Communities At Indian Haven,

Based on observations, and staff interviews, it was determined that the facility failed to ensure that medications were properly stored for one of 32 residents reviewed (Resident 4).Findings include:A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 4, dated December 19, 2025, indicated that the resident was cognitively intact, required assistance from staff for daily care needs, received an antidepressant medication, anticoagulant medication, and anti-convulsant medication. Resident 4 had diagnoses that included heart failure and diabetes. Observation of Resident 4 on January 28, 2026, at 9:53 a.m. revealed the resident was sitting in her wheelchair beside her bed and an unsupervised medicine cup containing 7 unlabeled clean and dry pills was sitting on her overbed table. Interview with Resident 4 at that time revealed that they were her morning medications that the nurse left for her to take.Interview with Licensed Practical Nurse 2 on January 28, 2026, at 9:57 a.m. revealed that she believed that Resident 4…

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 plans of correction for previous surveys, and the results of the current survey, it was determined that the facility's Quality Assurance Performance Improvement (QAPI) committee failed to correct quality deficiencies and ensure that plans to improve the delivery of care and services effectively addressed recurring deficiencies. Findings include:The facility's deficiencies and plan of corrections for an annual survey ending February 5, 2025, revealed that the facility developed plans of correction that included quality assurance systems to ensure that the facility maintained compliance with cited nursing home regulations. The results of the current survey, ending January 30, 2026, identified repeated deficiencies related to a failure to accurately complete MDS assessments, failure to create individualized care plans, quality of care, and infection control.The facility's plan of correction for a deficiency regarding accurate MDS assessments, cited during the survey ending February 5, 2025, revealed that the facility would complete audits and report…

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 policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that proper infection control practices were followed during the administration of a treatment for one of 38 residents reviewed (Residents 48). Findings include:The facility policy regarding nephrostomy tubes dated April 15, 2025, indicated that the steps in completing nephrostomy tube dressing changes and irrigation include to wash and dry your hands, open a sterile (completely free from germs/microorganisms (like bacteria) ) drape and create a sterile field (a designated, microorganism-free area prepared to prevent contamination during procedures), open several packages of gauze pads, open several packages of povidone-iodine swabs, and open the disposable waste bag and place it away from the sterile field. The steps for the dressing change include to position resident on their side opposite of the tube, place a pad under the resident, wash your hands and put on clean gloves, careful remove the wet or soiled dressing, discard the…

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

Based on review of facility policies, clinical records, and investigation documents, as well as staff interviews, it was determined that the facility failed to ensure that staff reported an allegation of neglect in a timely manner for one of seven residents reviewed (Resident 3). Findings include: The facility's abuse policy, dated March 4, 2024, revealed that all allegations of abuse shall be reported immediately to the charge nurse, Director of Nursing, Nursing Home Administrator, and resident's physician for investigation into the circumstances of the incident. The staff member who discovers the incident, suspected abuse situation, or has the initial knowledge of such incidents will be responsible for immediately notifying his or her supervisor. The supervisor who becomes aware of such incidents must immediately report to the Nursing Home Administrator and Director of Nursing, in person or by telephone. A quarterly Minimum Data Set (MDS) assessment (a mandatory assessment of a resident's abilities and care needs) for Resident 3, dated February 19, 2025, revealed that the 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.

Based on review of job descriptions and the deficiencies cited during the current survey, it was determined that the Nursing Home Administrator (NHA) and the Director of Nursing (DON) failed to assume responsibility for effective management of the facility to ensure that the residents' environment remained free from neglect, and for ensuring that staff reported abuse and protected the residents from further abuse/neglect. Findings include: The job description for the NHA, dated January 15, 2025, indicated that the primary function of this position was to provide general oversight and direction to all services provided by The Communities at Indian Haven. Maintains compliance with the Department of Health, Welfare, Medicare, and Educational regulatory requirements. Supervision and coordination of services to include overseeing budget and corporate policies and procedures related to the care of all residents. The job description for the DON, dated November 26, 2024, indicated that the primary function of this position was to organize, administrate, and supervise the total nursing…

