Lebanon Skilled Nursing And Rehabilitation Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff interview, it was determined that the facility failed to assess residents with a diagnosis of post-traumatic stress disorder (PTSD) and develop and implement an individualized person-centered care plan to render trauma informed care for one of 31 sampled residents. (Resident 1)Findings include: Clinical record review revealed that Resident 1 was admitted to the facility on [DATE] , 2026, with diagnoses that included PTSD, depression, polyneuropathy (nerve damage), and insomnia. Review of the Minimum Data Set assessment dated [DATE], revealed that the resident had no cognitive impairment, required substantial assistance from staff for activities of daily living, and had a diagnosis of PTSD. There was no documentation to support that the resident was assessed for symptoms or triggers related to the diagnosis of PTSD. The care plan for Resident 1 did not include any measures to address the resident's history of trauma or identify triggers. There were no specific…

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

Based on clinical record review and staff interview, it was determined that the facility failed to ensure that the physician acknowledged the pharmacist's recommendations for two of 31 sampled residents. (Residents 6 and 12)Findings include: Clinical record review revealed that on March 20, 2026, the consultant pharmacist made recommendations regarding Resident 6's medication regimen. There was no documented evidence regarding the recommendation or that the attending physician had acknowledged or acted upon this recommendation. Clinical record review revealed that on October 20, 2025, and February 26, 2026, the consultant pharmacist made recommendations regarding Resident 12's medication regimen. There was no documented evidence regarding the recommendations or that the attending physician had acknowledged or acted upon these recommendations. In an interview on April 17, 2026, at 10:22 a.m., the Director of Nursing confirmed that there was no documented evidence that the medication review recommendations for Residents 6 and 12 were addressed by the physician. 28 Pa. Code…

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 employee personnel and education records and staff interview, it was determined that the facility failed to ensure that each nurse aide received 12 hours of in-service training annually, including training for dementia management, resident abuse prevention, and identified performance weaknesses for two of two nurse aides reviewed (NA 1 and NA 2).Findings include:Review of NA 1's personnel record revealed that the facility hired them on August 28, 2023.Review of facility training records dated April 17, 2025, to April 17, 2026, revealed that NA 1 completed only 31 minutes of in-service education in infection control and respirator use. Review of Employee NA 2's personnel record revealed that the facility hired them on December 19, 2023.Review of facility training records dated April 17, 2025, to April 17, 2026, revealed that NA 2 completed only 3 hours and 48 minutes of in-service education in safe resident handling, mechanical lift use, elopement prevention, and ethics. In an interview on April 17, 2026, at 12:59 p.m., the Director of Nursing and the Nursing…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, facility documentation review, and staff interview, it was determined that the facility failed to report an alleged violation of potential neglect for one of six sampled residents. (Resident 1)Findings include: Review of the facility policy entitled, Abuse Prohibitions, last reviewed February 24, 2025, revealed that the facility prohibited abuse, mistreatment, neglect, and exploitation, for all residents. The facility was to implement abuse prohibition through the following, to include reporting of incidents, investigations, and the facility's response to the results of their investigations immediately upon receiving information concerning a report of suspected neglect or abuse. The designee was to report the allegations involving neglect to the appropriate state and local authorities. Clinical record review revealed that Resident 1 had diagnoses that included chronic respiratory failure with hypoxia, heart failure, and venous insufficiency (leg veins become damaged or weak…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, review of facility documentation, and staff interview, it was determined that the facility failed to implement a comprehensive care plan that addressed individual resident needs as identified in the comprehensive assessment for one of six sampled residents. (Resident 1)Findings include: Clinical record review revealed that Resident 1 had diagnoses that included chronic respiratory failure with hypoxia, heart failure, and venous insufficiency (leg veins become damaged or weak preventing efficient blood return to the heart). The Minimum Data Set assessment dated [DATE], indicated that the resident was able to communicate her needs clearly and was dependent for activities of daily living (ADL), including bed mobility, transfers, and toileting. A review of the care plan revealed that the resident had an ADL self-care deficit and was dependent for ADL care in bed mobility, transfers, locomotion, and toileting related to limited mobility and interventions included assistance of two 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 resident interview, review of facility documentation, and results of a test tray audit, it was determined that the facility failed to provide food and beverages that were at an appetizing temperature on one of five nursing units. ([NAME] unit) Findings include: In an interview on May 27, 2028, at 10:43 a.m., Resident 1 stated that he had a hard time getting coffee that was not cold. Review of facility documentation entitled, Food and Nutrition Services Test Tray Evaluation, revealed that the coffee should be greater than 140 degrees Fahrenheit (F) at point of service to the resident. Results of a test tray audit conducted on May 27, 2025, at 12:27 p.m., after the last resident meal tray was served from the dining cart, revealed the coffee at a temperature of 128 degrees F. The previously mentioned beverage was noted to be below 140 degrees F. 28 Pa. Code 201.14(a) Responsibility of licensee.

