Loyalhanna Care Center

Based on review of policies and clinical records, as well as resident and staff interviews, it was determined that the facility failed to ensure that a resident who was incontinent of bowel received appropriate treatment and services to restore as much normal bowel function as possible for one of 35 residents reviewed (Resident 3), and failed to ensure that physician's orders for an indwelling urinary catheter were followed for one of 35 residents reviewed (Resident 4).Findings include: The facility's policy regarding bowel and bladder management and training, dated January 1, 2026, indicated that the purpose of the policy was to promote continence, maintain resident dignity, prevent complications (skin breakdown, urinary tract infections, constipation, fecal impaction), and meet regulatory requirements through individualized bowel and bladder assessments, training, and management. The bowel training program is a planned bowel evacuation schedule utilizing diet, fluids, activity, positioning, and medications as needed. Bowel assessments were to be completed on admission, quarterly,…

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 March 20, 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 April 2, 2026, identified repeated deficiencies related to care plan creation, care plan revisions, quality care, pharmaceutical services, food in a form to meet an individuals needs, and infection control.The facility's plan of correction for a deficiency regarding care plan creation, cited during the survey ending March 20, 2025, revealed that the facility would complete audits and report…

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 ensure that proper infection control practices were followed while providing medications for one of 35 residents reviewed (Resident 67).Findings include:The facility's policy regarding medication administration, dated January 1, 2026, indicated that staff were to remove the medication from the source, taking care not to touch the medication with their bare hand. Observations during medication administration on April 1, 2026, at 8:08 a.m. revealed that Registered Nurse 2 prepared to administer medications to Resident 67 and took out pills from the medicine cup with her bare hands and placed them in a bag to be crushed. She then administered the medications to Resident 67. Interview with Registered Nurse 2 on March 11, 2025, at 8:10 a.m. confirmed that she should not have touched the medication with her bare hands. Interview with the Director of Nursing on April 1, 2026, at 3:04 p.m. confirmed that staff were not to touch residents' 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 review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that physician's orders for medications were followed for three of 36 residents reviewed (Residents 1, 21, 75). Findings include: The facility's policy regarding medication administration, dated January 13, 2025, revealed that medications shall be administered in a safe and timely manner, and as prescribed. Vital signs must be checked/verified for each resident prior to administering medications. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated February 18, 2025, revealed that the resident was cognitively intact, required substantial assistance to dependent with care needs, received insulin, and had a diagnosis of diabetes. Physician's order for Resident 1, dated December 20, 2024, included an order for the resident to receive 16 units of Humalog insulin subcutaneously (medication administered into the subcutaneous fat under the skin) one time a day at 11:30…

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 clinical records, as well as staff interviews, it was determined that the facility failed to flush a peripherally-inserted central catheter (PICC- catheter inserted in a vein used to deliver fluids and/or medications) and a midline catheter (a type of peripheral catheter inserted into a large vein in the upper arm used to deliver fluids and/or medications) prior to and/or after medication administration for two of 36 residents reviewed (Residents 1, 283). Findings include: The facility's policy regarding intravenous therapy (administration of fluids and/or medications directly into a person's vein), dated January 13, 2025, included to attach a 5 milliliter (ml) syringe of normal saline and confirm patency of vascular access device as per protocol prior to medication administration. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated February 18, 2025, revealed that the resident was cognitively intact, required substantial assistance to dependent with care needs,…

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, as well as observations and staff interviews, it was determined that the facility failed to label insulin with the date it was opened, failed to discard an expired insulin pen in one of two medication carts reviewed (North Hall), and failed to provide a separately-locked, permanently-affixed compartment in the refrigerator for the storage of controlled drugs (medications that can be abused). Findings include: The facility's policy regarding medication labeling and storage, dated January 13, 2025, indicated that when the original seal of a manufacturer's container or vial are initially broken, the container or vial will be dated. The nurse shall place a date opened sticker on the medication and enter the date opened and the new expiration date. The expiration date of the vial or container will be 30 days unless the manufacturer recommends another date or regulations/guidelines require different dating. The nurse will check the expiration date of each medication before administering it. All expired medications will be removed from the active…

