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Based on review of policies and clinical records, as well as resident and staff interviews, it was determined that the facility failed to provide appropriate care for one of 42 residents reviewed (Resident 102) who had an indwelling urinary catheter. Findings include: The facility's policy regarding catheter care (a tube placed and held in the bladder to drain urine), dated June 19, 2025, indicated that residents with indwelling catheters should receive appropriate catheter care.A care plan for urinary catheter for Resident 102, dated August 29, 2025 included that staff will perform foley catheter care every shift and staff are to monitor urinary output every shift.Physician's orders for Resident 102 dated August 29, 2025, included an order for foley catheter care every shift.Resident 102's Treatment Administration Records (TAR's) for August 2025 and September 2025 revealed no documented evidence that catheter care was completed or that urinary output was being documented. Interview with the Nursing Home Administrator on September 5, 2025, at 10:49 a.m. confirmed that Resident 102'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 review of policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure an oxygen concentrator and filter was cleaned and tubing and humidification were changed per physician's orders for one of 42 residents reviewed (Resident 74), and failed to obtain an order for oxygen for one of 42 residents reviewed (Resident 97). Findings include:A Quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 74, dated July 31, 2025, indicated that the resident was cognitively impaired, was dependent on staff for daily care needs and had a diagnoses that included Chronic Obstructive Pulmonary Disease (a progressive lung disease that causes ongoing inflammation and narrowing of the airways, making it difficult to breathe). Physician's orders for Resident 74, dated December 4, 2024, included an order for the night nurse to check every week on Wednesdays, if oxygen used, to makesure filter…

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 policy and clinical records, as well as staff interviews, it was determined that the facility failed to respond timely to a pharmacy recommendation for one of 42 residents reviewed (Resident 84).Findings include: A facility policy for drug regimen review, dated June 19, 2025, revealed that a summary of all recommendations is provided to the Director of Nursing and Facility Medical Director every month. The timing of the recommendations should be responded to prior to the next medication review. A Quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 84, dated August 15, 2025, revealed that the resident was cognitively intact, required partial care from staff, and was medicated with an antianxiety medication. A pharmacy consultant note for Resident 84, dated May 15, 2025, revealed that the pharmacist recommended that the physician attempt a Gradual Dose Reduction for the residents order of 25mg Zoloft. A pharmacy consultant note for Resident 84, dated August 15, 2025, revealed that the pharmacist…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policies and medication package inserts, as well as observations and staff interviews, it was determined that the facility failed to discard expired medical supplies/biologicals, and failed to label multi-dose containers of medications with the date they were opened in one of two medication rooms reviewed (tri west medication room). Findings include: The facility's policies regarding medication storage and disposal, dated [DATE], revealed that the facility would not use outdated supplies, and properly date medication vials after they were opened. An undated package insert for tubersol (medication used to test for tuberculosis) indicated that the medication was to be discarded 30 days after it was entered.Observations in the Tri west medication room on [DATE], at 9:54 a.m. revealed that there were 47 packets of blood collection sets that expired [DATE], three blood collection tubes, two blue and one purple which expired [DATE], and one vial of tuber sol that was open and not dated with…

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

Based on review of facility policies, as well as observations and staff interviews, it was determined that the facility failed to serve food in accordance with professional standards for food service safety by failing to ensure that dietary staff wore beard coverings that completely covered their beard during food handling, and failed to ensure that food items were stored in accordance with professional standards for food service safety in one of three nursing unit pantry refrigerators (100 hall).Findings include:The facility's dietary policy regarding personal hygiene, dated June 19, 2025, revealed that all dietary staff are to wear a hair restraint (hairnet, hat and/or beard restraint) to prevent hair from contacting food.Observations in the kitchen on September 4, 2025, at 12:01 p.m. revealed that the dietary director was in the kitchen where food was being plated without a beard guard.Interview with the Dietary Director on September 4 ,2025, at 12:05 p.m. revealed that he only wears a beard guard when he is cooking and not in the food preparation area.Interview with 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.

Based on a review of clinical records and facility investigations, as well as staff interviews, it was determined that the facility failed to ensure that residents' clinical records were complete and accurately documented for one of 42 residents reviewed (Resident 6).Findings include: A Quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 6, dated June 16, 2025, indicated that the resident was cognitively impaired, required substantial assistance with care needs, and was receiving enteral nutrition PEG feedings (a method of providing nutrients directly into the gastrointestinal (GI) tract through a feeding tube into the stomach or intestines). Review of nurse aide documentation for Resident 6, dated August and September 2025, revealed that there was no nurse aide documentation completed for PEG feeds and amount consumed of pleasure feeds on August 1, 2025 for day shift, August 3, 2025 for day and evening shift, August 9, 2025 for day shift, August 18, 2025 for day shift, August 20, 2025 for day and night shift,…

