Harborview Rehabilitation And Care Center At Lansd

Based on observation, clinical record review, staff interview and review of facility policy, it was determined that the facility failed to ensure that a resident preference was honored and to accommodate resident's allergies for two of 25 residents reviewed. (Resident R23 and Resident R39) Findings include: Review of the facility policy titled Dietary Services - Menus and Nutritional Adequacy dated 2/18/2024 revealed that the facility will ensure that all menus are developed and prepared to meet the resident choices including their nutritional, religious, cultural, and ethnic needs while using established national guidelines. Review of Resident R23's quarterly Minimum Data Set (MDS- a federal mandated assessment tool for all residents) dated June 9, 2025, revealed that Resident R23 was admitted into the facility on November 21, 2024 with diagnosis of diabetes (chronic medical condition that affects how your body process blood sugar), seizure disorder (a neurological condition characterized by recurrent seizures), anxiety (a feeling or worry, nervousness or unease) and bipolar…

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 call bells were functioning properly for two of 25 residents reviewed. (Resident R73 and Resident 106)Findings include: Review of Resident R73's clinical record revealed that Resident R73 was admitted to the facility on [DATE]. Further review of Resident R73's clinical record revealed that Resident R73 has a diagnosis of Pain in Unspecified Knee, and difficulty walking. Observation conducted on August 18, 2025, at 10:56AM revealed that the Resident R73 was in bed wearing a gown. Further observation revealed that Resident R73 was yelling for help. Further observation revealed that the call bell outlet located on the wall left side of Resident R73's bed above his bed side table revealed that two call bell prongs attached to it. Further, one prong did not have a cord and the other prong had a cord cut 3 inches from the prong. Observation conducted on August 18, 2025, at 10:56AM revealed that the Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interviews, review of facility's policy and the review of clinical records, it was determined that the facility failed to ensure that complete and accurate documentation for two out of eleven residents reviewed (Resident R6 and R7). Findings Include: Review of the facility policy, Behavior Management Program Overview, Overview-The facility promotes the utilization of a behavior intervention and management program based on individual resident/patient needs. Review of Resident R6's clinical record revealed Resident R6 was admitted to the facility on [DATE] with a diagnosis of: Unspecified Dementia, Mood Disorder, and Anxiety Disorder. Review of Resident R7's clinical record revealed Resident R7 was admitted to the facility on [DATE] with a diagnosis of Anxiety Disorder, Depression, Bipolar Disorder. Review of a social services note dated June 16, 2025, documented that the social worker spoke with the resident regarding Resident with BIMS (Brief Interview for Mental Status) score of 13 when tested…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of clinical records and staff interviews, it was determined that the facility failed to develop and implement a comprehensive person-centered care plans related to elopement for one of eight residents reviewed. (Resident R1). Findings include: Review of Resident R1's clinical record revealed that the resident was admitted on [DATE], with diagnoses including, but not limited to, psychosis (a mental health condition characterized by a disconnection from reality, which may involve symptoms such as hallucinations (seeing or hearing things that are not present) and delusions (strongly held false beliefs)) and schizophrenia (a mental health condition that disrupts several different areas of your brain. This condition typically affects your thinking abilities, memories and senses. People with schizophrenia commonly struggle to tell what's real and what isn't. They often have hallucinations and delusions and struggle with disorganized thinking). Further review of Resident R1's clinical record revealed…

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

Based on observations, review of facility policy and interview with staff, it was determined that the facility did not ensure drugs and biologicals were stored according to professional standards of practice for two out of three medication storage rooms observed (2nd floor and 3rd floor unit medication storage rooms) Findings include: Review of facility's policy 'Medication storage in the facility,' indicates that K. Medications requiring 'refrigeration' or 'temperatures between 2C /36F (Fahrenheit) and 8C/46F are kept in a refrigerator with a thermometer to allow temperature monitoring. During observations of the medication cart on November 11, 2024 at 9:30 am, on 2nd floor unit, revealed that the eye drop medication Latanoprost - 0.005%, with instructions to 'refrigerate before opening.' Finding was confirmed that the eye medication was in the medication cart and not rerigerated with Licensed nurse, Employee E18. Further observations of the medication cart on 3rd floor unit, on November 13, 2024 at 10:46 am, revealed the following expired nutritional supplement: Glucerna with carb…

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 interviews with residents and staff, review of clinical records, review of monthly resident council minutes and review of facility policy, it was determined that the facility did not ensure prompt efforts were made to resolve residents' grievances and/or concerns elated to, billing clarification, status of the activity van, request for room change and missing items for 11 of 11 residents attending resident council (Residents R10, R12, R16, R17, R38, R52, R66, R79, R90, R91 and R101) and two of 25 resident records reviewed (Resident R26 and R41). Findings include: Review of facility policy titled, Grievance/Concern Management not dated, states, Residents/patients have the right to present concerns on behalf of themselves and /or others to the staff and/or administrator of the facility, to governmental officials or to any other person . these rights also include the right to prompt efforts by the facility to resolve resident concerns. The same policy states, attempts to resolve concern are within 3…