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 clinical records, as well as staff and resident interviews, it was determined that the facility failed to honor a resident's right regarding diet consistency for one of 36 residents reviewed (Resident 8). Findings include: A facility policy regarding Promoting/Maintaining Resident Self-Determination/Resident Right to Refuse, dated January 13, 2025, indicated that it is the practice of the facility to protect and promote resident rights by facilitating resident self-determination through support of resident choice. The facility will ensure that each resident has the opportunity to exercise his/her autonomy regarding those things that are important in his/her life such as interests and preferences. Each resident has the right to make choices about aspects of his or her life in the facility that are significant to the resident. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 8, dated February 5, 2025, revealed that the resident was cognitively intact, was understood 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 review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to develop and implement an individualized care plan for three of 36 residents reviewed (Resident's 12, 21, 75). Findings include: The facility's policy regarding care plans, dated January 13, 2025, indicated that the facility will develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs and all services that are identified in the resident's comprehensive assessment and meet professional standards of quality. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 12, dated February 26, 2025, revealed that the resident was cognitively intact, required assistance with care needs, received an anticoagulant (blood thinner), and had a diagnoses that included a history of thrombosis (formation of a blood clot inside a…

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

Based on review of facility policies and clinical records, a well as staff interviews, it was determined that the facility failed to ensure that a resident's care plan was updated/revised to reflect the resident's specific care needs for one of 36 residents reviewed (Resident 46). Findings include: The facility's policy regarding care plans, dated January 13, 2025, indicated that the comprehensive care plan would be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS assessment. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 46, dated February 26, 2025, indicated that the resident was moderately cognitively impaired, required staff assistance with care, and had a colostomy (an artificial opening in the bowel). Physician's orders, dated January 28, 2025, included orders for the resident to have a colostomy bag and wafer every shift. The resident's current care plan indicated that the resident had a colostomy and also had a history of placing silverware into her…

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 Pennsylvania's Nursing Practice Act, facility policies, clinical records, and facility investigation documents, as well as staff interviews, it was determined that the facility failed to clarify physician's orders for one of 36 residents reviewed (Resident 17) and failed to ensure that a licensed registered nurse followed professional standards regarding the administration of medications for one of 36 residents reviewed (Resident 75). Findings include: The Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing 21.11 (a)(1)(2)(4) indicated that the registered nurse was responsible for assessing human responses and plans, implementing nursing care, analyzing/comparing data with the norm in determining care needs, and carrying out nursing care actions that promote, maintain and restore the well-being of individuals. The facility's medication administration policy, dated January 13, 2025, revealed that medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by 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 facility policies, clinical record reviews, and staff interviews, it was determined that the facility failed to ensure that gastrostomy tube care was provided as ordered by the physician for one of 36 residents reviewed (Resident 17). The facility's policy regarding gastrostomy tubes (a tube inserted through the belly that delivers nutrition directly to the stomach), dated January 13, 2025, revealed that the facility would ensure that gastrostomy flushes were provided as ordered by the physician. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 17, dated December 12, 2024, indicated that the resident was cognitively impaired, did not speak, was totally dependent on staff for daily care needs, had a gastrostomy tube, and had diagnoses that included anoxic brain injury (due to a lack of oxygen to the brain). Physician's orders for Resident 17, dated June 21, 2024, included orders for the resident to have her gastrostomy tube flushed every four hours with 130 mL (milliliters) of free water. 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 review of facility policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to clarify a resident's continuous oxygen order when not in use for one of 36 residents reviewed (Resident 1). Findings include: The facility's policy regarding oxygen therapy, dated January 13, 2025, indicated that oxygen is administered to residents who need it, consistent with professional standards of practice, the comprehensive person-centered care plans, and the resident's goals and preferences. Staff shall document the initial and ongoing assessment of the resident's condition warranting oxygen and the response to oxygen therapy. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated February 18, 2025, revealed that the resident was cognitively intact, required substantial assistance with care needs, received oxygen therapy, and had a diagnosis of congestive heart failure (the heart can not pump blood well enough to meet the body's needs). Physician's…

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

Based on review of facility policies and 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 one of 36 residents reviewed (Resident 6). Findings include: The facility's policy regarding medication administration, dated January 13, 2025, indicated that staff were to sign the Medication Administration Record (MAR) after administering medications to residents. An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 6, dated January 27, 2025, revealed that the resident had moderate cognitive impairment, had frequent pain, received pain medication as needed, and received an opioid (a controlled pain medication). Physician's orders, dated February 17, 2025, included an order for the resident to receive 50 milligrams (mg) of Tramadol (narcotic pain reliever) every six hours as needed for moderate pain. A controlled drug accountability record for February and March 2025 revealed that 50 mg…

