William Penn Care Center

Based on a review of facility policy, facility provided documentation, and staff interviews, it was determined the facility failed to designate a consistent qualified individual(s) onsite, who is responsible for implementing programs and activities to prevent and control infections for one of 10 months (April 2026).Findings included: Review of facility Infection Control Plan, Program and Committee policy last reviewed 1/6/26, indicated the facility has established and maintains an infection control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. The designated Infection Preventionist is responsible for oversight of the program and serves as a consultant to our staff on infectious diseases, resident room placement, implementing isolation precautions, staff and resident exposures, surveillance and epidemiological investigations of exposures and infectious disease During an interview completed on 5/6/26, at 1:59 p.m. Human Resource (HR) Employee E15 revealed 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 policy, clinical record reviews and staff interviews, it was determined that the facility failed to initiate a thorough investigation for incident or accidents for one of five residents (Residents R1).The facility Incident and Accident policy dated 1/28/25, indicated for staff to report, investigate, and review and accidents or incidents that occur or allegedly occur, on facility property and may involve or allegedly involve a resident. Review of the clinical record indicated Resident R1was admitted to facility 10/18/24. Review of Resident R1s Minimum Data Set (MDS, periodic assessment of resident care needs) dated 1/18/26 included diagnoses of cardiomegaly (enlarged heart), hyperlipidemia and anxiety. Review of Section C: Cognitive Patterns, Questions C0500 BIMS Summary Score revealed Resident R1' score to be 13, cognitively intact. Review of a progress note dated 2/17/26, at 11:36 a.m. indicated Registered Nurse was made aware that resident was outside in wheelchair by rehab. This nurse went outside to assess resident and was met by 2 another rehab…

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, clinical records, facility documents, and staff interviews, it was determined that the facility failed to provide adequate supervision resulting in an elopement (resident exits to an unsupervised or unauthorized area without the facility's knowledge) for one of five residents (Resident R1). Review of facility policy Elopements and Wandering Residents dated 1/28/25, indicated the facility ensures that residents which exhibit wandering behaviors and/or are at risk for elopement receive adequate supervision to prevent accidents, and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement risk. Alarms are not a replacement for necessary supervision. Staff are to be vigilant in responding to alarms in a timely manner. The facility shall establish and utilize a systemic approach to monitoring and managing residents at risk for elopement or unsafe wandering, including identification and assessment 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 facility policy, clinical records and staff interview, it was determined that the facility failed to provide documentation of medication regimen reviews (MRR) completed at least monthly for three of three sampled resident records (Resident R20, R59, R67). Finding include: The facility Medication regimen review policy dated 1/28/25, indicated that the drug regimen review of each resident is at least monthly by a licensed pharmacist and includes a review of the resident's medical chart. A medication regimen review (MRR) or drug regimen review, is a thorough evaluation of the medication regimen of a resident with the goal of promoting positive outcomes. Review of Resident R20's admission record indicated she was admitted to the facility on [DATE]. Review of Resident R20's MDS assessment (MDS: Minimum Data Set assessment-a periodic assessment of resident care needs) dated 5/13/25, indicated she had diagnoses that included dementia (group of symptoms affecting memory, thinking, and social abilities…

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 policy, observation and staff interview, it was determined that the facility failed to properly maintain kitchen equipment in a sanitary condition creating the potential for cross contamination in the main kitchen of the facility. Findings include: A review of facility policy Food Safety and Sanitation dated 1/28/25, indicated all local, state and federal standards and regulations will be followed in order to assure a safe and sanitary food and nutrition department. During an observation on 6/2/25, at 10:00 a.m., of the walk-in cooler in the main kitchen, conducted with Certified Dietary Manager (CDM) Employee E1, revealed that the cold air condenser unit had a build-up of dust, grime, and dark colored debris around the fan covers and ceiling immediately forward of the fans. CDM Employee E1 confirmed observation by surveyor when viewed. During an interview on 6/2/25, at 10:05 a.m., CDM Employee E1 confirmed that the facility failed to properly maintain kitchen equipment, walk-in cooler, in a sanitary condition creating the potential for cross contamination in…

