Greenwood Center For Rehabilitation And Nursing

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff interview, it was determined that the facility failed to identify triggers related to a resident's diagnosis of Post-Traumatic Stress Disorder, to provide culturally, competent, trauma-informed care, and to eliminate or mitigate re-traumatization for one of six residents reviewed for mood/behavior (Resident 4). Findings include: Clinical record review for Resident 4 revealed the facility admitted him on June 2, 2025. A diagnosis of Post Traumatic Stress Disorder (PTSD, a mental and behavioral disorder that develops related to a terrifying event) was added to his diagnosis list on July 11, 2025. A review of Resident 4's quarterly Minimum Data Set (MDS, an assessment completed by the facility at specific intervals to determine care needs) assessment dated [DATE], indicated a diagnosis of PTSD for Resident 4. Review of Resident 4's care plan identified that he had a diagnosis of PTSD. There were no identified triggers (everyday situations that cause a person to…

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

Based on clinical record review and staff interview, it was determined that the facility failed to develop and implement an individualized person-centered care plan to address dementia and cognitive loss displayed by one of three residents reviewed (Residents 4). Findings include: Clinical record review for Resident 4 revealed the facility admitted him on June 2, 2025. A diagnosis of Dementia (loss of memory, language, problem-solving, and other thinking abilities that interfere with daily life) was added to his diagnosis list on June 26,2025. A review of Resident 4's quarterly Minimum Data Set Assessment (MDS, a form completed at specific intervals to determine care needs) dated, October 18, 2025, indicated that Resident 4 had a diagnosis dementia. A review of Resident 4's care plan revealed that the facility failed to develop a person center care plan with individualized interventions related to his diagnosis of dementia. An Interview with the Director of Nursing on January 8, 2026, at 11:39 AM confirmed that the facility failed to develop a person-centered care plan related 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 observation and staff interview, it was determined that the facility failed to ensure a medication error rate below five percent (100 Nursing Unit; Residents 21 and 46).Findings include: The facility's medication error rate was eight percent based on 25 medication opportunities with two medication errors. Review of Resident 46's current physician orders dated [DATE], indicated staff were to administer Centrum Silver Oral Tablet (multiple vitamin with minerals); give one tablet by mouth daily. Observation of Resident 46's medication administration pass on [DATE], at 9:12 AM revealed that Employee 1, licensed practical nurse, prepared the medications prior to administration. This preparation included a Senior Tab Multivitamin (house stock substituted for the Centrum Silver oral tablet per Employee 1). Employee 1 proceeded to administer the medication to Resident 46. Upon review, it was determined that the Senior Tab Multivitamin had expired in [DATE]. Review of Resident 21's current physician orders…

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

Based on clinical record review, and resident and staff interview, it was determined that the facility failed to obtain dental services for one of nine residents reviewed for dental concerns (Resident 122).Findings include: Interview with Resident 122 on November 5, 2026, at 2:10 PM revealed that she was concerned about her teeth chipping and breaking. Concurrent observations of the resident's teeth revealed multiple teeth that appeared chipped and broken. Clinical record review revealed that Resident 122 had last received dental services on May 13, 2025. The exam indicated five teeth that were fractured and not restorable. The consultant requested a referral to an oral surgeon for radiographic imaging (images on a sensitive plate or film by X-rays, gamma rays, or similar radiation examination) and extractions of any teeth with a less than favorable prognosis. Interview with the Nursing Home Administrator and the Director of Nursing on January 8, 2026, at 2:30 PM confirmed that there no evidence that a referral to an oral surgeon had been attempted. 28 Pa. Code 211.15 Dental…

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 staff and resident interview, it was determined that the facility failed to obtain professional dental services for three of nine residents reviewed for dental concerns (Residents 9, 28, and 125). Findings include: Interview with Resident 28 on January 6, 2026, at 11:47 AM revealed that she has decayed and broken teeth that cause her pain. She said the facility dentist has seen her and he is waiting for her to get her teeth pulled so he can start making her dentures. She said she has to see an oral surgeon that will accept her insurance. Observation of Resident 28 during the interview confirmed her statement that she has decayed and broken teeth. Interview with the Director of Nursing on January 7, 2026, at 2:21 PM revealed that Resident 28 has been seen by the dentist and by the oral surgeon and she would provide all the dental consultation notes. The facility provided the following documents related to Resident 28's dental visits: Review of dental consult documentation dated March 14, 2025, revealed that Resident 28 was seen 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 a review of facility procedures, observation, and resident and staff interview, the facility failed to follow proper infection prevention practices for foot care equipment for two of 27 residents reviewed (Residents 29 and 48). Findings include: Observation of the 500 Hall on January 7, 2026, at 11:08 AM revealed Employee 1, nurse aide (NA), retrieved nail clippers from a staff member standing near a med cart and began trimming Resident 48's fingernails. At 11:12 AM, Employee 1 walked over to Resident 29 and began to trim his fingernails. Review of the facility policy and procedure entitled Care of Fingernails/Toenails under the section titled Steps in the Procedure revealed that step 20 instructs staff to clean reusable equipment and supplies, and step 25 instructs staff to wash and dry hands thoroughly. Employee 1 did not clean the fingernail clippers or wash and dry her hands between each resident's nail care. Interview with Resident 29 on January 7, 2026, at 12:35 PM revealed that he does have his own personal nail clippers in his room, but he stated that they must have…

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.