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

Based on review of the Resident Assessment Instrument User's Manual and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that Quarterly Minimum Data Set assessments were completed within the required timeframe for seven of 43 residents reviewed (Residents 19, 33, 35, 38, 43, 54, 62). Findings include: The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which provides instructions and guidelines for completing required Minimum Data Set (MDS) assessments (mandated assessments of residents' abilities and care needs), dated October 2024, indicated that the completion date for a quarterly assessment is the Assessment Reference Date (ARD - the last day of an assessment's look-back period) plus 14 days. A quarterly assessment is due every 92 days (ARD of most recent assessment + 92 days). A quarterly MDS assessment for Resident 19, with an ARD of September 3, 2024, was due to be completed on September 16, 2024; however, it was not completed until October 4, 2024, which was 18 days late. A quarterly MDS…

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

Based on a review of facility policies and written menus, as well as observations and staff and resident interviews, it was determined that the facility failed to follow their planned menu. Findings include: A facility policy, dated January 15, 2024, indicated that food menu substitutions for unplanned situations, such as an emergency event, food unavailability, or special dining events, would be communicated to residents prior to meal service. The facility's written and printed menu for the dinner meal on February 4, 2025, indicated that the residents were to receive vegetable soup, chicken salad croissant, roasted vegetables, and sliced peaches. Observations of the lunch meal in the dining room on February 4, 2025, at 5:00 p.m. revealed that the facility served chicken salad on a hamburger bun and not a croissant as listed on the menu. Interview with Dietary Aide 2 on February 4, 2025, at 5:22 p.m. confirmed that staff made a mistake, and that the Dietary Manager was to update staff and residents. Interview with the Resident 51, who was the resident council president, on February…

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 and clinical records, as well as staff interviews, it was determined that the facility failed to develop comprehensive care plans that included specific and individualized treatment for two of 43 residents reviewed (Residents 37, 293) who were receiving intravenous antibiotics and anticoagulants. Findings include: A facility policy for care plans, dated January 15, 2024, revealed that the care plan is based on the resident's comprehensive assessment. admission orders for Resident 37, dated December 18, 2024, included an order for the resident to receive 10 milligrams (mg) normal saline to flush the peripherally inserted central catheter or PICC line (a thin flexible tube inserted into a vein in the upper arm for fluid or medication administration), and for the resident to receive 1.5 grams Vancomycin (antibiotic) every 24 hours for a left hip infection. Observations of Resident 37 on February 3, 2025, at 1:03 p.m. revealed that the resident had a PICC line in her right upper extremity. Resident 37's Medication Administration Record (MAR) 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.

Based on clinical record reviews and staff interviews, it was determined that the facility failed to provide medications as ordered by the physician for one of 43 residents reviewed (Resident 41). Findings include: A quarterly MDS assessment for Resident 41, dated December 19, 2024, revealed that the resident was cognitively intact, required moderate assistance from staff for daily care, and had diagnoses that included high blood pressure. Physician's orders for Resident 41, dated February 4, 2025, revealed that the resident was to stop taking 5 milligrams (mg) amlodipine (a medication to treat high blood pressure) and to start taking 5 mg of lisinopril (a medication to treat high blood pressure). Observations of Licensed Practical Nurse 1 during medication administration on February 5, 2025, at 8:00 a.m. revealed that she dropped a 5 mg tablet of amlodipine on the cart, picked it up with her bare hands, and administered the pill to Resident 41. Interview with Licensed Practical Nurse 1 at that time confirmed that she administered 5 mg of amlodipine and not 5 mg of lisinopril 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.

