Kadima Rehabilitation & Nursing At Latrobe

Based on review of facility policies, manufacturer's prescribing information, facility's medications not to be crushed list, and residents' clinical records, as well as observations and staff interviews, it was determined that the facility failed to maintain a medication error rate of less than five percent. Findings include: The facility's policy regarding medication administration, dated August 13, 2025, revealed that medications were to be administered in accordance with good nursing principles and practices and in order to ensure the safe, accurate and timely administration of medications. All drugs, devices and related materials will be administered in accordance with federal and state laws and regulated.The facility's list of medications not to be crushed, revised August 13, 2025, revealed that metformin extended release (ER), Myrbetriq ER, and propranolol hydrochloride (HCL) were not be crushed.Physician's orders for Resident 32, dated January 17, 2025, included an order for the resident to receive 20 milligrams (mg) Propranolol hydrochloride (HCL) three times a day, an order…

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

Based on a review of the facility policies, the facility's list of medications that are not to be crushed, as well as observations and staff interviews, it was determined that the facility failed to label medications with the appropriate instructions for administration for one of 45 residents reviewed (Resident 32).Findings include:The facility's policy regarding medication administration, dated August 13, 2025, revealed that medications were to be administered in accordance with good nursing principles and practices and in order to ensure the safe, accurate and timely administration of medications. All drugs, devices and related materials will be administered in accordance with federal and state laws and regulated.The facility's list of medications not to be crushed, revised August 13, 2025, revealed that propranolol HCL, metformin hydrochloride (HCL) extended release (ER), and Myrbetriq ER were not be crushed.A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 32, dated February 3, 2026, 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 review of the facility's plans of correction for previous surveys, and the results of the current survey, it was determined that the facility's Quality Assurance Performance Improvement (QAPI) committee failed to correct quality deficiencies and ensure that plans to improve the delivery of care and services effectively addressed recurring deficiencies. Findings include:The facility's deficiencies and plan of corrections for an annual survey ending December 10, 2025, revealed that the facility developed plans of correction that included quality assurance systems to ensure that the facility maintained compliance with cited nursing home regulations. The results of the current survey, ending March 19, 2026, identified repeated deficiencies related to quality care, IV fluids, and labeling drugs.The facility's plan of correction for a deficiency regarding accurate MDS assessments, cited during the survey ending December 10, 2025, revealed that the facility would complete audits and report the results of the audits to the QAPI committee for review. The results of the current…

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

Based on review of clinical records, as well as staff interviews, it was determined that the facility failed to maintain accountability for controlled medications (drugs with the potential to be abused) for three of five residents reviewed (Residents 2,3,5).Findings include: The facility's policy regarding medication administration, dated May 14, 2025, indicated that nursing staff who administer medications to residents shall record and sign on the individual medication record of each resident the medication, dosage and time the medication was administered. Documentation is to be done immediately after the administration. An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 2, dated October 20, 2025, revealed that the resident was cognitively intact, required assistance for care needs, was at risk for pain related to spinal stenosis and discitis (inflammation and infection in the disc space in the spine).Physician's orders for Resident 2, dated October 20, 2025, included an order for the resident to receive…

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 clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that residents were provided with proper colostomy care for two of 33 residents reviewed (Residents 4 and 84). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 4 indicated that the resident was cognitively intact, required assistance from staff for daily care needs, had a diagnosis of paraplegia (the partial or complete paralysis of the lower half of the body, including both legs), and had an ostomy (a surgically created opening in the abdomen- part of the body between the chest and the hips). Care plan for Resident 4 dated September 11, 2025, indicated that the resident had a colostomy (opening on your abdomen that connects your colon (large intestine) to the outside of your body) and staff were to change the colostomy appliance as necessary. A nurse's note for Resident 4, dated October…

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

Based on review of facility policy and clinical records, as well as observations staff interviews, it was determined that the facility failed to provide adequate treatment and care for a peripherally inserted central catheter (PICC - a thin tube that's inserted through a vein in your arm and passed through to the larger veins near your heart) for one of 33 residents reviewed (Resident 58).Findings include:A facility policy for the care and maintenance of PICC and midline catheters (a small flexible tube inserted through a vein in your arm that is shorter than a PICC) dated May 14, 2025, indicated that registered nurses will routinely care for and maintain PICC and midline catheters. PICC's and midlines require the first dressing change 24 hours after insertion and require further dressing changes every week and as needed. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 58 dated August 8. 2025, indicated that the resident had moderate cognitive impairment, required the assistance of staff for daily care…

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 facilty policy and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that communication was shared regarding a resident's health status or changes in condition before and after dialysis for one of 33 residents reviewed that received dialysis (Resident 1). Findings include:A facility policy for Dialysis Care, dated May 14, 2025, indicated that residents ordered dialysis therapy will be monitored, and documentation will be maintained in the medical record. Medical information/record received from the dialysis provider shall be maintained as part of the facility's medical record for the residents. Should such information not be received from the dialysis provider upon return, the facility shall contact the dialysis provider to obtain such medical information. An annual Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated October 23, 2025, revealed that the resident was cognitively intact, required assistance from staff for daily care…