Based on facility policy review, observation, and staff interview, it was determined that the facility failed to store food in a sanitary manner in the dietary department. Findings include: Review of the facility policy entitled, Food Handling, dated February 24, 2025, revealed that staff were to label food items with the date prepared or opened and then discard after seven days after opening an item or three days after a food was prepared. Observations during the kitchen tour on March 23, 2025, at 9:30 a.m., revealed the following: In the walk-in cooler, there was an opened bag of shredded mozzarella that was dated March 10, 2025, and a pan of ham salad that was dated March 9, 2025. There was a pan of egg salad, a bag of lettuce, and a pan of raw pork cubes that were not dated. In the freezer, there was an opened bag of 20 sausage patties that was not dated. In an interview on March 23, 2025, at 11:00 a.m., the Dietary Manager confirmed that the previously mentioned items should have been dated and were not and the expired items should have been removed. CFR 483.60(i) Food Safety…

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

Based on a review of facility policy, review of facility documentation, and staff interview, it was determined that the facility failed to perform infection surveillance in accordance with facility policy. Findings include: Review of the facility policy entitled, Infection Control Outcome and Process Surveillance and Reporting, last reviewed February 24, 2025, revealed that the Infection Preventionist would conduct regular surveillance related to infections. During the review of the facility infection control program on March 26, 2025, there was no documented evidence of any infection surveillance since January 2025. In an interview on March 26, 2025, at 10:54 a.m., the Director of Nursing confirmed that infection surveillance should be done monthly and was not done per facility policy since January 2025. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on staff interview, it was determined that the facility failed to employ a full-time qualified dietary services manager in the absence of a full-time qualified dietitian. Findings include: During an interview on March 23, 2025, at 10:30 a.m., the Dietary Manager stated the facility did not employ a certified dietary manager. In an interview conducted on March 25, 2025, at 12:05 p.m., the Administrator confirmed that there was not a full-time dietitian employed onsite at the facility and that the facility did not employ a qualified certified dietary manager in the absence of a full-time dietitian. 28 Pa. Code 201.18(b)(3) Management.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, observation, and resident and staff interviews, it was determined that the facility failed to ensure that a call bell was answered in a timely manner for one of 29 sampled residents. (Resident 16) In addition, the facility failed to provide services to enhance each resident's quality of life by offering showers as scheduled to one of 29 sampled residents. (Resident 47) Findings include: Clinical record review revealed that Resident 16 had diagnoses that included chronic obstructive pulmonary disease, diabetes mellitus, and chronic pain. The Minimum Data Set (MDS) assessment dated [DATE], revealed that the resident had no cognitive impairment, required assistance from staff with transfers and mobility, and was able to make his needs known. Review of Resident 16's care plan revealed that staff were to provide assistance with transfers and toileting. Observation on March 24, 2025, at 10:23 a.m., revealed the resident was observed out of bed sitting in the wheelchair with the 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, and resident and staff interview, it was determined that the facility failed to ensure that a resident received care from staff as she preferred in order to attend activities of her choice for one of 29 sampled residents. (Resident 4) Findings include: In an interview on March 24, 2025, at 10:40 a.m., Resident 4 expressed a concern that she was not able to attend her preferred morning group activites last Monday and Tuesday due to the staff not getting her up and ready in time to go to the activities held in the morning. She was concerned because staff had not helped her to get up and ready until after 11:00 a.m She further stated that she had told staff that she preferred to be up out of bed and dressed for breakfast and morning activites by 7:00 a.m She stated that did not like to miss the activities and interacting with her peers. Clinical record review revealed that Resident 4 had diagnoses that included congestive heart failure and osteoarthritis of the knee. The Minimum…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff interview, it was determined that the facility failed to develop a comprehensive care plan that addressed individual resident needs as identified in the comprehensive assessment for two of 29 sampled residents. (Residents 51 and 141) Findings include: Clinical