Lancaster Nursing And Rehabilitation Center

Based on a review of facility policy, clinical records, and staff interview, it was determined that the facility failed to ensure weights were monitored and a significant weight change was promptly addressed for five out of 15 residents reviewed (Residents 27, 74, 158, 202, and 338). Findings include: A review of the facility's policy titled Weight Assessment and Interventions, last revised in March 2022, states Resident weights are monitored for undesireable or unintended weight loss or gain. Any weight change of 5% or more since the last weight assessment must be retaken the next day for confirmation. A. If the weight is verified, nursing will notify the dietitian. Review of Resident 27's physician's orders included an order to weigh monthly every day shift every four weeks. Review of the clinical record revealed a weight of 153.9 pounds on September 16, 2024, and a weight of 139.4 pounds on September 30, 2024, indicating a loss of 14.5 pounds (9.4%). Further review of the clinical record indicated that a weight was not obtained until October 9, 2024 (9 days after the identified…

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

Based on a review of the facility policy, review of the medication manufacturer's guidelines, observations, and staff interviews, it was determined that the facility failed to properly store and label medication on four of four medication carts reviewed (7th Floor South Side Cart, 7th Floor North Side Cart, 8th Floor North/South Cart and 8th Floor Southeast/Northeast Cart) Findings include: A review of the facility's policy titled Medication Labeling and Storage, revision date of February 2023, revealed that medications and biologicals are stored in the packaging, containers, or other dispensing systems they are received. Only the issuing pharmacy is authorized to transfer medications between containers. Medications may not be transferred between containers. Multi-dose vials opened and accessed are dated and discarded within 28 days unless the manufacturers specify a shorter or longer time for the open vial. A review of manufacturers' storage guidelines for Lantus Insulin Pen (long-acting insulin) revealed that the medication may be stored at room temperature and must be discarded…

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

Based on observations, clinical records review, and staff interview, it was determined that the facility failed to ensure dignity was maintained during meals for one of the 35 residents reviewed (Resident 51). Findings include: A review of Resident 51's Minimum Data Set (MDS- A standardized assessment tool that measures health status in long-term care residents) dated March 11, 2025, revealed that Resident 51 had a moderate cognitive impairment. The same MDS revealed that the resident had a diagnosis of Traumatic Brain Injury (A brain dysfunction caused by an outside force, usually a violent blow to the head). An observation conducted on April 9, 2025, at 9:16 a.m., revealed Resident 51 was sitting on a recliner in the hallway outside of his/her room. The resident was alert to themself with difficulty finishing words. When the resident was asked by the surveyor if they could talk inside his room, non-licensed Employee E5 who was passing another resident's breakfast meal tray suddenly interrupted and stated No, he's going to have breakfast. Instead of placing the meal tray and…

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

Based on a review of the facility's policy, clinical records, and facility documentation, as well as staff interviews, it was determined that the facility failed to timely notify the physician of an unwitnessed fall with a facial bruise for one of 35 residents reviewed (Resident 305). Findings include: A review of the facility's policy titled Change in Resident's Condition or Status, with a revision date of February 2021, revealed that the facility promptly notifies the resident, attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status. The nurse will notify the resident's attending physician or physician on call when there has been an: Accident or incident involving the resident; and need to alter the resident's medical treatment significantly. Except in medical emergencies, notifications will be made within 24 hours of a change occurring in the resident's medical/mental condition or status. Clinical records review revealed Resident 305's diagnosis list includes Dementia (A term used to describe a group of symptoms…

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 housekeeping routine schedule, observations, and resident and staff interviews, it was determined that the facility failed to maintain a safe, clean, and home-like environment for one of 40 sampled residents (Resident R197). Findings include: The facility's ISH Health Services, Job Routine H4 states that housekeeping is scheduled to clean Resident R197's room between 8:00 a.m. and 9:00 a.m. An interview with Resident R197 on April 8, 2025, at 9:45 a.m. revealed that housekeeping had not cleaned his room for several days. Observations of Resident R197's room revealed a dried, light brown substance under the resident's urinary drainage bag. Resident R197 reported that the substance had been there for over four days. Further observations on April 9, 2025, at 9:16 a.m. and 12:43 p.m. confirmed that housekeeping had not cleaned the room, as the dried light brown substance remained under the urinary drainage bag. Additional observations on April 10, 2025, at 9:59 a.m. showed the same dried light brown substance under the urinary drainage bag. A review of Resident R197's clinical…

