Rose City Nursing And Rehab At Lancaster

Based on the review of job descriptions, review of facility documentation and interviews with staff, it was determined that the Nursing Home Administrator (NHA) and the Director of Nursing (DON) did not effectively manage the facility to ensure the safety of residents when residents who smoke were permitted to keep smoking materials unsecured in their rooms and on their person. This failure resulted in an Immediate Jeopardy situation.Findings Include:Review of the job description for the Nursing Home Administrator (NHA) states position purpose is to manage the Facility in accordance with current applicable federal, state, and local guidelines, and regulations that govern long term care facilities. To follow all facility policies and apply them uniformly to all employees. To ensure the highest degree of quality care is provided to our residents at all times.Review of the job description for the Director of Nursing (DON) states that the position is to: Plan, organize, develop and direct the overall operation of the Nursing Service Department in accordance with current federal, state,…

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 staff interview, observation, and clinical record review, it was determined that the facility failed to ensure an accurate clinical medical record for 1 of 1 resident reviewed (Resident 106). Findings include:A review of the facility policy titled Charting and Documentation, last revised July 2017, revealed the policy states, Documentation in the medical records will be objective, complete, and accurate.A review of Resident 106's diagnoses included Muscle Weakness (generalized weakness meaning overall reduced strength throughout the body).A review of Resident 106's physician order dated February 16, 2026, at 3:00 p.m., revealed an order for Weekly Skin Review on Mondays 3-11 shift. Complete Weekly Skin Review on the Tab FORMS. Document refusal every evening shift every Mon. and another physician order dated April 8, 2026, at 3:00 p.m., for Triad Hydrophilic Wound Dress External Paste (Wound Dressings) Apply to left buttocks topically every day and evening shift for Wound care.A review of Resident 106's…

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

Based on observation, clinical records review, and staff interviews, it was determined that the facility failed to provide behavioral services in a timely manner for one out of three residents reviewed (Resident 1).Findings: A review of the facility's policy titled Behavioral Health Services, undated, revealed the facility will provide and residents will receive behavioral health services as needed to attain or maintain the highest practicable physical, mental, and psychosocial well-being in accordance with the comprehensive assessment and plan of care. Review of Resident 1's diagnosis list revealed the following diagnoses: Alzheimer's disease (irreversible, progressive degenerative disease of the brain, resulting in loss of reality contact and functioning ability), Dementia (A term used to describe a group of symptom affecting memory, thinking and social abilities severely enough to interfere with daily life), and Mood Disorder (A mental health condition that primarily affects your emotional state). Review of Resident 1's Annual Minimum Data Set (MDS- A standardized assessment tool…

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 policy review, interviews and records reviews it was determined that the facility failed to employ an Activity Director with the appropriate certification and/or qualifications for the position. Findings include:Review of facility policy titled Activities Staffing dated March 2015, revealed a statement noting the activity program is staffed with qualified personnel to meet the needs of residents. Per the policy the department is under the direction of a qualified Therapeutic Recreational Specialist (TRS) or an Activities Professional (AP) who is eligible or certified as a TRS or AP by a recognized accrediting body on or after October 1, 1990 or has two years of experience in a social or recreational program within the last five years, one of which was full-time in a resident activities program in a health care setting. Review of facility records revealed upon acceptance of the position on March 19, 2023, the Activity Director Employee E3 signed an agreement of understanding documenting E3 would be registering for classes to become a Certified Activity Director. E3's goal…