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, clinical records, facility documents, and staff interviews, it was determined that the facility failed to provide adequate supervision resulting in an elopement (resident exits to an unsupervised or unauthorized area without the facility's knowledge) for one of four residents (Resident R44). Findings include: Review of facility policy Elopements and Wandering Residents dated 1/28/25, indicated the facility ensures that residents which exhibit wandering behaviors and/or are at risk for elopement receive adequate supervision to prevent accidents, and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement risk. Alarms are not a replacement for necessary supervision. Staff are to be vigilant in responding to alarms in a timely manner. The facility shall establish and utilize a systemic approach to monitoring and managing residents at risk for elopement or unsafe wandering, including identification 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of the facility policy, clinical record review and staff interview, it was determined that the facility failed to accurately assess the nutritional status, and failed to update an individualized care plan to address the resident's specific nutritional concerns for one of four residents (Resident R65) records reviewed. Findings include: Review of facility's policy Nutritional Assessment, dated 1/28/25, indicated part of the comprehensive assessment, a nutritional assessment, including current nutritional status and risk factors for impaired nutrition, shall be conducted for each resident. The dietitian, in conjunction with the nursing staff and healthcare practioners, will conduct a nutritional assessment for each resident upon admission (within current baseline assessment timeframes) and as indicated by a change in condition that places the resident at risk for impaired nutrition. As part of the comprehensive assessment, the nutritional assessment will be a systemic, multidisciplinary process…

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 facility policy and staff interview it was determined that the facility failed to provide medical record access for one of four residents (Resident R1). Findings include: Review of Release of Medical Records dated 1/1/25, indicated medical records will be released with a valid request and in accordance with state and federal laws. Requests for records should be referred to the Director of Nursing or Administrator, or another staff member previously designated by the facility. The facility should request copies of any legal papers necessary to authenticate authority. The legal papers should be attached to the request for records. The corporate office/risk manager should be notified of the request for records. Upon receipt of a request for medical record copies, the facility should notify the requesting party, in writing of the cost for obtaining records and that records are available two days after the receipt of payment for the copies. Records should be assembled in chronological order. When documents…

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 record review, and staff interview, it was determined that the facility failed to implement an effective discharge planning process that focuses on the resident's discharge goals and effectively transition them to post-discharge care for one of three residents (Resident R2). Findings include: Review of the clinical record indicated Resident R2 was admitted to the facility on [DATE]. Review of Resident R2's Minimum Data Set (MDS - a periodic assessment of care needs) dated 2/14/25, indicated diagnoses of encounter for surgical aftercare following surgery on the digestive system, colostomy (a surgical procedure that changes the way stool exits your body), and high blood pressure. Review of Resident R2's care plan dated 2/12/25, indicated to assist the resident with obtaining durable medical equipment (DME) and medical supplies prior to discharge. Review of a physician order dated 2/12/25, indicated to administer oxygen at two liter per minute (LPM) continuously. Review of a physician…

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 record review and staff interviews it was determined that the facility failed to follow physician orders for one of two residents (Resident R1). Findings include: Review of the clinical record indicated that Resident R1 was admitted to the facility on [DATE], with diagnosis that included malignant neoplasm of upper lobe, right bronchus or lung, cyst of kidney and ischemic cardiomyopathy (a condition that occurs when the heart muscle is damaged by a lack of blood flow). Review of Resident R1's physician orders dated 1/8/25, indicated that Resident R1 is to be Nothing by Mouth(NPO) diet, NPO texture, NPO consistency, enteral feed every shift by j-port. A review of Resident R1's physician orders dated for January indicated two medications were ordered to be given by mouth. They include the following: Oxycodone HCl Oral Tablet 5 MG (Oxycodone HCl),semi-synthetic narcotic analgesic, give 0.5 tablet by mouth every 6 hours as needed Claritin Oral Tablet 10MG (Loratadine), an antihistamine…

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 provide a transfer notice to a representative of the Office of the Long-Term Care Ombudsman Division for three out of nine residents (Residents R1, R2 and R3). Findings include: Review of Resident R2's admission record indicated she was originally admitted on [DATE], with diagnoses that included diabetes, anxiety disorder and fibromyalgia (chronic condition that causes widespread pain and tenderness in the body). Review of Resident R2's annual MDS assessment (MDS-Minimum Data Set assessment: periodic assessment of resident care needs) dated 8/29/24, indicated that the diagnoses were current upon review. Review of Resident R2's clinical record revealed that the resident was transferred to the hospital on 8/20/24, and returned to the facility on 9/9/24. Review of Resident R2's clinical record indicated the facility failed to include documented evidence that the facility provided a written transportation notification…