The facility failed to store and prepare food in accordance with professional standards for food safety in the main kitchen and on one of three nursing units (100/300 solarium pantry). Findings include: The United States Food and Drug Administration (FDA) Cooling Cooked Time/Temperature Control for Safety Foods and the FDA Food Code: for Food Employees stipulates that the FDA Food Code requires a two-step cooling process for cooked food: a two-hour rapid cool from 135 degrees Fahrenheit to 70 degrees Fahrenheit followed by a four-hour window where foods must be cooled to 41 degrees Fahrenheit or less. This means that within two hours, the food must be cooled from cooking temperature (135 degrees Fahrenheit) to 70 degrees Fahrenheit to eliminate risk of pathogen growth. Over the next four hours the food must be cooled from 70 degrees Fahrenheit to 41 degrees Fahrenheit or less. If 70 degrees Fahrenheit is reached before two hours, you have the remaining time to reach 41 degrees Fahrenheit or less. Observation of a walk-in freezer in the facility's main kitchen on March 25, 2025, at…

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

Based on observation and resident and staff interview, it was determined that the facility failed to provide adequate housekeeping and maintenance services to ensure a clean, safe, and orderly environment on three of five nursing halls (100, 200, and 400 Nursing Halls, Residents 16, 42, 91, and 101). Findings include: Clinical record review for Resident 91 revealed that the facility admitted him on March 5, 2025. On March 25, 2025, at 12:10 PM the drywall to the right of Resident 91's wall heater was marred and gouged. Concurrent interview with Resident 91 revealed that this occurred before their admission. On March 26, 2025, at 1:59 PM the drywall was marred behind Resident 42's head of the bed. Concurrent interview with the Director of Nursing acknowledged the drywall concerns for both Resident 91 and 42. Observation of Resident 16's room on March 25, 2025, at 11:27 AM revealed marring and uneven drywall on the wall outside the bathroom and between the closets. The bathroom walls were also marred. A cobweb was observed hanging from the wall to the center ceiling light in the…

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

Based on staff interview it was determined the facility failed to employ qualified activity personnel to oversee the facility's activity program (Employee 6) Findings included: Interview with Employee 6, Activity Director, on March 28, 2025, at 12:17 PM revealed that she was promoted from her nurse aide position to the activity director on February 17, 2025. Interview with the Director of Nursing on March 28, 2025, at 1:00 PM confirmed that Employee 6's qualifications were a certified nurse aide and that she did not possess the regulatory qualifications required to oversee the facility's activity programs. The facility failed to employee a qualified activity professional. 28 Pa Code: 201.3 (i)(ii) Resident activities coordinator. 28 Pa. Code: 201.18(b)(3) Management.

Based on clinical record review and resident and staff interview, it was determined that the facility failed to ensure routine prophylactic dental services for three of six residents reviewed for dental concerns (Residents 10, 39, and 109). Findings include: Clinical record review for Resident 39 revealed an admission MDS (an assessment completed at intervals by the facility to determine care needs of the resident) dated October 18, 2024, that indicated she was edentulous (had no teeth) and had upper and lower dentures. Further clinical record review revealed no evidence that Resident 39 was seen by a dental provider or afforded the opportunity to receive dental services for prophylactic (routine) care. Interview with the Director of Nursing on March 27, 2025, at 2:02 PM confirmed the above noted findings that there was no evidence Resident 39 was provided or afforded the opportunity for prophylactic dental services. Interview with Resident 10 on March 26, 2025, at 10:18 AM indicated that she had natural teeth, had a history of having five teeth extracted, but she had not received…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and family and staff interview, it was determined that the facility failed to provide a personal funds quarterly statement for one of one resident reviewed for personal funds concerns (Resident 25). Findings include: Clinical record review for Resident 25 revealed that her sister was designated as her first emergency contact and her responsible party. An active physician's order dated [DATE], assessed Resident 25 as incapable of understanding (her rights and responsibilities). Interview with Resident 25's sister on [DATE], at 11:44 AM revealed that she has never received an accounting statement of her sister's personal funds. Resident 25's sister confirmed that Resident 25's social security income is automatically forwarded to the facility for her care, and that she has obtained money from the business office to buy incidentals for her sister. Resident 25's sister stated that she did not know the balance in her sister's personal funds account. The surveyor reviewed the above…

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 involve a resident in establishing advance directives for one of 32 residents reviewed (Resident 93). Findings include: Clinical record review for Resident 93 revealed the resident was admitted to the facility on [DATE]. Review of a 5-day admission MDS (minimum data set, an assessment completed at periodic intervals of time to assess resident care needs) completed on [DATE], revealed facility staff assessed the resident as having a BIMS (brief interview of mental status) score of 15, indicating the resident was cognitively intact. Record review for Resident 93 also revealed a POLST (Pennsylvania orders for lift sustaining treatment) dated [DATE], that indicated Resident 93 desired to be a full code (attempt CPR (cardiopulmonary resuscitation) when the person has no pulse and is not breathing). The POLST was signed by the resident's sister who was listed as an emergency contact and a responsible party in the…