record review revealed that Resident 51 was admitted to the facility on [DATE], and had diagnoses that included dementia. The Minimum Data Set (MDS) Care Area Assessment summary dated December 11, 2024, noted that the resident's cognitive decline/dementia was to be addressed in the care plan. There was no evidence that interventions to address Resident 51's cognitive decline/dementia were included in the current care plan. Clinical record review revealed that Resident 141 had diagnoses that included a deep tissue injury on her right heel. Review of the MDS assessment dated [DATE], indicated that the resident had an injury on her foot. The MDS Care Assessment Area dated March 6, 2025, noted that the resident's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and resident and staff interview, it was determined that the facility failed to provide a restorative ambulation program as recommended by physical therapy for one of one sampled resident who was recommended for a restorative ambulation program. (Resident 94) Findings include: Clinical record review revealed that Resident 94 had diagnoses that included chronic obstructive pulmonary disease, stroke, and abnormal gait and mobility. The Minimum Data Set assessment dated [DATE], indicated that the resident was alert and oriented and had limited range of motion on one side of her upper and lower extremities. A review of the care plan revealed that the resident required assistance with activities of daily living related to having impaired balance. On February 19, 2025, there was an intervention for staff to implement and deliver restorative nursing programs as indicated which included ambulation with a walker. Review of an physical therapy Discharge summary dated [DATE], revealed 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 facility policy review, clinical record review, observation, and resident and staff interviews, it was determined that the facility failed to implement physician's orders for five of 29 sampled residents. (Residents 37, 51, 119, 141, 355) In addition, the facility failed to obtain a physician order for a compression stocking and a compression wrap for one of one sampled resident. (Resident 355) Findings include: Review of the policy entitled, Medication Administration, last reviewed February 24, 2025, revealed that staff were to administer medications in accordance with the written orders of the physician. Vital signs were to be entered into the Medication Administration Record (MAR) as indicated. Clinical record review revealed that Resident 37 was admitted on [DATE], and had diagnoses that included heart failure. On February 2, 2025, a physician ordered that staff obtain a daily weight for the resident. A review of Resident 37's record revealed that there was no documented evidence to support a weight…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and observation, it was determined that the facility failed to implement interventions to prevent further decline and/or improve range of motion for one of five sampled residents at risk for limited range of motion. (Resident 101) Findings include: Clinical record review revealed that Resident 101 had diagnoses that included dementia, a right knee contracture, and muscle weakness. Review of the Minimum Data Set assessment dated [DATE], revealed that the resident had cognitive impairment and was dependent on staff for personal hygiene and dressing. On June 1, 2023, the physician ordered for staff to apply a splint to Resident 101's right lower extremity in the morning. Review of the care plan revealed that the resident was at risk for loss of range of motion related to contractures with an intervention for staff to apply the right lower extremity splint in the morning. Observations on March 23, 2025, at 11:50 a.m., and 1:50 p.m., March 24, 2025, at 9:09 a.m., and 10:49 a.m., 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 facility policy review, clinical record review, and staff interview, it was determined that the facility failed to ensure that adequate catheter care was provided for one of two sampled residents with an indwelling urinary catheter. (Resident 44) In addition, the facility failed to assess bladder incontinence and provide services to restore bladder function as much as possible for one of two sampled residents at risk for bladder function loss. (Resident 144) Findings include: Review of the facility policy entitled, Catheter: Indwelling Urinary - Care of, last reviewed February 24, 2025, revealed that staff would perform catheter care twice a day and as needed and document the care provided. Clinical record review revealed that Resident 44 had diagnoses that included dementia and urinary retention. On September 5, 2024, the physician ordered for the resident to have an indwelling catheter every shift. Observations on March 23, 2025, revealed Resident 44 in his wheelchair with his indwelling catheter 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 a review of facility policy and observation, it was determined that