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 interviews with residents and review of clinical records, it was determined that the facility failed to ensure residents receive proper treatment and care to maintain good foot health in accordance with professional standards of practice for two of 25 residents reviewed (Resident R26 and R41). Findings include: Review of Resident R26's clinical records revealed the resident was admitted to the facility in November 2020, alert and oriented with diagnoses of heart failure and Type II Diabetes (High blood sugar levels can damage nerves in feet, making it harder to sense pain increasing risk of injury). Interview with Resident R26 on November 12, 2024, at 11:00 a.m. with her roommate Resident R41 indicated they have not been seen by the podiatrist. I think they skipped over us. Documentation review of Resident R26's podiatry appointment dated April 19, 2024, noted the resident's toenails were professionally treated to relieve pain due to pressure and should be treated in 60 days due to systemic conditions or sooner if complications should arise. The following appointment dated,…

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 provided documentation, and interview with staff, it was determined that facility failed to provide sufficient nursing staff to assure resident safety for one of 22 residents reviewed (Resident R9) Findings include: Review of facility's assessment, updated on September 30, 2024, revealed that 40 residents out of approximately 110 residents residing in the facility require special treatment under Behavioral Health Needs. Review of investigation report, dated July 15, 2024, at 8:24 pm, revealed Resident R9 with medical history of Dysphagia (difficulty swallowing), Bipolar Disorder (condition which a person has periods of depression and periods of being extremely happy), Parkinsonism (nervous system disorder), Schizophrenia (mental disease characterized by loss of reality). Review of Resident R9's July 2024 physician's orders revealed an order for the resident to receive a mechanical soft diet (diet consisting of any foods that can be blended, mashed, pureed, or chopped using a kitchen tool). Review of Resident R9's nursing notes dated July 15, 2024, at 4:50…

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 facility documentation and interviews with staff, it was determined that the Nursing Home Administrator and Director of Nursing failed to effectively manage the facility resulting in an Immediate Jeopardy situation related to ensure that a hot beverages was serve at safe temperatures resulting in a burn to the resident (Resident R97). Findings include: Review of the job description of the Nursing Home Administrator (NHA) revealed that he was to ensure that all facility personnel, residents, visitors, etc, follow established safety regulations to include accident prevention. Review of facility policy, Hot Liquid Management, dated March 2017, revealed that prior to delivering beverage carts to designated unit, dietary staff temp (take the temperature) to validate it is not > 165F (Fahrenheit). If temp is > 165F, allow to cool to 165F and record temperature on the log. A review of Resident R97's quarterly Minimum Data Set assessment (MDS - an assessment of care needs) dated October 28, 2024, revealed that the resident had a BIMS (Brief Interview 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 observation, interview with staff and review of facility policy, it was determined that the facility did not implement enhanced barrier precautions for four residents (Residents R97, R59, R36, and R17) and no enhaced barrier precaution signage for two of six residents on barrier precautions. (Resident R10 and Resident R103). Findings include: Review of facility policy, Enhanced Barrier Precautions, revised June 2023, revealed, Use Enhanced Barrier Precautions for the management of residents colonized or infected with targeted or epidemiologically important MDRO's (e.g. wounds or indwelling devices present ) where contact precautions do not apply, according to the Healthcare Infection ControlPractices Advisory Committee (HICPAC) Consideration for use of Enhanced Barrier Precautions in Skilled Nursing Facilities (2021). Continued review of above policy revealed: Enhanced Barrier Precautions include: Use of gown and gloves during high risk activities including: dressing, bathing, transferring, changing…

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 interviews with residents and staff and facility documentation, it was determined that the facility did not maintain a safe, and comfortable water temperatures for residents, staff and the public for three of three floors. (1st, 2nd and 3rd floor) Findings include: During a group meeting with 11 residents on November 14, 2024, at 10:00 a.m. Resident R79 and R90 who reside on the second floor complained about the water temperatures. Resident R90 stated when taking a shower this week, suddenly the water temperature changed and felt warmer. Interview with the Nursing Home Administrator on November 14, 2024, at 11: 45 a.m. revealed the facility did not have a policy regarding water temperatures , We go by the state regulations of 110 degrees. Review of the maintenance log for water temperatures revealed temperatures were maintained within the policy. Surveyors recorded water temperatures on all three floors at all three shower rooms, on each floor of residents' rooms, at each end and the middle of each hallway. Two temperatures were recorded at 115.5 degrees on the first floor…