Based on review of facility policy and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that laboratory specimens were obtained as ordered by the physician for one of 43 residents reviewed (Resident 37). Findings include: A facility policy for lab and diagnostic testing, dated January 15, 2024, revealed that the physician will order diagnostic testing and the staff will process test requisitions and arrange for tests. Physician's orders for Resident 37, dated January 21, 2025, included an order for the resident to have a vancomycin (antibiotic) trough (a blood test to monitor the therapeutic dose of vancomycin) 30 minutes prior to vancomycin administration on January 24, 2025. A nursing note for Resident 37, dated January 25, 2025, at 1:15 p.m. revealed that the vancomycin trough was missed on January 25, 2025. New orders were received by the physician to have the vancomycin trough drawn 30 minutes prior to vancomycin administration on January 25, 2025. Interview with the Nursing Home Administrator on February 5, 2025, at 10:52 p.m.…

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 policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that clinical records were complete and accurately documented for one of 43 residents reviewed (Resident 37). Findings include: The facility's policy for medication administration, dated January 15, 2024, revealed that the facility shall maintain a medication administration record to document all medications administered. An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 37, dated December 17, 2024, revealed that she was cognitively intact and required partial staff assistance with her daily care needs. Physician's orders for Resident 37, dated December 17, 2024, included orders for the resident to receive 1.5 grams of vancomycin HCL in dextrose intravenous solution 1.5-5 grams/300 ml (an antibiotic) every 24 hours; 10 milliliters (ml) of normal saline solution (NSS) intravenously after receiving her antibiotic; 5 ml of Heparin Porcine (an anticoagulant) intravenously…

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 plans of correction for previous surveys, and the results of the current survey, it was determined that the facility's Quality Assurance Performance Improvement (QAPI) committee failed to correct quality deficiencies and ensure that plans to improve the delivery of care and services effectively addressed recurring deficiencies. Findings include: The facility's deficiencies and plans of corrections for a State Survey and Certification (Department of Health) survey ending March 21, 2024, and October 2, 2024, revealed that the facility developed plans of correction that included quality assurance systems to ensure that the facility maintained compliance with cited nursing home regulations. The results of the current survey, ending January 24, 2025, identified repeated deficiencies related to timely quarterly MDS assessments, accurate MDS assessments, comprehensive care plans, and quality of care. The facility's plan of correction for a deficiency regarding a failure to provide quarterly assessments at least every three months, cited during the survey…

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, observations, and staff interviews, it was determined that the facility failed to ensure that proper infection control practices were followed while administering medications for one of 43 residents reviewed (Resident 41). Findings include: Physician's orders for Resident 41 included orders for the resident to receive 5 mg amlodipine (a medication that is used to treat high blood pressure) that was discontinued on February 4, 2025. Observations of Licensed Practical Nurse 1 during medication administration on February 5, 2025, at 8:00 a.m. revealed that she dropped a 5 mg tablet of amlodipine on the cart and picked it up with her bare hands, then administered the pill to Resident 41. Interview with Licensed Practical Nurse 1 at that time confirmed that she should not have touched the 5 mg tablet of amlodipine with her bare hands and administered it to the resident. Interview with the Nursing Home Administrator on February 5, 2025, at 10:07 a.m. confirmed that staff were not to touch residents' medications with their bare hands. 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 review of the Resident Assessment Instrument User's Manual and residents' clinical records, as well as staff interviews, it was determined that the facility failed to ensure that comprehensive admission Minimum Data Set assessments were completed in the required timeframe for two of 11 residents reviewed (Residents 2, 4). Findings include: The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which provides instructions and guidelines for completing required Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2024, indicated that for admission MDS assessments, the assessment completion date was to be no later than the resident's admission date plus 13 calendar days. An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 2, dated August 22, 2024, revealed that the resident was admitted on [DATE]. The resident's MDS was documented in section Z0500B…

