Ellen Memorial Rehabilitation and Healthcare Cente

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of clinical records, select facility policy and facility incident reports, observations, and staff interviews, it was determined that the facility failed to provide the necessary treatment and services to maintain the highest practicable level of mental, physical and psychosocial well being of three residents with a diagnosis of dementia out of 21 sampled residents (Residents 74, 80, and 77 ). Findings include: A review of a facility policy entitled Behavioral Management that was last reviewed on January 16, 2024, indicated that residents exhibiting behaviors that could endanger themselves, other residents, or staff may benefit from a behavioral care plan to ensure that they receive appropriate services and interventions to meet their needs. A behavioral health care plan could include a schedule of daily life events that address the individuality of the resident and should reflect the resident's personal preferences, and usual routines, to the extent possible. The care plan should include 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 review of clinical records and the facility's abuse prohibition policy and staff interview, it was determined that the facility failed to implement their established procedures for thoroughly investigating an injury of known source, a fractured leg, sustained by one resident, to rule out abuse, neglect or mistreatment as the potential cause for out of 21 residents sampled (Resident 57). Findings include: A review of the facility's Abuse Policy, last reviewed by the facility on January 16, 2024, indicated that incidents of unknown origin will be investigated as abuse until root cause can be identified. Written procedures for investigation include: identifying staff responsible for the investigation; exercising caution in handling evidence that could be used in a criminal investigation; investigating different types of alleged violations; identifying and interviewing all involved persons, including alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations;…

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 policies and clinical records, staff and resident interview it was determined that the facility failed to provide necessary behavioral health care to promote the highest practicable physical and psychosocial well-being of one resident out of 21 sampled (Resident 5). Findings include: A review of facility policy entitled Behavioral Management last reviewed January 16, 2024, indicated that residents who exhibit behaviors which could endanger themselves, other residents or staff may benefit from a behavioral care plan to ensure they are receiving appropriate services and interventions to meet their needs. Behaviors should be documented clearly and concisely by facility staff and documentation should be specific behaviors, time and frequency of behaviors, observations of what may be triggering behaviors, what interventions were utilized and the outcomes of the interventions. Behaviors should be identified and approaches for modification or redirection should be included I 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, a review of clinical records, select facility policy, current infection control guidance and the facility's resident testing logs for COVID-19 infection, and staff interview, it was determined that the facility failed to implement and maintain infection control practices, including infection control precautions, to prevent spread of infection COVID-19. Findings include: According to information provided by the Centers for Disease Control and Prevention (CDC) dated September 23, 2022, and updated February 8, 2023, health care providers that test positive for COVID-19 and are asymptomatic throughout their infection and not moderately to severely immunocompromised could return to work after the following criteria have been met: at least 7 days have passed since the date of their first positive viral test if a negative viral test is obtained 48 hours prior to returning to work (or 10 days if testing is not performed or if a positive test at day 5-7). Interview with the Nursing Home Administrator on October 5, 2023, at approximately 9 AM revealed that on September…

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 abuse prohibition policy and procedures and employee statements it was determined that facility staff failed to timely report alleged resident abuse of one out of 7 residents sampled (Resident 5). Findings include: The facility's Abuse Policy, dated as reviewed by the facility August 15, 2022, indicated that the facility will provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. An alleged violation is defined as a situation that is observed or reported by staff, resident, relative, visitor or others but has not yet been investigated and, if verified, could be indication of noncompliance with the Federal requirements related to mistreatment, exploitation, neglect, or abuse, including injuries of unknown source, and misappropriation of resident property. Mistreatment is defined as inappropriate treatment or exploitation of a resident. Reporting of alleged violation 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 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. 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 current facility policy entitled Date Marking for Food Safety provided during the survey ending March 17, 2023, indicated that the facility adheres to a date marking system of ready-to-eat,…

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 grievances lodged with the facility and resident and staff interviews, it was determined that the facility failed to develop a comprehensive grievance policy and ensure the necessary information for filing a grievance was posted and/or provided/available to residents or their representatives and failed to make residents aware of the procedure for filing a concern/grievance, written or verbally, and the procedure to file an anonymous grievance as reported by three of four residents (Residents 5, 52, and 73) during a group meeting. Findings include: A review of the facility's policy entitled Resident and Family Grievances (reviewed/revised November 1, 2022) indicated that it is the facility's policy all grievances and complaints filed will be investigated and corrective actions will be taken to resolve the grievance(s). Observations of the hallway next to the chapel, conducted on the days of survey from March 15, 2023, through March 17, 2023, revealed a posting regarding the facility's grievance policy, however the posted…

