care in settings where nursing takes place. (b) The LPN administers medication and carries out the therapeutic treatment ordered for the patient 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.

Based on the review of clinical records and interviews with staff, it was determined that the facility failed to ensure that pain management was provided consistent with physician orders for one of one resident reviewed for pain management. (Resident R98) Findings include: Interview with Resident R98 on July 10, 2024, at 9:53 a.m. revealed that she was not receiving pain medication as ordered. She stated when she was not receiving pain medication when her pain level was 10 of a scale of 10. It also affected her activities and sleep. She stated did not receive her morphine sulfate pain medication for over 48 hours. Resident stated she has pain to lower back, right leg, and left leg pain radiates down to the foot. Review of physician orders for Resident R98 for July 2024, revealed orders for the following pain medications: Lyrica 150 milligrams (mg) every 12 hour for chronic pain; Morphine sulfate 15 mg every 8 hour for chronic pain; and Oxycodone 10 mg every 6 hour for chronic pain. Review of Medication Administration Record for the month of July 2024 revealed that on July 8, 2024,…

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

Based on review of clinical records, review of facility's policy and staff interview, it was determined that the facility did not ensure that a drug regimen review was conducted at least monthly and did not ensure the attending physician's reviewed/responded to pharmacist's recommendations for one of five residents reviewed. (Resident R13) Findings include: Review of facility's policy medication regimen reviews, revealed that the consultant pharmacist performs a medication regimen review (MMR) for every resident in the facility receiving medication, and MRR's are done upon admission and at least monthly thereafter, or more frequently if indicated. Reviews for short-stay individuals are done upon admission and as needed to identify individuals with potential medication-related issues and for those who may be experiencing adverse consequences from their medications. Review of Resident R13's clinical records revealed no evidence of medication regimen review completed upon admission since June 8, 2024. Facility unable to provide evidence of MRR completion upon request. Review of…

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

Review of facility documentation, state legislation, and interview with staff, it was determined that the facility failed to conduct a review of reportable infection to PA-PASR and report as indicated for two of six months reviewed. (May 2024 and June 2024) Findings Include: Review of act 52 of 2007 Medical Care Availability and Reduction of Error (MCARE) act chapter 4. Health care-associated infections 40 p.s. § 1303.401 - 1303.411 (2007) revealed that § 1303.404. Health care facility reporting (a) NURSING HOME REPORTING. - In addition to reporting pursuant to The Health Care Facilities Act, a nursing home shall also electronically report health care-associated infection data to the department and the authority using nationally recognized standards based on CDC definitions, provided that the data is reported on a patient-specific basis in the form, with the time for reporting and format as determined by the department and the authority The Pennsylvania Patient Safety Authority developed the Pennsylvania Patient Safety Reporting System, known as PA-PSRS (pronounced PAY-sirs), 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 a review of facility documentation, facility policies and staff interviews, it was determined that the facility failed to maintain an effective antibiotic stewardship program that includes a system that includes antibiotic use protocols and a system to effectively monitor antibiotic usage for five of five months of antibiotic stewardship program data reviewed. (February 2024, March 2024, April 2024, May 2024 and June 2024). Findings Include: Review of facility policy Antibiotic Stewardship dated December 2016 , revealed that Antibiotics will be prescribed and administered to residents under the guidance of the facility's antibiotic stewardship program. Further review of facility policy and protocol revealed that the facility policy did not include a system that includes antibiotic use protocols. A review of CDC (Centers for Disease Control and Prevention) guidelines, The core element of Antibiotic Stewardship for Nursing Homes, revealed that Improving the use of antibiotics in healthcare to protect patients and reduce the threat of antibiotic resistance is a national…