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 clinical records, as well as staff interviews, it was determined that the facility failed to ensure that the physician responded timely to a pharmacy recommendation for four of 36 residents reviewed (Residents 2, 23, 66, 68). Findings include: The facility's policy regarding medication regimen review, dated January 13, 2025, revealed that the consultant pharmacist was to perform a comprehensive review of each resident's medication regimen and clinical record at least monthly. The medication regimen review (MRR) included evaluating the resident's response to medication therapy to determine that the resident maintains the highest practical level of functioning and preventing or minimizing adverse consequences related to medication therapy. Recommendations were to be acted upon and documented by the facility staff and/or the prescriber. The prescriber was to accept and act upon suggestions or rejected and provided an explanation for disagreeing. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities 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 review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that residents were free from unnecessary psychotropic medications, by failing to ensure that non-pharmacological (non-medication) behavioral interventions (individualized, non-pharmacological approaches to care), were attempted prior to the administration of as needed antianxiety medications for one of 36 residents reviewed (Resident 66). Findings include: The facility's policy regarding psychotropic medications (any medication that affects brain activities associated with mental processes and behavior), dated January 13, 2025, indicated that non-pharmacological approaches must be attempted, unless clinically contraindicated, to minimize the need for psychotropic medications, use the lowest possible dose, or discontinue the medications. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 66, dated January 21, 2025, revealed that the resident was cognitively impaired,…

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 obtain laboratory studies as ordered by the physician for one of 36 residents reviewed (Resident 53). Findings include: The facility's policy regarding laboratory specimens, dated January 13, 2025, revealed that the facility would provide or obtain laboratory services when ordered by a physician, physician assistant, nurse practitioner, or clinical nurse specialist in accordance with state law. The facility would provide or obtain laboratory services to meet the needs of its residents. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 53, dated December 18, 2024, revealed that the resident was cognitively intact, received dialysis services, received an anticonvulsant medication, and had diagnoses that included seizures and kidney failure. Physician's orders for Resident 53, dated September 5, 2021, included an order for staff to obtain a complete blood count with differential (CBC 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 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 a State Survey and Certification (Department of Health) survey ending April 11, 2024, as well as a complaint visit on May 22, 2024, 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 20, 2025, identified repeated deficiencies related to a failure to develop care plans, care plan timing and revision, services provided to meet professional standards, to follow physician's orders, gastrostomy tube maintenance, oxygen therapy, preventing issues with the accountability 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 established infection control guidelines, facility policy, and residents' clinical records, as well as observations and staff interviews, it was determined that the facility failed to follow infection control guidelines from the Centers for Medicare/Medicaid Services (CMS) and the Centers for Disease Control (CDC) to reduce the spread of infections and prevent cross-contamination for three of 36 residents reviewed (Residents 6, 75, 283). Findings include: CDC guidance on isolation precautions and Implementation of Personal Protective Equipment (PPE) use in Nursing Homes to Prevent Spread of Multidrug-Resistant Organisms (MDRO's - bacteria that have become resistant to certain antibiotics, and these antibiotics can no longer be used to control or kill the bacteria), dated July 12, 2022, indicates that MDRO transmission is common in skilled nursing facilities, contributing to substantial resident morbidity and mortality and increased healthcare costs. Enhanced Barrier Precautions (EBP) are an infection control intervention designed to reduce transmission 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 clinical records reviews and staff interviews, it was determined that the facility failed to follow physician's orders related to bowel medications for one of six residents reviewed (Resident 2). Findings include: An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 2, dated December 23, 2025, revealed that the resident was understood, could understand others, was cognitively intact, and was occasionally incontinent of bowel. Physician's orders for Resident 2, dated December 19, 2024, included orders for the resident to receive 30 milliliters (mL) of Milk of Magnesia (an oral laxative) as needed for constipation if no bowel movement by the third day. If the Milk of Magnesia (MOM) was not effective then one Bisacodyl suppository (a laxative inserted rectally) was to be administered as needed for constipation. If there were no results from the MOM or suppository, then one Fleets enema (a liquid inserted rectally to stimulate a bowel movement) was to be administered as needed for constipation. Resident 2'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 facility policies and residents' clinical records, as well as staff interviews, it was determined that the facility failed to ensure that the residents maintained acceptable parameters for nutritional status by failing to ensure timely notification of the dietician and physician about significant weight losses for two of six residents reviewed (Residents 1, 2), resulting in a delay in treatment for Resident 2, and failing to ensure timely notification of the physician about a decline in hydration consumption for one of six residents reviewed (Resident 2). Findings include: The facility's policy regarding weight assessment and intervention, dated January 13, 2025, indicated that if any resident had a weight change of five percent or more since the last weight, they would have the weight re-taken the next day for confirmation. If the weight was verified, nursing would immediately notify the dietitian/designee. The physician and the multidisciplinary team will identify conditions and medications that may be causing anorexia (an eating disorder that involves severe…