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

Based on clinical record review, review of select policies and procedures, and staff and resident interview, it was determined that the facility failed to thoroughly investigate and notify the appropriate agencies of an identified incident of potential resident misappropriation of property (money) for one of two residents reviewed for abuse concerns (Resident 36). Findings include: Review of the facility's active policy entitled Abuse Prevention Program, revealed it is the facility's policy to have the residents be free from abuse, neglect, misappropriation of resident property and exploitation. The policy indicates all reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source will be promptly reported to local, state, and federal agencies (as defined by the current regulations) and thoroughly investigated by facility management. The individual conducting the investigation will at a minimum, review the completed documentation forms, review the resident's medical record to determine events leading up 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 a review of select facility policies and procedures, a review of select personnel records, and staff interview, it was determined that the facility failed to complete required background check screening for one of five newly hired employees reviewed (Employee 3) Findings include: In accordance with Act 13 Elder Abuse Mandatory Reporting and Act 169 Criminal Background Checks, nursing facilities are required to obtain a criminal background check on all newly hired employees. Facilities are required to obtain the Pennsylvania State Police (PSP) background check within 30 days of hire on all prospective employees. If the applicant has not been a Pennsylvania resident for the two years before application, they will need to have a PSP criminal history background check completed and a Federal Bureau of Investigation (FBI) Background Check. The facility policy entitled, Criminal History Background Check Policy, last reviewed without changes on January 29, 2025, revealed that if the applicant/employee has been a resident of Pennsylvania for more than two years, the criminal history…

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, observation, and staff and resident interview, it was determined that the facility failed to provide personal and oral hygiene assistance for dependent residents for three of three residents reviewed for activities of daily living (ADL) concerns (Residents 110, 36, and 93). Findings include: Observation of Resident 110 on March 25, 2025, at 12:46 PM revealed that his fingernails were several millimeters longer than the tips of his fingers and were discolored. Interview with Resident 110 on the date and time of the observation revealed that he required the assistance of staff to trim his fingernails. Resident 110 stated that staff told him that they would trim them; however, no one has. Clinical record review for Resident 110 revealed a plan of care initiated by the facility on September 25, 2024, due to Resident 110's deficits in ADL self-care performance. Interventions listed on the plan of care instructed staff to check Resident 110's nail length and trim and clean his nails on…

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

Based on family and staff interview, and review of facility documents, it was determined that the facility failed to provide an ongoing program of activities designed to meet the individual needs and interests for one of three residents reviewed (Resident 101). Findings include: An interview with Resident 101's responsible party revealed concerns that there are no activities in the evenings on the 200 hall, memory care unit. Review of the facility activity calendars for January, February, and March 2025, revealed that there were no activities scheduled after 4:00 PM. Interview with the Director of Nursing and the Activity Director on March 27, 2025, at 2:15 PM confirmed the above noted findings related to the activity program for Resident 101 and the 200 hall. The facility failed to provide an ongoing program of activities to meet the needs of Resident101 and the 200 hall residents. 28 Pa. Code 201.29 (a) Resident rights

Based on clinical record review, observation, and resident and staff interview, it was determined that the facility failed to provide the highest practicable care regarding physician ordered interventions and treatments for one of 24 residents (Resident 42); and regarding an implanted cardiac pacemaker for one of 24 residents reviewed (Resident 30). Findings include: Clinical record review for Resident 42 revealed current physician orders for the following: Geri sleeves to all four extremities and remove for care every shift for skin alterations Bilateral fall mats in place while resident was in bed every shift Observation of Resident 42 revealed the following: On March 26, 2025, at 1:55 PM Resident 42 was in bed resting. On March 27, at 1:05 PM Resident 42 was dressed in the solarium in their wheelchair. On March 27, 2025, at 2:06 PM Resident 42 was in bed resting. No Geri sleeves were observed on Resident 42's four extremities and no bilateral fall mats were observed while Resident 42 was in bed during the above observations. The above information was reviewed during an interview…

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 implement interventions to prevent future falls or accidents for two of three residents reviewed for falls (Residents 93 and 110). Findings include: An interview and observation of Resident 93 on March 25, 2025, at 12:23 PM revealed she had been to the hospital recently for stitches in her head after she fell when she was trying to reach over and pick something up off the floor from the bed. A reddened area was observed on the right side of her eyebrow. Clinical record review for Resident 93 revealed a medical practitioner's note dated March 11, 2025, at 3:23 PM that indicated the resident was being seen as a follow up to an emergency room visit due to a fall with a laceration requiring eight stiches. Further clinical record review for Resident 93 revealed she was admitted to the facility from the hospital on May 8. 2024, after repeated falls at her prior place of living. Resident 93 was noted to have a fall in the facility on August 8, 2024, sustaining a skin tear to her elbow. 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 closed clinical record review, select facility policies and procedures, and staff interviews, it was determined that the facility failed to ensure that intravenous catheters were assess and maintained per the resident plan of care for one of one resident reviewed (Resident 120). Findings include: Review of the policy entitled Midline Dressing Changes, last reviewed by the facility on January 29, 2025, indicates that the facility will change a resident's midline (an access line placed in an arm to administer medications) catheter 24 hours after its insertion, then every five to seven days. Nursing staff are to document the date and time of the dressing change, description of insertion site, and any noted complications. Review of Resident 120's clinical record revealed nursing documentation dated October 29, 2024, at 4:59 AM that indicated a midline was to be placed for intravenous (IV) access. The physician's order dated October 29, 2024, indicated nursing staff were to administer Rocephin (used to treat bacterial infections) 1 gm (gram) every day for 10 days through the IV.…