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 facility assessment and staff interview, it was determined that the facility failed to provide a qualified full time social worker for a facility with more than 120 beds. Findings include: The facility assessment dated [DATE], indicated that the facility will have a full time Social Services Director. The faciliy has a capacity of 145 requiring a full time Social Worker. Interview with the Nursing Home Administrator (NHA) revealed that the Social Worker left 9/6/24. The facility hired a new social worker, start date in a few weeks. During an interview on 9/17/24, at 11:45 a.m. the Nursing Home Administrator confirmed there is currently no social worker employed at the facility as required. 28. Pa. Code: 201(b)(2) Management. 28. Pa. Code: 201(a) Social services.

Based on review of facility financial documents, interviews with vendor and staff, it was determined that the facility failed to pay bills in a timely manner. Findings include: 28 PA Code Commonwealth of Pennsylvania Long Term Care Licensure Regulations, subsection 201.14(g), dated July 1, 2023, indicated that a facility owner shall pay in a timely manner bills incurred in the operation of a facility that are not in dispute and that are for services without which the residents' health and safety are jeopardized. Review of the Nursing Home Administrator's signed job description dated 9/20/21, indicated the primary purpose of the nursing home administrator is to direct the day-to-day functions of the facility with current federal, state, and local standards, guidelines and regulations that govern nursing facilities to assure that the highest degree if quality care can be provided to our residents at all times. During an interview on 9/9/24, at 9:36 a.m. Kitchen Manager, Employee E1 stated Vendor 1 has cut of services a couple of times. Kitchen Manager, Employee E1 indicated she is 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 a review of facility policies, observations and staff interviews it was determined that the facility failed to properly store food products, and verify the washing temperature of the dish machine in the Main Kitchen (Main Kitchen), which created the potential for food borne illness. Findings Include: Review of the facility policy Cleaning Dishes/Dish Machine, last reviewed 1/320/24, indicated that the dish machine will be checked prior to meals to assure proper functioning and appropriate temperatures for cleaning and sanitizing. Prior to use, verify proper temperatures and machine function. Staff should check the dish machine gauges throughout the cycle to assure proper temperatures for sanitization. Thermal strips may be used as verification that the temperature is adequately hot. During an observation in the Main Kitchen walk-in refrigerator, on 7/15/23, at 9:45 a.m., a plastic bag containing an employee's lunch dated 7/14/24, was noted to be stored amongst the residents' food supply. During an additional observation on 7/16/24, at 10:40 a.m. in the Main Kitchen walk-in…

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 the facility policy, clinical record review and staff interview, it was determined that the facility failed to assess the nutritional status of three of six residents ( Resident R3, R35, and R67) records reviewed. Findings include: Review of facility's policy Role Delineation for Certified Dietary Manger, dated 1-30-24, indicated that the Certified Dietary Manager (CDM) may write progress notes by stating factual information such as diet order, percent of food intake, as noted by nursing, height, weight, usual body weight, lab values, medications, etc. Review of the clinical record indicated Resident R3 was admitted to the facility on [DATE]. Review of Resident R3's Minimum Data Set (MDS - a periodic assessment of care needs) dated 5/8/24, indicated diagnoses of high blood pressure, hallucinations (a perception of having seen, heard, touched, tasted, or smelled something that wasn't actually there), and schizophrenia (a mental disorder characterized by disruptions in thought processes,…

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 facility policy, clinical record review, observation, and staff interview, it was determined that the facility failed to follow enhanced barrier precautions for two of twenty residents (Residents R33 and R74), failed to have proper signage for Transmission Based Precautions, and staff knowledge for one of one positive Covid resident (Resident R180). Findings include: Review of the facility policy Enhanced Barrier Precautions (EBP) dated 1/30/24, indicated EBP refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDRO) that employs targeted gown and glove use during high contact resident care activities. A physician order will be obtained for EBP for residents with any of the following wounds, indwelling medical devices even if the resident is not known to be infected with a MDRO. Review of the facility provided Pennsylvania Health Alert Network (PAHAN) 694, dated 5/11/23, indicated establish a process to identify and manage individuals with…