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

Based on review of the facility's plans of correction for previous surveys, and the results of the current survey, it was determined that the facility's Quality Assurance Performance Improvement (QAPI) committee failed to correct quality deficiencies and ensure that plans to improve the delivery of care and services effectively addressed recurring deficiencies.Findings include: The facility's deficiencies and plans of corrections for a State Survey and Certification (Department of Health) survey ending August 15, 2024, revealed that the facility developed plans of correction that included quality assurance systems to ensure that the facility-maintained compliance with cited nursing home regulations. The results of the current survey, ending September 5, 2025, identified repeated deficiencies related to safe, clean, comfortable, homelike environment, accurate Minimum Data Set assessments, labeling storage drugs and biologicals, and food procurement. The facility's plan of correction for a deficiency regarding safe, clean, comfortable, homelike environment, cited during the survey…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of clinical records, as well as staff interviews, it was determined that the facility failed to ensure that a resident with pressure ulcers received the necessary treatment and services consistent with professional standards of practice for one of eight residents reviewed (Resident 3). Findings include: An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 3, dated March 31, 2025, revealed that the resident was admitted to the facility on [DATE], was cognitively intact, required maximum staff assistance for care, and had a Stage 1 pressure ulcer. A wound care note, dated April 7, 2025, revealed that Resident 3 had a Stage 2 pressure wound on the left buttock. A care plan for Resident 3, dated March 24, 2025, revealed that the resident was to have barrier cream applied to her buttocks three times a day to prevent skin breakdown. A review of Resident 3's clinical record revealed that there was no documented evidence that the…

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

Based on review of facility policy, clinical records, and staff interviews, it was determined that the facility failed to ensure that physician's orders were followed for one of eight residents reviewed (Resident 1) who had an indwelling urinary catheter. Findings include: The facility's policy regarding indwelling urinary catheter's revealed that the nursing staff were to review the physician's orders prior to inserting an indwelling urinary catheter (a tube inserted into the bladder to continuously drain urine) or a straight catheter (a tube inserted into the bladder to obtain a sample of urine and then removed) for a urine sample. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated April 30, 2025, revealed that the resident was cognitively intact and required assistance from staff for her daily care needs. A nursing note for Resident 1, dated February 19, 2025, revealed that an indwelling urinary catheter was inserted for urinary retention; however, there was no documented evidence that a physician's…

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

Based on review of facility policies, as well as observations and staff interviews, it was determined that the facility failed to ensure that food stored in the residents' refrigerators/freezers was properly dated, labeled, and secured in two of four refrigerators observed (100 and 500 hall kitchenettes). Findings include: The facility's date marking policy for food safety, dated November 27, 2024, indicated that all food brought in for residents or stored for resident use will be secured and clearly dated and labeled. Observations of the resident's refrigerator/freezer in the 100-hall kitchenette on March 27, 2025, at 9:10 a.m. revealed the following items that were opened and undated and/or unlabeled: a 32-ounce container of chicken broth, 24-ounce jar of pickles, two half-gallon containers of milk, two 24 ounce half-gallon containers of raspberry ice tea, 46 ounce container of thickened apple juice, 48 ounce containers of macaroni and potato salad, and a 20 ounce bag of chicken chunks, which additionally was open to the air. Observations of the resident's refrigerator/freezer in…

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

Based on review of Pennsylvania's Nursing Practice Act and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that an assessment was completed by a professional (registered) nurse after an injury occurred for one of 10 residents reviewed (Resident 2). Findings include: The Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.11 (a)(1)(2)(4) indicated that the registered nurse was to collect complete and ongoing data to determine nursing care needs, analyze the health status of individuals and compare the data with the norm when determining nursing care needs, and carry out nursing care actions that promote, maintain, and restore the well-being of individuals. A facility policy, dated November 27, 2024, regarding accidents and incidents, indicated that falls require an incident and accident reports, with the nurse entering the information to the appropriate form or system within 24 hours of the occurrence and will document all pertinent information. The supervisors or other designee will be…

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

Based on review of clinical records, as well as resident and staff interviews, it was determined that the facility failed to maintain clinical records that were complete and accurately documented for one of four residents reviewed (Resident 3). Findings include: A facility policy, dated November 27, 2024, regarding accidents and incidents, indicated that falls require an incident and accident reports, with the nurse entering the information to the appropriate form or system within 24 hours of the occurrence and will document all pertinent information. The documentation should include the date, time, nature of the incident, location, initial findings, immediate interventions, notifications and orders obtained or follow-up interventions. A quarterly minimum data set (MDS) assessment (mandated to assess the resident abilities and care needs) for Resident 3, dated October 21, 2024, indicated that the resident was sometimes able to understand others; was sometimes understood by others; was severely cognitively impaired; required supervision and touch assistance with ambulation, 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.

Based on observations and staff interviews, it was determined that the facility failed to provide a clean and homelike environment. Findings include: Observations in the lounge area on the 400 hall on August 12, 2024, at 11:15 a.m. revealed a five-gallon bucket on a cart containing old food scraps. Observations in the 300, 400, and 500 halls on August 14, 2024, at 12:26 p.m. revealed a five-gallon bucket with food scraps in it on each hallway. In the 500 hallway the bucket on a cart was at the beginning of the hallway across from the nurses' station, in the 300 hall the bucket was halfway down the hallway in front of resident rooms, and in the 400 hallway the bucket was in the lounge area directly behind a resident who was sitting on a couch eating lunch. Staff are scraping leftover food into each of the buckets on the hallways and placing the dishes under the bucket on the cart. Interview with Nurse Aide 1 on August 14, 2024, at 12:45 p.m. revealed that the buckets were disgusting and embarrassing, that family members have made statements regarding the buckets full of old food…