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 documentation, personnel records and interviews with staff, it was determined that the facility failed to ensure that staff completing the MDS (Minimum Data Set, comprehensive resident assessment) were properly licensed and registered to practice nursing in Pennsylvania for one of ten personnel files reviewed. (Employee E15) Findings include: Review of documentation submitted by the facility on October 23, 2024, revealed that Employee E15, who works at the facility remotely from outside the United States of America, revealed no license to review that showed that she was licensed to practice nursing in the state of Pennsylvania. Review of the Pennsylvania Licensing System Verification website revealed that Employee E15's name was not found in the database for nurses licensed to practice in Pennsylvania. Review of the Quarterly MDS submitted on August 14, 2024, for Resident R5 revealed that Employee E15 completed and signed Section Z0400 for assessments completed for sections A, GG, H, I J, L, M, N, O and P. Review of the Quarterly MDS submitted 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, review of the resident clinical record, and interviews with staff, it was determined that the facility failed to provide American Sign Language translation for a resident's representative as required for a care plan meeting for one of eleven residents reviewed. (Resident R11) Findings Include: Review of the facility policy titled Baseline Care Plan undated states, Intent- It is the policy of the facility to promote seamless interdisciplinary care for our residents by utilizing the interdisciplinary plan of care based on assessment, planning, treatment, service and intervention. It is utilized to plan for and manage resident care as evidenced by documentation from admission through discharge for each resident. Review of Resident R11's clinical record revealed the resident was admitted to the facility on [DATE] with the following diagnoses: Dysphagia, Anxiety, Type 2 Diabetes, Hypertension, Major Depressive Disorder, Heart Failure, Hyperlipidemia, Chronic Kidney Disease, 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 observation, resident and staff interviews and review of facility documentation, it was determined that the faciltiy failed to ensure that air conditioning units (PTAC units) were in functioning condition in 3 of 3 nursing units (1st, 2nd and 3rd floor) Findings include: Observations conducted with the Maintenance Director, Employee E1 on June 10, 2024 from 4:10 p.m. to 4:45 p.m. revealed that the following PTAC (Package Terminal Air Conditioning- a self contained heating and air condition system designed to be mounted through a wall) units in resident rooms and dining areas were non-functioning: room [ROOM NUMBER]- PTAC unit in the room was not working and floor fan was placed in room. room [ROOM NUMBER]- PTAC unit was on but not blowing cool air. room [ROOM NUMBER]- PTAC unit was on but not blowing cool air. room [ROOM NUMBER]- PTAC unit non-functioning. Resident R1 and Resident R2 confirmed that their room felt warm. room [ROOM NUMBER]- 82- PTAC unit the front panel hanging off the unit and resting…

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 interviews with staff, it was determined that the facility failed to post how to file a complaint with the State Survey Agency as required for three of three nursing units. (First, second and third floor nursing) Findings include: Observation on February 6, 2024, at 10:08 a.m. of the main lobby area as well as the first, second and third floor nursing units revealed that the complaint hotline number for the State Survey Agency was not posted. Interview on February 6, 2024, at 10:18 a.m. the Nursing Home Administrator confirmed that the complaint hotline number for the State Survey Agency was not posted. 28 Pa Code 201.14(a) Responsibility of licensee 28 Pa Code 201.18(b)(2) Management

Based on observations and interviews with staff, it was determined that the facility failed to ensure that the results of the most recent survey of the facility, as well as any surveys, certifications and complaint investigations and any plan of correction during the preceding three years, were readily accessible and available for review as required on thre of three nursing floors. (first, second and third floor nursing units). Findings include: Observation on February 6, 2024, at 10:08 a.m. of the first, second and third floor nursing units revealed a sign posted on each unit, indicating that survey results could be found in the lobby area. Observation of the lobby area revealed that the most recent survey information made available to residents was from 2019. Interview on February 6, 2024, at 10:18 a.m. the Nursing Home Administrator confirmed that the survey results that were made available to residents were not up to date and were from 2019. 28 Pa Code 201.14(a) Responsibility of licensee 28 Pa Code 201.18(b)(2) Management

Based on review of facility documentation and interviews with staff, it was determined that the facility failed to ensure that the surety bond had sufficient funds to cover the residents' personal funds deposited with the facility. Findings include: Review of facility documentation titled, Trial Balance dated February 5, 2024, at 1:52 p.m. revealed that the facility was holding $226,626.68 for individual resident funds and burial accounts. Review of the facility's Surety Bond (an agreement between the facility and an insurance company), dated effective June 14, 2018, revealed that the bond was in the amount of $200,000.00. Interview on February 5, 2024, at 2:15 p.m. the Nursing Home Administrator confirmed that the surety bond did not have sufficient funds to cover the full amount of residents' funds deposited within the facility. 28 Pa Code 201.14(a) Responsibility of licensee 28 Pa Code 201.18(b)(2) Management