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

Based on observation, clinical record review, and staff interview, it was determined that the facility failed to provide appropriate respiratory care and services for one of one resident reviewed (Resident 42). Findings include: According to the American Association for Respiratory Care proper cleansing of respiratory (nebulizer) equipment reduces infection risk. The longer a dirty nebulizer sits and is allowed to dry, the harder it is to clean thoroughly. Parts of the aerosol drug delivery device should be rinsed and then washed with soap and hot water after each treatment. Once completely dry, store the nebulizer cup and mouthpiece in a zip lock bag. Clinical record review for Resident 42 revealed the following current physician orders: Change the oxygen tubing weekly and as needed (PRN) every night shift every Sunday Change humidifier bottle (to help prevent dry nostrils [nose] while on oxygen) once weekly on Sunday during night shift and PRN Observation of Resident 42 revealed the following: On March 25, 2025, (Tuesday), at 12:15 PM Resident 42's oxygen tubing was dated March…

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 select facility policies and procedures, clinical record review, observation, and staff interview, it was determined that the facility failed to thoroughly assess the potential entrapment risks from the use of bed rails for one of five residents reviewed for accident hazards (Resident 10). Findings include: The facility policy entitled, Bed Safety, last reviewed without changes on January 29, 2025, indicated that the facility would strive to provide a safe sleeping environment for the resident. The resident's sleeping environment shall be assessed by the interdisciplinary team, considering the resident's safety, medical conditions, comfort, and freedom of movement, as well as input from the resident and family regarding previous sleeping habits and bed environment. Inspection by maintenance staff of beds and related equipment is part of the regular bed safety program to identify risks and problems including potential entrapment risks. The facility will ensure that bed side rails are properly…

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 and implement an individualized person-centered care plan to address dementia and cognitive loss displayed by two of three residents reviewed (Residents 39 and 99). Findings include: Clinical record review for Resident 39 revealed the facility admitted her on October 12, 2024. A diagnosis of Dementia (loss of memory, language, problem-solving, and other thinking abilities that interfere with daily life) was added to her diagnosis list on October 22, 2024. A review of Resident 39's admission Minimum Data Set Assessment (MDS, a form completed at specific intervals to determine care needs) dated October 18, 2024, indicated that the facility determined a care plan for dementia and cognitive loss would be developed. A review of Resident 39's care plan revealed that there was no indication that the facility had developed and implemented a person-centered care plan to address the resident's dementia and cognitive…

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

Based on observation, clinical record review, and resident and staff interview, it was determined that the facility failed to implement enhanced barrier precautions for one of two residents reviewed for infection control concerns (Resident 173). Findings include: Review of the Centers for Medicare and Medicaid Services (CMS) memo entitled, Enhanced Barrier Precautions in Nursing Homes, dated March 20, 2024, revealed that nursing care facilities are to use enhanced barrier precautions (EBP, gown and glove use) for residents with chronic wounds or indwelling medical devices (i.e., indwelling urinary catheters) during high-contact resident care activities regardless of their multidrug-resistant organism status. High-contact activity would include things like dressing, transferring, changing linens, providing hygiene, changing briefs, wound care, or device care. Interview with Resident 173 on March 25, 2025, at 3:31 PM revealed that she has had a surgical wound open, that will not heal completely, since November 2024. Observation of Resident 173's room on the date and time of the…

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

Based on clinical record review and staff interview it was determined that the facility failed to provide bathing assistance for a dependent resident for one of six residents reviewed (Resident 1). Findings include: Clinical record review for Resident 1 revealed a plan of care developed by the facility to address her deficits to perform activities of daily living (bathing, dressing, toileting, etc.) related to her diagnoses of dementia (disease that affects memory, thinking and interferes with daily life) and Parkinson's disease (a degenerative brain condition that affects muscle control and movement). The plan of care indicated that Resident 1 preferred a shower and that she required extensive assistance by staff for bathing or showering. Review of Resident 1's Task List (electronic documentation completed by nurse aide staff to record care for a resident's activities of daily living) documentation dated July, August, and September 2024, revealed that Resident 1 was to receive a shower weekly. The nurse aide staff documented the following: July 1, 2024, bed bath July 8, 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 clinical record review and staff interview, it was determined that the facility failed to provide the highest practicable care regarding physician ordered vital signs for one of six residents reviewed (Resident 1). Findings include: Clinical record review for Resident 1 revealed a physician's order dated May 2, 2024, for vital signs (measurements of the body's most basic functions to include body temperature, pulse rate, respiration rate, and blood pressure) to be completed every eight hours for three days. Review of Resident 1's clinical documentation revealed that the facility only obtained his vital signs on May 2, 2024, at 6:00 PM, during the three days that they were to be obtained, from May 2-5, 2024. The Director of Nursing confirmed the above noted findings during an interview on May 29, 2024, at 11:25 AM. 28 Pa. Code 211.10(c) Resident care policies 28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing services