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

Based on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to notify the resident and resident representative in writing regarding the reason for transfer to hospital, and failed to notify the ombudsman for the hospitalizations for five of 32 residents reviewed (Residents 4, 7, 14, 41, 69). Findings include: The facility's policy for Admission, Transfer and Discharge Notification, dated December 1, 2024, indicated that upon transfer to the hospital the resident and resident representative will be notified in writing, and the ombudsman will be notified. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 4, dated May 27, 2024, indicated that the resident was cognitively intact, required assistance with care needs, required supplemental oxygen and had diagnoses that included congestive heart failure (the heart cannot pump blood well enough to meet the body's needs), chronic respiratory failure (blood does not have enough oxygen and causes…

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

Based on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that care plans were updated/revised to reflect changes in care needs for five of 32 residents reviewed (Residents 4, 29, 38, 41, 63). Findings include: The facility's policy regarding care plans, dated December 1, 2023, included that care plans were to be revised as changes in the resident's condition dictated and should reflect the professional services that were responsible for each element of care. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 4, dated May 27, 2024, indicated that the resident was cognitively intact, required assistance with care needs, required supplemental oxygen, and had diagnoses that included congestive heart failure (the heart cannot pump blood as well as it should causing weight gain due to fluid to build up in the lungs and lower legs), chronic respiratory failure (blood does not have enough oxygen and causes difficulty breathing), and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to obtain physician's orders for the care and services related to tube feedings for one of 32 residents reviewed (Resident 81). Findings include: A facility's policy regarding gastrostomy feeding, dated December 1, 2023, indicated that placement of the gastrostomy tube (a mechanical device surgically implanted into the stomach to provide nutrition, fluids and medications to a person who is unable to eat or drink by mouth) will be done by placing a stethoscope to the stomach and injecting 10 cubic centimeters (cc) of air. A facility policy regarding gastric tube care, dated December 1, 2023, indicated that gastric tube care was to be done to prevent irritation and skin breakdown, prevent odor and prevent discomfort, and was to be documented in the Treatment Administration Record (TAR). Resident 81 was admitted to the facility on [DATE], with a diagnosis of…

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

Based on review of clinical records, as well as staff interviews, it was determined that the facility failed to ensure that the resident and/or resident representative had an opportunity to develop an advance directive or assist in formulating an advance directive for one of 32 residents reviewed (Resident 11). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 11, dated July 5, 2024, revealed that the resident was cognitively impaired and had absence of speech; However, the MDS indicated that she had no impairment with short and long-term memory and had some difficulty making decisions in new situations only. She was dependent with care needs and had diagnoses that included hemiplegia and hemiparesis (paralysis or weakness to one side of the body due to brain injury), cerebral infarction (lack of blood supply to the brain resulting in brain death to parts of the brain), and aphasia (a disorder that affects speaking or understanding language) due to a stroke. Review of Resident 11's medical…

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

Based on review of the Resident Assessment Instrument User's Manual and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that a significant change Minimum Data Set assessment was completed for one of 32 residents reviewed (Resident 38). Findings include: The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which provides instructions and guidelines for completing required Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2023, indicated that a significant change MDS assessment (significant change - a major decline or improvement in a resident's status that meets specific criteria, including the initiation of hospice) was to be completed no later than 14 days from the date the significant change was identified. Physician's orders, dated July 8, 2024, for Resident 38 indicated that the resident was ordered hospice services related to a terminal prognosis of heart failure. There was no documented evidence that the facility completed a significant…

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

Based on review of the Resident Assessment Instrument User's Manual and clinical records, as well as staff interviews, it was determined that the facility failed to complete accurate comprehensive Minimum Data Set assessments for two of 32 residents reviewed (Residents 41, 59). Findings include: The Resident Assessment Instrument (RAI) User's Manual, which gives instructions for completing Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2023, indicated that Section P0200E was to be coded to capture the use of wander/elopement alarms. The section was to be coded zero (0) for not used, one (1) for used less than daily, or two (2) for used daily. Physician's orders for Resident 41, dated May 23, 2024, included orders for the resident to use a wanderguard alarm. Review of Resident 41's Treatment Administration Records (TAR) for June 2024 indicated that the resident used a wanderguard alarm for the entire month of June 2024. A quarterly MDS assessment for Resident 41, dated June 7, 2024, revealed that Section P0200E was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy and clinical records, as well as staff interviews, it was determined that the facility failed to develop and implement a comprehensive person-centered care plan for three of 32 residents reviewed (Resident's 15, 59, 285). Findings: A facility policy, dated December 1, 2023, revealed that the facility will develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 15, dated July 29, 2024, revealed that the resident was cognitively intact, required assistance from staff for her daily care needs, and had diagnoses that included a right below-the-knee amputation and diabetes. Observations of Resident 15 on August 12, 2024, at 12:30 p.m. revealed that the resident had a prosthetic leg in her room that she used…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record reviews, staff interviews, and observations, it was determined that the facility failed to clarify and/or obtain physician's orders for three of 32 residents reviewed (Residents 11, 59, 81). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 11, dated July 5, 2024, indicated that the resident was cognitively impaired, required assistance with care needs, and had a feeding tube (a mechanical device surgically implanted into the stomach to provide nutrition, fluids and medications to a person who is unable to eat or drink by mouth). Review of Resident 11's clinical record revealed special instructions that indicated she was to receive her medications through her feeding tube. Current physician's orders for Resident 11 included orders for the resident to receive two 325 milligrams (mg) tablets of Acetaminophen by mouth every four hours as needed for pain or fever, two 8.6 mg tablets of Senna (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 clinical record reviews and staff interviews, it was determined that the facility failed to perform a physical assessment after an elopement for one of 32 residents reviewed (Resident 29). Findings include: The facility's policy regarding elopements and wandering residents, dated December 1, 2024, revealed that when a resident elopes (leaves the premises without authorization), a registered nurse will perform a physical assessment upon return and document and report the findings to the physician. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 29, dated May 15, 2024, indicated that the resident was severely cognitively impaired, required assistance with daily care needs, and had diagnoses that included dementia with Lewy bodies (a progressive neurogenic disorder that leads to a decline in thinking, reasoning, memory and often includes sleep disturbances). A nursing note for Resident 29, dated December 29, 2023, at 3:04 a.m., indicated that the resident expressed that she was tired and wanted to go…

