Lock Haven Rehabilitation And Senior Living

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff interview, it was determined the facility failed to ensure that a resident with a limited range of motion received appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion for two of 29 residents reviewed (Residents 9 and 17).Findings Clinical record review revealed the facility readmitted Resident 9 on June 2, 2025. Review of Resident 9's most recent MDS (Minimum Data Set, an assessment completed at specific intervals to determine care needs) dated September 7, 2025, noted staff assessed Resident 9 as having impairment to his range of motion (ROM, movement of the body to maintain a resident's ability) of his bilateral lower extremities. Review of Resident 9's plan of care-initiated June 23, 2023, revealed Resident 9 has a potential for decreased function in functional abilities due to dementia, immobility, poor attention span, weakness, and deconditioning. An intervention the facility noted was may participate…

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 interview, 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 dressing changes for four of four employees reviewed for competencies (Employees 7, 8, 9, and 10). Findings The Centers for Medicare and Medicaid Services (CMS) QSO-24-13-NH memo dated June 18, 2024, noted that requirements specify that the facility assessment must include an evaluation of diseases, conditions, physical or cognitive limitations of the resident population, acuity (the level of severity of residents' illnesses, physical, mental, and cognitive limitations, and conditions) and any other pertinent information about the resident population as a whole that may affect the services the facility must provide. The assessment of the resident population should drive staffing decisions and inform the facility about what skills and competencies staff must possess to deliver the necessary care required by the residents being served. 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 a review of Resident Council meeting minutes, resident grievances, and resident and staff interview, it was determined that the facility failed to resolve resident complaints regarding laundry services on three of four nursing units (Units 2, 3, and 4; Residents 5, 6, 12, 38, 93, 95, 108, and 115). Findings include: A review of Resident Council meeting minutes dated July 16, 2025, revealed residents voiced concerns at the meeting regarding resident laundry being backed up and residents were missing their clothing, blankets, and other personal items. A review of the Resident Council meeting minutes dated August 13, 2025, revealed environmental services was going to introduce a new laundry system bag and tag, (place all resident laundry in mesh bag in the room and wash to keep it together), and a lost and found display was to be set up for residents to claim items. Review of facility resident/family grievance/concern forms for July 2025, revealed concerns regarding laundry being wrinkled, missing/lost clothes, and not getting clothing returned when sent to laundry to 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff interview, it was determined that the facility failed to ensure assessments accurately reflected a resident's status for two of 29 residents reviewed (13 and 30). Findings include:Clinical record review for Resident 30 revealed a quarterly MDS (Minimum Data Set, an assessment tool completed at specific intervals to determine resident care needs) dated July 3, 2025, that facility staff assessed Resident 30 as receiving an anticoagulant medication during the last seven days in the assessment period. Further clinical record review revealed no evidence that Resident 30 received an anticoagulant medication during the assessment period for the MDS noted above. Interview with the Director of Nursing on September 19, 2025, at 9:49 AM confirmed that Resident 30's July 3, 2025, MDS was coded in error regarding receiving an anticoagulant medication. Clinical record review for Resident 13 revealed an annual MDS assessment dated [DATE]. Review of the assessment revealed that 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 clinical record review, and resident and staff interview, it was determined that the facility failed to provide appropriate treatment and services regarding incontinence care for one of one resident reviewed (Residents 5). Findings include: Interview with Resident 5 on September 17, 2025, at 11:42 AM revealed that she has repeated issues with getting a urinary tract infection (UTI) and that she is scheduled to see a urologist but not until after the first of the year. She also indicated that she does not get help and that she feels as though she is not always able to get herself clean. Clinical record review for Resident 5 revealed a diagnosis of stress incontinence (when movement or activity puts pressure on the bladder causing urine to leak) and urge incontinence (an uncontrollable urge to pee). She also has chronic cystitis with hematuria (inflammation of the bladder accompanied by blood in the urine). Further clinical record review for Resident 5 revealed that she had a UTI on April 8, 2025, that revealed greater than 100,000 Escherichia (E. coli, a type of bacteria)…