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 policies, as well as observations and staff interviews, it was determined that the facility failed to ensure that ice was stored under sanitary conditions for the ice machine located in the dining room. Findings include:The facility's policy for ice storage, dated May 14, 2025, revealed that the facility was to make sure there was a gap between the drain from the ice machine and the drainage pipe.Observations of the ice machine in the main dining room on November 6, 2025, at 8:42 a.m. revealed that the ice machine drain was positioned into a PVC pipe that ran to a bucket under the sink, which was to be drained by a sump pump. The opposite end of the PVC drain pipe was laying on the rim of a bucket that was full of stagnant water. There was no air gap between the ice machine drain pipe and PVC pipe or the opposite end of the PVC pipe and the bucket located under the sink. Interview with the Maintenance Director on November 6, 2025, at 8:45 a.m. confirmed that there was no air gap between the ice machine drain. He indicated that the sump pump was not functioning…

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 and personnel records, as well as staff interviews, it was determined that the facility failed to ensure that reference checks were obtained prior to hire for five of five new employees reviewed (Nurse Aides 1 and 2, Licensed Practical Nurse 3, Registered Nurse 4, Maintenance Director).Findings include:The facility's policy regarding the screening of new hires, dated May 14, 2025, indicated that new employees would be screened for hire and their complete personnel record would include documentation of verified references.The personnel file for Nurse Aide 1 revealed that she was hired on September 2, 2025, and there was no documented evidence that reference checks from previous employers were obtained prior to the staff's start date.The personnel file for Nurse Aide 2 revealed that she was hired on September 11, 2025, and there was no documented evidence that reference checks from previous employers were obtained prior to the staff's start date.The personnel file for Licensed Practical Nurse 3 revealed that she was hired on July 7, 2025, and 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record reviews and staff interviews, it was determined the facility failed to ensure that a discharge summary was completed by the physician for one out of 33 residents reviewed (Resident 100). Findings include: A review of Resident 100's clinical record revealed that the resident was admitted to the facility on [DATE].A nursing note, dated September 4, 2025, at 12:40 p.m. revealed Resident 100 was discharged from the facility to a senior living community.There was no documented evidence in the resident's clinical record at the time of the survey ending November 6, 2025, the physician completed a discharge summary upon the resident's discharge from the facility. An interview with the Assistant Director of Nursing on November 5, 2025, at 2:51 p.m. confirmed that the physician did not complete a discharge summary upon the resident's discharge from the facility.28 Pa. Code 201.29(j) Resident Rights.

Based on review of facility policy and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that physician's orders regarding medication administration were followed for one of 33 residents reviewed (Resident 78).Findings include:The facility policy for medication administration dated May 14, 2025, included that medications are administered in accordance with written orders of attending physicians, and that electronic medication administration record (E-MAR) documentation of medication orders includes pulse or blood pressure where appropriate or respiration rate. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 78, dated October 21, 2025, revealed that the resident was cognitively intact, independent with personal care needs, and had diagnoses that included Diabetes.Physician's orders for Resident 78, dated October 15, 2025, included an order for the resident to have his amlodipine (medication used to treat high blood pressure and certain types of chest pain)…

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

Based on review of facility policy and clinical records, as well as staff interviews, it was determined that the facility failed to provide medication as ordered by the physician, resulting in a significant medication error for one of 33 residents reviewed (Resident 78)Findings include:The facility policy for medication administration dated May 14, 2025, included that medications are administered in accordance with written orders of attending physicians. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 78, dated October 21, 2025, revealed that the resident was cognitively intact, independent with personal care needs, and had diagnoses that included diabetes.Hospital discharge records for Resident 78, dated July 12, 2025, included physician's orders for the resident to receive insulin aspart (a rapid acting insulin) using sliding scale coverage (an insulin dosing method where the amount of insulin administered is based on an individual's current blood sugar level) three times a day before meals; 22 units 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 review of facility policies and manufacturer's instructions, as well as observations and staff interviews, it was determined that the facility failed to label multi-dose containers of medications with the date they were opened in one of three medication rooms observed (East 1 medication room). Findings include:The facility's policy regarding medication storage, dated May 14, 2025, revealed that medications were to be stored in a safe, secure, and orderly manner in accordance with federal and state regulations, and facility policies. Manufacturer's directions for use of Aplisol (tuberculin purified protein derivative), dated March 2016, indicated that the vials in use more than 30 days should be discarded due to possible oxidation and degradation, which may affect potency.Observations of the medication refrigerator in the East 1 medication room on November 6, 2025, at 10:23 a.m. revealed three opened and undated bottles of Aplisol solution.Interview with the Assistant Director of Nursing at the time of observation confirmed that the opened bottles of Aplisol solution should…

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

Based on review of facility policy and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that the designated interdisciplinary team member obtained the required information from the contracted hospice provider for one of 33 residents reviewed (Resident 42) who were receiving hospice services.Findings include: A facility policy for Hospice Care dated May 14, 2025, indicated that all hospice assessments, plans of care, progress notes and services provided will be maintained in the medical record and integrated with the facility plan of care. Nursing staff will ensure there is a current physician ' s order, physician progress note regarding hospice care, and hospice documentation is current and available on the medical record. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 42, dated September 26, 2025, indicated that the resident was cognitively impaired, was dependent on staff for daily care needs, had diagnoses that included dementia, and was receiving…

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

Based on review of the facility's plans of correction for previous surveys, and the results of the current survey, it was determined that the facility's Quality Assurance Performance Improvement (QAPI) committee failed to maintain compliance with nursing home regulations and ensure that plans to improve the delivery of care and services effectively addressed recurring deficiencies.Findings include:The facility's deficiencies and plans of correction for a State Survey and Certification (Department of Health) survey ending May 20, 2025, and July 30, 2025, revealed that the facility developed plans of correction that included quality assurance systems to ensure that the facility maintained compliance with cited nursing home regulations. The results of the current survey, ending November 6, 2025, identified repeated deficiencies related to failure to comply with abuse policies, providing quality care, proper storage of medications, and food procurement-storing/preparing/serving food under sanitary conditions.The facility's plan of correction for a deficiency regarding abuse policies,…