the facility failed to ensure that medications/biologicals were securely stored in a medication or treatment cart on one of six nursing units. ([NAME] nursing unit) Findings include: Review of the facility policy entitled Medication Storage, last reviewed February 24, 2025, revealed that the medication supply shall be accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medication and that medication rooms, cabinets and supplies should remain locked when not in use or attended by persons with authorized access. Observations on March 24, 2025, on the [NAME] nursing unit, from 10:30 a.m. through 11:35 a.m., revealed the medication cart in the hallway with two tubes of medicated creams (Permetherin) on top, unattended and accessible to anyone in the vicinity. Observations from 11:55 a.m. through 12:28 p.m., revealed the treatment cart, with medicated creams (lidocaine), wound…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and observation, it was determined that the facility failed to ensure that residents were served preferred food items on their meal trays for three of 29 residents. (Residents 94, 96 and 118) Findings include: Clinical record review revealed that Resident 94 had diagnoses that included diabetes and depression. The Minimum Data Set (MDS) assessment dated [DATE], indicated that the resident was alert and oriented. A review of a care plan revealed that the resident was at risk for altered nutrition due to her medical diagnoses. There was an intervention for staff to honor her food preferences within her meal plan. In an interview on March 23, 2025, at 12:25 p.m., Resident 94 stated that she often did not get certain preferred food and drink items that were listed on her tray card. At that time, she was served her lunch in her room. Review of the tray card revealed that she was to receive pickles with her sandwich. She did not receive pickles as listed on her tray card. Observation on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy review, clinical record review, and staff interview, it was determined that the facility failed to consistently implement an antibiotic stewardship program and maintain a system to effectively monitor antibiotic usage for one of two residents receiving antibiotics. (Resident 355) Findings include: Review of the facility policy entitled, Antibiotic Stewardship, last reviewed February 24, 2025, revealed that medical providers were to document antibiotic orders containing dose, duration, and indication for use. Front-line nursing staff (RNs and LPNs) were to perform a time-out on all antibiotics when a resident was admitted to the center. The Consultant Pharmacist during the monthly medication regimen review would review antibiotic courses for appropriateness of administration and/or indication and monitor provider compliance with proper documentation of antibiotic orders-dose, duration, and indication. The Infection Preventionist would track antibiotic starts through the use of line…

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 facility policy review, clinical record review, and staff interview, it was determined that the facility failed to offer pneumococcal disease vaccines in accordance with facility policy to five of 29 residents whose vaccines were reviewed. (Residents 41, 51, 56, 80, 137) Findings include: Review of the facility policy entitled, Pneumococcal Vaccination, last reviewed February 24, 2025, revealed that upon admission, the facility would assess each resident to determine if they had been previously vaccinated for pneumococcal disease and offer the vaccine if the resident had not received it. Staff were to document education, including benefit of vaccination, and whether resident received the vaccination or declined in the electronic medical record. Clinical record review revealed that Resident 41 was admitted to the facility on [DATE]. There was no documented evidence that the facility offered a pneumococcal disease vaccine or determined if the resident had received it prior to admission. Clinical record…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and policy review, it was determined that the facility failed to ensure that the baseline care plan summary was provided to the resident or representative for three of six sampled residents. (Residents 2, 3, 4) Findings include: Review of the facility's policy entitled, Person-Centered Care Plan, dated January 25, 2024, revealed that a baseline plan of care was to be developed within 48 hours of admission. The baseline care plan was to include healthcare information necessary to properly care for a resident and must include initial goals based on admission orders, physician orders, dietary orders, therapy orders, social services, and pre-admission screening resident review, if applicable. The baseline care plan was to be updated as needed to meet the resident's needs until the comprehensive care plan was developed. The resident and/or representative were to be provided a written summary of the baseline care plan. Clinical record review