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 upon clinical record review, and staff interview it was determined the facility failed to ensure Minimum Data Set Assessments (MDS) were completed accurately for two of two residents reviewed (Resident 193 and Resident 244). Findings include: Review of Resident 193's diagnosis list revealed diagnoses including traumatic brain injury, diabetes mellitus (DM - failure of the body to produce insulin to enable sugar to pass from the blood stream to cells for nourishment), protein calorie malnutrition, gastrostomy (feeding tube) and tracheostomy (breathing tube). Review of Resident 193's Quarterly Minimum Data Set (MDS - periodic assessment of resident needs) dated January 25, 2025, revealed Resident 193 had a significant weight loss. Review of Resident 193's Weight Summary failed to reveal evidence of a significant weight loss. Interview with Licensed Employee E11 on April 10, 2025, at 12:15 p.m. revealed that Resident 193's Quarterly MDS was completed in error regarding the significant weight loss and 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 observations, clinical record review, and staff interview, it was determined that the facility failed to develop a comprehensive care plan for two of the 35 residents reviewed (Resident 23 and 111). Findings include: A review of Resident 23's Minimum Data Set (MDS- A standardized assessment tool that measures health status in long-term care residents) dated February 16, 2025, revealed that the resident had severe cognitive impairment. The same MDS revealed that the resident utilizes a wheelchair for mobilization. A review of the nursing progress notes dated March 19, 2025, at 4:00 p.m., revealed Resident 23 was found on the ground floor of the building with clothes stating she/he was leaving. An Alpha Watch (device that triggers alarms if they approach restricted areas or attempt to leave) was applied to the resident's wheelchair. A review of Resident 23's Elopement Evaluation dated March 19, 2025, revealed a Yes check mark for the following questions: Resident with a history of elopement or attempted leaving the facility without informing the staff; Resident verbally…

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

Based on observation, interview with residents and staff, it was determined that the facility failed to ensure resident call bells were answered and addressed in an appropriate amount of time for one of one resident (Resident R197). Finds include: Review of Resident R197's clinical record revealed the following diagnoses: unspecified injury at an unspecified level of the cervical spinal cord (spinal cord injury), quadriplegia (a symptom of paralysis that affects all of a person's limbs and body from the neck down), and muscle wasting and atrophy (thinning of muscle tissue). Review of Resident R197's care plan revealed the following interventions: TRANSFER: Resident is dependent on the assistance of two staff members using a mechanical lift (Hoyer lift) for all transfers; non-ambulatory. This care plan had a start date of March 4, 2019. An interview conducted with Resident R197 on April 8, 2025, at 9:45 a.m. revealed that when he activates his call bell (a system used to notify staff that assistance is required), staff will enter his room, turn off the call bell, and then leave…

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 upon clinical record review and interview, it was determined the facility failed to follow physician orders for medication administration and fluid restrictions for 3 of 3 residents reviewed (Resident 1, Resident 27 and Resident 371). Findings include: Review of Resident 1's diagnosis list includes Congestive Heart Failure (CHF-A weakened heart condition that causes fluid buildup in the feet, arms, lungs, and other organs) and Acute Respiratory Failure. Review of Resident 1's physician order dated October 21, 2024, revealed an order for 2000 ml fluid restriction every 24 hours. 1020 ml- dietary, and 980 ml - nursing. Review of April 2025 Medication Administration Record (MAR) revealed no documentation that the fluid restriction was followed. Review of Resident 27's care plan revealed resident had a diagnosis of hyponatremia (low blood sodium level) with a need for fluid restriction. Review of physician's orders included an order for 1000 milliliter (mL) fluid restriction (Nursing total=280 ml in 24 hours; Dining total=720 ml in 24 hours). Review of the March 2025 and April…

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 ased on observations, clinical records review, and staff interviews, it was determined that the facility failed to follow a wound treatment order for one of the four residents reviewed (Resident 111). Findings include: Clinical records review revealed Resident 111 was admitted to the facility on [DATE], with a Stage 4 Pressure Ulcer (Full-thickness skin and tissue loss) to the sacrum (The triangular bone just below the lumbar vertebrae). admission skin assessment revealed that the sacral wound measured 12 x 9.0 x 1.0 cm. with 10% slough (A non-viable yellow, tan, gray, green, or brown tissue; usually moist, can be soft, stringy, and mucinous in texture. Slough may be adherent to the base of the wound or present in clumps throughout the wound bed). Further review revealed that the resident has Osteomyelitis (bone infection) and was receiving Intravenous (Medication administered through a vein) Antibiotics (medication used to fight infections). A review of resident 111's physician's order dated March 12, 2025,…