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 policies and clinical records, as well as staff interviews, it was determined that the facility failed to develop care plans to address individualized resident care needs for one of 11 residents reviewed (Resident 4). Findings include: The facility's policy regarding care plans, dated January 15, 2024, indicated that a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychological and functional needs is developed and implemented for each resident. Assessments of residents are ongoing and care plans are revised as information about the resident and the resident's condition changes. Physician's orders for Resident 4, dated August 16, 2024, included an order for the resident to be admitted to hospice (specialized care that provides physical comfort and emotional, social, and spiritual support for people nearing the end of life). A nursing note for Resident 4, dated August 7, 2024, revealed that the resident was seen by the physician regarding his admission to the facility and that the…

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

Based on review of the Resident Assessment Instrument User's Manual and residents' clinical records, as well as staff interviews, it was determined that the facility failed to ensure that a quarterly Minimum Data Set assessment was completed in the required timeframe for one of 11 residents reviewed (Resident 1). Findings include: The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which provides instructions and guidelines for completing required Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2024, indicated that a quarterly assessment was to have a completion date (Section Z0500B) that was no later than the assessment reference date (ARD-last day of the observation/look-back period) plus 14 calendar days. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, with an ARD of August 2, 2024, revealed that the resident's MDS was documented in section Z0500B as being completed on September 3, 2024, which was 32 days…

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 policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that care plans were updated to reflect changes in residents' care needs for three of 11 residents reviewed (Residents 1, 2, 4). Findings include: The facility's policy regarding care plans, dated January 15, 2024, indicated that a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychological and functional needs is developed and implemented for each resident. Assessments of residents are ongoing and care plans are revised as information about the resident and the residents' condition changes. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated August 2, 2024, revealed that the resident was understood and was able to understand others, required assistance with care needs, received diuretic medications (medications used to treat fluid build-up), and had diagnoses that included congestive heart…

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, as well as resident and staff interviews, it was determined that the facility failed to maintain clinical records that were complete and accurately documented for one of 11 residents reviewed (Resident 1). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated August 2, 2024, revealed that the resident was understood and was able to understand others, required assistance with care needs, received diuretic medications (medications used to treat fluid build-up), and had diagnoses that included congestive heart failure (the heart cannot pump blood as well as it should causing weight gain due to fluid to build up in the lungs and lower legs), hypertension (high blood pressure), and chronic obstructive pulmonary disease (COPD) (chronic lung disease making breathing difficult). A nurse's note for Resident 1, dated September 25, 2024, at 4:34 p.m., revealed that the resident's daughter had concerns related to his recent low blood pressures, diuretic…

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, as well as staff interviews, it was determined that the facility failed to ensure that baseline care plans included the information and instructions needed to provide person-centered care for four of 36 residents reviewed (Residents 77, 78, 79, 82). Findings include: The facility's policy regarding baseline care plans, dated January 15, 2024, indicated that a baseline plan of care to meet the resident's immediate needs would be developed for each resident within forty-eight hours of admission. The interdisciplinary team would review the healthcare practitioner's orders (e.g., dietary needs, medications, routine treatments, etc.) and implement a baseline care plan to meet the resident's immediate care needs including, but not limited to the following: initial goals based on admission orders, physician orders, dietary orders, therapy services, and social services. admission information for Resident 77 revealed that she was admitted to the facility on…

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 policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that care plans were updated to reflect changes in care needs for four of 36 residents reviewed (Residents 6, 25, 57, 67). Findings include: The facility's policy regarding care plans, dated January 15, 2024, indicated that nursing staff and/or the interdisciplinary team were to update care plans as information about the residents and the residents' conditions change. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 6, dated January 17, 2024, revealed that the resident was understood; could understand; was cognitively intact; had diagnoses that included osteoarthritis (degeneration of the joints), high blood pressure and anxiety; wore bilateral hearing aides; and was dependent on staff for daily care needs. Observations of Resident 6 in bed on March 18, 2024, at 11:41 a.m. revealed that her hearing aides were not in her ears. Her roommate stated that they are…