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 employee personnel record review and staff interview, it was determined that the facility failed to complete a performance evaluation of each nurse aide at least once every 12 months for one of two nurse aides reviewed (Employees 6).Findings include: The facility noted Employee 6, nurse aide, was hired on September 5, 2023. A request to review the annual performance evaluations (EPR, employee performance review) revealed no documented evidence that the facility completed performance evaluations for Employee 6 at least once every 12 months. Interview with the Director of Nursing on September 18, 2025, at 10:14 AM confirmed that Employee 6's performance evaluation was not completed annually. 28 Pa. Code 201.19 (2) Personnel policies and procedures

Based on clinical record review, observation, and staff interview, it was determined that the facility failed to assist residents to obtain routine dental care for one of three residents reviewed (Resident 1). Findings include: Observation of Resident 1 on September 16, 2025, at 9:55 AM revealed that she had natural teeth, with several teeth that appeared to be broken. Clinical record review revealed the facility admitted Resident 1 on December 10, 2024, with payment sources that included the state Medicaid benefit. Further review of Resident 1's clinical record revealed that she has not been offered dental care. Review of Resident 1's admission MDS (Minimum Data Set, an assessment completed at specific intervals to determine resident care needs) dated December 13, 2025, revealed staff assessed Resident 1 as having obvious or likely cavities or broken natural teeth. Further review of Resident 1's clinical record revealed a plan of care initiated December 17, 2024, noting Resident 1 has impaired dentition related to carious teeth. There was no documentation that indicated Resident 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 observation, clinical record review, and staff interview, it was determined that the facility failed to implement appropriate Transmission Based Precautions (TBP) for one of four residents reviewed on TBP (Resident 135).Findings included: Review of the facility's current policy entitled Categories of Transmission Based-Based Precautions revealed Transmission-Based Precautions will be used whenever measures more stringent than standard based precautions (gloves and hand hygiene), are needed to prevent or control the spread of infection. The policy also indicated that Contact Precautions would be implemented for residents known or suspected to be infected or colonized with microorganisms that can be transmitted by direct contact with the resident or indirect contact with environmental surfaces or resident-care items in the resident's environment. Examples of infections requiring Contact Precautions included diarrhea associated with Clostridium difficile (C diff - bacteria that causes an infection of the colon). Steps for administering the contact precautions indicated 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 a review of employee personnel and education records and staff interview, it was determined that the facility failed to ensure that each nurse aide received 12 hours of in-service training annually for one of one nurse aide reviewed (Employee 6). Findings include: Review of Employee 6's personnel record revealed that the facility hired her on September 5, 2023. The surveyor requested training records for Employee 6 during an interview with the Nursing Home Administrator and the Director of Nursing on September 17, 2025, at 2:15 PM. Review of training records provided by the facility for Employee 6 dated September 5, 2024, to September 5, 2025, revealed that Employee 6 completed only 8.6 hours of in-service education. Interview with the Director of Nursing on September 19, 2025, at 9:48 AM confirmed the above findings for Employee 6. 28 Pa. Code 201.19(7) Personnel policies and procedures 28 Pa. Code 201.20(a)(6)(d) Staff development

Based on staff interview and clinical record review, it was determined that the facility failed to ensure that a medication was available in a timely manner for two of four residents reviewed for medication availability concerns (Residents CR1 and 2). Findings include: Closed clinical record review for Resident CR1 revealed a physician's order dated August 7, 2024, for the resident to be administered insulin glargine (a long-acting insulin medication used to control blood sugar levels) to be administered/injected via an insulin pen 30 units two times a day for a diagnosis of diabetes (a disease effecting the body's ability to control blood sugar levels). Resident CR1 was also ordered blood sugar checks before meals and at bedtime for use of sliding scale insulin. Review of Resident CR1's medication administration record for January 2024, revealed Resident CR1's evening dose of routine insulin glargine noted above for January 3, 2025, was identified as not administered. A corresponding medication administration record note dated January 3, 2025, at 8:26 PM noted the insulin was not…