Based on observation and staff interview, it was determined the facility failed to store food to prevent the potential spread of food borne illness and maintain food service/storage equipment in a sanitary manner in the facility's main kitchen and one of three dining areas nursing units (100/300 dining room). Findings include: An observation of the facility's main kitchen on March 26, 2024, at 9:58 AM revealed the following: A large white bin next to the ice machine contained a white powdery substance. The bin was labeled as flour and dated September 7, 2023, with a use by date of March 7, 2024. An additional white bin next to the flour also contained a white powdery substance and was not labeled or dated. Employee 7, dietary manager, indicated it was thickener in the bin. An air vent on the front of the industrial ice machine was covered in dust on the exterior and interior of the vent. The lower shelf of a preparation table holding a food processor was dusty and contained dried particles on the shelf. A shelf extending from the wall over the above preparation table was observed…

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 resident or resident representative received written notice of the facility bed hold policy at the time of transfer for three of six residents reviewed for hospitalizations (Residents 41, 75, and 221). Findings include: Clinical record review revealed that Resident 41 was transferred to the hospital on November 8, 2023, after they had a change in condition. There was no documentation available that the facility provided written notice regarding a bed hold to the resident and/or the resident's responsible party upon transfer out to the hospital. Clinical record review revealed that Resident 221 was transferred to the hospital on March 1, 2024, after they had a change in condition. There was no documentation available that the facility provided written notice regarding a bed hold to the resident and/or the resident's responsible party upon transfer out to the hospital. The surveyor reviewed the above information for during an interview with the Director of Nursing 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 clinical record review, observation, and staff and resident interview, it was determined that the facility failed to provide bathing assistance for residents dependent on staff assistance for five of six residents sampled for activities of daily living (Residents 52, 60, 64 and 96), and the facility failed to provide a resident with transfer assistance out of bed for a resident dependent on staff assistance, for one of six residents sampled. (Resident 92). Findings include: Clinical record review for Resident 60 revealed that he is to have a bed bath on Fridays dayshift due to wound dressings. Review of Resident 60's care plan for self-care deficit revealed that he required one assist with his activities of daily living. He also had a care plan intervention that indicated he was to receive a bed bath related to dressings on both of his lower legs. Review of Resident 60's task documentation (computerized documentation of care that is done for the resident) revealed that he did not have his complete bed…

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 and implement individualized person-centered care plans to address dementia and cognitive loss displayed by four of four residents reviewed (Residents 17, 43, 44, 94). Findings include: Clinical record review for Resident 17 revealed the facility admitted her on July 19, 2022, with diagnoses including dementia (loss of memory, language, problem-solving, and other thinking abilities that interfere with daily life). A review of Resident 17's most recent annual Minimum Data Set Assessment (MDS, a form completed at specific intervals to determine care needs) dated June 9, 2023, indicated that the facility assessed Resident 17 as having a diagnosis of dementia. The facility determined that a care plan for dementia and cognitive loss would be developed. A review of Resident 17's care plan revealed that there was no indication that the facility had developed and implemented a person-centered care plan to address…

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 select policies and staff interview, it was determined that the facility failed to implement an effective Water Management Program for the prevention and control of water-borne contaminants, such as Legionella (a bacteria that may cause Legionnaires' Disease, a serious type of pneumonia). Findings include: The CDCs (Centers for Disease Control and Prevention) current Water Management Program Toolkit, Practical Guide to Implementing Industry Standards, indicated that many buildings need a water management program to reduce the risk for Legionella (bacteria that can grow and spread in water systems and can cause a serious type of pneumonia (lung infection) known as Legionnaires' disease) growing and spreading within their water system and devices. Developing and maintaining a water management program is a multi-step process that requires continuous review. Steps to building an effective Legionella water management program include: A description of the building's water system using flow diagrams…

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 staff education records and staff interview, it was determined that the facility failed to ensure that all nurse aide staff completed a minimum of 12 hours of in-service education training each year for three of three nurse aides reviewed (Employees 1, 2, and 3). Findings include: During an interview with the Nursing Home Administrator and the Director of Nursing on April 12, 2023, at 2:00 PM the surveyor requested evidence of annual in-service education for the three nurse aide staff as follows: Employee 8, nurse aide, hired March 14, 2022. Employee 9, nurse aide, hired December 7, 2021. Employee 10, nurse aide, hired January 31, 2022. Interview with the Director of Nursing on March 29, 2024, at 11:00 AM confirmed that the facility had no evidence of any in-service education for Employees 8, 9, or 10, that included dementia training, abuse prevention training, and any areas of weakness or resident special care needs in the past year. 483.95 (g)(g 1-4) Training requirements Previously cited 4/14/23 28 Pa. Code 201.18(b)(3) Management 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 review of select facility policies and procedures, review of employee personnel records, observation, and staff interview, it was determined that the facility failed to investigate a resident's injuries of unknown origin for one of 25 residents sampled (Resident 75) and failed to implement its abuse prohibition policy pertaining to screening for one of five newly hired employees reviewed (Employee 1). Findings include: Review of the facility policy entitled Abuse Prevention Program, last reviewed January 4, 2024, revealed all reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment, and/or injuries of unknown source (abuse) will be thoroughly investigated by facility management. The current facility policy entitled Abuse, Neglect, Exploitation, and Misappropriation last reviewed without changes on January 4, 2024, revealed that the facility will not tolerate abuse, neglect, exploitation of its residents or the misappropriation of resident property and will undertake background checks on all employees. Prior to hiring a new…