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 upon review of consultant pharmacist's Medication Review, it was determined the facility failed to provide a pain scale as recommended by the pharmacist and agreed to by the nurse practitioner for the use of a narcotic and failed to provide Non-pharmaceutical Interventions prior to the administration of narcotic pain medication for one of five residents reviewed (Resident 371). Findings include: Review of Resident 371's diagnosis list revealed diagnoses including encephalopathy (swelling in brain), osteoarthritis of the left shoulder, and chronic tension headaches. Review of Resident 371's physician's orders dated January 22, 2025, revealed an order for Hydromorphone (narcotic pain medication) HCl 2 milligrams (mg) give one half tablet (1 mg) by mouth every 2 hours as needed (PRN) for pain. Review of Resident 371's consultant pharmacist's Medication Regimen Review (MRR) dated February 27, 2025, revealed the need to add a pain scale for the administration of Hydromorphone. Review of Resident 371's March 2025 and April 2025 Medication Administration Record (MAR) failed to reveal…

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

Based on observations and staff interviews, it was determined that the facility failed to ensure infection control prevention and management was practiced during medication administration and meal set up for two 35 residents reviewed (Resident 1 and 51). Findings include: An observation of the medication administration was conducted with licensed Employee E6 on April 8, 2025, at 9:55 a.m. The observation revealed that after preparing Resident 1's medication, Employee E6 approached Resident 1 who was lying in bed to give the medication. While the resident was trying to pick up the medications in the cup, one of the pills fell on the resident's tray table. Further observations revealed Employee E6 picked up the pill that fell with bare hands without performing hand hygiene and then gave it to the resident to swallow. An observation conducted on April 9, 2025, at 9:16 a.m., revealed Resident 51 was sitting on a recliner in the hallway outside of his/her room holding a puzzle book. While talking to the resident, non-licensed Employee E5 who was observed passing another resident's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, review of clinical records, and staff interview it was determined that the facility failed to provide reasonable accommodation of needs for one of five residents reviewed (Resident R1). Findings Include: Review of Resident R1's clinical record revealed the resident was admitted to the facility on [DATE], with the following diagnosis: acute respiratory failure with hypoxia (not enough oxygen in the blood due to a failure in oxygen exchange in the lungs), chronic obstructive pulmonary disease (a lung condition caused by damage to the airways that limit airflow in and out of the lungs), anxiety disorder (characterized by excessive, persistent and uncontrollable worry and fear about everyday situations), muscle wasting and atrophy (deterioration of ones muscles), and difficulty in walking. Review of Resident R1's clinical record revealed a progress note dated September 26, 2024, at 10:25 a.m. stating call placed to [power of attorney for care] who stated she requested 2 siderails [power of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff interview, it was determined that [NAME] Nursing and Rehabilitation Center failed to ensure a resident was monitored for weight loss and follow physician orders for one of two residents reviewed (Resident R1). Findings include: Review of Resident R1's clinical record revealed diagnoses including but not limited to following: unspecified injury of head, Obesity, Depression (mood disorder that causes a persistent feeling of sadness and loss of interest in activities of daily living), Chronic pain, and Congenital Malformation of Corpus Callosum (brain defect where there is a complete or partial absence of the corpus callosum, a bundle of nerves connecting the right and left side of the brain). Review of Resident R1's clinical record revealed the resident had a recorded weight of 275.7 pounds on May 1, 2024. Further review of Resident R1's clinical record revealed a weight of 180 pounds on June 6, 2024. Additional review of Resident R1's clinical record revealed 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 clinical record review and staff interview it was determined the facility failed to follow physician orders for three of 40 residents reviewed. (Residents 67, 222, and Resident 223) Findings include: Review of Resident 67's physician's orders included an order dated July 5, 2022, for a 24-hour fluid restriction of 1800 milliliters (ml) with 660 mL from nursing and 1140 mL from dining. Review of Resident 67's clinical record including April 2024 Medication Administration Record (MAR) revealed the resident exceeded the amount of fluids provided by nursing on 29 of 30 occasions. Review of Resident 67's clinical record including May 2024 MAR revealed that the resident exceeded the amount of fluids provided by nursing on 12 of 20 occasions. Further review of the clinical record revealed no documentation of the amount of fluids consumed with meals for May 2024. The above information was presented to the Nursing Home Administrator (NHA) on May 21, 2024, at 1:45 p.m. Review of Resident 222's physician order dated April 6, 2024, revealed an order for a Milk of Magnesia Suspension…