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, review of clinical records and facility documentation, review of personnel files and interviews with residents and staff, it was determined that the facility failed to ensure that clinical nursing staff, including licensed nurses and nurse aides, had specific and appropriate skills sets needed to provide resident care for four of five newly hired personnel files reviewed (Employees E15, E16, E17 and E18). Findings include: Review of Resident R47's Quarterly MDS (Minimum Data Set - a mandatory periodic resident assessment tool), dated November 8, 2023, revealed that the resident was admitted to the facility on [DATE], and had diagnoses including multiple sclerosis (a disease in which the immune system attacks nerve cells resulting in nerve damage that disrupts communication between the brain and the body). Continued review revealed that the resident was dependent for toileting hygiene. Further review revealed that the resident was always incontinent of bowel and bladder. Review of 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 a review of facility documentation and interviews with staff, it was determined that the facility failed to complete performance reviews for two of two nurse aides reviewed as required (Employees E12 and E13). Findings include: Review of facility documentation, Active Employee Listing, dated February 6, 2024, revealed that Employee E12 was hired by the facility as a nurse aide on March 1, 1990. Continued review revealed that Employee E13 was hired by the facility as a nurse aide on June 9, 2022. During an interview on February 7, 2023, at 1:05 p.m. with the Assistant Director of Nursing, annual performance reviews were requested for Employees E12 and E13. The Assistant Director of Nursing confirmed that both Employees E12 and E13 were actively working at the facility as nurse aides. Interview on February 8, 2024, at 4:07 p.m. the Nursing Home Administrator stated that it is the facility's policy not to do annual performance evaluations for nursing staff. The Nursing Home Administrator stated that he was unable to provide the above referenced policy, and that he was unable…

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

Based on review of facility policies, clinical record review and interviews with residents and staff, it was determined that the facility failed to provide routine medications to meet resident needs for 3 of 34 residents reviewed (Residents R16 and R77) Findings include: Review of facility policy, Pharmacy Policy dated March 19, 2018, revealed that it is the policy of the facility to provide a comprehensive medication program. Review of Resident R16's Medication Administration Records (MARs) revealed that the resident was admitted to the facility September 14, 2018, and had diagnoses including cellulitis (infection) of left lower limb (leg) and epilepsy (seizure disorder). Continued review of Resident R16's MARs revealed a physician's order, dated August 28, 2019, for Levetiracetam (a medication used to treat epilepsy) 1000 m.g (milligrams) at every 12 hours. The MAR indicated that on December 27, 2023, the medication was not administered and no documentation. Continued review of Resident R16's MARs revealed a physician's order, dated December 20, 2023, for Keflex (medication used…

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 documents and residents and staff interviews, it was determined that the facility failed to ensure that residents received services from a licensed barber. Findings include: Review of, Title 49 of the Pennsylvania Code, Chapter 3: State Board of Barber Examiners, a student of barber is required to be instructed in barber science which curriculum includes the following: shaving and various uses of the straight razor, scalp and skin disease, sterilization and sanitation, hygiene, and bacteriology. The total minimum hours required for a student in barber school is 1, 250 hours of instruction. Review of Chapter 3: State Board of Barber Examiners states that an application to take the examination for a barber should include payment of a fee, and a notarized statement certifying the completion of the hours of instruction, either from a barber-teacher or manager-teacher or manager-barber with whom the student has studied and trained. Also, § 3.61. Out-of-shop services. When barbering services are provided outside a licensed barbershop, 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.

Based on observations, review of facility polices, clinical record reviews and interviews with staff, it was determined that the facility failed to maintain an effective infection prevention for one of 25 residents (Resident R12) reviewed and the infection control program polices and infection committee meetings. Findings include: Observation, on February 5, 2024, at 12:11 p.m. on the First Floor Nursing Unit, revealed that Resident R12 had a bright pink sign on his bedroom door that stated Contact Precautions. There was no additional information posted on the sign, such as what types of personal protective equipment were required. Interview, at the time of the observation, Employee E9, licensed nurse, stated that did not know what type of precautions or personal protective equipment Resident R12 required and to ask the unit manager. Interview on February 5, 2024, at 12:20 p.m. Employee E7, unit manager, stated that Resident R12 was still on contact precautions. Review of physician orders for Resident R12 revealed an order, dated December 13, 2023, for Enhanced Barrier Precautions:…