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 complete and accurate Minimum Data Set (MDS) assessments for one of 25 residents reviewed (Resident 110). Findings include: Review of Resident 110's clinical record revealed the facility admitted her on January 12, 2024. A review of Resident 110's admission Minimum Data Set Assessment (MDS, a form completed at specific intervals to determine care needs) dated January 18, 2024, noted staff assessed Resident 110 as utilizing a limb restraint less than daily. Observation of Resident 110 on March 26, 2024, at 11:04 AM, and March 27, 2024, at 9:42 AM revealed no evidence of a limb restraint. Review of Resident 110's physician orders did not include evidence of Resident 110 utilizing a restraint. An interview with the Director of Nursing on March 28, 2024, at 10:52 AM confirmed the MDS was incorrect, and Resident 110 never utilized a restraint. 28 Pa. Code 211.5(f) Clinical records 28 Pa. Code 211.12(d)(1)(5) Nursing services

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 develop and implement a comprehensive person-centered care plan to maintain the highest practicable care for one of one resident reviewed (Residents 50). Findings Include: Clinical record review for Resident 50 revealed a psychiatry note dated [DATE], that indicated she wanted to die so she can be with her babies. The note indicated that she did not have a plan and that she stated she would never harm herself. Further review of the psychiatry note revealed that Resident 50 indicated that she mourns her son's death. She stated he died one- and one-half days after he was born, and she never got to hold him. She also reported that she mourns the loss of multiple pregnancies that ended in miscarriage and cycles through the grieving process when the anniversary date of these events occurs. The note also indicated that she hears her deceased mother's voice and seeing her deceased mother from time to time.…

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 family and staff interview, it was determined that the facility failed to promote resident and/or responsible party involvement with care plan development for one of one resident reviewed (Resident 101). Findings include: Clinical record review for Resident 101 revealed that the facility conducted care plan meetings for her on August 4, 2023, September 6, 2023, and November 20, 2023. During a telephone interview with Resident 101's responsible party on March 26, 2024, at 1:51 PM she revealed that she only attended one care plan meeting and that she did not get invited to other ones. She indicated that she had to invite herself to the one she did attend by requesting a meeting. The Director of Nursing (DON) was made aware of the concern related to Resident 101's care plan meetings on March 27, 2024, at 2:00 PM. The Director of Nursing provided the surveyor with evidence that Resident 101's responsible party attended a meeting on March 18, 2024. The DON also confirmed at this time that this was a meeting that was requested by Resident 101's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff interview, it was determined that the facility failed to provide services to maintain a resident's range of motion for one of 5 residents reviewed (Resident 44). Findings include: Clinical record review revealed a quarterly MDS (Minimum Data Set, an assessment completed at specific intervals to determine resident care needs) dated August 2, 2023, noting staff assessed Resident 44 as having no upper or lower extremity impairments. Review of physical therapy documentation revealed Resident 44 was discharged from physical therapy on August 4, 2023. A review of Resident 44's physical therapy discharge summary revealed his prognosis to maintain his current level of function would be good with consistent staff follow-through. The physical therapy discharge summary noted the facility does not offer restorative nursing programs. Further review of Resident 44's clinical record revealed his next quarterly MDS assessment dated [DATE], nursing staff assessed Resident 44 as having 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 observation, review of select facility policies, facility documents, clinical record review, and staff and resident interview, it was determined that the facility failed to implement appropriate interventions to prevent falls for one of five residents reviewed for falls (Resident 52). Findings include: In an interview an observation of Resident 52 on March 26, 2024, at 1:33 PM the resident was observed in bed with several steri strips (strips used to heal wounds by pulling two sides of a wound together) on his left hand. Resident 52 stated he fell out of bed a couple days ago. Clinical record review for Resident 52 revealed a nursing note dated March 20, 2024, at 4:11 PM, which noted when the resident was being changed, the resident rolled out of bed, landed on his knees, then rolled onto his right side, and hit his head on the wheel of the bed. It was also noted the resident's knees were red and excoriated, and a hematoma was present on the left side of his head. A nursing note dated March 21, 2024, at 1:14 AM for Resident 52 noted the resident's hand was assessed status…