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 ensure the treating hospital received the medical records necessary to provide continuity of care and appropriate treatment for one of one resident reviewed (Resident R1).Findings include:A phone interview conducted with the complainant on November 12, 2025, at 9:18 a.m. revealed that the facility had not provided the hospital with the medical records required to initiate care for Resident R1.Review of Resident R1's clinical record did not contain documentation verifying that the facility faxed the medical records to the treating hospital.An interview conducted with the Director of Nursing (DON) and Nursing Home Administrator (NHA) on November 12, 2025, at 9:50 a.m. indicated that the Assistant Director of Nursing (ADON) faxed the necessary medical records to the hospital on November 6, 2025.Review of the facility's fax log revealed that the attempt to transmit the required medical records on November 6, 2025, was unsuccessful.A follow-up interview with the DON and NHA confirmed that…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility documents and staff interview, it was determined that the facility failed refund to the resident or resident representative any and all refunds due to the resident within 30 days from the resident's date of discharge from the facility for one of three residents (Resident R1). Findings include: Review of the clinical record indicated Resident R1 was admitted to the facility on [DATE] and ceased to breathe while in the facility on 5/28/25. Review of the record of Resident R1's payer source revealed that Resident R1 had privately paid for care. During an interview on 8/6/25, at 9:55 a.m., the Business Office Manager (BOM) confirmed that she had submitted a request for a refund of payment to Resident R1's Representative. The BOM provided evidence of a communication with the financial office, dated 6/11/25. The BOM was able to provide a request for an update Resident R1's Representative refund, dated 8/5/25. The BOM was able to provide evidence that the refund request was processed 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 upon review of staffing records and performance reviews it was determined the facility failed to ensure performance reviews were completed for five of five staffing records reviewed, ( Employee E5,Employee E6,Employee E7,Employee E8 and Employee E9). Findings include: Review of staffing records and performance reviews revealed five staff members, E5, E6, E7, E8 and E9, did not have annual performance reviews performed within the last year. Interview with the Nursing Home Administrator on April 25, 2025, at 12:30 p.m. confirmed staff performance reviews were not completed. 28 Pa. Code 201.20(a)(c) Staff Development

Based upon review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to ensure medication regimen reviews were acted upon by a physician for five of five residents reviewed (Residents 37, 43, 59, 75, and 84). Findings include: Review of undated facility policy titled, Pharmacy Medication Regimen Review, indicated that the clinical pharmacist reviews condition concerns and reviews resident's medication regimen to identify any potential causes/concerns. The clinical pharmacist then faxes recommendations back to the facility. The clinical nurse then reviews recommendations and contacts physician for further orders. The physician signs Medication Regimen Review when reviewed. Review of Resident 37's clinical record revealed that medication regimen reviews were completed on January 15, 2025, February 12, 2025, March 13, 2025, and recommendations were made. Further review of Resident 37's clinical record revealed no evidence of the reviews, recommendations, or evidence that the recommendations were addressed by the physician. Review…

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 staff documentation, it was determined the facility failed to ensure the required 12 hours of annual training was completed by five of five staff members reviewed (Employee E5, Employee E6, Employee E7, Employee E8 and Employee E9. Findings include: Review of Employees E5, E6, E7, E8, E9 training documentation regarding 12-hour annual training failed to reveal evidence that Employees E5, E6, E7, E8 andE9 completed the annual 12-hour training as required. Interview with the Nursing Home Administrator April 25, 2025, at 12:30 p.m. confirmed Employees E5, E6, E7, E8 and E9 did not complete the required 12-hour annual training. 28 Pa. Code 201.18(b)(1)(3)(e)(1) Management

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 resident assessments accurately reflect the residents' status for three of 23 residents reviewed (Residents 32, Resident 52 and Resident 67). Findings include: Review of Resident 32's quarterly MDS (Minimum Data Set - periodic assessment of resident needs) dated February 8, 2025, revealed under section N0415 - High Risk Drug Classes, that the resident was not marked for receiving opioid. Further review of Resident 32's physician orders dated November 1, 2024, revealed evidence that the resident was ordered Oxycodone HCl oral Tablet 5 mg every 6 hours as needed for pain. Review of the February 2025 and April 2025 Medication Administration Record (MAR) revealed that the resident did receive a daily dose of Oxycodone HCl 5 mg daily except for April 19, and April 23 2025. Interview with Licensed Employee E3 on April 25, 2025, at 12:33 p.m. confirmed that the assessment was coded inaccurately for Residents…