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

Based on review of clinical records and select facility procedures and staff interviews it was determined the facility failed to accurately monitor bowel activity and carry out physician orders for a prescribed bowel protocol to promote normal bowel activity for one resident out of 22 sampled (Resident 31). Findings include: Review of the current facility Procedure on Bowel Protocol indicated that the facility will identify and provide interventions to residents who have not had a bowel movement in 72-hours. Nursing assistants are responsible to document each resident's bowel movements daily on every shift in Point Click Care (PCC). If a resident does not have a bowel movement on their shift, not applicable is to be documented in the PCC system in the section for bowel movements. If a resident has not had a bowel movement over a three-day period, Milk of Magnesia will be administered on the 3-11 shift as per the physician's orders and documented in PCC. If the resident has not had a bowel movement by the fourth day, a Dulcolax suppository will be administered on the 11 PM - 7 AM…

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 attending physician failed to timely act on a pharmacist's identification of an irregularity in the drug regimen of one resident out of five sampled (Resident 74). Findings include: A review of the clinical record revealed that Resident 74 was admitted to the facility on [DATE], with diagnoses to include dementia. A review of Resident 74's clinical record revealed the pharmacist conducted a drug regimen review on July 25, 2022, and identified irregularities in the resident's drug regimen and made recommendations to the attending physician. There was no documented evidence that the attending physician acted upon the reported drug irregularity. The consultant pharmacist identified the same drug irregularity on November 20, 2022, four months after the original recommendation, on July 25, 2022. However, there was no documented evidence that the attending physician had acted upon the pharmacy recommendation. 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 observations, select facility policy review and staff interviews it was determined that the facility failed to ensure accurate labeling to promote accurate drug administration to one resident (Resident 2) out three residents observed during medication administration and failed to adhere to use by/discard dates for multi-dose medications on one medication carts out of three medication carts reviewed. Findings include: According to the National Association of Boards of Pharmacy, Uniform Prescription Labeling Requirements, indicate that critical information on prescription labels include the Use by date, which is the Date by which medication should be used, not expiration date of medication or expiration date of prescription. Observation of medication administration pass on [DATE], at 8:25 AM revealed that Employee 2 administered Oxycodone 10 mg by mouth to Resident 2. Observation of the medication label on the Oxycodone blister pack revealed that the label indicated to that the resident was to take one…

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, resident and staff interview, test tray results, and a review of minutes from the facility's food committee meeting and select facility policy, it was determined that the facility failed to serve food at safe and palatable temperatures. Findings include: Review of the current facility policy entitled Food Preparation Guidelines indicated that food and drinks shall be palatable, attractive, and at safe and appetizing temperatures. Strategies to ensure resident satisfaction include to serve hot foods/drinks hot and cold food/drinks cold. Interviews with Residents 5, 14, 52, and 73 during a group meeting conducted on March 16, 2023, at 11:15 AM, revealed that the residents expressed concerns that their meals were not consistently served at palatable temperatures. The residents relayed that hot food was not always served hot enough and cold food was not always served cold enough for their preferences. During an observation in the facility's kitchen of the lunch meal tray service on March 16, 2023, at 11:35 AM, revealed that the temperatures of the meal, obtained,…

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 the facility's antibiotic stewardship program and staff interview, it was determined that the facility failed to fully develop and implement an antibiotic stewardship program. Findings include: A review of the facility's Antibiotic Stewardship Policy (ASP) dated March 18, 2019, indicated that the Infection Prevention and Control Committee will support and promote antibiotic use protocols which include assessment of residents using standardized tools and criteria. The committee will review the ASP policy and antibiotic use protocols annually and make recommendations for changes to the program. The Infection preventionist will collect and analyze infection surveillance and treatment data to ensure that infection prevention and antibiotic stewardship activities are supported. The facility will monitor antibiotic use, stewardship actions, and outcomes related to antibiotic use (excluding topical or ophthalmic antibiotics) in order track compliance and impact of the ASP. The facility will track physician habits monthly to determine what antibiotics are frequently…

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 interviews, 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 22 sampled (Resident 78). Findings include: A review of Resident 78's Quarterly MDS assessment dated [DATE], revealed in Section J1800, Any Falls Since admission or Prior Assessment (OBRA or PPS), whichever is more recent, revealed that the resident had not falls since admission or the prior assessment. However, a review of Resident 78's clinical record revealed that the resident had a incurred a fall from her wheelchair on November 30, 2022. Interview with Employee 4, Registered Nurse Assessment Coordinator on March 16, 2023, at approximately 1:30 PM confirmed that the residents MDS's was inaccurate with respect to the resident's fall. 28 Pa. Code 211.5(g)(h)…