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 assess and implement individualized interventions to promote bowel and bladder continence for one of two residents reviewed for incontinence (Resident 115). Findings include: On March 29, 2024, at 12:35 PM The Director of Nursing (DON) indicated that the facility did not have a policy on evaluating resident bowel and bladder incontinence. Clinical record review for Resident 115 revealed a care plan that was initiated on March 4, 2024, that indicated she was incontinent of bowel and bladder. Further clinical record review for Resident 115 revealed a bowel and bladder program screener dated March 9, 2024, that indicated she was always continent of bladder and never incontinent of bowel. Care plans initiated March 4, 2024, indicated that Resident 115 is incontinent of bowel and incontinent of bladder. Review of Resident 115's task documentation (computerized documentation of the care provided) revealed that Resident 115 was documented as being incontinent of bowel 15 times and bladder 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 clinical record review and staff interview, it was determined that the facility failed to implement interventions to promote acceptable parameters of nutrition for one of six residents reviewed (Resident 42). Findings include: Clinical record review revealed the facility admitted Resident 42 on January 23, 2024. Further review of Resident 42's clinical record revealed the following weight assessments: January 23, 2024, 145 pounds January 29, 2024, 127.8 pounds (a 17.2 pound, an 11.8 percent severe weight loss) January 30, 2024, 127.8 pounds February 2, 2024, 127.0 pounds February 7, 2024, 124.2 pounds February 13, 2024, 122.6 pounds Further review of Resident 42's clinical record revealed a nutrition progress note dated January 30, 2024, which noted resident showing a weight loss, request a re-weight. A nutrition progress note dated January 31, 2024, revealed Resident 42 was noted to have a 16.8-pound weight loss over seven days. The registered dietician recommended fortified foods for added calories for weight stabilization. An addendum was added to the note indicating…

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

Based on observation, clinical record review, and staff interview, it was determined that the facility failed to provide appropriate respiratory care and services for one of three residents reviewed (Resident 75). Findings include: Observation of Resident 75 on March 27, 2024, at 9:39 AM revealed Resident 75 was in her room with oxygen on and running at 3 liters per minute. Observation of Resident 75 on March 27, 2024, at 10:28 AM revealed she was in the dining room without oxygen. Further observation revealed Resident 75's oxygen was running in her room at 3 liters per minute, with the nasal cannula tubing lying across Resident 75's bed. Review of Resident 75's clinical record revealed there was no physician's order for Resident 75 to receive oxygen. An interview with Employee 5 (assistant director of nursing) confirmed the above findings for Resident 75. Employee 5 indicated she was unsure when staff began administering Resident 75's oxygen but noted documentation in Resident 75's clinical record that Resident 75 utilized oxygen starting on March 22, 2024. Nursing staff obtained…

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

Based on clinical record review and staff interview, it was determined that the facility failed to provide the highest practicable care regarding physician ordered pain medications for one of four residents reviewed (Resident 91). Findings include: Review of Physiopedia's and Wikipedia's definition of the numeric pain rating scale (parameters) from zero to 10 indicated that no pain was identified as zero, mild pain was identified as one to three, moderate pain was identified as four to six, and severe pain was identified as seven to 10. Clinical record review for Resident 91 revealed physician's orders for the following pain medications: Ordered on April 20, 2023, Acetaminophen (Tylenol, for mild pain) 325 milligrams (mg) 2 tablets by mouth (PO) every 6 hours as needed (PRN) for pain 1-4. Ordered on August 8, 2023, and discontinued on July 15, 2024, Tramadol (for moderate to severe pain) 50 mg PO every 4 hours PRN for pain. Ordered on January 15, 2024, Tramadol (for moderate to severe pain) 50 mg PO every 4 hours PRN for pain 6-10. Review of Resident 91's August, September, October,…

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

Based on clinical record review, observations, and staff and resident interview, it was determined that the facility failed to ensure the availability of necessary emergency supplies for two out of three residents reviewed receiving hemodialysis (Residents 70 and 90). Findings include: Clinical record review for Resident 70 revealed the resident had an AV fistula (a connection that's made between an artery and a vein for dialysis access) in his left wrist for dialysis treatment. A physician's order for Resident 70 dated March 22, 2024, indicated the resident was to receive hemodialysis (a machine that performs a basic function of the kidney by cleansing the blood of impurities) every Tuesday, Thursday, and Saturday at a dialysis center. An additional physician's order dated March 22, 2024, indicated the resident was to have and emergency dialysis kit at bedside to contain two sterile 4x4's, hemostats (a tool used to control bleeding), and tape, and to replace the kit if needed. An observation and interview with Resident 70 on March 26, 2024, at 2:50 PM the resident stated he…

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 identify triggers related to a resident's diagnosis of Post-Traumatic Stress Disorder, to provide culturally, competent, trauma-informed care and eliminate or mitigate re-traumatization for one of one resident reviewed (Resident 50). Findings include: Clinical record review for Resident 50 revealed a quarterly Minimum Data Set (MDS, an assessment completed by the facility at intervals to determine care needs of the resident) assessment dated [DATE], that indicated she had an active diagnosis of PTSD (Post Traumatic Stress Syndrome, a mental and behavioral disorder that develops from experiencing a traumatic event). Interview with Resident 50 on [DATE], at 10:35 AM revealed that she has PTSD from being raped by her mom's brother and by her father, after her mother died. She also indicated that she was beaten in a past relationship. A psychiatric note dated [DATE], revealed that Resident 50 indicated she…