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

Based on observation, review of the clinical record, and interview with resident and staff, it was determined that the facility failed to develop a comprehensive care plan for three of 24 residents reviewed (Residents 32, 37, and 91). Findings include: Observation on April 22, 2025, at 10:25 a.m. revealed Resident 32 was receiving oxygen at 4 liters per minute through a nasal cannula (device used to deliver supplemental oxygen or increased airflow to a person in need of respiratory help). Review of Resident 32's physician's orders included an order on June 20, 2024 for oxygen at 4 Liter/minute via nasal cannula every shift for shortness of breath. Review of the Resident 32's current active care plan failed to reveal a care plan or interventions for oxygen therapy. Interview with the Nursing Home Administrator on April 25, 2025, at 12:20 p.m. confirmed that Resident 32 did not have a care plan for oxygen therapy. A review of Resident 37's diagnosis list includes End Stage Renal Failure (ESRD- Where kidney function has declined to the point that the kidneys can no longer function 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 observations, a review of the facility's policy and clinical records, and interview with resident and staff, it was determined that the facility failed to ensure medications and fluid restriction orders for dialysis residents were followed for two of three residents reviewed (Residents 37 and 56). Findings include: A review of the facility's policy titled Encouraging and Restricting Fluids, undated, revealed the following guidelines for restricting fluids: Remove the resident's water pitcher and cup from the room. Store in designated area. If the resident refuses to have the water pitcher removed, notify the supervisor and in turn the physician; Record the amount of fluid consumed on the intake and output record. Record fluid intake in ml's; and Remove fluid container. Documentation includes the amount (in ml's) of fluids consumed by the resident during the shift. A review of Resident 37's diagnosis list includes End Stage Renal Failure (ESRD- Where kidney function has declined to the point that the kidneys can no longer function on their own), and dependence on renal…

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 review, and staff interview, it was determined that the facility failed to ensure residents receiving psychotropic medications (any medication that affects brain activity associated with mental processed and behavior) were monitored for their side effects for three of five residents reviewed (Residents 37, 43, and 59). Findings include: Review of facility policy Psychotropic Medication Use, revised February 2025, revealed that residents are monitored for adverse consequences associated with psychotropic medications. A review of Resident 37's diagnosis list includes major depressive disorder, recurrent, with severe psychotic symptoms. A review of Resident 37's physician order dated January 23, 2025, revealed an order for Aripiprazole (An anti-psychotic medication) 2 mg (milligram) given one tablet by mouth one time daily. Clinical records review failed to reveal that Resident 37 was monitored for a side effect of the medication from January 23, 2025, until April 23, 2025. A review of Resident 43's diagnosis list includes anxiety…

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, a review of the medication manufacturer's guidelines, and staff interviews, it was determined that the facility failed to ensure that medications were properly stored and labeled on one of two medication carts (Fourth Floor Medication cart) and one of two Medication Rooms (Second Floor Medication Room). Findings Include: A review of the manufacturer's storage guidelines for Novolog Insulin (fast-acting insulin), revealed that the medication must be stored at room temperature and discarded within 28 days after opening. A review of manufacturers' storage guidelines for Lantus Insulin Pen (long-acting insulin) revealed that the medication may be stored at room temperature and discarded within 28 days after opening. A review of the manufacturer's guidelines for Basaglar Insulin Kwikpen (a long-acting insulin) revealed that the medicine should be discarded 28 days after opening or removal from refrigeration. A review of the manufacturer's storage guidelines for Aplisol-Purified Protein Derivative (PPD) (a combination of proteins that are used in the diagnosis of…

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

Based upon review of clinical records, it was determined the facility failed to notify the physician of a significant weight loss for one of 21 residents reviewed (Resident 34). Findings include: Review of Resident 34's Weight Summary revealed Resident 34 weighed 192.3 pounds on August 2, 2024. Further review of Resident 34's Weight Summary revealed that on October 8, 2024, the next available weight, Resident 34 weighed 178.0 pounds indicating a 7.4 percent weight loss. Review of Resident 34's clinical record failed to reveal evidence that Resident 34's physician was notified of Resident 34's significant weight loss. Interview with the Nursing Home Administrator and Director of Nursing on April 25, 2025, at 10:08 a.m. confirmed that Resident 34's physician was not notified of Resident 34's weight loss. 28 Pa. Code 211.12(c)(d)(3) Nursing Services Previously cited 8/12/2024

