Highlands Rehabilitation And Healthcare

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, review of select policies and procedures, and staff interview, it was determined that the facility failed to provide the highest practicable care for one of one resident reviewed for behavioral health related to suicidal ideation. (Resident 82). Findings include: The facility policy entitled, Suicide Prevention and Intervention Guideline, last reviewed without changes on August 27, 2025, revealed it is the policy of the facility that individuals voicing and/or displaying feelings and/or actions which indicated suicidal ideation (thoughts, or preoccupations with ending one's own life, ranging from fleeting, passing thoughts to detailed, active planning), receive services and interventions to help them manage these feeling and maintain their psychosocial well-being. Employees are responsible for monitoring acute mood and behavior changes which may indicate potential suicidal ideation and for reporting these changes to their supervisor for appropriate assessment and interventions.…

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 select facility policies and procedures, observation, clinical record review, and family and staff interview, it was determined that the facility failed to provide routine dental care for one of one resident reviewed for dental concerns (Resident 58).Findings include: The facility policy entitled, Dental Consultant, last reviewed August 27, 2025, revealed that dental care shall be provided through the services of a consultant dentist. A consultant dentist is retained by the facility and is responsible for providing a dental assessment of each resident within ninety (90) days of admission and, .performing or supervising an annual dental revaluation for each resident. The policy did not confirm that the facility would provide dental services provided by the State Medicaid plan (e.g., prophylactic dental cleanings every six months). Interview with Resident 58's daughter on February 2, 2026, at 10:12 AM revealed that she believed Resident 58 needed to have her teeth fixed, and that Resident 58 had natural teeth that likely needed to be extracted. Resident 58'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 review of select facility policies, clinical record review, and staff interview, it was determined that the facility failed to provide services to maintain or improve a resident's range of motion (ROM) and mobility for four of five residents reviewed (Resident 19, 48, 59, and 74). Findings include: Review of the facility policy entitled, Restorative Nursing Services, last reviewed without changes on August 15, 2024, revealed that residents will receive restorative nursing care as needed to help promote optimal safety and independence. Restorative nursing care consists of nursing interventions that may or may not be accompanied by formalized rehabilitative services. Restorative goals and objectives are individualized and resident-centered and outlined in the resident's plan of care. Restorative goals may include but are not limited to supporting and assisting the resident in adjusting or adapting to changing abilities; developing, maintaining, or strengthening their physiological and psychological resources; maintaining their dignity, independence, and self-esteem; 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 resident interview, clinical record review, and staff and resident interview, it was determined that the facility failed to provide written notice regarding the facility's bed-hold policy for one of five residents reviewed for hospitalization concerns (Resident 63). Findings include: Interview with Resident 63 on January 13, 2025, at 12:12 PM revealed that he was hospitalized with symptoms that were questionably indicative of a stroke (cerebrovascular accident, interruption of blood flow or bleeding in the brain), but he returned to the facility after his hospitalization. Clinical record review for Resident 63 revealed nursing documentation dated October 12, 2024, at 12:24 PM that indicated Resident 63 was calling for help, had an elevated temperature, increased confusion, and agreed to transfer to the hospital for evaluation. Nursing documentation dated October 12, 2024, at 12:47 PM revealed that Resident 63 left the facility via an ambulance in route to the hospital. Nursing documentation dated October 12, 2024, at 1:25 PM revealed that staff spoke to Resident 63's sister…

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 that the facility failed to ensure a complete and accurate Minimum Data Set (MDS) assessment for one of 22 residents reviewed (Resident 34). Findings include: Review of Resident 34's clinical record revealed that the facility admitted her with a diagnosis of Schizophrenia. Further review revealed a PASRR (Pennsylvania Preadmission Screening Resident Review Identification Level 1 form) completed on May 22, 2019, that indicated the resident had a mental health condition or suspected mental illness that may lead to a chronic disability and the resident met the criteria (positive screen) to have a PASRR Level 2 evaluation done. A completed PASRR Level 2 by the Pennsylvania Department of Human Services Office on Mental Health and Substance abuse services dated August 1, 2019, indicated Resident 34 had evidence of a Mental Health condition that met the criteria, and the resident was determined as eligible for Mental Health services. Review of Resident 34's last comprehensive (annual) MDS (minimum Data set - an…