revealed that Resident 2 was admitted to the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff interview, it was determined that the facility failed to review the care plan within seven days after the completion of the comprehensive assessment for three of six sampled residents. (Residents 1, 5, 6) Findings include: Clinical record review revealed that Resident 1 was admitted on [DATE], and had diagnoses that included spinal stenosis (abnormal narrowing of the spinal canal), heart failure, and diabetes. The Quarterly Minimum Data Set (MDS) assessment was completed on November 3, 2024. There was a lack of documentation to support that the facility had conducted an interdisciplinary care plan meeting to review the care plan. Clinical record review revealed that Resident 5 was admitted on [DATE], and had diagnoses that included heart failure and diabetes. The Quarterly MDS assessment was completed on November 20, 2024. There was a lack of documentation to support that the facility had conducted an interdisciplinary care plan meeting to review the care plan. Clinical…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff interview, it was determined that the facility failed to ensure that physician's order were implemented for one of six sampled residents. (Resident 1) Findings include: Clinical record review revealed that Resident 1 had diagnoses that included spinal stenosis (abnormal narrowing of the spinal canal), heart failure, and diabetes. A physician's order dated December 4, 2024, directed staff to administer morphine ER (pain medication) twice a day. Nursing documentation dated December 5, 2024, revealed the pharmacy did not have morphine available. On December 9, 2024, the physician ordered oxycodone HCl ER (a medication for severe pain) every 12 hours-discontinue when morphine ER arrives, as a temporary replacement for morphine. Review of Resident 1's Medication Administration Record revealed that staff did not administer the oxycodone HCl ER on [DATE], at 9:00 p.m. In addition, upon receiving the morphine ER on [DATE], staff did not discontinue the oxycodone HCl ER. In 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy review, clinical record review, observation and interview, it was determined that the facility failed to provide care and services in a manner respectful of each resident's dignity and preferences to promote the quality of life for one of five sampled residents. (Resident 1) Findings include: Review of the facility policy entitled, Safe Resident Handling Program, last reviewed July 25, 2024, revealed that the facility was to maintain a safe care environment for residents. Clinical record review revealed that Resident 1 was admitted to the facility with diagnoses that included congestive heart failure. On November 14, 2023, Resident 1 was admitted to hospice care. Review of the Minimum Data Set assessment dated [DATE], revealed that the resident was not cognitively impaired and required staff assistance for bed mobility. Review of the nursing notes revealed that on July 30, 2024, the hospice nurse and the resident requested a draw sheet placed beneath her for repositioning in bed due 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 facility policy review, clinical record review, and staff interview, it was determined that the facility failed to thoroughly investigate injuries of unknown origin for one of five sampled residents. (Resident 1) Findings include: Review of the facility policy entitled, Abuse Prohibition, last reviewed July 25, 2024, revealed that injuries of unknown origin would be investigated to determine if abuse or neglect was suspected. Clinical record review revealed that Resident 1 had diagnoses that included congestive heart failure and depression. The Minimum Data Set assessment dated [DATE], indicated that the resident was not cognitively impaired and needed staff assistance for bed mobility. On August 16, 2024, a nurse noted that the resident had a bruise on top of her right forearm that measured 5 centimeters (cm) long by 5 cm wide. Review of the facility incident investigation revealed that a 5 cm by 5 cm bruise was observed on top of the resident's right forearm just above her wrist. Further 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the Resident Assessment Instrument (RAI) User's Manual, clinical record review, and staff interview, it was determined that the facility failed to complete Minimum Data Set (MDS) assessments in a timely manner for seven of 29 sampled residents. (Residents 5, 27, 46, 90, 105, 115, and 135) Findings include: Review of the Long-Term Care Facility RAI (federally mandated assessment tool), dated October 2023, User's Manual which provided instructions and guidelines for completing required MDS assessments, revealed that significant change in status assessments, quarterly assessments, and admission assessments were to be completed no later than 14 days after the Assessment Reference Date (ARD) which refers to the last day of the assessment observation period. Clinical record review