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, facility policy and procedure review, clinical record review, and staff interview, it was determined that the facility failed to ensure that residents were free from the use of restraints for one of the eight residents reviewed. (Residents 74). Findings include: A review of the facility's policy titled Use of Restraints, revised in July 2023, revealed, that restraints shall only be used for the safety and well-being of the resident(s) and only after other alternatives have been tried unsuccessfully. Examples of devices that are/may be considered physical restraints include leg restraints, arm restraints, hand mitts, soft ties or vests, wheelchair safety bars, Geri-chairs, and lap cushions and trays that the resident cannot remove. Prior to placing a resident in restraints, there shall be a pre-restraining assessment and review to determine the need for restraints. Restraints shall only be used upon the written order of a physician and after obtaining consent from the resident and/or…

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

Based on review of facility policy, review of clinical record, review of facility documentation and staff interview, it was determined that the facility failed to conduct a comprehensive investigation for an injury of unknown origin for one of 19 residents reviewed (Resident 47). Findings include: Review of facility policy, Abuse Policy, undated, indicated that all reports of resident abuse, neglect,, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source shall be thoroughly investigated by the administrator or designee. Review of Resident 47's quarterly MDS (Minimum Data Set - periodic assessment of resident needs) dated December 6, 2024, indicated that the resident had severe cognitive impairment and had a diagnosis of dementia (irreversible, progressive degenerative disease of the brain, resulting in a loss of reality contact and functioning ability). Review of Resident 47's nursing progress note of December 31, 2024, revealed an assessment of the resident showed a 5 x 6 (no further unit of measurement) hematoma with a 3 x 3 purple…

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 records review, and resident and staff interview, it was determined that the facility failed to follow the physician's order for a diabetic wound order for one of three residents reviewed (Resident 37). Findings include: A review of Resident 37's diagnoses list includes End Stage Renal Disease (ESRD- Where kidney function has declined to the point that the kidneys can no longer function on their own), and Diabetes (A group of metabolic disorders characterized by a high blood sugar level over a prolonged period of time). Clinical records review revealed Resident 39 goes out for Hemodialysis (A process of purifying the blood of a person whose kidneys are not working normally) three times a week. An interview with Resident 37 was conducted on April 22, 2025. At 9:50 a.m., confirmed going to dialysis three times a week every Tuesday, Thursday, and Saturday. The resident reported leaving the facility at approximately 10:15 a.m. and returning to the facility at around 5:00 p.m. Clinical records review revealed Resident 39 had a Diabetic wound (Open sores or wounds that…

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

Based upon review of clinical records and interview, it was determined the facility failed to ensure that a current smoking assessment for one of one resident reviewed (Resident 24). Findings include: Review of Resident 24's diagnosis list revealed diagnoses including Multiple Sclerosis (slow progressive disease of the central nervous system), major depressive disorder and unspecified dementia (irreversible, progressive degenerative disease of the brain, resulting in loss of reality contact and functioning ability). Interview with Resident 24 on April 23, 2025, at 12:00 p.m. revealed Resident 24 to be alert and oriented. Resident 24 stated that resident periodically leaves the premises to smoke and follows the rules of the smoking agreement with the facility. Review of the facility Smoking Agreement revealed the resident must leave the property to smoke and never to smoke on the premises or in the building. Further review of the Smoking Agreement revealed the resident will never share nor give, nor hand out any smoking materials to any other resident. Further review of the Smoking…