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 resident, family, and staff interview, it was determined that the facility failed to revise residents' care plans for three of 21 residents reviewed (Residents 79, 81, and 86). Findings include: Interview with Resident 79's daughter on January 13, 2025, at 10:29 AM indicated that she believed that her mother could become verbally and/or physically abusive to staff when she gets anxious. She stated that she believed that her mother has an anxious response when approached by two staff to perform care and that she suggested to the facility that her mother receive care by one staff. Resident 79's daughter also indicated that she provides soda for staff to give her mother to provide caffeine since she no longer smokes cigarettes or drinks coffee to lessen her behaviors and improve her compliance with care. Clinical record review for Resident 79 revealed social services documentation dated November 26, 2024, at 1:39 PM that during a care plan meeting, Resident 79's daughter expressed concerns that Resident 79 may be more combative in the morning with…

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

Based on clinical record review and resident and staff interview, it was determined that the facility failed to provide care and services to maintain or improve the ability to perform activities of daily living for one of two residents reviewed for rehabilitation concerns (Resident 12). Findings include: Interview with Resident 12 on January 13, 2025, at 12:58 PM revealed that she had a walker device in her room that is used when staff walk with her; however, that does not occur, too much because they (the facility) don't have too many people (staff). A discharge summary by physical therapy staff dated November 29, 2023, indicated that services included patient and caregiver training, and instruction regarding an in-home exercise program (HEP) to preserve Resident 12's current level of function and prevent functional decline. Resident 12's prognosis was assessed as good with consistent staff follow-through. Discharge recommendations included that Resident 12 was to continue with the HEP restorative nursing program for gait and independent transfers and wheelchair mobility. Review of…

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

Based on observation, clinical record review, and staff interview, it was determined that the facility failed to implement physician ordered supplemental oxygen consistent with professional standards of practice for one of one resident reviewed for supplemental oxygen concerns (Resident 63). Findings include: Clinical record review for Resident 63 revealed a physician's order dated November 11, 2024, for staff to administer supplemental oxygen at two liters per minute as needed to keep oxygen saturation levels above 90 percent, use as needed for oxygen saturations of less than 90 percent. Review of Resident 63's medication administration records and treatment administration records (MAR and TAR, electronic documentation completed by staff to record the completion of medications and treatments) dated November 2024, December 2024, and January 2025, revealed that staff did not obtain routine assessments of Resident 63's oxygenation saturations to determine the need for supplemental oxygen. Observation of Resident 63 on January 13, 2025, at 12:20 PM revealed no supplemental oxygen in…

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

Based on clinical record review and staff interview, it was determined that the facility failed to develop and implement an individualized person-centered care plan to address dementia and cognitive loss displayed by one of one resident reviewed (Resident 43). Findings include: Clinical record review for Resident 43 revealed the facility admitted her on October 31, 2024, with diagnosis including Dementia (loss of memory, language, problem-solving, and other thinking abilities that interfere with daily life). A review of Resident 43's most recent annual Minimum Data Set Assessment (MDS, a form completed at specific intervals to determine care needs) dated November 6, 2024, indicated that the facility assessed Resident 43 as having a diagnosis of dementia. The facility determined that a care plan for dementia and cognitive loss would be developed. A review of Resident 43's care plan entitled impaired cognitive function related to dementia revealed that there was no indication that the facility had implemented an individualized person-centered care plan to address the resident's…