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 policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to maintain professional practices that support infection prevention and control for three of 33 residents reviewed (Resident 58, 63, and 103).Findings include:A facility policy for hand hygiene/handwashing dated May 14, 2025, included that effective hand hygiene reduces the incidence of healthcare-associated infections. Handwashing may be used for routinely decontaminating hands in the following clinical situation: after removing gloves. If hands are not visibly soiled, an alcohol-based hand rub may be used for routinely decontaminating hands in the following clinical situation: after removing gloves. The use of gloves does not eliminate the need for hand hygiene. Remove gloves promptly after use, before touching non-contaminated items and environmental surfaces, and before caring for another patient. Wash hands after removing gloves. Non-surgical hand hygiene technigue includes to wet hand with running water, apply hand washing agent to hands,…

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 reviews, as well as staff interviews, it was determined that the facility failed to follow physician's orders for one of three residents reviewed (Resident 2).An admission Minimum Data Set (MDS) assessment (a mandatory assessment of a resident's abilities and care needs) for Resident 2, dated July 3, 2025, revealed that the resident was cognitively intact, needed assistance from staff for daily care needs, and had medical diagnoses that included infection of joint prothesis and diabetes mellitus. Physician's orders for Resident 2 dated, June 28, 2025, included an order for the resident to receive 15 units of Glargine (insulin for diabetes mellitus) subcutaneously (injected into the skin) at bedtime, and take as needed when blood sugar is greater than 300 mg/dl, however, a review of Resident 2's June and July 2025 Medication Administration Record revealed no documented evidence that the residents blood sugar was being monitored per physician orders. Interview with the Director of Nursing on July 30, 2025 at 1:12 p.m. confirmed that there was no documented…

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 policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that care plans were updated to reflect changes in residents' care needs for five of 36 residents reviewed (Residents 3, 17, 33, 58, 61). Findings include: The facility's policy regarding care plans, dated May 14, 2025, indicated that the resident will be reassessed at least quarterly, and the care plan will be reviewed by the interdisciplinary team. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's care needs and abilities) for Resident 3, dated February 21, 2025, indicated that the resident was cognitively intact and required assistance from staff for daily care needs. A care plan for Resident 3, dated June 14, 2024, indicated that the resident had a foley catheter (thin flexible tube inserted into the bladder to drain urine). A nurse's note for Resident 3, dated January 22, 2025, indicated that the resident's foley catheter came out and orders were received to not re-insert the foley catheter. 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 review of clinical records, as well as staff interviews, it was determined that the facility failed to ensure that residents received care and treatment in accordance with professional standards of practice, by failing to ensure that physician's orders were followed for two of 36 residents reviewed (Residents 17, 78). Findings include: An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 17, dated February 3, 2025, revealed that the resident was understood, could understand others, and had a diagnosis of included hypertension (high blood pressure). Physician's orders for Resident 17, dated March 6, 2025, included an order for staff to administer one 25 milligram (mg) tablet of Metoprolol (used alone or in combination with other medications to treat high blood pressure) two times a day, and staff was to hold the medication if the systolic blood pressure (the top number of a blood pressure reading) was less than 90 millimeters of mercury (mmHg) or if the heart rate was less than 60 beats per minute.…

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 manufacturer's instructions, observations, and staff interviews, it was determined that the facility failed to ensure that ice was stored under sanitary conditions for the ice machine next to the kitchen. Findings include: The manufacturer's instructions, undated, for the use of the ice machine in the main dining room, stated that the drain line must have a 1.5-inch drop per 5 feet of run and must not create traps and that the floor drain must be large enough to accommodate drainage from all drains. Observations of the ice machine in the main dining room on May 17, 2025, at 9:17 a.m. revealed that the ice machine drain was draining into a bath basin and that the drain pipe was lying in the stagnant water in the basin. There was a small pump pumping some of the water into the nearby sink. There was no air gap between the drain pipe and the basin. Interview with Nursing Home Administrator on May 18, 2025, at 9:52 a.m. revealed that the ice machine was removed from service until the proper drainage system with air gap could be installed. 28 Pa. Code 211.6(f)…

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 reviews and resident and staff interviews, it was determined that the facility failed to honor the resident's right to make informed choices and participate in his/her treatment for one of 36 residents reviewed (Resident 52). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 52, dated January 31, 2025, indicated that the resident was always understood, could always understand others, and was cognitively intact. A nursing note for Resident 52, dated April 29, 2025, revealed that the resident was to be discharged into the care of his brother on May 9, 2025. An interview with Resident 52 on May 17, 2025, at 10:15 a.m. revealed that the resident was looking for answers regarding his discharge plans. He stated that he thought he was supposed to go home a couple weeks ago, but that no one has talked to him to explain anything to him. He stated that his mother told him that the staff were dragging their feet about his discharge. Interview with the Nursing Home Administrator…

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 policies and employee files, as well as staff interviews, it was determined that the facility failed to ensure that license checks were obtained prior to hire for one of one registered nurse reviewed (RN 1). Findings include: The facility's policy regarding protection from abuse, dated November 1, 2024, indicated that policies and procedures were developed to aid in preventing abuse, neglect, or mistreatment of residents, and protocols for conducting employment background checks and screening of employees. The personnel file for Registered Nurse 1 revealed a start date of March 9, 2025, with a license check done on March 10, 2025. There was no documented evidence that a license check was obtained prior to the staff's start date of March 9, 2025. Interview on May 19, 2025, at 12:50 p.m. with Regional Human Resources Director revealed that Registered Nurse 1's license check should have been completed prior to her start date and it was not. 28 Pa. Code 201.14(a) Responsibility of Licensee 28 Pa. Code 201.18(e)(1) Management.