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 incident reports, and staff interview, it was determined that the facility failed to review and revise the comprehensive care plan to address the current safety needs of one resident to prevent recurrence of falls for one resident (Resident 78) out of 22 residents reviewed. Findings include: A review of the clinical record revealed that Resident 78 was admitted to the facility on [DATE], with diagnoses to include dementia, anxiety disorder, abnormalities of gait and mobility and muscle weakness. A facility incident report dated January 7, 2023, at 0630 (6:30 AM) revealed that staff found the resident lying on the floor of her room. Immediate interventions planned after this fall were to apply a chair and bed alarm. These interventions were both discontinued on March 3, 2023, because they increased the resident's agitation. Interview with Employee 3, Licensed Practical Nurse, on March 15, 2023, at 11 AM revealed that the resident's chair and bed alarms were…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of select facility policy and clinical records and staff interview, it was determined that the facility failed to administer pain medication as prescribed by the physician and attempt non-pharmacological interventions to alleviate pain prior to the administration of pain medication prescribed on an as needed basis for one of 22 residents reviewed (Resident 65). Findings include: A review of the facility policy entitled Pain Management Policy last reviewed January 30, 2023, indicated that the facility will utilize a systemic approach for recognition, assessment, treatment and monitoring of pain. The management and treatment of pain will include non-pharmacological interventions which include but are not limited to environmental comfort (adjusting room temperature, comfortable seating or assistive devices, or smoothing linens), loosening any constrictive bandages or clothing, physical modalities (cold compress, warm shower/bath, massage, turning/repositioning), and cognitive/behavioral…

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 address a resident with a diagnosis of Post Traumatic Stress Disorder for one out of 22 residents reviewed (Resident 76). Findings include: A review of the clinical record revealed that Resident 76 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 the survey ending March 17, 2023, did identify the resident PTSD diagnosis. However, the resident's care plan did not identify the resident's real and potential triggers related to this diagnosis and failed to include the specific interventions planned in response to provide individualized person-centered care to the resident. The facility failed to develop and implement an individualized person-centered plan to address, modify and manage this resident's…

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

Based on observation, review of nurse staffing, and staff and resident interviews it was determined that the facility failed to provide and/or efficiently deploy sufficient nursing staff to consistently provide timely and quality of care to residents as required, including timely provision of assistance with activities of daily living, to residents dependent on staff and to accommodate resident the preferences for daily routines to maintain a resident's psychosocial well-being for one resident (Resident 28) out of 22 sampled. Findings include: During observations performed of the blue unit on March 15, 2023, at 11:00 AM, Resident 28's call bell was observed to be activated. The resident was observed to be in bed at that time wearing pajamas. During an interview with Resident 29, who was cognitively intact, on March 15, 2023, at 11:03 AM, revealed that she had activated her call bell and was now waiting for two staff members to get her out of bed and provide her morning care so she could be dressed for the day and on time for lunch in the main dining room. Resident 28 stated that she…

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 employee personnel records and Pennsylvania State nurse aide registry information and staff interview, it was determined that the facility failed to ensure current nurse aide registry verification for two facility employees working as nurse aides in the facility (Employees 5 and 6). Findings include: A review of personnel records conducted during the survey ending [DATE], revealed that Employee 5's nurse aide certification expired [DATE] and Employee 6's nurse aide certification expired [DATE]. A review of facility staffing records revealed that Employee 5 worked at the facility on the following dates: [DATE], 22, and 24, 2022; [DATE], 8, 12, 16, 20, 22, 23, 25, 26, and 30, 2022; [DATE], 10, 12, 14, 21, 23, 25, 27, 28, and 30; [DATE], 6, 11, 14, 15, 16, 18, 19, 23, 24, 26, and 27, 2023; February 1, 2, 3, 7, 8, 9, 11, 12, 14, 16, 20, 21, 23, 25, 26, and 28, 2023; [DATE], 6, 9, 11, 12, 14, and 15, and 17, 2023. Employee 6 worked at the facility on the following dates: [DATE] and 11, 2022; [DATE], and 25,…

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 attempt gradual dose reductions of psychoactive medications and failed to monitor the effectiveness of antipsychotic drugs as treatment for targeted behavioral symptoms and for potential adverse consequences for one resident (Resident 19) out of five residents sampled Findings included: A review of the clinical record revealed that Resident 19 was admitted to the facility on [DATE], and had diagnoses that included Alzheimer's disease (a type of brain disease that causes a long-term and often gradual decrease in the ability to think and remember how to perform normal activities such as bathing, dressing and eating). The resident had a physician's order dated February 19, 2021, that was current at the time of the survey ending March 17, 2023, for Haloperidol (an antipsychotic medication used to treat certain mental/mood conditions) 2 mg by mouth twice daily for dementia with behavioral disturbance. A review of…

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

Based on a review of select facility policy, directives established by the Centers for Medicare and Medicaid Services, and employee vaccine data, and staff interviews, it was determined the facility failed to fully develop and implement procedures to ensure that all staff were vaccinated for COVID-19. The facility's staff vaccination rate was 99.2% at the time of the survey ending March 17, 2023. Findings include: A review of a DEPARTMENT OF HEALTH & HUMAN SERVICES, Center for Clinical Standards and Quality/Quality, Safety & Oversight Group dated October 28, 2022, QSO 23-02-ALL memo stated that within 60 days after the issuance of this memorandum the facility demonstrates that policies and procedures are developed and implemented for ensuring all facility staff, regardless of clinical responsibility or patient or resident contact are vaccinated for COVID-19; and 100% of staff have received the necessary doses to complete the vaccine series (i.e., one dose of a single-dose vaccine or all doses of a multiple-dose vaccine series), or have been granted a qualifying exemption, 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.