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

Based on observation and staff interview, it was determined that the facility failed to store and serve food in accordance with professional standards for food service safety and sanitation to prevent the potential for food borne illness in the facility's main kitchen. Findings include: An observation of the facility's main kitchen on October 15, 2024, at 9:40 AM revealed the following: A large storage area located outside the entrance to the kitchen containing a milk cooler, storage cabinets, bread products and other storage, contained dried food and dirt debris on the flooring under the pieces of equipment and along wall and equipment edges where they meet the floor. An ice scoop was observed stored on the side of the ice machine totally open to air and potential contaminants. The exterior of the convection ovens contained significant dust and debris buildup on the top of the ovens and control panels. The wall behind the oven, fryer, and stove top area contained dried food splatter. The flooring under and behind the equipment contained significant debris. The drain on the front 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 clinical record review and staff interview, it was determined that the facility failed to establish clear and consistent resident wishes regarding advance directives or provide resident's an opportunity to formulate an advance directive for nine of 16 residents reviewed for advance directives (Residents 5, 14, 18, 20, 53, 61, 112, 126, and 238). Findings include: Clinical record review for Resident 61 revealed a physician's order dated [DATE], indicating the resident was a full code, which would include CPR (cardiopulmonary resuscitation). Other than an order for resuscitation, there was no evidence Resident 61 was provided written information on advance directives (written instruction, such as a living will or durable power of attorney, relating to the provision of healthcare for a resident that may be incapacitated and not able to make decisions) or assisted with the opportunity to formulate advance directives regarding treatment in the event Resident 61 could not make decisions regarding her health…

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 staff and resident interview, it was determined that the facility failed to provide adequate housekeeping and maintenance services to maintain a clean and orderly environment on three of four nursing units (Unit 1, 2, and 3; Residents 14, 18, 23, 86, 106, and 116). Findings include: Observation of Resident 106's room on October 15, 2024, at 12:47 PM revealed the resident was out of bed in her specialty chair. The chair had dried food, dried spills, dust, and debris on the arms of the chair and metal frame. The sheets on the resident's bed were observed with brown stains and food crumbs on the bed. The flooring was observed with dried liquid spots and black smudges. A fall mat folded at the front of the room was covered in dust, debris, and dried liquid spills. Two tray tables observed in the room contained dried food, dried spills, and a significant amount of adhesive residue all around the perimeter of the tray tables. Significant crumbs and debris were observed on the floor around the air conditioning unit. The corner of the wall near the resident's…

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

Based on review of select facility policies and procedures, clinical record review, and staff interview, it was determined that the facility failed to provide care and services identified to reduce a resident's decline in ADL's (activities of daily living) for three of three residents reviewed (Residents 29, 34, and 128). Findings include: Clinical record review for Resident 29 revealed that she had a diagnosis of a stroke which affected her left side. There was a current physician's order for staff to complete a restorative nursing program (RNP) of ADL tasks for self-grooming with set up and upper body dressing with extensive assist. Review of Resident 29's task documentation revealed that staff did not complete the RNP self-grooming task on the following dates: Day Shift: July 1, 4, 5, 14, and 25, 2024 August 2, 3, 5, 24, and 31, 2024 September 1, 6, 7, 8, and 16, 2024 October 6, 13, and 15, 2024 Evening Shift: July 7, 2024 August 17 and 26, 2024 September 9, 2024 October 8, 2024 Further review of Resident 29's RNP self-grooming task revealed that staff documented NA (not…