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 documentation and interviews with staff, it was determined that the facility failed to ensure that an effective training program was maintained as required for three of three nursing staff personnel files reviewed (Employees E11, E12 and E13) Findings include: Review of facility documentation, Active Employee Listing, dated February 6, 2024, revealed that Employee E11 was hired by the facility as a licensed nurse on March 26, 2015. Continued review revealed that Employee E12 was hired by the facility as a nurse aide on March 1, 1990. Further review revealed that Employee E13 was hired by the facility as a nurse aide on June 9, 2022. During an interview on February 7, 2023, at 1:05 p.m. with the Assistant Director of Nursing, annual in-service trainings were requested for Employees E11, E12 and E13. The Assistant Director of Nursing confirmed that Employees E11, E12 and E13 were actively working at the facility. Interview on February 8, 2024, at 4:07 p.m. the Nursing Home Administrator stated that the Assistant Director of Nursing was responsible for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews with residents and staff and reviews of policies and procedures, it was determined that the facility failed to ensure that an inventory of personal property was maintained for one of one residents reviewed related to personal inventories (Resident R16). Findings include: Review of the facility policy entitled Residents personal property, revealed that the facility had developed a policy to record all items of the residents personal effects. Clinical record review for Resident R16 indicated that this resident was admitted to the facility on [DATE]. Review of the resident's admission comprehensive assessment (MDS-an assessment of care needs) dated January 10, 2024, revealed that Resident R16 was cognitively intact and independent with decision making. Interview and observation of Resident R16 on February 5, 2024, at 1:30 p.m. revealed that this resident was missing an iPad, $175 gift card, multiple bottles of cologne and a box of greeting cards. Resident R16 also pointed to a…

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 interviews and the review of facility documentation, it was determined that the facility failed to ensure that the resident and her responsible party received written notification of all room changes before the room change occurred for 1 out of 25 residents reviewed (Resident R106). Findings include: Review of the facility's undated policy, Resident Room Location, indicated that the resident's social, and cognitive needs are assessed and considered prior to the relocation of the resident. The policy also indicated that the social services staff will assess the resident's ability to cope with and adapt to change, how the room change will affect the resident's current relationship and social support systems, in addition to the resident's willingness to move to a new location. Review of a physician's note dated December 11, 2023 at 1:34 p.m. indicated that the resident was admitted into the facility on December 7, 2023 after receiving treatment at a behavioral health unit due to aggressive outburst. 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 staff interviews and the review of clinical records, it was determined that the facility failed to ensure that a guardian's request to deny visitation was respected for 1 out of 25 residents reviewed (Resident 102). Findings include: Review of the facility undated policy, Visitation, indicated that the facility designs and implements processes that strive to ensure that each resident/patient has the right to free and open communication with the persons of their choice. The policy also indicate that staff would obtain a physician's order based on medical necessity and explained that certain residents/patients required limited visitation privileges in order to promote their healing. Review of the February 2024 physician orders for Resident R102 included the diagnoses of hypertension (high blood pressure); heart disease (a range of conditions that affect the heart); diabetes (a condition that happens when your blood sugar is too high); alcohol abuse; seizures (sudden, uncontrolled electrical disturbance in the brain which can cause changes in behavior, movements, feelings, 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 observations and interviews, it was determined that the facility failed to ensure that resident had access to private telephone for 2 out of 25 residents reviewed (Resident R27 and R109). Findings include: During an observation on the 2nd floor nursing unit on February 5, 2024 at 10:31 a.m., Resident R27 came to the nursing station to use the phone that was on top of the nursing station counter. Resident R27 called what seemed to be a medical office. Resident R27 was standing at the nursing station and could be heard stating over the phone that she did not know the number she was calling from she stated that she needed an epidural and that she spoke to someone at the office regarding the epidural Resident R27 then passed the phone to Employee E26 (licensed nurse), who then told them to send the information to the medical director. During an observation on the 2nd floor nursing unit on February 7, 2024, at 12:58 p.m. Resident R109 asked the Employee E26 (licensed nurse) that she wanted to use the telephone to call her daughter. Employee E26 placed the nursing desk phone 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 and resident interviews, it was determined that the facility failed to ensure that bed linens were maintain in clean sanitary condition for for 1 out of 25 residents reviewed (Resident R60). Findings include: Review of the February 2024 physician orders for Resident R60 included the diagnoses of morbid obesity; schizophrenia (a serious mental disorder in which people interpret reality abnormally); asthma and hypertension (high blood pressure). Review of the resident's Quarterly Minimum Data Set Assessment (MDS- a periodic assessment of a resident's needs) dated December 15, 2023 indicated that the resident was awake, alert and oriented. During an observation in resident's room on February 6, 2024, at 11:04 a.m. Resident R60 was observed lying in his bed. An odor was also detected, and the source of the odor could not be determined during the observation. In addition, the resident's bed sheet that was covering him while he was lying in bed had 4 red dime size spots, and red spots that appeared to be dried blood. During an observation in Resident R60's room 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, review of facility policies and documentation and interviews with residents and staff, it was determined that the facility failed to ensure that residents had access to grievance forms, access to the contact information of the grievance official, and failed to ensure that grievances were appropriately resolved for 2 of 34 residents reviewed (Residents R16 and R13). Findings include: Review of facility policy, Abuse, Neglect, Mistreatment and Misappropriation of Resident Property, and Exploitation dated last revised October 19, 2023, revealed that the posting of grievance officer information shall be posted, in an area accessible to residents, employees, and visitors the name, title, location and telephone number of the social worker or designee who is the individual . that is responsible for receiving complaints and ensuring that a complaint investigation is completed. Observations on February 5, 2024, at 10:45 a.m. of the first and second floor nursing units revealed that no grievance…