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, as well observations and staff interviews, it was determined that the facility failed to maintain an environment free of potential safety hazards related to the facility's hot water temperatures and failed to monitor temperatures weekly as per policy. Findings include: A facility policy for safe water temperatures, dated January 13, 2025, indicated that water temperatures will be set to a temperature of no more than 110 degrees Fahrenheit (F) or the state's allowable maximum water temperature. Maintenance staff will check water heater temperature controls and temperatures of tap water in all hot water circuits weekly and as needed. Documentation of testing will be maintained for three years and kept in the maintenance office. Observations of Maintenance Worker 1 checking water temperatures in the sink in resident room [ROOM NUMBER] on February 12, 2025, at 11:11 a.m. revealed that the water temperature was 125 degrees F. Observations of Maintenance Worker 1 checking water…

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 that residents had a clean and homelike environment on the South and North halls of the facility. Findings include: Observations on January 22, 2024, at 9:11 a.m. revealed that the floors in the hallway on the south side of the building contained what appeared to be scattered dirt/debris and three moderate size clumps of brown dust entering into Corridor B, and black marking, reported to be floor glue, in various locations on the vinyl flooring in the hallway. Varying amounts of dust and debris were noted on the carpeting in corridor A. Wallpaper on Corridor A on the South hall was noted to be peeling from the wall and had tape attempting to hold it in place, as well as peeling wallpaper above the kiosk in the hallway that had a brown, clumpy substance noted on the wall. rooms [ROOM NUMBER] had transition strips in the doorways that had pieces missing from them. The shower in the North hall had a pink substance noted…

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 and resident interviews, it was determined that the facility failed to ensure that residents were provided with showers/baths as scheduled for one of four residents reviewed (Resident 2). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 2, dated November 5, 2024, revealed that the resident was cognitively intact, required assistance from staff for showers, and had diagnoses that included dementia. Resident 2's bathing record, dated December 2024 and January 2025, revealed that the resident was to receive a shower every Sunday and Wednesday evening; however, there was no documented evidence that the resident was offered or refused a shower during the six days between December 4, 2024, and December 11, 2024; the 11 days between December 11, 2024, and December 23, 2024; the eight days between December 23, 2024, and January 1, 2025; the six days between January 1, 2025, and January 8, 2025; the six days between January 8, 2025 and January 15,…

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, Resident Council meeting minutes, and grievance records, as well as staff interviews, it was determined that the facility failed to make ongoing efforts to resolve grievances for the residents. The deficiency is being cited as past non-compliance. Findings include: The facility's policy regarding grievances, dated October 28, 2024, indicated that the facility would support each resident's right to voice grievances; to ensure that after receiving a complaint/grievance, the facility would take any immediate actions needed to prevent further potential violations of any resident rights; and would make prompt efforts to resolve grievances. The Grievance Official would take steps to resolve the grievance, and record information about the grievance, and those actions, on the grievance form, and would keep the resident appropriately apprised of the progress towards resolution of the grievances. Resident Council meeting minutes, dated September 11, October 16, and November 5, 2024, revealed that the residents reported staff were slow with answering call…

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 information provided by the facility, as well as observations and staff interviews, it was determined that the facility failed to serve food items at appetizing temperatures. Findings include: The facility's policy regarding taste and temperature control, dated October 28, 2024, revealed that the temperatures of all food items will be taken and properly recorded prior to service of each meal. All hot food items must be cooked to appropriate internal temperatures, held and served at a temperature of at least 135 degrees Fahrenheit (F). All cold food items must be stored and served at a temperature of 41 degrees F or below. Observations of the lunch meal service in the main kitchen on December 6, 2024, revealed that the second North unit cart containing a test tray left the main kitchen at 12:19 p.m. and arrived on North unit at 12:20 p.m. Trays were passed to the residents that were in their rooms 12:21 p.m. and the last resident was served at 12:29 p.m. The test tray was removed from the cart at 12:30 p.m. and the temperature of the iced tea…