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 facility policy and procedure and review of clinical records, it was determined the facility failed to ensure weight loss and weight gain was adequately monitored for two of 23 residents reviewed (Resident 34 and Resident 79). Findings include: Review of facility policy and procedure titled Weight Assessment and Intervention, revised March 2022, revealed Any weight change of five percent or more since the last weight assessment is retaken the next day for confirmation. If the weight is verified, nursing will immediately notify the dietitian in writing. Review of Resident 34's diagnosis list revealed diagnoses including dysphagia (inability/difficulty swallowing), Diabetes Mellitus (DM - failure of the body to produce insulin to enable sugar to pass from the blood stream to cells for nourishment), and dementia (irreversible, progressive degenerative disease of the brain, resulting in loss of reality contact and functioning ability). Review of Resident 34's physician orders dated September 2022 revealed an order for monthly weights. Review of Resident 34's Weight…

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 staff interview, it was determined the facility failed to comprehensively assess a resident who developed a pressure ulcer for one of four residents reviewed (Resident 4). Findings include: Review of Resident 4's clinical record included diagnoses of but not limited to Paraplegia (paralysis of the legs and lower body caused by a problem with the spinal cord or nerves, type 2 Diabetes (condition resulting from insufficient production of insulin, resulting in high blood sugar), and Peripheral Vascular Disease (condition that affects blood flow to the limbs and organs outside of the heart and brain). Review of physician's orders included an order for weekly skin assessment, progress note, and vital signs. Document skin assessment under Forms tab Weekly Skin Review every day shift every Thursday. Review of Resident R4's nursing progress note of July 9, 2024, revealed resident observed with a 3 centimeter (cm) by 2 cm open area to the right buttock. Area was cleansed and treatment applied. Treatment order received July 9, 2024, for the right buttock…

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 and staff interview, it was determined that the facility failed to maintain a safe environment for one of four resident bathrooms on the second floor. Findings include: Observation of the bathroom in room [ROOM NUMBER] on August 12, 2024, at 11:00 a.m. revealed a missing ceiling tile, exposing pipes in the ceiling. An additional observation revealed that the plastic grab bar for the toilet was cracked. Interview with the Nursing Home Administrator on August 12, 2024, at 1:00 p.m. confirmed the above observations. 28 Pa. Code 207.2 (a) Administrator's responsibility

Based on review of facility policy, observations and interview with staff, it was determined that the facility failed to maintain appropriate temperatures during dishwashing. Findings include: Review of facility policy, Dish Machine Temperatures (High Temperature Machines), revised July 2023, indicated a minimum wash temperature of 150 degrees Fahrenheit and a minimum rinse temperature of 180 degrees Fahrenheit. Additionally, the policy revealed that if the temperature does not reach the required minimum, DO NOT run any dishes through a wash/rinse cycle. If minimum temperatures are not reached, the Culinary & Nutrition Services Manager and/or the Administrator should be notified. Observation on March 14, 2024, at 9:15 a.m. with the Food Service Director (FSD), revealed staff using the dishmachine, but the gauges were not working on the dishmachine. The FSD indicated that the gauges had stopped working the day before and staff had used the three compartment sink to wash dishes. The FSD was not sure if the dishmachine was a high temperature machine (uses heated water for sanitation)…

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 minutes from Residents' Council meetings and grievances lodged with the facility and staff and resident interviews it was determined that the facility failed to demonstrate efforts to respond and resolve resident complaints raised at resident group meetings including those voiced by four Residents (Residents 20, 65, 57, and Resident 24). Findings include: Review of resident concern/Grievance log revealed there were no grievances recorded for the months of August 2023, September 2023, October 2023, November 2023, or December 2023. During resident council meeting on March 13, 2024, 10:00 a.m. four residents (Residents 20, 65, 57, and Resident 24) all reported filing grievances during the months listed above. Interview conducted with the facility's social worker (SW) on March 14, 2024, at 11:28 a.m. revealed social worker started working in the facility near the end of December 2023. SW reported the previous SW did not keep any copies or list of grievances for the months of August 2023, September 2023, October 2023, November 2023, or December 2023. The social…