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

Based on clinical record review, observation, and resident and staff interview, it was determined that the facility failed to provide routine dental services related to partial dentures for one of two residents reviewed for dental concerns (Resident 86). Findings include: Interview with Resident 86 on January 14, 2025, at 11:37 AM revealed that she had partial dentures for her upper and lower jaw but they went missing. Resident 86 stated that they (the facility's consultant dental provider) are supposed to be making new ones. Resident 86 indicated that it was eight months to one year that she did not have her partial dentures. Observation of Resident 86 on the date and time of the interview revealed that she had natural teeth and was missing teeth. Clinical record review for Resident 86 revealed a plan of care created by the facility on Resident 86's admission date of December 8, 2023, to address her self-care deficits in her activities of daily living (ADL). The plan of care noted that Resident 86 had partial upper and lower dentures. Progress note documentation by the facility's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff interview, it was determined that the facility failed to ensure residents' medical records included documentation that residents' representatives were provided education regarding the risks and benefits of immunizations for two of five residents reviewed for immunization concerns (Residents 21 and 46). Findings include: Clinical record review for Resident 21 revealed a quarterly MDS (minimum data set, an assessment completed by the facility at intervals to determine care needs) assessment dated [DATE], that indicated Resident 21 had a BIMS (Brief Interview for Mental Status) score of three, indicating she had severe cognitive impairment. A psychiatric note dated October 4, 2024, at 12:00 PM indicated that Resident 21 was awake, alert, and oriented. Review of Resident 21's Influenza Vaccination (a shot that protects against the flu) consent form revealed that there was no signature by the resident or her responsible party indicating that she received and understood 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 clinical record review and staff interview, it was determined that the facility failed to ensure a residents' medical records included documentation that the residents' representative was provided education regarding the risks and benefits of receiving a COVID-19 immunizations for one of five residents reviewed for immunization concerns (Residents 46). Findings include: Clinical record review for Resident 46 revealed a quarterly MDS assessment dated [DATE], that indicated resident had a BIMS score of three, indicating she had severe cognitive impairment. A physician's progress note dated October 3, 2024, at 5:23 PM revealed that Resident 46 is alert with confusion and has a diagnosis of dementia (a group of thinking and social symptoms that interferes with daily functioning). Review of Resident 46's COVID-19 vaccine consent/administration record provided by the facility, revealed that Resident 46 signed the form on November 7, 2024, indicating that she understood the benefits and risks of the vaccine…

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 protect a resident's right to be free from physical abuse for one of one resident reviewed for resident-to-resident interactions (Resident 1). Findings include: Clinical record review revealed the facility admitted Resident 1 on March 7, 2012, with diagnosis including unspecified dementia (a decline in mental ability that affects thinking, memory, and behavior, and interferes with daily life). Review of nursing documentation revealed a fall occurrence note dated November 30, 2024, at 4:37 PM indicating Resident 1 was noted to be on the floor next to her bed laying on her right side. Resident 1 was noted to be guarding her right arm and complaining of pain to her right arm. The fall was unwitnessed by staff. Resident 1's statement indicated Resident 1 reported her roommate (Resident 2) pushed me out of bed, and I'm scared. Nursing documentation dated December 1, 2024, at 1:22 PM revealed the facility received…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and resident and staff interview, it was determined that the facility failed to maintain comfortable and safe temperature levels between 71 and 81 degrees Fahrenheit on two of two floors (Second and Third floors). Findings include: Observation of the facility on October 19, 2024, at 3:00 PM revealed the following temperatures: Second Floor: Resident room [ROOM NUMBER], 83 degrees Fahrenheit Resident room [ROOM NUMBER], 84 degrees Fahrenheit Resident room [ROOM NUMBER], 84 degrees Fahrenheit Resident room [ROOM NUMBER], 82 degrees Fahrenheit Resident room [ROOM NUMBER], 83 degrees Fahrenheit Resident room [ROOM NUMBER], 83 degrees Fahrenheit Resident room [ROOM NUMBER], 82 degrees Fahrenheit Second Floor Medication room [ROOM NUMBER].4 degrees Fahrenheit Third Floor: Resident room [ROOM NUMBER], 88 degrees Fahrenheit Resident room [ROOM NUMBER], 87 degrees Fahrenheit Resident room [ROOM NUMBER], 86 degrees Fahrenheit Resident room [ROOM NUMBER], 86 degrees Fahrenheit Resident room [ROOM…