Based on a review of the Resident Assessment Instrument User's Manual and clinical records, as well as staff interviews, it was determined that the facility failed to complete accurate Minimum Data Set assessments for five of 36 residents reviewed (Residents 17, 20, 21, 25, 61). Findings include: The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which provides guidance and instructions for the completion of Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2024, indicated that the intent of Section N was to record the number of days, during the seven days of the assessment period, that any type of injection, insulin, and/or select medications were received by the resident. Section N0410F1 (Antibiotic Medications) was to be coded if an antibiotic medication was taken by the resident at any time during the seven-day look-back period; Section N0415B was to be coded yes if the resident received an anti-anxiety medication; and Section N0415I1 (Antiplatelet Medications - medications used 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.

Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to complete safety assessments for one of 36 residents reviewed who used siderails (Resident 3) and two of 36 residents reviewed (Residents 9, 25) who used an air mattress. Findings include: A facility policy for siderails dated May 14, 2025, indicated that an assessment will be made to determine the resident's symptoms or reason for using siderails. The use of siderails will be evaluated in terms of risk and benefit for each individual resident. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 3, dated February 21, 2025, indicated that the resident was cognitively intact, required assistance from staff for daily care needs, and had diagnoses that included infection of a right knee prosthesis (artificial replacement). A side rail/assist bar evaluation/assessment for Resident 3, dated March 21, 2025, indicated that the resident was being assessed for an assist bar. Section D was not…

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

Based on clinical record reviews and observations, as well as staff interviews, it was determined that the facility failed to ensure urinary output was monitored for two of 36 residents reviewed (Residents 33, 78) who had an indwelling urinary catheter. Findings include: A quarterly Minimum Data Set (MDS) assessment (a federally-mandated assessment of the resident's abilities and care needs) for Resident 33, dated February 4, 2025, revealed that the resident was cognitively impaired and had an indwelling urinary catheter (a flexible tube inserted and held in the bladder to drain urine). A care plan for Resident 33, dated November 1, 2024, revealed that the resident had an indwelling catheter related to a diagnosis of benign prostatic hyperplasia (a condition where the prostate gland becomes enlarged, which can cause urinary problems) and staff was to measure the urinary output as ordered. Physician's orders for Resident 33, dated February 19, 2025, included an order for staff to document the indwelling urinary catheter output every shift. Observation of Resident 33 on May 19, 2025,…

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

Based on observations and staff interviews, it was determined that the facility failed to ensure that the posting of their nurse staffing was current. Findings include: Observations on May 17, 2025, at 9:00 a.m. revealed that the nurse staffing information that was posted at the main entrance of the facility was dated May 15, 2025, and was not current. Interview with the Nursing Home Administrator on May 17, 2025, at 9:55 a.m. confirmed that the nurse staffing information that was posted was dated May 15, 2025, and was not the current staffing information as required. 28 Pa. Code 201.14(a) Responsibility of Licensee.

Based on review of policies, as well as observations and staff interviews, it was determined that the facility failed to ensure that a controlled drug was properly stored in one of two medication rooms reviewed (East Side Medication Room). Findings include: The facility's policy regarding storing controlled medications, dated November 1, 2024, indicated that Ativan (a controlled substance used to treat anxiety) was to be under double-lock security. The access key to controlled medications is not the same key that allows access to other medications. Observations of the East Side medication room on May 17, 2025, at 12:10 p.m. revealed one opened vial of Ativan that was not stored in a separately locked, permanently affixed container. Interview with Licensed Practical Nurse 2 on May 17, 2025, at 12:10 p.m. confirmed that there was no separately locked, permanently affixed container for the Ativan, and that it was just stored in the medication refrigerator with other non-controlled medications. Interview with Director of Nursing on May 18, 2025, at 9:58 a.m. confirmed that the vial 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 review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to maintain clinical records that were accurately documented for two of three residents reviewed (Residents 2, 3). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 32, dated May 2, 2025, revealed that the resident was confused. A nursing note for Resident 32, dated May 30, 2025, revealed that the resident was missing a part of her front tooth and a piece of the tooth next to it. She was crying, asking for a dentist, and stating that her tooth hurt. There was no indication in the Resident 32's clinical record that her pain was assessed by the nurse or that the resident was referred to the dentist. Interview with the Director of Nursing on May 20, 2025, at 1:02 p.m. revealed that the resident did see the dentist on March 31, 2025, and she provided his consult report. She stated that it should have been a part of Resident 32's clinical record. A quarterly MDS assessments 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 review of the facility's plans of correction for previous surveys, and the results of the current survey, it was determined that the facility's Quality Assurance Performance Improvement (QAPI) committee failed to correct quality deficiencies and ensure that plans to improve the delivery of care and services effectively addressed recurring deficiencies. Findings include: The facility's deficiencies and plans of corrections for an annual survey ending December 4, 2024, and a complaint survey ending January 6, 2025, revealed that the facility developed a plan of correction that included quality assurance systems to ensure that the facility maintained compliance with cited nursing home regulations. The results of the current survey, ending May 20, 2025, identified a repeated deficiency related to pharmaceutical services/accountability of narcotics. The facility's plan of correction for a deficiency regarding inaccurate MDS assessments, cited during the survey ending December 4, 2024, revealed that the facility would complete audits and report the results of the audits 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 facility policy, observations, and staff interviews, it was determined that the facility failed to provide a safe and sanitary environment in three of three soiled utility rooms. Findings include: The facility's policy for Infection Control, dated January 2, 2024, indicated that the facility is committed to preventing adverse outcomes such as health care associated infections and their related events, improving resident care by supporting the staff in all areas of the facility, minimizing occupational hazards associated with the delivery of healthcare, and fostering evidence-based decision making. The goal of the program is to provide a safe and sanitary environment. The facility's policy for the laundry process, dated January 2, 2024, indicated that proper laundry processing is done to ensure resident and facility linen items are correctly cleaned and stored. Observations of the facility's three separate utility rooms revealed that the rooms were full of soiled linen bags thrown on the floor. Interview with Laundry Attendant 1 on February 24, 2024, at 9:38 a.m.…