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

Based on clinical record review and staff interviews, it was determined that the facility failed to provide enteral nutrition (delivery of nutrition by a feeding tube) in accordance with physician's order for four of 11 residents receiving enteral feeding (Residents 72, 244, 259, and 364). Findings include: A review of the facility's policy titled Enteral Nutrition, revised in November 2018, revealed facility will provide adequate nutritional support through enteral nutrition to the residents as ordered. Review of Resident 72's physician's order of October 18. 2023 included an order for enteral feeding Jevity 1.5 via peg tube continuous at a rate of 55 milliliter(mL)/hour for a total volume of 1210 mL/24 hours. Review of Resident 72's April 2024 Medication Administration Record (MAR) revealed that the resident exceeded 1210 mL/24 hours for six of 30 days. Documentation on four of 90 shifts revealed staff were documenting the rate of 55 mL/hour instead of the volume received. Review of the May 2024 MAR revealed that the resident exceeded 1210 mL/24 hours for three of 20 days and two…

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

Based on observations, clinical record reviews, and staff interviews, it was determined the facility failed to ensure Enhanced Barrier Precautions (EBP-infection control prevention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities) were in place for residents requiring enhanced barrier precautions for nine of nine residents reviewed (Residents 59, 67, 72, 106, 130, 152, 220, 343, and 364). Findings include: Review of the facility's policy titled Enhanced Barrier Precautions (EBP) dated April 2024, revealed EBP employees targeted gown and glove use during high-contact resident care activities in which there is an opportunity for transfer of MDRO (Multiple Drug Resistant Organisms) to staff hands and clothing. EBP is indicated for residents with the following: Wounds and/or indwelling medical devices regardless of MDRO infections or colonization status; Indwelling medical devices: urinary catheters, feeding tubes, tracheostomies, and ventilators. Appropriate notification/signage is…

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 ensure that assessments accurately reflected the resident's status for three of 35 residents reviewed (Residents 165, 250, and 396). Findings include: Review of Resident 165's progress note of November 1, 2023, revealed resident was found on the floor and reported severe pain to the lower back and right hip area. The physician was notified and ordered the resident be sent to the hospital. Review of additional progress note of November 1, 2023, revealed that a CT scan (computed tomography scan - type of x-ray that creates cross-sectional images) showed a comminuted impacted right acetabular (hip) fracture with right iliac (hip) muscle hematoma (bruise) and right inferior pubic ramus (part of the pelvis) fracture. Review of Resident 165's significant change MDS (Minimum Data Set - periodic assessment of resident needs) of November 10, 2023, section J1700A indicated that the resident did not have a fall any time 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.

Based on review of clinical records and staff interview, it was determined that the facility failed to develop a comprehensive care plan for one of 35 residents reviewed (Resident 73). Findings include: Review of Resident 73's physician's orders included an order dated September 22, 2023, for Eliquis (anticoagulation - medication used to prevent blood clots) 2.5 milligrams one tablet twice a day for paroxysmal atrial fibrillation (type of irregular heartbeat). Review of quarterly MDS (Minimum Data Set - periodic assessment of resident needs) of March 20, 2024, revealed that resident was receiving an anticoagulant. Review of Resident 73's current care plan revealed no care plan or interventions for anticoagulant medication. Interview with the Nursing Home Administrator on May 21, 2024, at 1:30 confirmed that Resident 73 did not have a care plan to address the anticoagulant. 483.21 Comprehensive Resident Centered Care Plan Previously cited 7/27/23 28 Pa. Code 211.5(f) Clinical records Previously cited 7/27/23 28 Pa. Code 211.12(d)(1)(5) Nursing services Previously cited 7/27/23

Based on facility policy, clinical record review, and staff interview, it was determined that the facility failed to obtain and monitor weights for two of 35 residents reviewed for nutrition (Residents 259 and 348). Findings include: Review of facility policy Weight Assessment and Intervention revised September 2008 indicated that any weight change of 5% or more since the last weight assessment will be retaken the next day for confirmation. If the weight is verified, nursing will immediately notify the dietitian in writing. The dietitian will notify nursing witin 48-72 hours after weight is reviewed for needed re-weights. Review of Resident 259's clinical records revealed Resident 259 had a diagnosis of Amyotrophic Lateral Sclerosis (ALS- nervous system disease that weakens muscles and impacts physical function). The resident had a Tracheostomy (An opening surgically created through the neck into the trachea to allow air to fill the lungs) and a Gastrostomy Tube (GT- medical device used to provide nutrition to people who cannot obtain nutrition by mouth). Review of the weight and…