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 facility policies and documentation, clinical record reviews and interviews with residents and staff, it was determined that the facility failed to report allegations of abuse, neglect and misappropriation within required timeframes for 3 of 34 residents reviewed (Residents R47, R13 and R16). Findings include: Review of facility policy, Abuse, Neglect, Mistreatment and Misappropriation of Resident Property, and Exploitation dated last revised October 19, 2023, revealed, If an incident or allegation is considered reportable, the Administrator or designee will make an initial (immediate or within 24 hours) report to the State Agency. A follow up investigation will be submitted to the State Agency within five (5) working days. Continued review revealed that, Verbal abuse is oral, written or gestured language that willfully includes disparaging and derogatory terms to residents or their families, within hearing distance, regardless of their age, ability to comprehend or disability.…

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 interviews, and review of clinical records and facility documentation, it was determined that the facility failed to ensure that a complete and through investigation was conducted for allegations of abuse/neglect/misappropriation of resident property for 2 out of 25 residents (Resident R13 and R16). Findings include: Review of the facility policy, Abuse, Neglect, Mistreatment and Misappropriation of Resident Property and Exploitation with a revision date of October 19,2023 indicated that it is the policy of the facility that reports of abuse are promptly and thoroughly investigated. The policy also indicated that the alleged incidents must be reported immediately to the Administrator and/or the Director of Nursing and that an immediate investigation must be conducted. Continued review of the policy indicated that the facility will ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source, misappropriation of resident property 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 observations, clinical record reviews and interviews with residents and staff, it was determined that the facility failed to ensure that MDS assessments accurately reflected residents' status related to respiratory and diabetic care, for two of 34 residents reviewed (Residents R21 and R82). Findings include: Review of Resident R82's admission MDS (Minimum Data Set - a mandatory periodic resident assessment tool), dated November 17, 2023, revealed that the resident was admitted to the facility on [DATE], and had diagnoses including respiratory failure (not enough oxygen passes from your lungs to your blood). Observation, on February 5, 2024, at 12:11 p.m. revealed that Resident R82 was wearing oxygen via a nasal cannula and oxygen concentrator machine. Interview, at the time of the observation, Resident R82 stated that he uses oxygen and a CPAP machine due to a respiratory condition. Review of physician orders for Resident R82 revealed an order, dated November 10, 2023, for oxygen at two liters per…

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 reviews and interviews with staff, it was determined that the facility failed to develop a baseline care plan that includes the instructions needed to provide effective and person-centered care that meet professional standards of quality care for one of 34 residents reviewed (Resident R21). Findings include: Review of Resident R21's admission MDS, dated [DATE], revealed that the resident was admitted to the facility on [DATE], and had diagnoses including coronary artery disease (damage in the heart's major blood vessels), pneumonia (lung inflammation caused by bacterial or viral infection), septicemia (bacterial infection in the blood) and cerebrovascular accident (damage to the brain from interruption of its blood supply). Review of hospital discharge records, dated January 8, 2024, revealed that Resident R21 was prescribed Metformin (medication used to treat diabetes) 500 milligram tabs, take two tabs twice per day. Review of Medication Administration Records revealed a physician'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 observations, clinical record review, review of facility documents and staff interviews, it was determined that the facility failed to revise a resident's care plan for recurrent fall prevention, for one of 27 residents reviewed (Resident R3). Findings include: Review of Resident R3's clinical record revealed the diagnoses of Senile Degeneration of Brain (Senile Degeneration of Brain causes cognitive decline, particularly memory loss), Major Depressive Disorder (A mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), and Cerebrovascular Disease (Cerebrovascular Disease is a term for conditions that affect blood flow to the brain). Review of clinical progress note, dated December 8, 2023, for Resident R3, indicated that the resident sustained fall while displaying aggressive and agitated behaviors, reportedly lost balance while throwing items in his room, he fell to his buttocks without apparent injuries, and the resident did not hit his head. Further review of clinical progress…

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, clinical record reviews and interviews with staff, it was determined that the facility failed to obtain physician orders related to blood sugar monitoring, acupuncture services, and refusal of medications for three of 34 residents reviewed (Residents R21, R102 and 106 ). Findings include: Review of facility policy, Diabetes - Clinical Protocol dated 2001, revealed, As part of the initial assessment, the Physician will help identify individuals with elevated blood sugar, impaired glucose tolerance, or confirmed diabetes, as well as factors that may influence glucose tolerance . For residents who meet the criteria for diabetes testing, the Physician will order pertinent screening. Review of facility policy, Nursing Care of the Resident with Diabetes Mellitus dated 2001, revealed, The management of individuals with diabetes mellitus should follow relevant protocols and guidelines. The physician will order the frequency of glucose monitoring. Review of Resident R21's admission…