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

Based on observations, staff and family interviews, and review of cleaning schedules, it was determined that the facility failed to provide a clean and homelike environment in residents' rooms for five of 12 residents reviewed (Residents 6, 8, 9, 10, 11) Findings included: Observations of Resident 6's room on December 30, 2024, at 12:45 p.m. and 2:30 p.m. revealed that the resident's privacy curtain was pulled around the foot of the resident's bed. The resident's privacy curtain had multiple colored stains that extended from the bottom of the curtain and upward approximately one-quarter the way up on the privacy curtain. The privacy curtain between the resident and her roommate had a reddish-colored stain to the bottom corner of the privacy curtain. Interview with the resident at 12:45 p.m. revealed that she could not recall when her room was cleaned last. Observations of Residents 8 and 9's room on December 30, 2024, at 12:41 p.m. and 2:30 p.m. revealed multiple food debris on the floor between the residents' beds. Observations of Residents 10 and 11's room on December 30, 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 facility policy, observations, and staff interviews, it was determined that the facility failed to provide a safe and sanitary environment in three of three soiled utility rooms. Findings include: The facility's policy for Infection Control, dated January 2, 2024, indicated that the facility is committed to preventing adverse outcomes such as health care associated infections and their related events, improving resident care by supporting the staff in all areas of the facility, minimizing occupational hazards associated with the delivery of healthcare, and fostering evidence-based decision making. The goal of the program is to provide a safe and sanitary environment. The facility's policy for the laundry process, dated January 2, 2024, indicated that proper laundry processing is done to ensure resident and facility linen items are correctly cleaned and stored. Observations of the facility's three separate utility rooms revealed that the rooms were full of soiled linen bags thrown on the floor. Interview with Laundry Attendant 1 on October 22, 2024, at 9:38 a.m.…

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

Based on review of facility policies, observations, and staff interviews, it was determined that the facility failed to ensure that each resident's personal privacy was maintained. Findings include: The facility policy related to the Health Insurance Portability and Accountability Act (HIPAA- a federal law that protects the privacy and security of sensitive health information), dated January 2, 2024, included in part, that the facility will keep information regarding a resident's health private and confidential, any paper containing information will not be disposed of in a trash container that is open and easily accessible, and staff will not allow any papers, documents, or any other format with resident information unattended. Observations of the outdoor trash receptacle on October 22, 2024, at 8:30 a.m. revealed a piece of plastic on the ground beside the rear dumpster, which appeared to be a lid for a bowl or cup, that included a resident's last name and the diet orders for a pureed diet with nectar thick liquids. Interview with the Registered Dietician on October 22, 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 clinical records, as well as staff interviews, it was determined that the facility failed to ensure that physician's orders for medications and treatments were followed for three of seven residents reviewed (Residents 1, 2, 3). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated September 2, 2024, revealed that the resident was cognitively impaired, required assistance with personal care needs, and had diagnosis that included high blood pressure and seizures. Physician's orders for Resident 1, dated October 10, 2024, included orders to cleanse right shin wounds with normal saline and apply Medihoney (a wound and burn gel with antibacterial and bacterial resistant properties) and dry dressing every dayshift. A review of the Treatment Administration Record (TAR) for Resident 1, dated October 2024, revealed that there was no documented evidence that the resident received treatment to his right shin wounds per physician's orders on October 11, 2024, and October 20, 2024.…

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

Based on review of facility policy, observations, and staff interviews, it was determined that the facility failed to properly contain and dispose of garbage in one of two outside dumpsters. Findings include: Review of facility policy for garbage and rubbish disposal, dated January 2, 2024, indicated that outside dumpsters provided by the garbage pick-up services must be kept closed and free of litter around the dumpster area. Observation of the facility's outdoor trash receptacle on October 22, 2024, at 8:30 a.m. revealed that the rear dumpster was uncovered, and there was garbage on the ground around the dumpster that included two plastic bags with garbage, white plastic gloves, washcloths, paper trash, and cardboard. An interview with the Registered Dietician on October 22, 2024, at 8:50 a.m. confirmed that the lid on the rear dumpster was open and should have been closed, and that there was garbage on the ground around the dumpster. An interview with the Director of Nursing on October 22, 2024, at 10:40 a.m. confirmed that the facility failed to properly contain and dispose 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 observations and interviews with staff, it was determined that the facility failed to provide a safe, comfortable, and functional environment related to laundry services. Findings include: Interview with Laundry Worker 1 on October 22, 2024, at 9:38 a.m. revealed that she was behind on completing the laundry because one washer and one dryer was broken, and that the facility was taking clothing to the laundromat to try to keep up. A new dryer was installed three weeks ago, and a new washer was installed last week. She was unsure how long they were without one washer and one dryer. Interview with Nurse Aide 2 on October 22, 2024, at 11:34 a.m. revealed that the facility's clothes washer had been broken recently and that she has observed some residents' clothing being returned to the residents appearing moldy and stained. Interview with Resident 7 on October 22, 2024, at 1:20 p.m. revealed that sometimes the facility is without clean washcloths and that on one occasion, when she was incontinent of bowel, staff provided incontinent care using paper towels, because she was told…