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 policies and clinical records, as well as staff interviews, it was determined that monitoring of the resident's restorative nursing programs for range of motion and transferring did not reflect the resident's progress toward program goals for two of 36 residents reviewed (Residents 3, 14). Findings include: The facility's policy regarding restorative nursing, dated January 15, 2024, revealed providing nursing interventions that promote the resident's ability to adapt and adjust to living as independently and safely as possible. This concept actively focuses on achieving and maintaining optimal physical, mental, and psychosocial functioning. The restorative nursing care programs are designed and designated to assist the resident in achieving and maintaining an optimal level of self-care and independence. Reassessment of progress, goals, and duration/frequency was part of the care plan process. Documentation of reassessment in the medical record with evidence of periodic evaluation was completed by a licensed staff member (at least quarterly). Documentation should…

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 policies and clinical records, as well as staff interviews, it was determined that the facility failed to administer pain medications as ordered by the physician for two of 36 residents reviewed (Residents 78, 82). Findings include: The facility's policy regarding pain medications, dated January 15, 2024, indicated that staff were to administer pain medications as ordered by the physician. Physician's orders for Resident 78, dated March 11, 2024, included orders for the resident to receive 5-325 milligram (mg) tablet of hydrocodone-acetaminophen (narcotic pain medication) every twelve hours as needed for a pain rating of 6 to 10 (on a scale of 1-10, with 10 being the worst pain). Resident 78's Medication Administration Record (MAR) for March 2024 revealed that staff administered hydrocodone-acetaminophen for a pain rating that was less than six on March 14 at 8:39 p.m., March 15 at 10:09 p.m., and March 19 at 7:51 p.m. Physician's orders for Resident 82, dated March 18, 2024, included orders for the resident to receive 5 mg of oxycodone (narcotic pain medication)…

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 policies and clinical records, as well as staff interviews, it was determined that the facility failed to maintain accountability for controlled medications (drugs with the potential to be abused) for one of 36 residents reviewed (Residents 63). Findings include: The facility's policy regarding controlled substances, dated January 31, 2024, indicated that accurate accountability of the inventory of all controlled drugs is maintained at all times. When a controlled substance was administered, the licensed nurse administering the medication was to immediately enter the following information on the accountability record and Medication Administration Record (MAR): date and time of administration, amount administered, remaining quantity, and the initials of the nurse administering the dose, completed after the medication is actually administered. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 63, dated January 20, 2024, revealed that the resident was cognitively intact and required assistance…

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 policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that it was free from significant medication errors for one of 20 residents reviewed (Resident 20). Findings include: The facility's medication administration policy, dated January 15, 2024, revealed that medications were to be administered as prescribed. Manufacturer's instructions for Aspart, revised February 2015, indicated that the medication should be administered within five or ten minutes of a meal. Physician's orders for Resident 20, dated December 9, 2023, included orders for the resident to receive 10 units of insulin Aspart (fast-acting insulin) in the morning before breakfast, 10 units before lunch, and 10 units before dinner. Medication Administration Records (MAR) for Resident 20 for January, February, and March 2024 revealed that he received his insulin at 9:00 a.m., 10:00 a.m. and 3:00 p.m. However, meal times were 8:10 a.m. for breakfast, 11:40 a.m. for lunch, and 4:40 p.m. for dinner. Resident 20's insulin administration was not within…

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, observations, and staff interviews, as well as medication package inserts, it was determined that the facility failed to discard expired medication in one of two medication rooms reviewed (Medication room [ROOM NUMBER]), failed to discard multiple bags of outdated IV (fluid that is administered into the vein) stock solution, and failed to administer insulin as per manufacture's instructions. Findings include: The facility's policy regarding medication storage, dated [DATE], revealed that the facility would not use outdated drugs or biologicals. Observations in Medication room [ROOM NUMBER] on [DATE], at 9:10 a.m. revealed that one Forteo (a man-made hormone that stimulates new bone growth) injection pen was labeled with an expiration date of [DATE], and there were five 100 cc bags of outdated IV stock solution, two that expired in [DATE] and three that expired in [DATE]. Interview with Registered Nurse 4 on [DATE], at 9:20 a.m. confirmed that the Forteo injection pen and the…