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, facility policy and procedure review, and staff interview it was determined the facility failed to monitor the nutritional status for three of nine residents reviewed. (Residents 53, 69, and Resident 87) Findings Include: Review of facility policy and procedure titled Weight Assessment and Intervention, revised March 2019, revealed the nursing staff will measure the resident weight on admission then weekly for four weeks. If no weight concerns are noted at this point, weights will be monitored monthly thereafter or as per Dietitian or MD. Weights will be recorded in each individual's medical record. Any weight change of 5 pounds or more since the last weight assessment will be retaken for confirmation. If the weight is verified, nursing will notify the Physician and Dietitian. The threshold for significant unplanned and undesired weight loss will be based on the following criteria. 1 month - 5% weight loss is significant, 3 months- 7.5% is significant, 6 months 10% 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.

Based upon clinical record review and review of facility documentation, it was determined the facility failed to protect a resident from abuse for one of 24 residents reviewed (Resident 91). Findings include: Review of Resident 91's diagnosis list revealed diagnoses including Dysphagia (inability/difficulty swallowing) and protein calorie malnutrition. Resident 91 expired on December 18, 2023, on hospice services. Review of Resident 91's clinical record revealed multiple occasions between November 2023 and December 2023, when a family member was observed forcefully feeding Resident 91 and causing the resident to cough and choke. Further review of the clinical record revealed staff members attempting to educate the family member, but the family member continued to provide the resident foods that were not on the resident's appropriate diet per physician's order. Further review of the clinical record revealed an incident that occurred on December 11, 2023, which prompted the facility to halt visitation by the family member. Review of Resident 91's progress notes dated December 11,…

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 review and revise the resident care plan quarterly for one of 24 residents reviewed. (Resident 53) Findings Include: Review of Resident 53's care plan revealed a target date of December 29, 2023. Review of Resident 53's clinical record revealed no documented evidence of a care plan conference in the past year. Interview with Social Worker E3 on December 15, 2024 at 11:30 a.m. confirmed Resident 53 has not had a care plan conference in the past year and the care plan was out of date. 28 Pa. Code 211.5(f) Clinical Records 28 Pa. Code 211.11(d) Resident Care Plan 28 Pa. Code 211.12(d)(1)(5) Nursing Services

Based on review of the Pennsylvania Professional Nursing Practice Act, facility policy and procedure review, observations and staff interview it was determined the facility failed to ensure staff met the professional standards for a Registered nurse during medications administration for one of three residents reviewed. (Resident 69) Findings Include: The Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.11 (a)(1)(2)(4) indicated that the registered nurse was to collect complete and on going data to determine nursing care needs, analyze the health status of individuals and compare the data with the norm when determining nursing care needs, and carrying out nursing care actions that promote, maintain and restore the well-being of individuals. Review of facility policy and procedure titled Medication Administration- General Guidelines, undated, revealed medications are administered at the time they are prepared. Medications are not pre-poured. Observations of medication administration on March 15, 2024 at 8:45 a.m. revealed Registered…

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, staff interview, clinical record review and facility policy and procedure review it was determined the facility failed to administer medications accurately to one of three residents reviewed resulting in a medications administration error rate of 25%. (Resident 70) Findings Include: Review of Facility policy and procedure titled Enteral Tube Medications Administration undated, revealed crushed medications are not mixed together. The powder from each medication is mixed with water, or other suitable dilutant if water is unacceptable, before administration. Each medication is administered separately to avoid interaction and clumping. Review of Resident 70's diagnosis list revealed a diagnosis of Gastrostomy (gastrostomy is the creation of an artificial external opening into the stomach for nutritional support). Review of resident 70's physician orders revealed an order dated January 5, 2023 stating may crush meds and administer per PEG (feeding tube). Observations of medications administration on March 15, 2024 at 8:45 a.m. revealed Registered Nursing Employee…