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 policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that the hypoglycemic protocol was followed for one of nine residents reviewed (Resident 1), failed to ensure that physician's orders for medications were followed for one of nine residents reviewed (Resident 4), failed to schedule appointments as ordered for two of nine residents reviewed (Residents 5, 9), and failed to ensure that residents were taken to scheduled appointments for one of nine residents reviewed (Resident 9). Findings include: The facility's medication administration policy, dated January 3, 2024, indicated that medications were to be administered in accordance with written orders of the attending physicians. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated May 28, 2024, revealed that the resident was cognitively intact, received insulin (used to lower blood sugar levels), and had diagnoses that included diabetes (a disease that interferes with blood…

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

Based on clinical record reviews and staff interviews, it was determined that the facility failed to notify the resident and legal guardian in writing regarding hospitalizations for three of nine residents reviewed (Residents 1, 5, 9). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated May 28, 2024, revealed that the resident was cognitively intact, received insulin (used to lower blood sugar levels), and had diagnoses that included diabetes (a disease that interferes with blood sugar control). Review of Resident 1's clinical record indicated that Family Member 1 was her Power of Attorney. A nursing note, dated June 22, 2024, at 11:17 p.m., revealed that Licensed Practical Nurse 1 erroneously administered 25 units of insulin aspart instead of 25 units of Levemir. The resident was given eight ounces of apple juice and two cups of pudding. The resident's blood glucose was 63 milligrams per deciliter (mg/dL) and glucagon and glucose gel were ordered and administered. The resident's blood…

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

Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that medications were administered as ordered by the physician for one of nine residents reviewed (Resident 1), resulting in significant medication errors for the resident. Findings include: The facility's medication administration policy, dated January 3, 2024, indicated that medications were to be administered in accordance with written orders of the attending physicians. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated May 28, 2024, revealed that the resident was cognitively intact, received insulin (used to lower blood sugar levels), and had diagnoses that included diabetes (a disease that interferes with blood sugar control). Physician's orders for Resident 1, dated April 17, 2024, included an order for the resident to receive 12 units of Novolog (fast acting insulin) subcutaneously (injected just under the skin into the fatty layer) twice a day with lunch and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of clinical records, as well as resident and staff interviews, it was determined that the facility failed to maintain clinical records that were complete and accurately documented for two of nine residents reviewed (Residents 5, 6). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 5, dated June 3, 2024, revealed that the resident was understood, could usually understand, was cognitively impaired, and required assistance with care needs. Interview and observations of Resident 5 on August 8, 2024, at 2:35 p.m. revealed that he was self propelling in his wheelchair back to his room and he stated that he would like to transfer to another facility to be closer to his sister. Interview with Director of Social Services on August 8, 2024, at 12:31 p.m. confirmed that one facility would not accept him because he was a positive Preadmission Screening and Resident Review (PASSAR - identified as having a serious…

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 family and staff, it was determined that the facility failed to provide a safe, comfortable and functional environment related to laundry services. Findings include: Interview with Nurse Aide 1 on May 8, 2024, at 9:20 a.m. revealed that the facility's clothes dryer has been broken for at least two weeks causing a lack of available linens. The dryer was working on this day and staff were going to laundry to get washcloths as soon as they were done being laundered; however, there have been multiple times when washcloths were not available, and pillowcases were used as washcloths. Interview with Nurse Aide 2 on May 8, 2024, at 9:35 a.m. revealed that she believed the facility clothes dryer had been broken for about a month, and there were times that pillowcases were used as washcloths because clean, dry washcloths were not available for use. Nurse Aide 2 also indicated that clean and dry linens, including bed sheets, were not always available. Interview with Maintenance Worker 3 on May 8, 2024, at 12:06 p.m. revealed that the facility clothes dryer was broken…

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 policies and clinical records, as well as staff interviews, it was determined that the facility failed to complete thorough investigations to rule out abuse or neglect following two falls for one of 12 residents reviewed (Resident 3). Findings include: A facility policy for incident and accident reports, dated January 2, 2024, revealed that the facility will document all unusual occurrences and events, and falls warrant an incident report. An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 3, dated April 29, 2024, revealed that the resident was understood and could usually understand, required substantial to maximum assistance for person hygiene needs, and had a diagnosis that included alcohol dependence. Nursing notes for Resident 3, dated April 26, 2024, at 6:51 p.m. and again on April 27, 2024, at 9:15 a.m. revealed that staff entered the resident's room and observed the resident out of bed lying on the floor. There was no documented evidence that an incident report or investigation was…

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

Based on review of clinical records, as well as staff interviews, it was determined that the facility failed to follow physician's orders for two of 12 residents reviewed (Residents 11, 12) who had an indwelling urinary catheter. Findings include: The facility's policy regarding catheter care, dated January 2, 2024, indicated that catheter care will be performed with morning and evening care and as needed after incontinence or bowel movements. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 11, dated February 1, 2024, revealed that the resident understood others and was understood, was cognitively intact, required assistance from staff for personal care needs, and had in indwelling urinary catheter (a thin flexible tube that is inserted into the bladder to drain urine). A care plan for Resident 11, dated August 15, 2022, indicated that the resident had an alteration in elimination related to use of an indwelling urinary catheter. Staff were to change the catheter per the physician's order. Current…