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 offer and/or provide the pneumococcal immunization to five of five residents reviewed (Resident R11, R3, R96, R23 and R20). Findings include: Review of facility policy Pneumococcal vaccine dated October 2019 revealed that Prior to or upon admission, residents will be assessed for eligibility to receive the pneumococcal vaccine series, and when indicated, will be offered the vaccine series within thirty (30) days of admission to the facility unless medically contraindicated or the resident has already been vaccinated. Assessments of pneumococcal vaccination status will be conducted within five (5) working days of the resident's admission if not conducted prior to admission. Pneumococcal vaccines will be administered to residents (unless medically contraindicated, already given, or refused) per our facility's physician-approved pneumococcal vaccination protocol. For residents who receive the vaccines, the date 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 clinical record review, review of policy and procedures and staff interviews, it was determined that the facility failed to ensure that residents were offered an opportunity to develop an advance directive for one of 13 residents reviewed. (Residents R94). Findings include: Review of the facility policy Advance Directive (revised [DATE]) reviewed in part the following: 1. Upon admission, the resident will be provided with written infom1ation concerning the right to refuse or accept medical or surgical treatment and to fonnulate an advance directive if he or she chooses to do so. 2. Written infom1ation will include a description of the facility's policies to implement advance directives and applicable state law. 3. If the resident is incapacitated and unable to receive infomrntion about his or her right to formulate an advance directive, the infomrntion may be provided to the resident's legal representative. 4. If the resident becomes able to receive and understand this information later, he or she will…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policies and clinical records and staff interviews, it was determined that the facility failed to ensure that a baseline care plan was developed and implemented, and that a written summary of the baseline care plan was provided to the resident and/or the resident's representative for 7 of 13 residents reviewed (Residents R148, R147, R153, R97 and R94). Findings include: Review of facility policy Care Plans, Comprehensive Person-Centered, revised March 2022, reveals that assessments of residents are ongoing and care plans are revised as information about the residents and the residents conditions change. Review of Resident R148's clinical record revealed that the resident was admitted to facility on June 23, 2024. Review of Wound- weekly observation tool, completed on June 25, 2024 by facility's nurse practitioner, Employee E15, revealed resident was assessed to have suspected deep tissue injury (SDTI) on sacrum, 7 cm in length and 4 cm width, 0.1 cm depth, with treatment plan 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 clinical record review and staff interview, it was determined that the facility failed to developed a personal center care plan related to elopment for one of 13 residents reviewed. (Resident R97) Findings include: A review of Resident R97's clinical record revealed that resident was admitted to the facility on [DATE], with diagnosis, including altered mental status dementia (progressive degenerative disease of the brain resulting in loss of reality function) and dehydration (lack of sufficient body fluid). Review of care plan for Resident R97 dated July 21, 2024, revealed that the resident had impaired cognitive function/ dementia or impaired thought process. Review of Resident R97's admission assessment revealed an instruction section which indicated Response of Ambulatory and Disoriented/intermittent confusion will score resident at risk for elopement. Review of progress note for Resident R97 dated July 5, 2024, revealed that resident was noted with wandering behavior and exit seeking behavior.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to conduct accurate assessments to ensure that bedrails were used to meet residents' needs and the risks associated with bedrail usage, failed to review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to installation for one of two residents (Residents R97). Findings include: A review of Resident R97's clinical record revealed that resident was admitted to the facility on [DATE], with diagnosis, including altered mental status dementia and dehydration. Review of care plan for Resident R97 dated July 21, 2024, revealed that the resident had impaired cognitive function/ dementia or impaired thought process. During an observation on 7/10/24, at 11:26 a.m. there were bilateral upper side rails on Resident R97's bed. Review of a side rail/entrapment risk evaluation for Resident R97 dated June 21, 2024 revealed that…

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

Based on clinical record review and staff interview, it was determined that the facility failed to ensure that laboratory study results were promptly obtained as ordered by the physician for one of 13 clinical records reviewed (Resident R94). Findings include: Interview with Resident R94's daughter on June 9, 2024 at 1:07 p.m. stated resident was more confused and fell 2 days ago. Daughter stated she was concerned that the resident might be anemic, and she requested blood work on Sunday. Daughter stated the blood was collected on Monday morning and still don't have the result. Review of Resident R94's physician progress note dated July 8, 2024 revealed that resident was anemic and monitor H&H (also known as a hemoglobin and hematocrit test, provides information about the blood's oxygen-carrying capacity) Review of physician order dated July 5, 2024 revealed an order to complete blood work CBC (complete blood count), CMP (complete metabolic panel) and Magnesium on July 8, 2024. Interview with Licensed Practical Nurse, Employee E18 on June 9, 2024 at 1:25 p.m. stated facility did not…

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

Based on review of facility policy, observations, and interviews with staff, it was determined that the facility did not ensure that food was stored and served in accordance with professional standards for food service safety. Findings include: Review of undated facility policy titled, Food Storage indicated that Food is stored, prepared and transported at an appropriate temperature and by methods designed to prevent contamination. Freezer temperature: temperature of for freezer should be 0 degrees or below and must be recorded daily An initial tour of the Food Service Department conducted on July 9, 2024, at 9:52 a.m. with Employee E19, Food Service Manager, revealed the following: Observations of the refrigerator inside the kitchen contained hot dogs buns with use by date of June 29, 2024, Inside the refrigerator there was a vegetable tray with no date A tray of cake with no date. A tray of Fresh fruit cup with use by date of July 8, 2024. Lettuce with use by date of July 8, 2024. Observation of the walk-in refrigerator revealed that the door was not completely closed. 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 observations and interviews with staff, it was determined that the facility failed to ensure that garbage was dispose of properly. Findings include: Observation in the receiving area and the garbage disposal area on July 9, 2024, at 10:30 a.m. with Employee E19, Food Service Manager, revealed one dumpster with the lid open revealing contents. There was brown colored liquid leaking from one dumpster, the leak created a stagnant brown colored liquid outside the dumpster on the floor. There were flies observed around the liquid. A follow up observation with regional dietary staff, Employee E19, on June 10, 2024, at 1:55 p.m. revealed the brown colored liquid was still present next to the dumpster and there were trash from the kitchen on the floor next to the dumpster. 29 Pa. Code 201.18 (b)(1) Management