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

Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to notify the ombudsman about hospitalizations for three of 36 residents reviewed (Residents 24, 49, 57). Findings include: The facility's current policy for Transfer and Discharge Notification indicated that upon transfer to the hospital the ombudsman would be notified. An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 24, dated December 29, 2023, indicated that the resident was cognitively intact, usually understood and could sometimes understand, required assistance from staff for her daily care needs, and had diagnoses that included congestive heart failure (inability of the heart to pump blood throughout the body sufficiently) and coronary artery disease (a condition that limits blood flow to the heart). Resident 24 was transferred to the hospital on March 15, 2024, for a cardiac evaluation. There was no documented evidence that a written notice of Resident 24's transfer 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 review of the Long-Term Care Facility Resident Assessment Instrument User's Manual and clinical records, as well as staff interviews, it was determined that the facility failed to complete accurate Minimum Data Set assessments for five of 36 residents reviewed (Residents 20, 27, 31, 58, 72). Findings include: The Resident Assessment Instrument User's Manual, which gives instructions for completing Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2023, revealed that Section B0700 was to be coded zero (0) if the resident was understood, one (1) if the resident was usually understood, two (2) if the resident was sometimes understood, and three (3) if the resident was rarely/never understood. Section B0800 was to be coded zero (0) if the resident could understand others, one (1) if the resident usually understood others, two (2) if the resident sometimes understands others and three (3) if the resident rarely/never understands others. Section C0100 was to be coded zero (0) if the resident is rarely/never…

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 policies and clinical records, as well as staff interviews, it was determined that the facility failed to develop and implement comprehensive care plans that included specific and individualized interventions to address specific care needs for three of 36 residents reviewed (Residents 20, 27, 72). Findings include: The facility's policy regarding care plans, dated January 15, 2024, indicated that resident's care plans would be developed based on their needs. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 20, dated Feburary 3, 2024, indicated that the resident was alert and oriented and able to make his needs known. A physician's order, dated August 30, 2023, included an order for the resident to receive 2.5 milligrams (mg) Xarelto (blood thinner) two times per day. Review of Resident 20's Medication Administration Record, dated February and March 2024, revealed that the resident received Xarelto twice a day. 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.

Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to follow physician's orders for two of 36 residents reviewed (Residents 57, 63). Findings include: The facility's policy regarding implementation of physican orders indicated that changes to the plan of care will be recorded, communicated, and implemented as ordered by the medical provider. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 57, dated February 15, 2024, revealed that the resident was cognitively intact, required moderate assistance from staff for daily care tasks, had a care plan that indicated the resident was at risk for urinary tract infections and sepsis (a life threatening infection in the blood), and had diagnoses that included chronic kidney disease with a left nephrostomy tube (a tube placed in the kidney to drain urine) placed in January. Physician's orders for Resident 57, dated February 12, 2024, included orders for staff to check the nephrostomy tube for patency…

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

Based on review of personnel files, as well as staff interviews, it was determined that the facility failed to ensure that nurse aide performance evaluations were completed annually based on hire dates for one of three nurse aides reviewed (Nurse Aide 3). Findings include: A list of nurse aides provided by the facility revealed that based on their months and days of hire, an annual performance evaluation for Nurse Aide 3 was due February 13, 2024. As of March 21, 2024, there was no documented evidence that the annual performance evaluation was completed as required for Nurse Aide 3. Interview with the Human Resource Director on March 21, 2024, at 11:38 a.m. confirmed that she could not provide evidence that the annual performance evaluation for Nurse Aide 3 was completed as required. 28 Pa. Code 201.14(a) Responsibility of Licensee. 28 Pa. Code 201.18(b)(1)(3)(e)(1) Management. 28 Pa. Code 201.20(a)(c) Staff Development.