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, it was determined the facility failed to ensure a Speech Therapy Evaluation was completed as ordered for one of 24 residents reviewed (Resident 91). Findings include: Review of Resident 91's diagnosis list revealed diagnoses including Dysphagia (inability/difficulty swallowing) and protein calorie malnutrition. Review of Resident 91's physician's orders dated [DATE] revealed an order for a speech evaluation and treatment. Review of Resident 91's clinical record revealed Resident 91 expired on [DATE]. Review of Resident 91's clinical record failed to reveal evidence that a Speech Evaluation was completed. Interview with the Nursing Home Administrator and Director of Nursing on [DATE] at 11:00 a.m. confirmed a speech evaluation was never completed for Resident 91 as per physician's order. 28 Pa. Code: 201.18(e)(4) Management 28 Pa. Code: 211.12(d)(3) Nursing Services

Based on staff interview it was determined that the facility failed to ensure that the facility had a full-time qualified dietary services manager for the month of December 2023. Findings include: Observation conducted during survey of January 3, 2023 revealed a newly hired certified dietary manager began managing the dietary department effective January 2, 2024. Interview with the Nursing Home Administrator (NHA) revealed for during the month of December 2023, the facility did not have a qualified dietary manager. Further interview with Nursing Home Administrator revealed the maintenance director, Employee E3 assumed the position of the dietary manager. Additional information received during the interview with the Nursing Home Administrator confirmed that Employee E3 did not have nor receive education/training regarding dietary/kitchen management. The NHA stated the facility utilitzed a remote dietitian but confirmed that she/he did not visit the facility during the month of December 2023. The facility failed to ensure that a full-time qualified dietary services manager was…

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 job description reviews, it was determined that the Nursing Home Administrator and Director of Nursing failed to effectively manage the facility by implementing monitoring, supervision, and effective safety measures to for a resident who demonstrated food seeking behavior, which resulted in harm to Resident CL1 as evidenced by the death of Resident CL1. The Administration failure resulted in an immediate jeopardy situation for Resident CL1. Findings include: Review of the job description for the Nursing Home Administrator (NHA) revealed the primary purpose of the job position is to manage the facility in accordance with current applicable federal, state, and local standards, guidelines, and regulations that govern long-term care facilities. To follow all facility policies and apply them uniformly to all employees. To ensure the highest degree of quality care is provided to our residents at all times. Review of the job description for the Director of Nursing (DON) revealed the purpose of the job position was to plan, organize, develop and direct the overall operation of 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 records and interviews with staff it was determined that the facility failed to ensure physician orders were followed for one resident out of five residents reviewed (Resident R2) Findings include: Based on the clinical record reviews the Resident R2 was admitted to the facility May 6, 2022, with the following (but not limited to) diagnosis: orthostatic hypotension (form of low blood pressure that happens when you stand up from sitting or lying down). Further review of the clinical record reveals a physician orders dated June 24, 2023 for Midodrine HCl Tablet 2.5 MG Give 3 tablet by mouth before meals Hold: SBP > (greater) 120/80 related to orthostatic hypotension. Review of the Medication Administration Record for July 2023 revealed that Midodrine was not held on the following days and times for a blood pressure greater than 120/80. For the 6:00 a.m. administration July 2, 2023 with a blood pressure of 134/86 and July 17, 2023 for a blood pressure of 137/85. For the 10:00 a.m. administration time the medication was given on July 1, 2023 with a blood pressure 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, staff interview and facility documentation it was determined that the facility failed to ensure residents were free from significant medication errors for one of three residents reviewed. (Resident R1). Findings include: Review of Resident R1's clinical record revealed resident was admitted to the facility on [DATE]. Review of Resident R1's clinical record including the Physician order Sheet revealed diagnoses including but not limited to following: Hypo-Osmolality (low water in the blood) and Hyponatremia (low concentration of sodium in the blood); Chronic Obstructive Pulmonary Disease (long term progress lung disease with limited air flow limitation); Encephalopathy; Idiopathic Epilepsy; Chronic Respiratory Failure; Morbid Obesity; Asthma; Hyperlipidemia; Bipolar Disorder (mental health condition that causes extreme mood swings that include emotional highs (mania or hypomania) and lows); Obstructive Sleep Apnea; Muscle Weakness; Hypertension (high blood pressure); Dysphagia…

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.