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, review of select facility policies and procedures, and staff interview, it was determined that the facility failed to ensure an effective infection control program for outbreak testing and transmission-based precautions to prevent the spread of infection on one of two nursing units (3rd Floor Nursing Unit; Residents 1 and 2, Employees 1 and 2). Findings include: Review of the policy entitled COVID-19 Testing Requirements last reviewed on May 10, 2023, indicates that a single new case of COVID-19 infection in any staff or resident should be evaluated to determine if others in the facility could have been exposed. The approach could involve either contact tracing or a broad-based approach. A broad-based approach is preferred if all potential contacts cannot be identified or managed with contact tracing or if contact tracing fails to halt transmission. Testing is recommended immediately, and again 48 hours after the first negative test, and if negative, again 48 hours after the second negative test. Testing should continue on affected units until there…

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, review of select policies and procedures, and staff interview, it was determined that the facility failed to implement their abuse policy regarding investigating an allegation of abuse for two of 11 residents reviewed (Residents 3 and 4). Findings include: Review of the facility's Abuse Policy implemented on April 1, 2024, indicated that allegations must be reported to the Administrator or other officials and an investigation will be initiated immediately. Review of Resident 3's clinical record revealed nursing documentation dated April 3, 2024, at 3:45 PM indicating that Resident 3 walked down the hallway and was witnessed striking Resident 4 in the face. This was witnessed by Employee 3, housekeeper, and that further investigation will be made. The documentation indicated that the incident was reported to the Director of Nursing. The facility was unable to provide documented evidence that an investigation was started regarding the physical incident between Resident 3 and Resident 4. There was no documented evidence that Resident 4 was assessed for…

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

Based on closed clinical record review and staff interview, it was determined that the facility failed to provide the highest practicable care regarding the administration of physician ordered pain medications for one of 11 residents reviewed (Resident CR1). Findings include: Review of Resident CR1's closed clinical record revealed a physician's order dated March 23, 2024, for nursing staff to administer Morphine Sulfate 20mg/ml (milligrams/milliliter) 0.5 ml every two hours as needed for pain. A physician's order dated March 24, 2024, indicated that nursing staff were to administer Morphine Sulfate 20mg/ml, 0.75 ml every four hours around the clock for pain, scheduled to be given at 12:00 AM, 4:00 AM, 8:00 AM, 12:00 PM, 4:00 PM, and 8:00 PM, every day. Review of Resident CR1's Medication Administration Record (MAR, a form utilized to document the administration of medications) dated April 2024, revealed that Employee 4, registered nurse, only administered 0.5 ml of Resident CR1's Morphine Sulfate dose on April 3, 2024, at 4:47 PM and again at 8:47 PM. Resident CR1's Morphine…

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 and staff interview, it was determined that the facility failed to store food items and maintain equipment in a safe and sanitary manner in the facility's main kitchen. Findings included: Initial tour of the facility's main kitchen on February 6, 2024, between 9:15 AM and 10:15 AM revealed the following: There was a significant amount of debris on top of the dishwasher. There was also a significant amount of dust accumulating on the ceiling above the dishwasher including where the clean dishes came out of the washer. A pipe just behind the dishwasher had an accumulation of dust and had a large piece of protective covering falling off the pipe. The dry storage room had a large bucket of rice with no date or expiration on the bucket. There were dried splashes on the entire wall behind the drink prep area. There was a large number of dead bugs and debris in the bottom of the ceiling light covering above the drink prep area. A plastic container holding lids for juice containers had two lids that were put away wet. There was a plastic drink pitcher with a maroon lid…

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 resident, family, and staff interview, it was determined that the facility failed to provide a comfortable and homelike environment on one of two nursing units reviewed (Third floor nursing unit; Residents 8, 51, and 67). Findings include: During an interview with Resident 8's family member on February 7, 2024, at 9:29 AM it was reported that the building gets too hot and sweltering, especially on warm winter days. This includes resident rooms and the lounge behind the elevator on the third floor. There are times the staff leave the front entrance doors open and when they do, there is no security. This past Christmas day was an example. Interview with Resident 67 on February 7, 2024, at 1:50 PM revealed his room is very hot and gets very hot in the afternoon and has a fan on. Concurrent observation of the thermostat in Resident 67's room revealed the thermostat read 83 degrees Fahrenheit. The surveyor then observed the thermostat in the room shared by Residents 8 and 51 and it read 82 degrees Fahrenheit. Concurrent…