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of clinical records, it was determined that the faciltiy failed to ensure that elopment assessments was accurately completed for one of 13 residents reviewed (Resident R97) Findings include: A review of Resident R97's clinical record revealed that resident was admitted to the facility on [DATE], with diagnosis, including altered mental status dementia (progressive degenerative disease of the brain resulting in loss of reality function) and dehydration (lack of sufficient body fluid). Review of care plan for Resident R97 dated July 21, 2024, revealed that the resident had impaired cognitive function/ dementia or impaired thought process. Review of Resident R97's admission assessment dated [DATE] revealed an elopement assessment which was not completed accurately. For a question Predisposing Disease it was documented as none present. However, an instruction for predisposing condition included Dementia, Organic Brain Syndrome, Alzheimer's disease, Mental Illness and Traumatic Brain Injury.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, review of facility policy and interview with staff, it was determined that facility did not ensure to maintain infection prevention and control program designed to provide a safe and sanitary environment and to help prevent the development and transmission of communicable diseases and infections for three of 13 residents reviewed. (Resident R148, R147 and Resident R96) Findings include: Review of facility policy Enhanced Barrier Precautions (EBP) , revealed that EBP's are indicated for residents with any of the following: wounds or indwelling medical devices, regardless of : multidrug resistant organisms (MDRO's) colonization status; infection or colonization with an MDRO when contact precautions do not otherwise apply Effective implementation of EBP requires staff training on the proper use of personal protective equipment and the availability of PPE and hand hygiene supplies at the point of care. Review of facility policy Laundry, Bedding, Soiled, dated July 2009 revealed that Place…

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 clinical records, review of facility provided documentation and interview with staff and residents, it was determined that facility did not ensure to include as part of its Quality Assurance and Performance Improvement (QAPI) program mandatory training that outlines and informs staff of the elements and goals of the facility's QAPI program for five of five employees reviewed (Employees E6, E7, E8, E9, and E10) Findings include: Review of Employee E7 and Employee E8's nurse aide personnel files revealed no evidence of training related to facility's QAPI program. Review of licensed nurse personnel files of Employee E6, Employee E9 and Employee E10 revealed no evidence of training provided regarding facility's QAPI program. Findings confirmed with facility's administrator on July 12, 2024. 28 Pa Code 201.14(a)Responsibility of licensee 28 Pa Code 201.18(b)(1) Management 28 Pa Code 201.20(a)(c)Staff development

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record reviews and interviews with staff, it was determined that the facility failed to develop a baseline care plan that included instructions related to a diagnosis of heart failure for one of two residents reviewed. (Resident R1). Findings include: Resident R1 was admitted to the facility on [DATE], diagnosed with encephalopathy ( a disease in which the functioning of the brain is affected), chronic kidney disease, unspecified heart failure (heart does not pump sufficiently) and high blood pressure. Physicians note dated December 19, 2023, stated, Elevated legs at rest. Compression stocking (used to improve blood flow from legs to the heart and to decrease swelling (edema) in legs) on in AM off before bed. Vitals daily and weigh weekly. Alert provider of weight gain of more than 2-3 pounds in a 24-hour period or more than 5 pounds in a week (weight gain is a marker for heart failure). Review of Resident R1's care plan failed to develop a plan of care related to Resident R1's diagnosis 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 resident records and interviews with staff, it was determined the facility did not follow/obtain nor clarify physician orders for medication and treatments for one of two residents reviewed (Resident R1). Findings include: Resident R1 was admitted to the facility on [DATE], diagnosed with encephalopathy, chronic kidney disease, unspecified heart failure and high blood pressure. Review of Resident R1's December 2023 electronic medication administration record (EMAR) physician orders instructed: Ticagrelor Oral Tablet 90 milligrams (mg) instructed to give one tablet by mouth every 12 hours at 9:00 a.m. and 9 p.m. for Post Carotid Surgery was not given during the 9 p.m. dose on December 17, and 20, 2024. Nursing note specified the medication was not available. Clonidine HCl Oral Tablet 0.3 mg instructed to give 0.3 mg by mouth two times a day for high blood pressure was not given on December 20, 2023. Nursing note specified the medication was not available. To weigh resident on admission and 24…

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 facility policy, and review of facility documentation it was determined that the facility did not ensure an effective infection prevention program was maintained related to hand hygiene observed for one of six residents observed. (Resident R6) Findings Include: Review of the facility policy titled, Handwashing/Hand Hygiene dated July 2023, reads, Policy Statement: This facility considers hand hygiene the primary means to prevent the spread of infections. 1. All personnel shall be trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections. 2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. 3. Hand hygiene products and supplies (sinks, soap, towels, alcohol-based hand rub, etc.) shall be readily accessible and convenient for staff use to encourage compliance with hand hygiene policies. 4. Triclosan-containing soaps will not be used. 5. Wash hands with soap (antimicrobial or…

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.