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 records and staff interviews, it was determined that the facility failed to have a designated Infection Preventionist (IP) qualified with specialized training in infection prevention and control for six of twelve months (February 2024 - July 2024). Findings include: Upon review of the infection prevention tasks during annual survey 7/15/24, it was discovered that the Director of Nursing was also the current Infection Preventionist. Interview on 7/15/24, at 9:18 a.m. the Nursing Home Administrator confirmed that the Director of Nursing has been covering the Infection Preventionist (IP) role since the previous IP's last day of work on 2/5/24. Interview on 7/19/24, at 12:30 p.m. the Nursing Home Administrator confirmed that the facility failed to have a designated Infection Preventionist (IP) qualified with specialized training in infection prevention and control for six of twelve months (February 2024 - July 2024). 28 Pa. Code 201.18(b)(3) Management. 28 Pa. Code: 201.14(a) Responsibility of licensee. 28 Pa. Code 211.12(d)(1)(3) Nursing services.

Based on review of facility in-service documentation, personnel records, and staff interviews it was determined that the facility failed to implement and maintain an effective training program for five of ten employee files reviewed (Nurse Aides (NA) Employee E9, NA Employee E16, NA Employee E25, NA Employee E27, and Licensed Practical Nurse (LPN) Employee E26). Findings include: Review of NA Employee E9's personnel record indicated a date of hire on 7/5/2010. Review of NA Employee E9's personnel record did not include annual in-service training on resident rights, abuse, quality assurance performance improvement (QAPI), and behavioral health training in the last year. Review of NA Employee E16's personnel record indicated a date of hire on 7/10/2014. Review of NA Employee E16's personnel record did not include annual in-service training on abuse, dementia care, infection control, communication, QAPI, falls/incident accident, restorative care, emergency preparedness, and fire safety in the last year. Review of NA Employee E25's personnel record indicated a date of hire on 7/5/12.…

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 facility provided documents, and staff interviews, it was determined that the facility failed to ensure that residents were free from misappropriation (the act of stealing something that you have been trusted to care of and using it for yourself) of $5,251.83 for one of three residents reviewed (Resident R5). Findings include: Review of the facility policy Abuse dated 1/30/24, indicated each resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. Review of admission record indicated Resident R5 was admitted to the facility on [DATE]. Review of Resident R5's Minimum Data Set (MDS- a periodic assessment of care needs) dated 6/4/24, indicated the diagnoses of high blood pressure, renal insufficiency (condition where the kidneys lose the ability to remove waste and balance fluids), and heart failure (heart doesn't pump blood as well as it should). Review of facility provided documentation dated 12/13/23, at 4:00 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical records, and staff interview, it was determined that the facility failed to implement written policies and procedures to prohibit and prevent abuse, neglect, and misappropriation of property of residents for one of three residents reviewed (Closed Record Resident CR1). Findings include: Review of the facility policy Abuse dated 1/30/24, indicated - Protection: the facility will take all reasonable measures to ensure protection of the resident during an abuse investigation from any possible existing threat. In the event that the alleged perpetrator is an employee, that employee will be suspended pending investigation outcome or police intervention. Review of the admission record indicated Resident CR1 was admitted to the facility on [DATE]. Review of Resident CR1's Minimum Data Set (MDS- a periodic assessment of care needs) dated 2/5/24, indicated the diagnoses of high blood pressure, renal insufficiency (condition where the kidneys lose the ability to remove waste 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical records, facility provided documents, resident, and staff interviews, it was determined that the facility failed to report an alleged allegation of misappropriation of property for one of three residents (Resident CR1). Findings include: Review of the facility's policy Abuse dated 1/30/24, indicated any reasonable suspicion of a crime committed against a resident of the facility will be reported to the Department of Health and at least one law enforcement entity. If the event that caused the suspicion did not result in serious bodily injury the facility will report the suspicion within 24 hours after forming the suspicion. Review of the admission record indicated Resident CR1 was admitted to the facility on [DATE]. Review of Resident CR1's Minimum Data Set (MDS- a periodic assessment of care needs) dated 2/5/24, indicated the diagnoses of high blood pressure, renal insufficiency (condition where the kidneys lose the ability to remove waste and balance fluids), 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical records, facility provided documents, and staff interview, it was determined that the facility failed to investigate a potential allegation of abuse/neglect for misappropriation of property for one of three residents (Closed Record Resident CR1). Findings include: Review of the facility's Abuse policy dated 1/30/24, indicated all allegations of abuse, neglect, exploitation, or mistreatment of residents will be thoroughly investigated by the administrator and support staff. Review of the admission record indicated Resident CR1 was admitted to the facility on [DATE]. Review of Resident CR1's Minimum Data Set (MDS- a periodic assessment of care needs) dated 2/5/24, indicated the diagnoses of high blood pressure, renal insufficiency (condition where the kidneys lose the ability to remove waste and balance fluids), and atrial fibrillation (irregular heart rhythm). Review of facility provided documentation dated 6/18/24, at 12:00 p.m. indicated the facility was contacted by…