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 resident and staff interview, it was determined that the facility failed to serve food that is palatable on one of two nursing units (Third floor nursing unit, Residents 67 and 90). Findings include: Review of food committee meeting minutes date November 29, 2023, revealed that the residents would like more gravy over their meats. Review of food committee meeting minutes dated December 27, 2023, revealed the residents reported the pork is dry. Neither meeting minutes mentioned follow-up of the previous month's concerns. Interview and observation on February 6, 2024, at 12:00 PM with Resident 90 revealed the pork chop was tough. The pork chop was dry and very difficult to cut. There was no gravy or broth on the pork chop. Interview with Resident 67 on February 7, 2024, at 10:09 AM revealed that he is on a soft diet and received a pork chop yesterday that he could not chew. On February 8, 2024, at 11:20 AM the surveyor tested a food tray of regular consistency foods in the presence of Employee 2, nurse aide. The surveyor…

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 select facility policies and procedures, clinical record review, and staff interview, it was determined that the facility failed to ensure residents' medical records included documentation that residents' representatives were provided education regarding the risks and benefits of immunizations for three of five residents reviewed for immunization concerns (Residents 88, 22, and 92); and that residents received the pneumococcal vaccine for two of five residents reviewed for immunization concerns (Residents 88 and 91). Findings include: The facility policy entitled, Influenza Vaccine, last reviewed February 22, 2023, indicated that all residents and employees who have no medical contraindications to the vaccine will be offered the influenza vaccine annually to encourage and promote the benefits associated with vaccinations against influenza. The facility will provide pertinent information about the significant risks and benefits of vaccines to staff and residents (or residents' legal representatives). Prior to the vaccination, the resident (or resident's legal…

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 the resident or resident's responsible party participation in the development of end-of-life treatment wishes for one of six residents reviewed for advance directive concerns (Resident 33). Findings include: Clinical record review for Resident 33 revealed an electronic physician's order dated [DATE], that instructed staff to not provide resuscitation (CPR, chest compressions and artificial breathing assistance upon a medical emergency and/or death). Review of Resident 33's physical chart revealed a POLST form (Physician Orders for Life-Sustaining Treatment, portable medical order form that records patients' treatment wishes so that emergency personnel know what treatments the patient wants in the event of a medical emergency) signed by Resident 33's brother/responsible party on [DATE], that indicated he wanted CPR/full treatment. Interview with Employee 6, licensed practical nurse, on February 7, 2024, at…

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 select facility policies and procedures, review of clinical record and facility documentation, and staff interview, it was determined that the facility failed to ensure that allegations of potential abuse were thoroughly investigated and reported to the appropriate agencies for two of four sampled residents (Residents 82, 84, 79, and 92). Findings include: The facility policy entitled, Abuse Investigation and Reporting, last reviewed February 22, 2023, revealed that all reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment, and/or injuries of unknown source shall be promptly reported to local, state, and federal agencies and thoroughly investigated by facility management. If an incident or suspected incident of resident abuse, mistreatment, neglect, or injury of unknown source is reported, the Administrator will assign the investigation to an appropriate individual. The role of the investigator, the individual conducting the investigation, will, at a minimum, review the resident's medical record to determine events…

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 documentation, and staff and resident interview, it was determined that the facility failed to develop and implement an effective discharge planning process, which begins on admission, including resident's assessments and goals for care for one of 24 residents reviewed (Resident 90). Findings include: Clinical record review for Resident 90 revealed that the resident was [AGE] years old and was admitted to the facility on [DATE], following a fracture of the right proximal humerus (upper arm). The surveyor requested an admission history and physical for Resident 90 and was provided with a history and physical competed by the referring hospital dated October 17, 2023. The history and physical revealed the resident lived at home prior to the hospitalization. The resident reported current drug use of marijuana and prescription drugs. Resident 90 lived with two roommates. Review of a care plan for Resident 90 dated October 23, 2023, revealed the resident concealed medications…