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

Based on clinical record review and staff interview, it was determined that the facility failed to provide the highest practicable care regarding physician ordered weights and vital signs for two of 27 residents (Residents 34 and 123). Findings include: Clinical record review for Resident 34 revealed physician orders for staff to administer and complete the following: From July 11, 2024, to October 14, 2024, check blood pressure (BP) and heart rate (HR) between 11:00 AM and 12:00 PM on Wednesdays. Call the physician if the systolic blood pressure (SBP, when the heart contracts) was less than 100 mmHg (millimeters of mercury) or the HR was greater than 120 BPM (beats per minute) or less than 60 BPM. Call results to the physician once weekly. From August 17, 2024, to October 10, 2024, Nifedipine Extended Release (ER) 24 hour 30 mg (milligrams) two tablets by mouth (PO) daily (QD) for Hypertension. Hold for SBP less than 110 mmHg. On August 6, 2024, Losartan Potassium 50 mg PO every 12 hours for BP. Hold if SPB is less than 110 mmHg. On October 10, 2024, Hydralazine 25 mg PO every…

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 seven of nine residents reviewed for hospitalizations (Residents 5, 14, 35, 79, 87, 104, and 131). Findings include: Clinical record review revealed that Resident 131 was transferred to the hospital on August 22, 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 the resident's responsible party upon transfer out to the hospital. Clinical record review revealed that Resident 5 was transferred to the hospital on August 18, 2024, and September 10, 2024, after she had a change in condition. There was no documentation available that the facility provided written notice regarding a bed hold to the resident and the resident's responsible party upon transfer out to the hospital. Clinical record review revealed that Resident 14 was transferred 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 clinical record review 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 two of two residents reviewed (Residents 78 and 86). Findings Include: Clinical record review for Resident 78 revealed an annual MDS (Minimum Data Set, an assessment completed at intervals by the facility to determine care needs) dated September 6, 2024, that indicated it is somewhat important to him to have books, newspapers, and magazines, to listen to music, to be around pets, keep up with the news, and to do his favorite activity. Review of Resident 78's current care plan entitled, adjustment to group living/activities related to new admission failed to address any of the activities that were somewhat important to him or identify what his favorite activity was to incorporate it into his activity plan. Clinical record review for Resident 86 revealed an annual MDS dated [DATE], that indicated it is…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, review of select facility policies and procedures, and staff interview, it was determined that the facility failed to assess and implement treatment and services to prevent the development and promote the healing of pressure ulcers for two of five residents reviewed for pressure ulcer concerns (Residents 104 and 14). Findings include: The facility policy entitled Pressure Injury Prevention and Treatment, last reviewed without changes January 2024 revealed each resident will be assessed routinely to prevent skin breakdown, provide appropriate treatment, and monitor healing progress. A Braden Pressure Injury Risk Assessment and identification of primary risk factors will be completed to identify residents individual risk needs related to the development of pressure injury. This assessment will be completed within eight hours of admission, quarterly, annually, and with each significant change in condition. The weekly skin assessment will be completed by the licensed nurse 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 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 one of two residents reviewed (Resident 78). Findings include: Clinical record review for Resident 78 revealed the facility admitted him on May 11, 2023, with a diagnosis of dementia (loss of memory, language, problem-solving, and other thinking abilities that interfere with daily life). A review of Resident 78's most recent annual Minimum Data Set Assessment (MDS, a form completed at specific intervals to determine care needs) dated September 6, 2024, indicated that the facility assessed Resident 78 as having a diagnosis of dementia and his cognition was moderately impaired. A review of Resident 78'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 loss. Interview with the Director of Nursing on October 17, 2024, at 3:15 PM confirmed 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, review of select facility policies, 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 two of five residents reviewed for transmission-based precaution concerns (Residents 19 and 288). Findings include: Review of the facility policy entitled Infection Control Plan, last approved September 6, 2024, indicated the infection control plan is comprehensive in that it addresses detection, prevention, and control of infections among residents and personnel and all staff are responsible for adhering to the plan, policies, and processes regardless of their position. The policy also indicated Transmission-Based Precautions (TBP) are the second tier of basic infection control and are used in addition to standard precautions for patients who may be infected or colonized with certain infectious pathogens for which additional precautions are needed requiring a gown and gloves for room entry 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 observation and staff and resident interview, it was determined that the facility failed to provide adequate housekeeping and maintenance services to maintain a clean and orderly environment on three of four nursing units (Unit 1, 2, and 3, Residents 1, 2, 3, 5, 6, and 9). Findings include: Observation of the shared room for Resident's 3 and 6 on August 8, 2024, at 11:00 AM revealed the flooring appeared dull and dirty. Dried food and debris were observed under Resident 6's recliner and under the head of bed against the wall. Resident 6 indicated housekeeping does sweep and mop the room. Pieces of cereal and dried food and debris were observed inside the heating/air conditioner through the top vent located beside Resident 6's recliner. An observation of Unit 1 and Unit 2 nursing units on August 8, 2024, at 11:11 AM revealed tile flooring of the hallways outside resident rooms and nursing stations appeared dirty, significantly blackened with black spots and streaks throughout the flooring. Observation of Resident 9's room on August 8, 2024, at 11:20 AM revealed the tile…