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

Based on review of facility policies and clinical record, as well as staff interviews, it was determined that the facility failed to ensure that fluid restrictions were being followed and documented per physician's orders and failed to ensure that a resident's weight was obtained and documented as per physician's order for one of 32 residents reviewed (Resident 4). Findings include: A facility policy regarding fluid restriction, dated December 1, 2023, indicated that the nurse will obtain and verify the physician's order for the fluid restriction, which will include the breakdown of the amount of fluid per 24 hours to be distributed between food, nutrition, and nursing departments, and will be recorded on the medication record or other format as per facility protocol. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 4, dated May 27, 2024, indicated that the resident was cognitively intact, required assistance with care needs, required supplemental oxygen, and had diagnoses that included congestive heart…

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

Based on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that residents were free from unnecessary psychotropic medications by failing to ensure that non-pharmacological (non-medication) behavioral interventions (individualized, non-pharmacological approaches to care) were attempted prior to the administration of as needed antianxiety medications for one of 32 residents reviewed (Residents 63). Findings include: The facility's policy regarding psychotropic medications (any medication that affects brain activities associated with mental processes and behavior), dated December 1, 2023, indicated that residents who use psychotropic drugs shall receive non-pharmacological interventions to facilitate reduction or discontinuation of the psychotropic drugs. Non-pharmacological interventions that have been attempted, and the target symptoms for monitoring, shall be included in the documentation. As needed orders for all for all psychotropic medications shall be used only when the medication is necessary to…

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

Based on review of physican's orders, as well as observations and staff interviews, it was determined that the facility failed to ensure that the facility's emergency controlled medications (narcotics) were properly secured in one of one medication rooms reviewed. Findings include: The facility's policy regarding the storage of medications, dated December 1, 2023, indicated that narcotic medications were to be stored behind a double lock and secured in a narcotics box in the refrigerator. Observations on August 12, 2024, at 1:55 p.m. revealed that the facility's emergency narcotic medications were stored in the medication room inside an unsecured refrigerator and could easily be removed from the medication room. Interview with Registered Nurse 2 on August 12, 2024, at 2:00 p.m. confirmed that the refrigerator containing the narcotic box was not secured to the refrigerator and that the narcotic box contained narcotics. Interview with the Assistant Director of Nursing on August 14, 2024, at 12:53 p.m. confirmed that the emergency narcotic medications should have been secured 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 review of facility policies, resident interviews, observations, and staff interviews, it was determined that the facility failed to serve food items at appetizing temperatures. Findings include: The facility's policy regarding food safety requirements, dated December 1, 2023, revealed that foods and beverages shall be distributed and served in a manner to prevent contamination, and food shall be maintained at a proper temperature and out of the danger zone. Observations on the 300 hall on August 12, 2024, at 11:15 p.m. revealed a cart with an opened half-gallon container of white milk, chocolate milk, cranberry juice, orange juice, and iced tea, as well as opened cans of soda that were not in cold containers. Observations on the 300 hall on August 14, 2024, at 12:11 p.m. revealed a cart with iced tea without a lid on it being stored on top of the cart and not in a cold container. There were also half-gallon containers of milk, juice, and iced tea being stored on top of cart both inside and outside of the cold containers. The milk container and several other containers were…

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

Based on review of policies, as well as observations and staff interviews, it was determined that the facility failed to store and prepare food in accordance with professional standards for food service safety. Findings include: The facility's policy regarding food labeling and dating, dated December 1, 2023, revealed that all foods stored in the refrigerator or freezer will be covered, labeled, and dated. Observations of the walk-in refrigerator on August 12, 2024, at 8:55 a.m. revealed an opened and undated container of cherries, three storage containers, one tray of peas, two pans of chicken, and one tray of breadsticks in a cart that were not dated. Observations of the walk-in freezer on August 12, 2024, at 9:10 a.m. revealed a half bag of onion rings, a half bag of french fries, and a bag containing three pitas that were opened and not dated or labeled. Interview with the Dietary Manager on August 12, 2024, at 9:13 a.m. confirmed that that the food items mentioned above should have been labeled and/or dated but were not. 28 Pa. Code 211.6(f) Dietary Services.