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 provide a clean, comfortable, and homelike environment for three of four residents reviewed (Residents 1, 2, 3). Findings include: The facility's safe and homelike policy, dated April 10, 2024, revealed that the facility will provide a safe, clean, comfortable and homelike environment including comfortable and safe temperature level meaning that the ambient temperature should be in a relatively narrow range that minimizes residents' susceptibility to loss of body heat and risk of hypothermia/hyperthermia and is comfortable for the residents. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated August 21, 2024, revealed that the resident was cognitively intact and required assistance with daily care needs. Interview with Resident 1 on October 23, 2024, at 10:30 a.m. revealed that her shower days are Monday and Friday afternoons. Resident 1 stated that during her showers the water temperature decreases to 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 review of facility policies, as well as observations and staff interviews, it was determined that the facility failed to provide a clean and homelike environment in residents' rooms for 10 of 14 residents reviewed (Residents 4, 5, 7, 8, 9, 10, 11, 12, 13, 14). Findings include: The facility's policy regarding daily room cleaning of resident rooms, dated April 10, 2024, indicated that the purpose was to provide a safe, clean, and sanitary living environment for the residents. Dust mopping must be completed daily to reduce the amount of dust built-up in corners and along the edges of the room. Use a metal scraper to remove any build-up on the floors, with a focus on the corners/edges and front transition. Each housekeeper is responsible for inspecting their rooms at a minimum of three times each day. During the inspection the housekeeper is looking for overflowing trash, spills, and trash on the floor. Anything identified during the inspections must be addressed immediately. Observations of Resident 7's room on July 25, 2024, at 9:26 a.m., 11:17 a.m., and 1:55 p.m. revealed…

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

Based on review of facility policies and clinical records, as well as interviews with staff, it was determined that the facility failed to ensure that residents were provided with showers as scheduled for two of 14 residents reviewed (Residents 2, 5). Findings include: A facility policy for resident showers, dated April 10, 2024, indicated that residents will be provided showers as per request or as per facility schedule protocols and based on resident safety. An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 2, dated June 20, 2024, revealed that the resident was understood and able to understand others, required set up and clean up assistance from staff for showering, and had diagnoses that included dementia. Review of Resident 2's care plan, dated June 15, 2023, indicated that the resident had a self-care performance deficit and required assistance with care from staff as needed and that the resident preferred showers in the morning. Resident 2's bathing record revealed that the resident was to get a 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of policies, clinical records, and investigation documents, as well as staff interviews, it was determined that the facility failed to ensure that residents were free from neglect for one of six residents reviewed (Resident 1) and failed to ensure that residents were free from neglect caused by a failure to administer medications as ordered by the physician for three of six residents reviewed (Residents 2, 3, 4). Findings include: The facility's abuse policy, dated January 1, 2024, indicated that each resident had the right to be free from abuse, neglect, misappropriation of resident property, corporal punishment, and involuntary seclusion. A significant change Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated March 21, 2024, indicated that the resident was severly cognitively impaired, required the extensive assistance of staff with all her care needs, had diagnoses that included dementia, and had an indwelling urinary…

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 Pennsylvania's Nursing Practice Act, job descriptions, and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that a registered nurse administered medications as ordered by the physician for three of six residents reviewed (Residents 2, 3, 4). Findings include: The Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.11 (a)(1)(2)(4) indicated that the registered nurse was to collect complete and ongoing data to determine nursing care needs, analyze the health status of individuals and compare the data with the norm when determining nursing care needs, and carry out nursing care actions that promote, maintain and restore the well-being of individuals. The facility's registered nurse job description signed by Registered Nurse 4 on May 1, 2024, indicated that the registered nurse was to supervise the day-to-day nursing activities of the facility during the tour of duty. The supervision was to be 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility investigations and clinical records, as well as staff interviews, it was determined that the facility failed to administer medications as ordered by the physician for three of six residents reviewed (Residents 2, 3, 4). Findings include: A witness statement from Licensed Practical Nurse 1, dated May 11, 2024, revealed that she was in the North nurses' station getting report when she overheard Resident 2 verbalize concerns of not receiving her nighttime medications to Registered Nurse 2. Resident 2 stated that her roommate got hers. After the report Licensed Practical Nurse 1 checked the cart and all of the medication packs for p.m. administration were out and not overlooked. The computer showed that p.m. medications were checked off. Then Registered Nurse 2 walked towards the nurses' station and stated that Resident 3 and Resident 4 stated that they were still waiting for their night medications. Licensed Practical Nurse 1 then went to tell the supervisor. They looked for the back…