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, review of pest control logs, and interviews with residents and staff, it was determined that the facility failed to maintain an effective pest control program on two of four nursing units (Unit Two, Unit Three, Residents 3, 6, 1, and 2). Findings include: A review of facility resident council minutes from a July 17, 2024, meeting it was noted Resident 3 stated there was a mouse in the heater of her room making messes. In an interview with Resident 3 on August 8, 2024, at 11:00 AM the resident stated she had not heard a mouse lately. In a concurrent interview with Resident 6, Resident 3's roommate who resides in the bed next to the window and heating/air conditioner unit, Resident 6 stated she has recently had mice in her room and pointed under her recliner and towards the head of the bed. Some food crumbs and paper wrappers were observed under the recliner base and towards the head of bed. Observation of the heating/air conditioner unit through the top vent revealed broken pieces of cereal…

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 two of four nursing units (Unit 3 and 4; Residents 3, 5, 6, and 7). Findings include: Observation of the facility on June 10, 2024, revealed concerns upon entry to Unit 4 at 3:42 PM. There was a faint underlying smell of urine with the urine smell becoming more notable/strong when nearing Resident 6's room and continued to Resident 5 and 7's room. Upon entering Resident 5 and 7's room a strong smell of urine was noted. When Resident 7 self-propelled into the room while speaking with Resident 5, the urine smell intensified. Undetermined spots and stains were noted in front of Resident 5's bed and to the right of Resident 7's recliner. Interview with Resident 5 and her roommate Resident 7 on June 10, 2024, at 3:43 PM acknowledged their floor had unknown spots and stains that were sticky. Resident 5 revealed their floors aren't mopped/cleaned very often. Interview with Resident 3…

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 and resident and staff interview, it was determined that the facility failed to ensure accurate and complete clinical documentation for three of 17 residents reviewed (Residents 2, 8, and 10). Findings include: Interview with Resident 8, on March 26, 2024, at 9:15 AM revealed that she continues to have issues with staff not washing her up in the mornings. Resident 8 indicated that she is incontinent overnight, and that nursing staff will not wash her properly in the morning but only hand her a washcloth and tell her to wash her face, then dress her. Resident 8 indicated that it happened this morning and keeps happening. Review of a grievance filed February 20, 2024, indicated that Resident 8 was not washed and that the nurse only dressed her. A grievance filed on March 19, 2024, again indicated that Resident 8 laid in piss all night and that she was not washed up this morning and that it has been happening all week. Review of Resident 8's clinical record revealed no documented evidence to indicate that AM care (morning care provided to get them…

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 pest control logs, and interviews with residents and staff, it was determined that the facility failed to maintain an effective pest control program on one of three nursing units (Unit Three, Residents 1 and 3). Findings include: Interview with Resident 1 on March 26, 2024, at 9:30 AM revealed that he sees mice come in his room all the time. Resident 1 indicated that the mice enter his room from the hallway. Interview with Employee 1, licensed practical nurse, on March 26, 2024, at 9:40 AM confirmed that staff are seeing mice on Unit Three all the time and mostly at night. Review of the facility's pest control logs revealed that a contracted company is coming in monthly. The pest control being completed monthly is spraying the baseboards in the kitchen and basement and placing exterior bait stations. There was no evidence to indicate that the pest control company was providing interior pest control to eradicate mice. Interview with Employee 2, director of maintenance, on March 26, 2024, at 10:00 AM confirmed that the facility has not spoken to the…