Based on review of the facility's plans of correction for previous surveys, and the results of the current survey, it was determined that the facility's Quality Assurance Performance Improvement (QAPI) committee failed to correct quality deficiencies and ensure that plans to improve the delivery of care and services effectively addressed recurring deficiencies. Findings include: The facility's deficiencies and plans of corrections for a State Survey and Certification (Department of Health) survey ending September 21, 2023, revealed that the facility developed plans of correction that included quality assurance systems to ensure that the facility-maintained compliance with cited nursing home regulations. The results of the current survey, ending August 14, 2024, identified repeated deficiencies related to accurate Minimum Data Set assessments, comprehensive and individualized care plans, professional standards, quality of care, tube feeding management, and food procurement. The facility's plan of correction for a deficiency regarding completing accurate MDS assessments, cited during…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of Pennsylvania's Nursing Practice Act, clinical records, and staff interviews, it was determined that the facility failed to clarify physician's orders for one of four residents reviewed (Resident 2). Findings include: The Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.11 (a)(1)(2)(4) indicated that the registered nurse was to collect complete and ongoing data to determine nursing care needs, analyze the health status of individuals and compare the data with the norm when determining nursing care needs, and carry out nursing care actions that promote, maintain, and restore the well-being of individuals. An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 2, dated June 17, 2024, indicated that he was understood and able to understand, required partial to moderate assistance with personal hygiene care, had diagnoses that included acute respiratory failure, and was receiving…

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

Based on review of facility policies and manufacturer's guidelines, as well as observations and staff interviews, it was determined that the facility failed to monitor medication refrigerator temperatures on one of two nursing units (300/400/500 unit). Findings include: The facility's policy regarding medication storage, dated December 1, 2023, indicated that all medications housed on the premises will be stored in the medication room according to manufacturer's recommendations and sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation and security. All medications requiring refrigeration will be stored within 36-46 degrees Fahrenheit. Charts are kept on each refrigerator, and temperature levels are recorded daily by the charge nurse or other designee. Observations of the first refrigerator in the 300/400/500 medication room on May 13, 2024, at 1:39 p.m. revealed three vials of Humalog insulin, three vials of Aplisol (tuberculosis skin testing solution), one vial of Lantus insulin, two Ozempic pens (medication used for diabetes), 1…

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

Based on review of facility policies, as well as observations and staff interviews, it was determined that the facility failed to ensure that food was served under sanitary conditions. Findings include: The facility's policy regarding personal hygiene, dated December 1, 2023, revealed that all dietary staff must wear hair restraints (e.g., hairnet, hat and /or beard restraint) to prevent hair from contacting food and to prevent contamination of food by food service employees. Observations in the main kitchen during service for the lunch meal on May 13, 2024, at 11:33 a.m. revealed that Dietary Aide 2 was placing meal tickets and silverware on the trays and Dietary Aide 3 was placing the food on the plates in the tray line. Dietary Aides 2 and 3 had hair nets on but they were not covering all their hair and there were strands of hair touching the backs of their necks. Interview with the Dietary Manager on May 13, 2024, at 1:24 p.m. confirmed that dietary staff should have their hair covered when working in the kitchen. 28 Pa. Code 211.6(f) Dietary Services.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the facility's policies and residents' clinical records, as well as staff interviews, it was determined that the facility failed to ensure that the resident's code status was clarified for one of seven residents reviewed (Resident 5). Findings include: The facility's policy regarding Physician Orders for Life Sustaining Treatment (POLST), dated [DATE], revealed that residents would be questioned upon admission about their preferences for resuscitation in the event of cardiac or respiratory arrest. The nurse will clarify physician discussions regarding the residents' diagnoses and prognosis with the resident and/or responsible party, as well as resuscitation status, existence of Advance Directives and/or Durable Power of Attorney. A stated desire to not have resuscitation instituted in the presence of a deteriorating, irreversible medical condition will be referred to the physician for discussion of the consequences of a DNR order. An annual Minimum Data Set (MDS) assessment (a mandated…

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

Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that a peripherally-inserted central catheter (PICC - a long, thin tube that is inserted through a vein in the arm and passed through to the larger veins near the heart) was flushed according to facility policy for one of seven residents reviewed (Resident 6). Findings include: The facility's policy regarding Intravenous Administration, dated December 1, 2023, revealed that the PICC line was to be flushed before and after each administration with 10 milliliters of normal saline. An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 5, dated April 25, 2024, revealed that the resident was cognitively intact, required assistance for daily care needs, and diagnoses that included osteomyelitis of the left foot (an infection in the foot) requiring intravenous medications. Physician's orders for Resident 6, dated May 7, 2024, included an order for the resident to receive 50 milligrams of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of facility policies, clinical record reviews, and staff interviews, it was determined that the facility failed to ensure that a resident's baseline care plan included information regarding the resident's immediate care needs for one of six residents reviewed (Resident 3). Findings include: A facility policy for baseline care plans, dated December 22, 2023, revealed that the facility will develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. The baseline care plan will be developed within 48 hours of a resident's admission. Review of clinical records for Resident 3 revealed that he was admitted to the facility on [DATE], with a diagnosis of muscle wasting, Parkinson's disease (disorder of the central nervous system that affects movement, often including tremors), and altered mental status. Physician's orders for Resident 3, dated March 11,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that a care plan was developed for discharge planning for three of six residents reviewed (Residents 1, 4, 6). Findings include: The facility's policy regarding care plans, dated December 22, 2023, indicated that an interdisciplinary team, in coordination with the resident, his/her family or representative (sponsor), would develop and maintain a comprehensive care plan for each resident. The comprehensive care plan would be designed to incorporate identified problem areas; incorporate risk factors associated with identified problems; build on the resident's strengths; reflect treatment goals and objectives in measurable outcomes; identify the professional services that are responsible for each element of care; prevent declines in the resident's functional status and/or functional levels; and enhance the optimal functioning of the resident by focusing on a rehabilitative program. A…