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 that the facility failed to provide bathing assistance for a resident dependent on staff assistance for one of two residents sampled for activities of daily living (Resident 71). Findings include: Clinical record review of Resident 71's task documentation (computerized documentation completed by staff to record residents care needs and care performed) revealed that his preference for bathing was to have a shower. His shower was to be completed on Wednesdays and Saturdays during the evening shift. Review of Resident 71's current plan of care revealed that he required limited (resident is highly involved in performing the activity but receives some physical help) to extensive (resident requires weight bearing support) assistance from staff for bathing. Review of Resident 71's bathing/shower documentation for December 2023, revealed that he did not receive a shower from December 1-12, 2023, with documentation on December 1, 5, 8, and 12 indicating NA (not applicable). Review of Resident 71's bathing/shower…

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, observation, and resident and staff interview, it was determined that the facility failed to implement interventions for injury prevention for one of seven residents reviewed for accident concerns (Resident 38). Findings include: Clinical record review for Resident 38 revealed an electronic medical record physician order dated January 26, 2024, to implement floor mats bilaterally (on both sides) when Resident 38 was in bed. Review of a plan of care developed by the facility to address Resident 38's risk for falls revealed interventions that included bilateral floor mats when in bed. Nursing documentation dated October 19, 2023, at 7:09 PM revealed that staff responded to Resident 38 yelling in her room. Staff found Resident 38 on the floor on the right side of her bed. Resident 38 reported that she rolled out of bed. Nursing documentation dated December 11, 2023, at 5:10 PM revealed that nurse aide staff reported to the nurse that Resident 38 was on the floor. The nurse observed Resident 38, face down, on her fall mat. Nursing documentation 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 observation, clinical record review, and resident and staff interview, it was determined that the facility failed to provide care and services for an indwelling catheter for two of five residents reviewed for catheter concerns (Residents 7 and 55). Findings include: Clinical record review for Resident 7 revealed a physician's order dated July 17, 2023, that instructed staff to change a Foley catheter (thin, flexible, tube inserted through the urethra into the bladder to drain urine) as needed. Another physician's order dated July 17, 2023, instructed staff to irrigate the Foley catheter with 60 milliliters of normal saline as needed for blockages. A physician's order dated September 6, 2023, instructed staff to attach the Foley catheter to a leg bag (smaller bag that can be attached to the leg under clothing to conceal urine collection during the day) when he was out of bed; and to a straight drainage bag (larger urine collection bag that can be hung from the bed frame) when he was in bed. Documentation by Resident 7's urologist (doctor that specializes in the urinary 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 clinical record review and staff interview, it was determined that the facility failed to identify triggers related to a resident's diagnosis of Post-Traumatic Stress Disorder, to provide culturally, competent, trauma-informed care and eliminate or mitigate re-traumatization for one of one resident reviewed. (Resident 93). Findings include: Clinical record review for Resident 93 revealed that the facility admitted her on December 8, 2023. Further review of her clinical record revealed that a diagnosis of Post-Traumatic Stress Disorder (PTSD, a mental and behavioral disorder that develops related to a terrifying event) was added to her medical diagnosis on December 13, 2023. Review of Resident 93's admission Minimum Data Set (MDS, an assessment completed by the facility at intervals to determine care needs) assessment dated [DATE], indicated PTSD was an active diagnosis for Resident 93. Clinical record review for Resident 93 on February 7, 2024, at 9:30 AM revealed that she did not have a care plan…

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 that the facility failed to ensure a resident's drug regimen was free from an unnecessary antibiotic medication for one of one resident sampled (Resident 90). Findings include: Review of a history and physical for Resident 90 dated October 17, 2023, revealed the genitourinary (a physical exam of the female internal and external urinary and reproductive system) exam was deferred (put off until a later time). Review of a nursing progress note for Resident 90 dated February 5, 2024, at 2:02 PM revealed that the physician was made aware that the resident had vaginal burning and odor. Augmentin (antibiotic to treat a bacterial infection) 875/125 milligrams was ordered to be given twice daily for seven days. Clinical record review for Resident 90 revealed that there was no related physical exam documented of the genitourinary system and that there was no details of the type of vaginal odor or signs of infection for use of an antibiotic. The antibiotic was ordered without adequate indication for its use. During an…