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, resident and staff interviews, and review of clinical records, it was determined that the facility failed to ensure that proper foot care was provided to residents for 2 out of 25 residents reviewed (Resident R57 and R94). Findings include: Review of the February 2024 physician orders for Resident R57 include the following diagnoses: cerebral infarction (a stroke); hypertension (high blood pressure); venous insufficiency chronic peripheral (a condition that affects the blood flow in your legs, causing swelling, pain, and skin changes) and dysuria (pain or burning sensation while passing urine). During a group interview with the resident on February 7, 2024, at 9:30 a.m. Resident R57 reported that he needed to see the podiatrist I need to get my feet checked out. It's been a while since I've seen the foot doctor. During an observation of the resident's feet on February 9, 2024 at 9:23 a.m. with the resident's nurse aide (Employee E28), revealed that the resident's feet were contorted, his big toes had a nail that was approximately 3 inches long, the other…

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 facility documentation, and interviews with residents and staff, it was determined that the facility failed to provide proper continence care for one of 34 residents reviewed (Resident R47). Findings include: Review of Resident R47's Quarterly MDS (Minimum Data Set - a mandatory periodic resident assessment tool), dated November 8, 2023, revealed that the resident was admitted to the facility on [DATE], and had diagnoses including multiple sclerosis (a disease in which the immune system attacks nerve cells resulting in nerve damage that disrupts communication between the brain and the body). Continued review revealed that the resident was dependent for toileting hygiene. Further review revealed that the resident was always incontinent of bowel and bladder. Review of Resident R47's admission Bowel and Bladder Program Screener, dated May 21, 2018, revealed that the resident never voided appropriately without incontinence, was incontinent of stool daily, 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, review of facility policies, clinical record reviews and interviews with residents and staff, it was determined that the facility failed to ensure the proper storage of tube feeding formula and supplies for one of two residents reviewed for tube feedings (Resident R91). Findings include: Review of facility policy, Enteral Feeding Tubes policy dated last revised December 22, 2023, revealed, Follow pharmacy guidance for administration of medication[s] and or feeding. Review of Resident R91's admission MDS (Minimum Data Set - a mandatory periodic resident assessment tool), dated September 7, 2023, revealed that the resident was admitted to the facility on [DATE], with diagnoses including pneumonia (lung inflammation caused by bacterial or viral infection), respiratory failure (not enough oxygen passes from your lungs to your blood) and gastrostomy status (a surgical opening and placement of a tube though a person's abdominal wall into their stomach). Continued review 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 observation, clinical record review, and staff interviews, it was determined that the facility failed to provide residents with necessary behavioral healthcare, to maintain the highest practicable mental and psychosocial well-being, for one out of 27 resident records reviewed (Residents R69). Findings include: Review of Resident R69's clinical record revealed that the resident was admitted in the facility, on October 30, 2018, with diagnoses of cellulitis (bacterial infection of the skin), depressive episodes (experiences of feeling sad, irritable, and empty; they may feel a loss of pleasure or interest in activities; a depressive episode is different from regular mood fluctuations; it lasts most of the day, nearly every day, for at least two weeks), and severe obesity due to excess calories. During observational tour of the facility, on February 5, 2024, at 11:43 a.m., an odor was detected in Resident R69. On February 5, 2024, at 11:45 a.m., interviewed with Nurse Supervisor, a Registered Nurse, Employee E8 revealed that Resident R69, refuses shower. Review of 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.

Based on observations and an interview with staff, it was determined that the facility did not ensure that garbage and refuse were disposed properly. Finding include: An initial tour of the Food Service Department, conducted on February 5, 2024, at 9:32 a.m., with the Dietary Manager, Employee E21, revealed the following concerns: An observation of trash compactor area revealed; one trash dumpster is overflowing, and its lid was not closed. Some of the trash bags contained used dirty briefs and other soiled incontinence wipes and supplies. Further observation of the loading dock revealed that the door sweep was missing for the exit door at the loading dock. An interview with Dietary manager, Employee E21, at the time of the finding, revealed that the maintenance and housekeeping departments were responsible to maintain the cleanliness of the area. 28 Pa. Code 201.18(b)(3) Management 28 Pa. Code 207.2(a) Administrator's responsibility

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interviews and the review of clinical records, it was determined that the facility failed to ensure complete and accurate documentation for clinical records for 1 out of 25 residents reviewed (Resident R13). Findings include: Review of the February 2024 physician orders for Resident R13 included the following diagnoses: spinal stenosis (occurs when the space inside the backbone is too small, which can pressure on the spinal cord and nerves that travel through the spine); diabetes (a group of diseases that affect how the body uses blood sugar), and an overactive bladder. Review of the resident's Significant Change Minimum Data Set assessment dated [DATE] indicated that the resident was awake, alert, and oriented. Review of the resident's person centered plan of care included a plan of care stating that the resident has a behavioral problem related to inappropriate of touching others with October 23, 2023 as the date that the plan of care was initiated. Review of nursing notes and clinical records…