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

Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that long-term intravenous catheters were flushed according to the facility's policy for two of six residents reviewed (Residents 1, 3). Findings include: The facility's policy regarding Intravenous (IV) Administration, dated September 22, 2023, indicated that the catheter was to be flushed with 10 cubic centimeters (cc's) of normal saline (sterile salt and water solution) before and after each administration unless otherwise indicated by the physician. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated October 9, 2023, indicated that the resident was cognitively impaired, had a urinary tract infection, and received intravenous medications. A nursing note, dated October 1, 2023, at 3:59 p.m. revealed that the physician saw Resident 1 and orders were received to place an IV, as well as IV antibiotics. At 6:00 p.m. the IV nurse was unable to get IV access and 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.

Based on clinical record reviews and staff interviews, it was determined that the facility failed to complete a safety assessment to ensure that the use of a power lift chair did not create a safety hazard for one of four residents reviewed (Resident 1). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated August 9, 2023, revealed that the resident was cognitively impaired, required extensive assistance for daily care needs, and had diagnoses that included heart failure and repeated falls. A nurse's note for Resident 1, dated August 27, 2023, at 4:32 p.m. revealed that the resident had raised his lift chair causing him to sustain a fall from the chair. A nurse's note for Resident 1, dated August 31, 2023, at 5:50 p.m. revealed that the resident was found on the floor in front of his recliner, and the recliner was in the stand-up position. A nurse's note for Resident 1, dated October 25, 2023, revealed that the resident had the chair control near him and changed the position 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 reviews, as well as staff interviews, it was determined that the facility failed to ensure that the physician was notified timely about the unavailability of a medication for one of 47 residents reviewed (Resident 88) and failed to ensure that the physician was notified timely about elevated blood sugar results as well as holding insulin for one of 47 residents reviewed (Resident 89). Findings include: Physician's orders for Resident 88, dated September 14, 2023, included an order for the resident to receive one 81 milligram (mg) tablet of Enteric Coated Aspirin (used to reduce fever and relieve mild to moderate pain) one time a day. Physician's orders for Resident 88, dated September 14, 2023, included an order for the resident to receive one 0.1 mg tablet of Clonidine (used alone or together with other medicines to treat high blood pressure) in the morning and one 0.1 mg tablet of Clonidine in the evening. Physician's orders for Resident 88, dated September 14, 2023, included an order for the resident to receive one 75 mg tablet of Clopidogrel (Plavix -an…

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

Based on review of clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that residents were positioned appropriately while eating for one of 47 residents reviewed (Resident 46). Findings include: A Quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 46, dated July 19, 2023, revealed that the resident was sometimes understood, sometimes understands, required extensive assistance from staff for his daily care tasks including with eating, and had diagnoses that included dementia and Parkinson's. The resident's care plan, dated July 17, 2023, indicated that the resident had a potential for alteration in nutrition/hydration related to a self-feeding deficit due to a history of dementia and Parkinson's. Staff was to aid in eating meals as per order. Physician's orders for Resident 46, dated April 30, 2023, included an order for the resident to be positioned in his BRODA chair (a wheelchair that provides supportive positioning through a combination of tilt,…

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

Based on review of clinical records, as well as staff interviews, it was determined that the facility failed to ensure that residents received care and treatment in accordance with professional standards of practice, by failing to ensure that physician's orders were followed for three of 47 residents reviewed (Residents 31, 79, 88). Findings include: Physician's orders for Resident 31, dated September 17, 2023, included an order for the resident to receive one 500 mg tablet of Nitazoxanide (an antiviral medication) two times a day for three days. Review of the Medication Administration Record (MAR) for Resident 31, dated September 2023, revealed that staff documented that the 500 mg tablet of Nitazoxanide was not available for administration on the morning shift of September 18 and 19, 2023, and during the evening shift on September 18, 2023. A medication administration note for Resident 31, dated September 19, 2023, at 8:11 a.m. indicated that Nitazoxanide Oral Tablet 500 mg was not available from pharmacy and was on backorder. The physician was updated, will await further…

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 the review of the facility policies, as well as obervations and staff interviews, it was determined that the facility failed to ensure that food stored was properly dated and labeled. Findings include: The facility's policy for food storage, dated September 23, 2022, indicated that all products, once opened, will be dated and labeled. Observations of the dietary walk-in freezer on September 18, 2023, from 8:56 a.m. to 9:04 a.m. revealed undated and/or unlabeled items that were not in their original delivery box, including a bag of approximately fifteen chicken tenders. Observations in the dietary walk-in cooler revealed three to four ounces of sliced ham and six pizza shells that were opened and undated. Observations of the walk-in refrigerator revealed an approximately two-pound bag of cranberries opened and not dated. Observations of the dry storge room revealed a bag of orange cake mix and approximately eight ounces of country gravy mix powder that were opened and undated. Interview with the Culinary Director on September 18, 2023, at 9:41 a.m. confirmed that all items…