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 and staff interviews and dietary schedules, it was determined that the facility failed to have sufficient dietary staff to perform essential kitchen duties. Findings include: An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 9, dated February 15, 2024, revealed that the resident was cognitively intact, was understood, could understand, and was independent with eating after set up. Interview with Resident 9 on March 19, 2024, at 10:52 a.m. revealed that the meals are served on styrofoam, mainly on the weekends, and he prefers to eat in his room. A dietary schedule indicated that meals were served on styrofoam on February 25, 2024, with management's permission. Interview with Dietary Staff 2 on March 19, 2024, at 12:07 p.m. revealed that meals are served on styrofoam when there is approval from management. Interview with the Dietitian on March 19, 2024, at 12:07 and 12:39 p.m. confirmed that the main entrees were served on styrofoam plates due to low staffing in the kitchen; there was not…

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

Based on review of facility policies and observations, as well as resident and staff interviews, it was determined that the facility failed to serve food items at palatable temperatures. Findings include: A facility policy regarding food temperature recordings, dated January 3, 2024, indicated that all hot food will be held at 135 Fahrenheit (F) and cold foods will be held at 41 F or below. Food will be served at a preferable temperature for the resident, as hot foods were to be served hot and cold food were served cold and in accordance with the resident preference. Observations of the lunch meal service in the main kitchen on March 19, 2024, revealed that the [NAME] Wing cart containing a test tray left the main kitchen at 12:19 p.m. and arrived on [NAME] Wing at 12:21 p.m. Trays were passed to the residents that were in their rooms. The last resident was served at 12:32 p.m. The test tray was removed from the cart at 12:33 p.m. and the temperature of the iced tea was 46 degrees F, the mixed fruit was 47 degrees F, the coffee was 144 degrees F, the peas and carrots were 131…

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 reviews, as well as observations and staff interviews, it was determined that the facility failed to provide a safe, clean and homelike environment in residents' shared shower rooms (East and West). Findings include: The facility's policy regarding Resident Environment, dated January 3, 2024, revealed that the facility will provide an environment that is safe, clean, comfortable and homelike, while allowing the residents to use their personal belongings to the extent possible. The facility's infection control policy concerning cleaning and disinfecting, dated January 3, 2024, revealed that cleaning and disinfecting of resident care items and environment will be conducted based on risk of infection involved. Staff were to clean all foreign materials such as blood, feces, dust, or dirt from a surface before disinfecting. Cleaning environmental surfaces such as floors, walls, and furniture should be done according to the schedule and as needed. Observations on March 19, 2024, at 10:17 a.m. and 2:48 p.m. in the East Hall shared shower room revealed a large area…

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 and clinical records, as well as observations and staff interviews, it was determined that the facility failed to develop and implement an ongoing infection prevention and control program in two shower rooms (East and [NAME] Hall) that are shared by residents. Findings include: The facility's infection control policy regarding cleaning and disinfecting, dated January 3, 2024, revealed that cleaning and disinfecting of resident care items and the environment will be conducted based on risk of infection involved. Staff were to remove all foreign materials such as blood, feces, dust, or dirt from surfaces before disinfecting. The cleaning of environmental surfaces, such as floors, walls, and furniture, should be done according to the schedule and as needed. Observations on March 19, 2024, at 10:17 a.m. and 2:48 p.m. in the East Hall shower room revealed a black substance on the wall above the showers near the ceiling and crown molding. Observations on March 19, 2024, at 10:21…

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 policies, clinical records, and investigation reports, as well as staff interviews, it was determined that the facility failed to ensure that one of 14 residents reviewed (Resident 4) was free from physical and verbal abuse. Findings include: The facility's abuse policy, dated January 3, 2024, revealed that each resident has the right to be free from abuse and neglect and are not to be subjected to abuse by anyone, including other residents. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 4, dated November 4, 2023, revealed that the resident was confused, did not have behaviors that put himself or others at risk for injury during the seven-day look-back period, and had diagnoses that included non-traumatic brain dysfunction, Alzheimer's, dementia, and violent behavior. The current behavior care plan for Resident 4 revealed that staff were to supervise the resident while in the hallways and redirect as needed, be direct with intrusive behavior, establish appropriate boundaries, and educate…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and staff interviews, it was determined that the facility failed to ensure essential equipment was in safe operating condition in resident bathrooms. Findings include: Observations on March 19, 2024, at 10:36 a.m. and 2:56 p.m. revealed that the shared bathroom between rooms [ROOM NUMBERS] did not have a sink and the wall and plumbing were exposed. Observations on March 19, 2024, at 2:56 p.m. revealed that the shared bathroom between rooms [ROOM NUMBERS] did not have a functioning toilet. The toilet was wrapped in a black garbage bag. Interview with the Nursing Home Administrator on March 19, 2024, at 2:56 p.m. confirmed that the bathroom between rooms [ROOM NUMBERS] did not have a sink and that it was removed sometime last week, and a new counter was ordered. She also confirmed that the bathroom between rooms [ROOM NUMBERS] did not have a functioning toilet and that the pipes needed to be fixed. The Nursing Home Administrator revealed that the Maintenance Director was on leave, and that…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, a review of clinical records, as well as staff and resident interviews, it was determined that the facility failed to maintain an effective pest control program. Findings include: Resident Council Meeting Minutes, dated December 28, 2023, revealed that the residents voiced concerns about continued gnats in the building. Observations on March 19, 2024, at 2:56 p.m. around the doorway of room [ROOM NUMBER] revealed small flying insects in the hallway. Interview with the Nursing Home Administrator on March 19, 2024, at 2:56 p.m. revealed that the pest control company has been providing services every two months; however, the only pest control records for the facility revealed service dates of February 7, 2024, and March 13, 2024. The facility was inspected and treated for pest activity by servicing fly lights and traps. There was no evidence of pest service before February 7, 2024. There was no evidence that the pest control treatments in February and March 2024 were effective in keeping the…