on April 10, 2024, revealed that Resident 5 had a Quarterly MDS assessment dated [DATE], that was still in progress and had not yet been completed as per the time requirements. Clinical record review on April 10, 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 facility policy review, clinical record review, and staff interview, it was determined that the facility failed to ensure physician's orders were implemented for five of 29 sampled residents. (Residents 27, 34, 44, 63, 76) Findings include: Review of the facility policy entitled, General Dose Preparation and Medication Administration, last reviewed March 28, 2024, revealed staff were to obtain vital signs if necessary, and document necessary medication administration information. Clinical record review revealed that Resident 27 had diagnoses that included hypertension and congestive heart failure. On July 15, 2023, a physician ordered staff to administer medication (amlodipine besylate) one time a day for hypertension (high blood pressure). Staff were not to administer the medication if the residents's systolic blood pressure (SBP, the measurement of blood pressure when the heart beats and the pressure is at its highest) was less than 100 millimeters of mercury (mm Hg). Review of Resident 27's March and April 2024 medication administration records (MARs) revealed that staff…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, facility policy review, and staff interview, it was determined that the facility failed to store food in a sanitary manner on two of three resident nourishment rooms. ([NAME] and [NAME]) Findings include: Review of the facility policy entitled, Food Brought in for Residents, dated March 28, 2024, revealed that foods stored in the refrigerator must be labeled with the resident's name and date the food was brought in and were to be discarded by staff after three days. Observation of the [NAME] resident nourishment room on April 11, 2024, at 10:55 a.m., revealed, in the freezer, there were three napkins and an opened gelato container not labeled or dated. In the refrigerator drawer, there was a container of opened sour cream with a use-by date of May 2, 2023. There was a package of opened cheese slices, a soda cup, an opened water bottle, a sandwich, a container of soup, a container of pasta, and an opened package of red grapes that were not labeled or dated. There were two containers of rice…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff interview, it was determined that the facility failed to complete an accurate Minimum Data Set (MDS) assessment for three of 29 sampled residents. (Residents 28, 63, 90) Findings include: Clinical record review revealed that section P of the MDS assessment dated [DATE], indicated that Resident 28 used a chair that prevents rising less than daily during the seven-day review period. Review of Resident 28's clinical record revealed that Resident 28 was not ordered and did not use a chair that prevents rising during the seven-day review period, as inaccurately identified on the MDS assessment. Clinical record review revealed that Resident 63 had fallen in her room on December 31, 2023. The MDS assessment dated [DATE], inaccurately reflected that Resident 63 did not fall since the prior assessment dated [DATE]. Clinical record review revealed that Resident 90 had diagnoses that included Alzheimer's, dysphagia, and protein-calorie malnutrition. On June 6, 2022, the physician…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff interview, it was determined that the facility failed to develop a care plan and interventions to meet each residents' needs as identified in the comprehensive assessment for one of 29 sampled residents. (Resident 1) Findings include: Clinical record review revealed that Resident 1 had diagnoses that included stroke, seizures, and kidney failure. Review of the Minimum Data Set (MDS) assessment dated [DATE], revealed that the resident required assistance with activities of daily living for self-care and/or mobility activities and was on an antidepressant medication (citalopram). The Care Area Assessment for this MDS triggered functional ability and psychotropic drug use as problem areas requiring a care plan. Resident 1's current care plan did not include interventions to address functional ability and psychotropic drug use. In an interview on April 12, 2024, at 12:10 p.m., the Director of Nursing confirmed that there was no care plan developed to address Resident 1'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 a review of facility policy observation, and resident and staff interviews, it was determined that the facility failed to provide nursing services consistent with professional standards of quality as defined by the PA Code Title 49, Professional and Vocational Standards for one of 29 sampled residents. (Resident 145) Findings include: Review of the facility policy entitled, Central Vascular Access Device Dressing Change, dated March 28, 2024, revealed that staff was to perform sterile dressing changes using standard