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

Based on review of the resident's record and staff interview, it was determined that the facility failed to exercise the rights of the resident representative for one of 47 residents (Resident 21). A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 21, dated August 8, 2023, revealed that the resident was cognitively impaired and had a diagnosis of dementia. Physician's orders for Resident 21, dated April 21, 2023, included an order for a regular diet, pureed texture with nectar thickened consistency liquids, and was permitted mechanical soft snacks/desserts as needed. A dietary note for Resident 21, dated July 24, 2023, revealed that the resident's Power of Attorney requested the resident be evaluated again by speech therapy in order to change her diet. There was no documented evidence that Resident 21 was evaluated by speech therapy per the Power of Attorney's request. Interview with the Director of Nursing on September 20, 2023, at 12:30 p.m. confirmed that there was no speech therapy evaluation as requested…

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

Based on review of the Resident Assessment Instrument Manual and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that quarterly Minimum Data Set assessments were completed within the required time frame for two of 47 residents reviewed (Residents 5, 12). Findings include: The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which provides instructions and guidelines for completing required Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2019, indicated that the assessment reference date (ARD - the last day of the assessment's look-back period) of a quarterly MDS assessment must be no more than 92 days after the ARD of the most recent assessment of any type, and the assessment was to have a completion date (Section Z0500B) that was no later than the ARD plus 14 calendar days. A quarterly MDS assessment for Resident 5 had an ARD of August 9, 2023, but it was not completed (Section Z0500B) until September 4, 2023. A quarterly MDS assessment…

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

Based on clinical record reviews and staff interviews, it was determined that the facility failed to transmit Minimum Data Set (MDS) assessments to the required electronic system, the Centers for Medicare, and Medicaid Services (CMS) Quality Improvement and Evaluation System (QIES) Assessment Submission and Processing (ASAP) System, within 14 days of completion for 15 of 47 residents reviewed (Residents 1, 2, 90, 91, 92, 93, 94, 95, 96, 97, 98, 99, 100, 101, 102) Findings include: The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which provides instructions and guidelines for completing required Minimum Data Set (MDS) assessments (federally mandated assessments of a resident's abilities and care needs), dated October 2018, indicated that comprehensive MDS assessments must be transmitted electronically within 14 days of the Care Plan Completion Date (V0200C2 + 14 days). All other MDS assessments must be submitted within 14 days of the MDS Completion Date (Z0500B + 14 days). Section Z0500B of a quarterly tracking MDS assessment for Resident 1 revealed…

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

Based on review of the Resident Assessment Instrument User's Manual and clinical records, as well as staff interviews, it was determined that the facility failed to complete accurate Minimum Data Set assessments for four of 47 residents reviewed (Residents 12, 46, 63, 71). Findings include: The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which provides guidance and instructions for the completion of Minimum Data Set (MDS) assessments (mandated assessments of residents' abilities and care needs), dated October 2019, revealed that Section N0350 (Insulin) was to be coded with the number of days the resident received an insulin injection (medication that helps control blood sugar) during the seven-day assessment period. A Quarterly MDS assessment for Resident 12, dated July 20, 2023, revealed that Section N0350 was coded (7), indicating that the resident received insulin injections during the seven-day assessment period. The Medication Administration Record (MAR) for Resident 12 for July 2023 revealed that the resident did not receive insulin injections.…

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 policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that a baseline care plan was developed and implemented for one of 47 residents reviewed (Resident 88). Findings include: The facility's policy regarding baseline care plans, dated September 23, 2022, revealed that the facility will develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meets professional standards of quality of care. The baseline care plan will: Be developed within 48 hours of a resident's admission. Include the minimum healthcare information necessary to properly care for a resident including, but not limited to initial goals based on admission orders; physician's orders; dietary orders; therapy services, and social services. The admitting nurse or supervising nurse on duty shall gather information from the admission, physical assessment, hospital transfer information, physician's orders, and discussion with the…

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

Based on clinical record reviews and staff interviews, it was determined that the facility failed to ensure that resident-centered care plans were developed and implemented for three of 47 residents reviewed (Residents 5, 63, 79). Findings include: The facility's policy regarding care plans, dated September 23, 2022, indicated that the facility would develop a written plan of care that was individualized for each resident's daily care routines and would be reviewed and revised as necessary and when a resident experiences a status change. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs for Resident 5, dated August 9, 2023, revealed that the resident was cognitively intact and required minimum assistance from staff for his care. Physician's orders for Resident 5, dated September 17, 2023, included an order for Azithromycin (an antibiotic) and Prednisone (steroid used to decrease inflammation) to treat Bronchitis (an acute inflammation of the airways leading to the lungs). Interview with Resident 5 on September 18, 2023, at…

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

Based on review of Pennsylvania's Nursing Practice Act, facility policy, and clinical record reviews, as well as staff interviews, it was determined that the facility failed to ensure that a professional (registered) nurse assessed a resident after a change in condition for two of 47 residents reviewed (Residents 1, 63). Findings include: The Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing 21.11 (a)(1)(2)(4) indicated that the registered nurse was responsible for assessing human responses and plans, implementing nursing care, analyzing/comparing data with the norm in determining care needs, and carrying out nursing care actions that promote, maintain, and restore the well-being of individuals. An annual Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated July 11, 2023, revealed that the resident was cognitively impaired and required extensive assistance from staff for daily care needs. A nursing note for Resident 1, dated July 9, 2023, indicated that the resident…