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 documentation and interviews with staff, it was determined that the facility failed to maintain an effective, comprehensive, data-driven quality assurance and performance improvement program (QAPI) that focuses on indicators of the outcomes of care and quality of life as required. Findings include: Review of facility policy, Quality Assurance and Performance Improvement (QAPI) Plan undated, revealed that the facility will, put in place systems to monitor care and services, drawing data from multiple sources. Feedback systems will actively incorporate input from staff, residents, families, and others as appropriate. It will include using performance indicators to monitor a wide range of care processes and outcomes and reviewing findings against benchmarks and/or goals the facility has established for performance. It also includes tracking, investigation and monitoring adverse events every time they occur, and action plans implemented through the plan, do study, act (PDSA) cycle of improvement to prevent recurrences. Continued review revealed, Targets for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility documentation and interviews with staff, it was determined that the facility failed to maintain an effective quality assurance and performance improvement program (QAPI) that includes actions taken aimed at performance improvement and program systematic analysis as required. Findings include: Review of facility policy, Quality Assurance and Performance Improvement (QAPI) Plan undated, revealed, Performance Improvement Projects (PIP): The QAPI committee annually prioritizes activities, endorses or re-endorses policies and procedures, and continually monitors for improvement using a QAPI self-assessment. In addition, the QAPI Steering Committee will implement and PIP topics indicated by data analysis . PIPs are implemented in accordance with CMS' [Centers for Medicare and Medicaid Services] protocol for conducting PIPs, including: Measurement of performance using objective quality indicators; Implementation of system interventions to achieve improvement in quality; Evaluation 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policies, clinical record reviews and interviews with staff, it was determined that the facility failed to ensure that residents were offered Pneumococcal vaccinations as required for one of five residents reviewed. (Resident R30). Findings include: Review of facility policy, Immunization, Administration of, revealed that the facility should obtain request or refusal of vaccine(s) on the applicable form: pneumococcal & annual influenza vaccination information and request. Review of physician's orders for Resident R30 revealed that the resident was admitted to the facility on [DATE], and had diagnoses including malignant neoplasm (cancerous tumor) of right bronchus or lung. Continued review of the clinical record for Resident R30 revealed that there was no documentation in the record available at the time of review to indicate that the resident was offered or screened for the Pneumococcal vaccine. Interview on February 8, 2024, the Director of Nursing, confirmed that there was no…

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 interviews with staff, it was determined that the facility failed to ensure that call bell systems were accessible to residents for 1 out of 25 residents reviewed (Resident R102). Findings include: Review of the February 2024 physician orders for Resident R102 included the following diagnosis: hypertension (high blood pressure); heart disease (a range of conditions that affect the heart); diabetes (a condition that happens when your blood sugar is too high);alcohol abuse; seizures (Sudden, uncontrolled electrical disturbance in the brain which can cause changes in behavior, movements, feelings, and consciousness) and aphasia (a disorder affecting an individual's reading, speaking and writing resulting from damage or injury to the specific area in the brain). During an observation in Resident R102's room on February 5, 2024 at 10:30 a.m. the resident was observed lying in the bed with no call bell. The Assistant Director of Nursing was notified and also observed that resident without a call bell for him to use at 10:37 a.m. on the above referenced dated.…

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 documentation, observation, and interviews with staff, it was determined that the facility failed to maintain an adequate supply of emergency water. Findings Include: An initial tour of the Food Service Department, conducted on February 5, 2024, at 9:32 a.m., with the Dietary Manager, Employee E21, revealed the following concerns: Facility had not maintained a three-day supply of emergency water on-site. An interview with Dietary manager, Employee E21, at the time of the finding, confirmed that the Facility had not maintained a three-day supply of emergency water on-site. 28 Pa Code: 201.18(b)(1)(3) Management 28 Pa Code: 211.10(a)(b)(c)(d) Resident care policies 28 Pa Code: 209.7(a) Disaster preparedness

Based on clinical record review, review of facility documents and interviews with staff, it was determined that the facility failed to conduct a complete and thorough investigation in a timely manner for an allegation of sexual abuse for one of eight residents reviewed (Resident R1). Findings include: Review of facility information sent to the Department on October 4, 2023, revealed: A male resident [Resident R8] was found in [Resident R1] room. The door was barricaded. This nurse, [Employee E2, DON] pushed the door opened and found [Resident R8] underwear and pants were down around his ankles. He was on top of [Resident R1]. Her underwear and pants were also down around her ankles. The male patient and female patient were laying on side of the bed and male patient was on top of the female patient in process of having sexual intercourse. The facility noted the date of the investigation to be completed as October 4, 2023, and the facility's conclusion was unable to confirm sexual abuse, however the facility failed to obtain interviews and witness statements in a timely manner to…

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.