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 interview, it was determined that the facility failed to employ a qualified director of food and nutrition services in the absence of a full-time dietitian. Findings include: During the initial tour of the facility's main kitchen on February 6, 2024, at 9:15 AM, Employee 3, Dietary Manager, stated that she was the dietary manager, and had been in that role since November 2023. An interview with Employee 3 on February 8, 2024, at 1:06 PM revealed she was not certified; however, the facility was discussing enrolling her in certified dietary manager courses. An interview with Employee 1, Director of Clinical Operations, on February 8, 2024, at 2:25 PM revealed the facility did employ a consultant dietitian; however, the dietitian was not full time and worked remotely 24 hours a week. Employee 1 confirmed there was no evidence that Employee 3 had any qualifications of food service manager certification/degree, or a certified dietary manager credential in the absence of a full-time dietitian. 28 Pa Code 201.18(e)(1)(6) Management

Based on a review of the facility's water management program and staff interview it was determined that the facility failed to assess the building's water system for waterborne pathogen risk; and implement measures to monitor and prevent the growth of opportunistic pathogens within the facility's water system. Findings include: The CDCs (Centers for Disease Control and Prevention) current Water Management Program Toolkit, Practical Guide to Implementing Industry Standards, indicated that many buildings need a water management program to reduce the risk for Legionella (bacteria that can grow and spread in water systems and can cause a serious type of pneumonia (lung infection) known as Legionnaires' disease) growing and spreading within their water system and devices. Developing and maintaining a water management program is a multi-step process that requires continuous review. Steps to building an effective Legionella water management program include: A description of the building's water system using flow diagrams and a written description to include details like connections to the…

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

Based on review of select facility policies and procedures, clinical record review, and staff interview, it was determined that the facility failed to ensure residents' representatives received education regarding the risks and benefits of the COVID-19 vaccination; and that residents' responsible parties were given the opportunity to accept or refuse the COVID-19 vaccination for residents incapable of making medical decisions independently for two of five residents reviewed for immunization concerns (Residents 22 and 88). Findings include: The facility policy entitled, Coronavirus Disease (COVID-19) - Vaccination of Residents, revised May 2023, revealed that residents who are eligible to receive the COVID-19 vaccine are strongly encouraged to do so. COVID-19 vaccine education, documentation, and reporting are overseen by the infection preventionist and coordinated by his or her designee. Before the COVID-19 vaccine is offered, the resident is provided with education regarding the benefits, risks, and potential side effects associated with the vaccine. Information is provided to the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, review of select facility policies, and staff interview, it was determined that the facility failed to provide behavior health care that was individualized to attain or maintain the highest practical physical, mental, or psychosocial well-being for one of five residents reviewed for behaviors (Resident 1). Findings include: The current facility policy entitled Behavioral Assessment, Intervention, and Monitoring, 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. Behavior symptoms will be identified using facility-approved behavior screening tools and a comprehensive assessment. As part of the comprehensive assessment, staff will evaluate based on input from the resident, family, and caregivers, review of medical records, and general observations. The interdisciplinary team…

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 select facilities policies and procedures, and staff interview, it was determined that the facility failed to store food, prepare, and distribute food, and ensure temperature monitoring was in place to prevent the potential spread of food-borne illness in the facility's main kitchen. Findings included: The current facility policy entitled Food Preparation and Service, revealed potentially hazardous foods are cooled rapidly. This is defined as cooling from 135°F (Fahrenheit) to 70°F within two hours and then to a temperature of 41°F or below within the next 4 hours. The total cooling time between 135°F and 41°F should not exceed 6 hours. Proper hot and cold temperatures are maintained during food distribution and service. Foods that are held in the temperature danger zone are discarded after 4 hours. The temperatures of foods held in steam tables are monitored throughout the meal service by food and nutrition services staff. The current facility policy entitled Food Receiving and Storage, revealed all foods stored in the refrigerator or freezer are…

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