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, resident records, admission documentation and staff interview, it was determined that the facility failed to maintain admission documentation for two of three residents (Resident R2, R60). Findings include: The facility Admissions policy last reviewed 1/30/24, indicates the facility will maintain an admissions policy governing admissions to the facility to ensure fair and impartial admisssion practices. Review of Resident R60 was admitted [DATE] with diagnoses that include dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), cardiomegaly(enlargement of the heart) and chronic kidney disease. Review of the Resident Assessment Instrument 3.0 User's Manual effective October 2019, indicated that a Brief Interview for Mental Status (BIMS) is a screening test that aides in detecting cognitive impairment. The BIMS total score suggests the following distributions: 13-15: cognitively intact 8-12:…

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 facility policy, clinical record review and staff interview, it was determined that the facility failed to make certain that the necessary resident information was communicated to the receiving health care provider for two out of two residents sampled with facility-initiated transfers (Residents R67, and R72). Findings include: Review of the facility policy Transfer or Discharge, Emergency dated 1/30/24, indicated that should it become necessary to make an emergency transfer or discharge to a hospital the facility will prepare a transfer form to send with the resident. Review of the clinical record indicated Resident R67 was admitted to the facility on [DATE]. Review of Resident R67's MDS dated [DATE], indicated diagnoses of Post Traumatic Stress Disorder (PTSD- a disorder that develops when a person has experienced or witnessed a scary, shocking, terrifying, or dangerous event), cerebral vascular accident (an interruption in the flow of blood to cells of the brain), and dysphagia (difficulty…

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, clinical records, observations, resident and staff interview it was determined that the facility failed to provide care as per physician's order and failed to provide weekly assessments for one out of four sampled residents with a surgical area (Resident R74). Findings include: The facility Negative pressure wound therapy policy dated 1/30/24, indicated that to promote wound healing, the facility will provide evidence-based treatments in accordance with current standards of practice and physician orders. Negative pressure wound therapy is an active wound care treatment that uses controlled sub-atmospheric (negative) pressure to assist and accelerate healing. The therapy will be provided in accordance with physician orders, including the desired pressure settings, continuous or intermittent therapy, and frequency of dressing change. Monitoring throughout the use of negative pressure wound therapy shall include pain, device functioning, settings, and response to therapy…

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, clinical record review, and staff interview, it was determined that the facility failed to provide appropriate care of respiratory equipment for two of four residents (Residents R70 and R71). Findings include: Review of the facility policy Replacement and Maintenance of Respiratory Equipment dated 1/30/24, indicated on Mondays all nasal cannulas (a thin tube in the nostrils to deliver oxygen supplementation) will be labeled with the date issued every fourteen days. Review of the clinical record indicated that Resident R70 was admitted to the facility on [DATE]. Review of Resident R70's Minimum Data Set (MDS - periodic assessment of care needs) dated 7/3/24, indicated diagnoses of high blood pressure, obstructive sleep apnea (intermittent airflow blockage during sleep), and insomnia. Review of Resident R70's physician's order dated 7/7/25 indicated to administer CPAP (continuous positive airway pressure- a respiratory therapy intervention used to help people…