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 staff interviews, it was determined that the facility failed to ensure that clinical records were complete and accurately documented for three of six residents reviewed (Residents 2, 3, 4). Findings include: A witness statement from Licensed Practical Nurse 1, dated May 11, 2024, revealed that she was in the North nurses' station getting report when she overheard Resident 2 verbalize concerns of not receiving her nighttime medications to Registered Nurse 2. Resident 2 stated that her roommate got hers. After the report Licensed Practical Nurse 1 checked the cart, and all of the medication packs for p.m. administration were out and not overlooked. The computer showed that p.m. medications were checked off. Then Registered Nurse 2 walked towards the nurses' station and stated that Resident 3 and Resident 4 stated that they were still waiting for their night medications. Licensed Practical Nurse 1 then went to tell the supervisor. They looked for the back hall empty…

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 clinical records, as well as staff interviews, it was determined that the facility failed to develop and implement comprehensive care plans that included specific and individualized interventions to address specific care needs for one of 29 residents reviewed (Resident 61). Findings include: The facility's policy regarding care plans, dated January 1, 2024, indicated that resident care plans were to be developed, reviewed and revised, as necessary, when residents experience a status change. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 61, dated February 2, 2024, revealed that the resident was understood, could usually understand, was cognitively intact, was dependent on staff for care needs, and was administered opioid medication. Physician's orders for Resident 61, dated March 29, 2023, included orders for the resident to receive an x-ray of the left knee due to increased pain. The findings of that x-ray concluded that the resident had moderate to severe…

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 a resident's care plan was updated/revised to reflect the resident's specific care needs for one of 29 residents reviewed (Resident 11). Findings include: The facility's policy regarding care plan development and revision, dated January 1, 2024, indicated that resident care plans are reviewed and revised, as necessary, when residents experience a status change. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 11, dated February 2, 2024, indicated that the resident was cognitively intact, was independent with most care needs, and was occasionally incontinent of urine. Physician's orders for Resident 11, dated March 19, 2024, revealed that the resident was to receive Keflex (an antibiotic) 500 milligrams (mg) two times a day for a urinary tract infection (infection involving any part of the urinary system including the kidney, ureters, bladder, and urethra). Nurse'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 facility policies, Pennsylvania's Nursing Practice Act, and clinical records, as well as staff interviews, it was determined that the facility failed to clarify a physician's order for one of 29 residents reviewed (Resident 51). Findings include: The facility's policy for hemodialysis (treatment to remove extra fluid and waste from the blood when the kidneys are not able to), dated January 1, 2024, revealed that the facility will ensure that each resident receives care and services for the provision of hemodialysis consistent with professional standards of practice. The Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.11 (a)(1)(2)(4) indicated that the registered nurse was to collect complete and ongoing data to determine nursing care needs, analyze the health status of individuals and compare the data with the norm when determining nursing care needs, and carry out nursing care actions that promote, maintain and restore the well-being of individuals. An admission Minimum Data Set (MDS) assessment (a mandated…