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

Based on clinical record review, it was determined the facility failed to administer as needed pain medications for appropriate pain levels for one of ten residents reviewed for unnecessary medications (Resident 97). Findings include: Review of Resident 97's physician's orders revealed an order dated January 30, 2024, for Oxycodone (narcotic pain reliever) 5 milligrams (mg) every 8 hours as needed for moderate to severe pain. Review of Resident 97's May 2024 Medication Administration Report (MAR) revealed the resident received Oxycodone on May 8, 2024, and May 10, 2024, for pain rated 1 on a scale of 1-10. Review of resident 97's April 2024 MAR revealed the resident received Oxycodone 5mg on April 3, 2024, and April 4, 2024, for pain rated 0, April 19, 2024, for pain rated 1, and April 21, 2024, for pain rate 3 on a scale of 1-10. Review of resident 97's March 2024 MAR revealed the resident received Oxycodone 5mg on March 1, 2024, March 2, 2024, and March 3, 2024, for pain rated 1 on a scale of 1-10. Interview with Director of Nursing (DON) on May 22, 2024, at 12:43 pm., confirmed…

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 resident interview and clinical record review, it was determined that the facility failed to ensure one of three residents reviewed for dialysis was free of significant medication errors (Resident 220). Findings include: Interview with Resident 220 on May 20, 2024, at approximately 1:10 p.m. revealed the resident received insulin (medication given to lower blood sugar) but was not receiving it correctly. Further interview with Resident 220 at this time revealed the resident did not receive certain medications on the days the resident attended dialysis. Review of Resident 220's physician's orders revealed an order dated May 2, 2024, for insulin lispro (fast acting insulin), inject per sliding scale: If blood sugar is 0-199 - give 0 units of insulin If blood sugar is 200-250 - give 4 units of insulin If blood sugar is 251-300 - give 6 units of insulin If blood sugar is 301-350 - give 8 units of insulin If blood sugar is 351-400 - give 10 units of insulin; and if blood sugar is greater than 400, give 10 units of insulin and call the physician. The order further read to hold…

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

Based on observation, resident, and staff interviews, it was determined that the facility failed to ensure assistive devices for eating were made available for one of the 18 residents reviewed (Resident 189). Findings include: Review of resident 189's diagnosis list includes Diabetes with Mononeuropathy (nerve damage caused by high blood sugar levels), legal blindness, and Brachial plexus disorder (An injury in the network of nerve fibers that innervates the skin and musculature of the upper extremity. It causes a burning sensation, numbness or weakness of the arm, severe pain, and inability to move or feel the affected arm). Review of Resident 189's Quarterly Minimum Data Set (MDS- standardized assessment tool that measures health status in long-term care residents) dated May 3, 2024, revealed Resident 189 was cognitively intact. The same MDS revealed resident had one side impairment of the upper extremity. Interview was conducted with Resident 189 on May 21, 2024, at 12:10 p.m. The resident reported that due to limitations on his/her hands/fingers, he was provided with a special…

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 medication manufacturer's guidelines, observation, and staff interviews, it was determined that the facility failed to ensure medications were properly labeled and stored on one of the medication carts observed (8th SW Floor Medication Cart). Findings include: Review of the manufacturer's storage guidelines for Insulin Lispro (Humalog-fast-acting insulin), revealed that the medication must be stored at room temperature and must be discarded within 28 days after opening. Review of manufacturer's storage guidelines for Insulin Gargline (long-acting insulin) revealed that the medication may be stored at room temperature and must be discarded within 28 days after opening. Review of the manufacturer's storage guidelines for Insulin Aspart (Novolog-fast-acting insulin), revealed that the medication must be stored at room temperature and must be discarded within 28 days after opening. Review of the manufacturer's storage guidelines for Novolog Insulin (fast-acting insulin), revealed that the medication must be stored at room temperature and must be discarded 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 observation and interviews it was determined that [NAME] Nursing and Rehabilitation Center failed to ensure a clean, sanitary environment in the kitchen and/or food storage area. Findings include: Observation conducted on November 1, 2023 at approximately 9:10 a.m. in the company of the assistant food/beverage director, Employee E3, of the dry storage room revealed one wall, approximately one yard in length, was noted to have splattered areas of black-like substance on it. The floor was visibly soiled in areas with food particles. Further observation revealed open packets of crackers on a shelving unit. Interview with Employee E3 on November 1, 2023 at approximately 9:12 a.m. confirmed the dry storage area was not sanitary/clean area. Employee E3 indicated the areas should be clean and free of any food debris or substances. 28 Pa Code 201.18(b)(1) Management 28 Pa Code 211.6(d) Dietary Services