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, resident record review, and staff interviews, it was determined that the facility failed to provide a trauma survivor with trauma informed care to eliminate or mitigate triggers that may cause re-traumatization of the resident for two of two residents (Resident R1, and R67). Findings include: Review of facility policy Trauma Informed Care dated 1/30/24, indicated that nursing staff are trained on screening tools, trauma assessment and how to identify triggers associated with re-traumatization. Caregivers are taught strategies to help eliminate, mitigate or sensitively address resident's triggers. Review of the clinical record indicated Resident R1 was admitted to the facility on [DATE]. Review of Resident R1's Minimum Data Set (MDS - a periodic assessment of care needs) dated 6/13/24, indicated diagnoses of Post Traumatic Stress Disorder (PTSD- a disorder that develops when a person has experienced or witnessed a scary, shocking, terrifying, or dangerous event), high blood…

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, observations, and staff interviews, it was determined that the facility failed to store medications properly and securely in two of three medications carts (East Hall Medication Carts A and B). Findings include: Review of the facility policy Medication Storage in the Facility dated 1/30/24, indicated when the original seal of a manufacturer's container or vial is initially broken, the container or vial will be dated. The nurse shall place a date opened sticker on the medication and enter the date opened and the new date of expiration. Observation on 7/15/24, at 11:18 a.m. of the East Hall medication cart B, the following medications failed to have a date opened: Resident R10's albuterol inhaler (breathing medication), opened without a date. Resident R21's ipratropium albuterol (breathing medication), opened without a date. Interview on 7/15/24, at 11:18 a.m. Licensed Practical Nurse (LPN) E18 confirmed the medications failed to have a date opened as required. Observation on 7/15/24, at 11:25 a.m. of the East Hall medication cart A, the following…

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 facility documents, resident clinical records, and staff interview, it was determined that the facility failed to ensure a representative signed a binding arbitration agreement on behalf of a resident lacking capacity to understand the agreement terms for two of three residents (Resident R2, R60). Findings include: The facility Facility Binding Arbitration Agreements policy last reviewed 1/30/24, indicates the facility asks all residents to enter into a binding arbitration agreement. Review of Resident R60 was admitted [DATE] with diagnoses that include dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), cardiomegaly(enlargement of the heart) and chronic kidney disease. Review of the Resident Assessment Instrument 3.0 User's Manual effective October 2019, indicated that a Brief Interview for Mental Status (BIMS) is a screening test that aides in detecting cognitive impairment. The BIMS total score suggests the following…

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, clinical record review and staff interview, it was determined that the facility failed to develop and implement a comprehensive person-centered care plan for identified resident problems for one for eight residents (Resident R1). Findings include: Review of facility policy Care Plans, Comprehensive Person-Centered dated 1/31/23, indicated that a comprehensive, person-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. A review of the clinical record revealed that Resident R1 was admitted to the facility on [DATE], with diagnoses that include Dementia(condition characterized by progressive or persistent loss of intellectual functioning), diabetes mellitus (disease in which the body ' s ability to produce or respond to the hormone insulin is impaired) and bipolar (psychiatric illness characterized by both manic and depressive episodes). 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical record review and staff interview, it was determined that the facility failed to develop and implement a comprehensive person-centered care plan for identified resident problems for one for eight residents (Resident R1). Findings include: Review of facility policy Incident/accident reporting dated 1/31/23, indicated to maintain resident safety in the least restrictive manner. A review of the clinical record revealed that Resident R1 was admitted to the facility on [DATE], with diagnoses that include Dementia(condition characterized by progressive or persistent loss of intellectual functioning), diabetes mellitus (disease in which the body's ability to produce or respond to the hormone insulin is impaired) and bipolar (psychiatric illness characterized by both manic and depressive episodes). A review of Resident R1's Minimum Data Set (MDS-a periodic assessment of resident care needs), dated 4/10/24, indicated diagnoses remained current. Review of Resident R1's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the facility assessment and staff interview, it was determined that the facility failed to provide a qualified full time social worker for a facility with more than 120 beds. Findings include: The facility assessment dated [DATE], indicated that the facility will have a full time Social Services Director. The faciliy has a capacity of 145 requiring a full time Social Worker. Interview with the Nursing Home Administrator (NHA) revealed that the Social Worker left at the end of October 2023. The facility hired a new social worker, start date 12/28/23. During an interview on 12/14/23, at 11:45 a.m. the Nursing Home Administrator confirmed there was no social worker employed at the facility from approximately 10/27/23 to current as required. 28. Pa. Code: 201(b)(2) Management. 28. Pa. Code: 201(a) Social services.