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

Based on clinical record reviews and interviews with residents and staff, it was determined that the facility failed to ensure that residents were provided with showers as scheduled for one of four residents reviewed (Resident 1). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident R1, dated July 16, 2023, indicated that the resident was alert and oriented, was independent with ADL's, and required supervision for bathing. Resident 1 was scheduled to have showers on Tuesdays and Fridays during the afternoon shift. A medication administration note for behaviors, dated October 4, 2023, revealed that Resident 1 refused a shower and stated that he would get one later on his own. Resident 1 frequently said he would get a shower later and then he did not. Resident 1 was noted with an odor due to refusing to bath or change his clothes, his hair and clothes were dirty, and his fingernails were long and dirty as he continued to refuse to perform any hygiene tasks or allow staff to assist. Review of the…

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

Based on review facility policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to use proper infection control practices for handling linen while providing care for two of six residents reviewed (Residents 5, 6). Findings include: The facility's infection control policy concerning handling of linen, dated October 26, 2023, revealed that staff is to handle soiled linen using standard precautions, such as wearing gloves, and to not place soiled linen on floor or furniture. An annual Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 5, dated July 12, 2023, revealed that the resident was cognitively intact and required extensive assistance for daily care needs. Observations on November 8, 2023, at 9:09 a.m. revealed that Nurse Aide 1 exited the room of Resident 5 carrying soiled laundry with her bare hands and placed them in the dirty linen bin in the hallway. Interview with Nurse Aide 1 on November 8, 2023, at 9:10 a.m. confirmed that she should wear gloves…

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 reviews and resident and staff interviews, it was determined that the facility failed to provide adequate, ongoing activities designed to meet the needs of residents for three of nine residents reviewed (Residents 7, 8, 9). Findings include: An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 7, dated May 17, 2023, indicated that he was alert and oriented and that it was very important to him to do things with groups of people and to do his favorite activites. Interview with Resident 7 on September 25, 2023, at 12:08 p.m. indicated that he really enjoyed activites, but they no longer have them every day and that he likes doing things instead of staring at the four walls every day. A quarterly MDS assessment for Resident 8, dated August 16, 2023, indicated that she was alert and oriented and required supervison for her care needs. The plan of care for Resident 8, dated June 22, 2023, indicated that she had a need for socialization and that she was to safely assist activity staff with…

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

Based on review of policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to monitor and record a resident's fluid intake for one of nine residents reviewed (Resident 4). Findings include: The facility's policy regarding measuring and recording intake, dated April 21, 2023, revealed that staff were to ensure that residents receive sufficient intake to maintain hydration and health, identify risk factors and/or clinical conditions in a resident that could lead to dehydration, and develop a plan of care to prevent dehydration from occurring. Physician's orders for Resident 4, dated February 6, 2023, included an order to offer 120 milliliters (ml) of fluids per shift. A quarterly MDS assessment for Resident 4, dated August 23, 2023, indicated that the resident had cognitive impairment, required extensive assistance from staff for daily care needs, and required extensive assist for eating. Resident 4's care plan, dated January 26, 2023, indicated that staff were to encourage greater than 50 percent fluid and food…

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 clinical records, as well as staff interviews, it was determined that the facility failed to accommodate a resident's preference for a shower for one of nine residents reviewed (Resident 1). Findings include: A quarterly admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated August 29, 2023, revealed that the resident was cognitively intact and required extensive assistance for daily care needs. The facility's current shower schedule revealed that Resident 1 was to receive showers on the 2:00 p.m. to 10:00 p.m. shift every Monday and Thursday. Review of Resident 1 's bathing records for July, August and September 2023 revealed that the resident preferred to receive a shower and was scheduled to receive her shower on Mondays and Thursdays during the evening (2:00 p.m. to 10:00 p.m.) shift. Documentation for Monday, July 17, 2023; Monday, July 24, 2023; Thursday, July 27, 2023; Monday, July 31, 2023; Thursday, August 3, 2023; Monday, August 14, 2023; Monday, August 28, 2023; Thursday,…

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 policies and agency employee files, as well as staff interviews, it was determined that the facility failed to ensure that licensure checks were obtained prior to hire for one of three agency employee files reviewed (Licensed Practical Nurse 1). Findings include: The facility policy for License and Registration of Nursing Personnel, dated April 21, 2023, indicated that the licensure/certification will be verified with the state Board of Nursing or Nurse Aide Registry. The employee file for Licensed Practical Nurse 1 indicated that she had an orientation checklist dated August 14, 2023. The facility indicated that her first scheduled work day was October 28, 2022. There was no documented evidence that the facily had a licensure check completed until September 25, 2023. Interview with Facility Scheduler 2 on September 25, 2023, at 4:04 p.m. confirmed there was no record of a licensure check prior to Licensed Practical Nurse 1's first day of work at the facility. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(e)(1) Management.