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

Based on review of policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to provide appropriate care to prevent urinary tract infections for one of 47 residents reviewed (Resident 80) who had an indwelling urinary catheter (a thin, hollow tube inserted through the urethra into the urinary bladder to collect and drain urine). Findings include: The facility's policy for urinary catheter care, dated September 23, 2022, indicated that the resident's plan of care will include strategies to prevent complications, and that catheter drainage bags will be covered at all times while in use. A diagnosis record for Resident 80, dated September 13, 2023, included UTI (urinary tact infection) and urinary retention (bladder does not empty properly). A physician's order for Resident 80, dated September 14, 2023, included an order for a catheter size 18 French with 10 cubic centimeter (cc) balloon to straight bag gravity drainage for urinary retention. Observations of Resident 80 sitting in her recliner on September 18, 2023, at 11:15…

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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of clinical records, as well as staff interviews, it was determined that the facility failed to monitor enteral feeding residuals for one of 47 residents reviewed (Resident 14). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 14, dated August 2, 2023, revealed that the resident was cognitively impaired and required extensive assistance from staff for her daily care needs. Resident 14 was dependent on enteral feeding for nutrition and had a gastrostomy tube (tube placed in stomach for provision of nutritional feedings). Physician's orders for Resident 14, dated August 24, 2023, included an order for the resident to receive an enteral feeding (a method of supplying nutrients directly into the gastrointestinal tract via a tube that has been surgically placed in the stomach) of Two Cal HN liquid at 50cc per hour for 12 hours for a total of 600 ml. Resident 14 was admitted to the hospital on [DATE], for a…

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

Based on review of clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that a resident's respiratory status was properly monitored as ordered for one of 47 residents reviewed (Resident 63). Findings include: An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 63, dated July 17, 2023, revealed that the resident was understood, could usually understand others, required extensive assist with daily care needs, and had diagnoses that included dementia. Physician's orders for Resident 63, dated August 27, 2023, included an order for the resident to receive oxygen at 2 liters per minute for shortness of breath or to maintain oxygen saturations (the measure of how much oxygen is traveling through your body in your red blood cells) greater than or equal to 92 percent. A review of Resident 63's vital sign records for August and September 2023 revealed no documented evidence that the resident's oxygen saturation was obtained to determine if she required…

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

Based on clinical records reviews, as well as staff interviews, it was determined that the facility failed to provide medication as ordered by the physician, resulting in significant medication error for one of 47 residents reviewed (Resident 88). Findings include: Physician's orders for Resident 88, dated September 14, 2023, included an order for the resident to receive 40 units of Insulin Glargine (Lantus - a long-acting insulin) one time a day. Resident 88's Medication Administration Record (MAR) for September 2023 revealed no documented evidence that the resident was administered the 40 units of Insulin Glargine on September 15, 2023. Physician's orders for Resident 88, dated September 14, 2023, included an order for the resident to receive Insulin Aspart (Novolog - a rapid-acting insulin) based on a sliding scale (the amount of insulin is based on the result of a fingerstick blood sugar test) before meals and at bedtime. The sliding scale included giving 4 units of insulin for a blood sugar of 181-200 milligrams per deciliter (mg/dL), 6 units for a blood sugar of 201-250 mg/dL,…

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 hospice contracts and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that the designated interdisciplinary team member obtained the required information from the contracted hospice provider for one of 47 residents reviewed (Resident 63). Findings include: The current agreement between the facility and hospice provider (provider of end-of-life services) indicated that the hospice provider would provide information to the facility to facilitate coordination of care that included the most recent hospice plan of care specific to each patient, physician certification or recertification, and a hospice benefit of elections form (a form signed to indicate that the individual waives all rights to traditional Medicare Part A payments for treatment related to the terminal illness). Physician's order for Resident 63, dated July 10, 2023, revealed that the resident was receiving hospice services for dementia. As of September 19, 2023, there was no documented evidence in the resident's clinical record, or in the hospice…

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

Based on review of the facility's plans of correction for previous surveys, and the results of the current survey, it was determined that the facility's Quality Assurance Performance Improvement (QAPI) committee failed to ensure that corrective plans to improve and/or correct quality deficiencies effectively addressed recurring deficiencies and ensured that the facility maintained compliance with nursing home regulations. Findings include: The facility's deficiencies and plans of correction for a State Survey and Certification (Department of Health) survey ending October 12, 2022, revealed that the facility developed plans of correction that included quality assurance systems to ensure that the facility maintained compliance with cited nursing home regulations. The results of the current survey, ending September 21, 2023, identified repeated deficiencies related to developing and implementing comprehensive care plans, quality of care, being free from significant medication errors, food procurement-storing, preparing and serving food under sanitary conditions, and infection…

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

Based on review of policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that proper infection control practices were followed during medication administration for one of 47 residents reviewed (Resident 45). Findings include: The facility's policy regarding medication administration, dated September 23, 2022, indicated that staff were to follow established infection control procedures in a manner to prevent contamination or infection. Current physician's orders for Resident 45 included orders for 81 milligrams (mg) of aspirin (promotes heart health)daily, 75 mg of plavix (prevents blood clots) daily, one chewable calcium with vitamin D3 (promotes bone health) twice a day, 40 mg of lasix (reduces fluid from the body) daily, 100 mg of colace (softens stool) twice a day, 10 mg of zetia (decreases cholesterol) daily, 10 mg of farxiga (improves blood sugar control) daily, 40 mg of protonix (reduces stomach acid) daily, 50 mg of metoprolol tartrate (lowers blood pressure) twice a day, and 600 mg of guaifenesin…

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.