aseptic non-touch technique (ANTT) at least weekly. Clinical record review revealed that Resident 145 had diagnoses of anemia, osteomyelitis (bone infection), and post-traumatic stress disorder (PTSD). In an interview on April 9, 2024, Resident 145 stated that staff had not changed the peripherally inserted central catheter (PICC) dressing in almost two weeks. Observations on April 9, 2024, at 1:36 p.m., through April 11, 2024, at 9:45 a.m., revealed Resident 145 with a right upper arm PICC with the dressing dated March 29, 2024. Title 49, Professional 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 facility policy review, clinical record review, and staff interview, it was determined that the facility failed to assess and document the status of wounds for three of seven sampled residents with wounds. (Residents 17, 46, 145) Findings include: Review of the facility policy entitled, Skin Integrity and Wound Management, last reviewed March 28, 2024, revealed that staff was to evaluate and document wound status weekly. Clinical record review revealed that Resident 17 was admitted to the facility on [DATE], with diagnoses that included chronic kidney disease. Review of the nursing notes and current care plan revealed that the resident was being treated for multiple wounds of the pubis and right lower quadrant (abdomen). Review of Resident 17's skin and wound evaluation records revealed that there was no documented evidence that staff assessed the resident's wounds after March 6, 2024. Clinical record review revealed that Resident 46 was admitted to the facility on [DATE], with diagnoses that included…

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

Based on clinical record review, observation, and resident and staff interview, it was determined that the facility failed to develop and implement an individualized person-centered plan to render trauma-informed care to a resident with a diagnosis of post-traumatic stress disorder (PTSD) for one of 29 sampled residents. (Resident 145) Findings include: Clinical record review revealed that Resident 145 had diagnoses that included anemia, osteomyelitis, and PTSD. On March 21, 2024, a physician noted that the resident had a diagnosis of PTSD, was recommended for an increase in sertraline (an antidepressant that can be used to treat PTSD), and was seen by a psychiatrist at the VA (Veterans Affairs). In an interview on April 9, 2024, at 1:07 p.m., Resident 145 reported daily thoughts about traumatic experiences in Vietnam, which had a continued negative affect. Observation on April 10, 2024, at 10:50 a.m., revealed that Resident 145 was physically shaking, hearing noises, and hallucinating. Resident 145 stated it was a flashback from Vietnam. There was no assessment completed or 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 clinical record review and staff interview, it was determined that the facility failed to ensure that the physician acknowledged the pharmacist's recommendations for two of 29 sampled residents. (Residents 63, 115) Findings include: Clinical record review revealed that on March 4, 2024, the consultant pharmacist made recommendations regarding Resident 63's medication regimen. There was no documented evidence regarding the recommendations or that the attending physician had acknowledged or acted upon these recommendations. Clinical record review revealed that on December 20, 2023, and March 5, 2024, the consultant pharmacist recommended that the physician consider decreasing Resident 115's psychotropic medications. There was no documentation that the attending physician had acknowledged or acted upon these recommendations. In an interview on April 12, 2024, at 12:15 p.m., the Administrator confirmed that the medication review recommendations were not addressed by the physician. 28 Pa. Code 201.18(e)(1)(3)(4) Management. 28 Pa. Code 211.12(d)(3)(5) Nursing services.

Based on clinical record review and staff interview, it was determined that the facility failed to ensure that each resident was offered medication as prescribed by the physician for three of six sampled residents. (Residents 1, 2, 4) Findings include: Clinical record review revealed that Resident 1 had diagnoses that included major depressive disorder, enlarged prostate, and stroke. On December 8, 2023, the physician ordered staff to administer amitriptyline, clopidogrel bisulfate, pravastatin sodium, tamsulosin, famotidine, and sodium bicarbonate daily. Review of the Medication Administration Record (MAR) for December 2023, revealed that the medications were not administered to the resident on December 9, 2023. Review of the MAR for January and February 2024, revealed that amitriptyline was not administered on January 10 and 27, 2024, and February 13, 2024. The tamsulosin was not administered on January 27, 2024. Review of nursing documentation revealed that the medications had not been delivered from the pharmacy. Clinical record review revealed that Resident 2 had diagnoses 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.