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 provide suprapubic urinary catheter care as ordered by the physician for one of 29 residents reviewed (Resident 1). Findings include: The facility's policy regarding indwelling urinary catheters, dated January 1, 2024, revealed that physician orders would be followed regarding the size, need for and frequency of catheter changes. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated February 13, 2024, revealed that the resident was cognitively intact, required extensive assistance with most daily care needs, had an indwelling supra pubic catheter (a thin tube inserted into the bladder to allow urine drainage), received hospice services, and had diagnosis of multiple sclerosis. Physician's orders for Resident 1, dated February 10, 2024, included orders for the resident to have a 16 French catheter with a 30 ml (milliliter) balloon (an inflatable balloon that helps keep the catheter inside 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 facility policies, clinical record reviews, and staff interviews, it was determined that the facility failed to ensure that gastrostomy tube care was provided as ordered by the physician for one of 29 residents reviewed (Resident 60). The facility's policy regarding gastrostomy tubes (a tube inserted through the belly that delivers nutrition directly to the stomach), dated January 1, 2024, revealed that the facility would ensure that gastrostomy flushes were provided as ordered by the physician. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 60, dated March 2, 2024, indicated that the resident was cognitively impaired, does not speak, was totally dependent on two staff for daily care needs, had a gastrostomy tube, and had diagnoses that included anoxic brain injury (due to a lack of oxygen to the brain). Physician's orders for Resident 60, dated January 15, 2024, included orders for the resident to have her gastrostomy tube flushed every four hours with 190 mL (milliliters) of free water. 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 review of facility policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to provide oxygen therapy as ordered for one of 29 residents reviewed (Resident 51). Findings include: The facility's policy for oxygen administration, dated January 1, 2024, revealed that oxygen therapy will be administered under orders of a physician and staff will document the initial and ongoing assessment of the resident's condition warranting oxygen and the response to oxygen therapy. Staff shall notify the physician of any changes in the resident's condition, including changes in vital signs, oxygen concentrations, or any complications related to use of oxygen. An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 51, dated February 4, 2024, indicated that the resident was cognitively intact, required assistance from staff with daily care needs, used supplemental oxygen, and had diagnoses including cardiomyopathy (a disease that affects the heart muscle that…

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

Based on review of facility policy and personnel files, as well as staff interviews, it was determined that the facility failed to verify registry verification prior to allowing individuals to work as a nurse aide for two of three newly hired nurse aides reviewed (Nurse Aides 3, 4). Findings include: The facility's abuse policy, dated January 1, 2024, revealed that the facility would verify registry with the Pennsylvania Nurse Aide Registry prior to hire for all nurse aides. The personnel file for Nurse Aide 3 revealed that she was hired by the facility on February 14, 2024. However, there was no documented evidence that the facility verified the nurse aide's standing with the state nurse aide registry until April 10, 2024. The personnel file for Nurse Aide 4 revealed that she was hired by the facility on January 18, 2024. However, there was no documented evidence that the facility verified the nurse aide's standing with the state nurse aide registry until April 10, 2024. Interview with the Nursing Home Administrator on April 11, 2024, at 1:04 p.m. confirmed that Nurse Aides 3 and 4…

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 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 two of 29 residents reviewed (Residents 51, 61). Findings include: The facility's policy regarding medication administration, dated January 1, 2024, indicated that the nurse would sign the Medication Administration Record (MAR) after the medications are administered. An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 51, dated February 4, 2024, indicated that the resident was cognitively intact, required assistance from staff with daily care needs, had pain that was rated 8 on a pain scale of 0-10 (a common measurement of pain intensity with 0 being no pain and 10 being the worst pain possible), and received opioid pain medication on a routine and as needed basis for pain management. Physician's order for Resident 51, dated January 29, 2024, included an order for the resident 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policies, as well as observations and staff interviews, it was determined that the facility failed to properly maintain the freezers in two of two medication rooms (North and South), and failed to discard expired medical supplies in one of two medication rooms (South). Findings include: The facility's policy regarding medication storage, dated [DATE], revealed that the facility would ensure that all medications and equipment stored in the medication rooms would be maintained and stored to ensure proper sanitation, temperature, moisture control, and function. Observations in the North medication room refrigerator/freezer on [DATE], at 9:03 am. revealed that there was a large build up of ice on the roof of the freezer that was dripping water onto the bags containing medications that were stored in the refrigerator. An interview with Registered Nurse Supervisor 2 and the Assistant Director of Nursing on [DATE], at 9:36 a.m. confirmed that the freezer should not have a large build up 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 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 a State Survey and Certification (Department of Health) survey ending May 3, 2023, as well as complaint visits on July 14, 2023, and January 26, 2024, 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 April 12, 2024, identified repeated deficiencies related to a failure to care plan timing and revision, services provided to meet professional standards, gastrostomy tube maintenance, and label/store drugs and biologicals. The facility's plan of correction for a deficiency regarding…