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, clinical record review, and staff and family interview, it was determined that the facility failed to assess for the risk of side rail entrapment, for three of five residents reviewed for side rails (Residents 74, 104, and 105). Findings include: Clinical record review for Resident 105 revealed that she was admitted on [DATE], with an assessment that indicated she did not need to utilize side rails. On January 30, 2024, a physician ordered Resident 105 to utilize bilateral (both sides) side rails to (her) bed for positioning. There was no documentation after the January 30, 2024, order that indicated the bilateral side rails were assessed to ensure the side rails were appropriate and the resident's ability to utilize them. Observation of Resident 105 on March 26, 2023, at 12:03 PM revealed that she was dressed and sitting in a chair. There were bilateral side rails observed on the bed. The surveyor reviewed the above information during an interview with the Director of Nursing on March 29,…

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

Based on review of facility documentation and staff interviews, it was determined that the facility failed to ensure that nursing staff possessed the appropriate competencies and skill sets related to the care and assessment of residents with enteral tube feeding, catheter care, medication administration, and dressing changes for two of six employee competencies reviewed (Employees 11 and 12). Findings include: A review of the facility documentation revealed that the facility had a total of 124 residents receiving medications, 10 residents with indwelling catheters (insertion of a tube into the bladder to remove urine), six residents with pressure ulcers, and two residents with enteral tube feedings (device that allows liquid food to enter your stomach or intestine through a tube). A request for nursing staff competencies for enteral tube feeding, catheter care, medication administration, and dressing changes revealed the facility was unable to provide any for Employees 11 and 12 (licensed practical nurses). The findings were reviewed with the Nursing Home Administrator and Director…

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 and responsible party interview, it was determined that the facility failed to monitor antibiotic use for one of one resident reviewed for a urinary tract infection (Resident 74). Findings include: In an interview with a responsible party for Resident 74 on March 26, 2024, at 1:01 PM, the responsible party indicated the resident had been sick and had to go to the hospital as she had a urinary tract infection. Clinical record review for Resident 74 revealed the resident was sent to the emergency room from the facility on February 13, 2024, for abdominal pain, and not eating. Review of Resident 74's emergency room visit summary dated February 13, 2024, revealed the resident received multiple studies and lab work at the emergency room, which included a urinalysis with culture and sensitivity and results were pending. The resident was returned to the facility with a diagnosis of hypernatremia (an elevated sodium level), headache, and loss of appetite. Resident 74 received intravenous fluids at the emergency room and was returned to the facility…

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

Based on clinical record review and staff interview, it was determined that the facility failed to ensure a resident received or was offered pneumococcal conjugate vaccines for one of five residents reviewed for immunization concerns (Resident 4). Findings include: Clinical record review for Resident 4 revealed that the facility admitted her on October 6, 2022. Further clinical record review revealed that the facility documented on admission that Resident 4 previously had a pneumovax 23 (a vaccine administered to prevent pneumonia) on March 1, 2007. There was no evidence in Resident 4's clinical record that indicated she was offered pneumococcal conjugate vaccines (vaccines that prevent against bacteria that cause pneumonia) Review of the document published April 1, 2022, by the Center for Disease Control and Prevention, entitled Pneumococcal Vaccine Timing for Adults, Resident 4 should have been offered a pneumococcal conjugate vaccine. Interview with Employee 2, Registered Nurse, Infection Preventionist, on March 29, 2024, at 12:30 PM confirmed the above noted findings for…

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

Based on review of facility documentation, clinical record review, and staff interview, it was determined that the facility failed to ensure an environment free from the potential spread of infection for one of six residents reviewed (Resident 1). Findings include: Clinical record review for Resident 1 revealed that she was diagnosed with end stage kidney failure, which required dialysis. Further review revealed that she tested positive for COVID-19 on December 16, 2023, while in the facility, and was placed on isolation. She attended dialysis on December 18, 2023. Upon return from dialysis on December 18, 2023, at 9:57 PM, staff documented that Resident 1 left for dialysis via a non-emergent transport company at 3:20 PM and returned from dialysis via the non-emergent transport company at 7:20 PM . The non-emergent transport company stated they were unaware of Resident 1 being COVID-19 positive upon returning to facility this evening. The non-emergent company (stated) that dialysis (was) also unaware as Resident 1 was not isolated nor masked at dialysis. Review of dialysis 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 clinical record review, observation, and staff interview, it was determined that the facility failed to assist a resident to retain and use personal possessions for two of five residents reviewed (Residents 1 and 2). Findings include: Observation of Resident 1 and 2's bathroom on August 16, 2023, at 3:20 PM and concurrent interview with the Director of Nursing (DON), revealed that there were many unlabeled/unidentified resident personal care items located in a plastic basin on the floor under the sink, in a graduated plastic container on the right side of the sink, and in a woven wooden basket with a clothe interior sitting on top of the toilet. These resident personal care items included shampoo, lotion, toothpaste, denture gel, and skin barrier creams. The toothpaste, denture gel, and one container of lotion were missing their lids and had the contents of the respective items on the outside of the container. There was a lid lying in the sink which was identified by the DON as the lid to the denture gel. There was an unidentified/labeled white denture cup that was closed…

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.