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 ensure that staff followed proper infection control practices during wound care for one of 29 residents reviewed (Resident 22). Findings include: The facility's policy regarding hand washing and hand hygiene, dated January 1, 2024, indicated to use alcohol-based hand rub containing at least 60 to 95 percent alcohol or soap and water when indicated with accepted standards of practice. The use of gloves does not replace hand hygiene. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 22, dated January 25, 2024, revealed that the resident was cognitively impaired, was dependent on staff for all daily care, and had a pressure ulcer (wound caused by pressure) that was present on admission to the facility. The resident's current care plan indicated that she was at risk for skin break down related to immobility and had a Stage III (full thickness wound) pressure ulcer 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 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 safety for your loved one, dated January 1, 2024, indicated that foods should be stored at appropriate temperatures to maintain safety. Cold foods should be kept at 41 degrees Fahrenheit (F) or less and hot foods should be held at 135 degrees F or higher. Observations of the lunch meal service in the main kitchen on March 21, 2024, revealed that the South 200 Hall cart containing a test tray left the main kitchen at 12:06 p.m. and arrived on South 200 Hall at 12:07 p.m. Trays were passed to the residents that were in their rooms. The last resident was served at 12:22 p.m. The test tray was removed from the cart at 12:23 p.m. and the temperature of the chocolate milk was 48.1 degrees F, the ice cream was 17 degrees F, the hot tea was 102 degrees F, the mixed vegetables were 121 degrees F, beef and noodles with Stroganoff gravy were 113 degrees F. 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 policies, clinical records, and the facility's investigation documents, as well as staff interviews, it was determined that the facility failed to ensure that the residents' environment remained as free from accident hazards as possible and failed to develop and implement interventions to prevent falls for one of five residents reviewed (Resident 1). Findings include: The facility's policy for managing falls and fall risk, dated January 1, 2024, indicated that nursing staff in conjunction with the attending physician, consultant pharmacist, therapy staff, and others will seek to identify and document risk factors for falls and establish a resident-centered falls prevention plan based on relevant assessment information. An admission Minimum Data Set (MDS) assessment (a federally-mandated assessment of the resident's abilities and care needs) for Resident 1, dated January 29, 2024, indicated that the resident was cognitively intact, required assistance from staff with daily care tasks, including transfers and ambulation, had a history of falls, and had diagnosis…

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 ensure that care-planned interventions for advanced directives were consistently implemented for one of six residents reviewed (Resident 3). Findings include: The facility's policy regarding Do Not Resuscitate orders, dated January 1, 2024, indicated that the interdisciplinary care planning team would review advance directives with the resident during quarterly care planning sessions to determine if the resident wishes to make changes. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 3, dated November 13, 2023, indicated that the resident was usually understood, could sometimes understand, was severely cognitively impaired, required extensive assistance with bathing, and was dependent on staff for transfers and toileting. An advance directive care plan for Resident 3, dated December 28, 2021, indicated that the resident had a code status of do not resuscitate (DNR) 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 review of Pennsylvania's Nursing Practice Act, facility policies, and residents' clinical records, as well as staff interviews, it was determined that the facility failed to ensure that treatments performed were documented by the nurse who performed the treatment for one of six residents reviewed (Resident 4). Findings include: The Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.18. Standards of nursing conduct (a)(5)(8) indicated that the registered nurse was to document and maintain accurate records. Not to falsify or knowingly make incorrect entries into the patient's record or other related documents. The Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.148. Standards of nursing conduct (a)(5)(8) indicated that the licensed practical nurse was to document and maintain accurate records. Not to falsify or knowingly make incorrect entries into the patient's record or other related documents. The facility's policy regarding charting and documentation, dated January 1, 2023,…

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 staff interviews, it was determined that the facility failed to ensure that residents' clinical records were complete and accurately documented for one of six residents reviewed (Resident 2). Findings include: The facility's policy regarding charting and documentation, dated January 1, 2023, indicated that the following information was to be documented in the resident medical record: Objective observations, changes in a resident's condition, treatments and services performed, and events, incidents, or accidents involving the resident. An admission summary note, dated January 15, 2024, indicated that Resident 2 was admitted on [DATE]. The resident was alert and oriented to person, place and time. A social service note for Resident 2, dated January 18, 2024, indicated that the facility received a call late at night regarding the resident sitting on a bed pan for four hours. Resident 2 told staff she was put on the bed pan but was not removed…

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.