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

Based on review of select policies and procedures and staff interview, it was determined that the facility failed to implement their abuse policy regarding reporting to the proper state agencies for misappropriation of resident property for five of 17 residents reviewed (Residents CR1, 4, 5, 6 and 7). Findings include: The policy entitled Abuse, last reviewed on July 6, 2023, indicates that the facility will ensure that all alleged violations involving misappropriation of resident property are reported immediately to the state survey and certification agency. Further reporting to law enforcement agencies will be initiated for misappropriation of resident funds and/or property. Interview with Employee 4, assistant director of nursing, on March 26, 2024, at 8:45 AM confirmed that the facility just recently investigated an incident where a large number of narcotics went missing. Review of the facility's investigation indicated that on February 19, 2024, it was noted that 60 tablets of Resident 7's hydrocodone/acetaminophen (a narcotic pain reliever) and 60 tablets of Resident 4'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 observations and staff and resident interview, it was determined that the facility failed to provide a clean, comfortable environment on two of four nursing units (Unit 3 and Unit 4; Residents 24, 81, 92, 119, and 124). Findings include: Observation of the Unit 4 Nursing Unit on October 31, 2023, at 12:00 PM and again on November 1, 2023, at 11:44 AM revealed two blue resident chairs in front of the elevators that had various white, dried stains. Observation of Resident 92's sink on November 1, 2023, at 10:47 AM revealed a large eight inch by eight inch damaged area of wall under the sink. The wall directly above the heating / air conditioning unit under the window was damaged and crumbling. Observation of the Unit 4 Nursing Unit shower room on November 1, 2023, at 12:20 PM revealed the following: A shower gurney had a significant accumulation of debris and hair under the white overlying padding. There were also brown colored stains on the blue fabric of the shower gurney underneath the padding. Two Tango shower chairs had a significant accumulation of hair in each wheel 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 clinical record review and staff and resident interview, it was determined that the facility failed to implement a restorative range of motion therapy program for five of six residents reviewed (Residents 18, 79, 81, 96, and 107). Findings include: Review of Resident 107's clinical record revealed that she was on occupational therapy caseload from July 22, 2023, until August 6, 2023, at which time Resident 107 was discharged from occupational therapy. Review of the occupational therapy Discharge summary dated [DATE], indicated that the occupational therapy discharge recommendations was to establish a restorative range of motion program by implementing active range of motion to Resident 107's bilateral upper extremities. There was no documented evidence in Resident 107's clinical record to indicate that the recommended occupational therapy restorative program was established. Occupational therapy documentation from September 24, 2023, until October 14, 2023, indicated that Resident 107 was 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 review of select facility policies, 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 two of four residents reviewed (Residents 29 and 40). Findings include: The facility policy entitled, Pain Management Guidelines, last reviewed without changes in January 2023, revealed that the facility identified 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 seven, and severe pain was identified as eight to 10. The facility policy entitled, Monitoring Usage of PRN (as needed) Pain Medication, last reviewed without changes on January 2023, revealed that the facility will monitor and review PRN pain drugs bi-monthly. Clinical record review for Resident 29 revealed physician's orders for the following pain medications: Ordered on August 29, 2023, Tylenol 325 milligrams (mg) 2 tablets by mouth (PO) every 6 hours PRN for mild…

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, review of select facility policies and procedures, and staff interview, it was determined that the facility failed to ensure a medication error rate below five percent (Residents 11, 62, and 88). Findings include: The facility's medication error rate was 11.54 percent based on 26 medication opportunities with three medication errors. The policy entitled Medication Administration, last reviewed in January 2023, indicates that medications are administered by licensed staff, as ordered by the physician, and in accordance with professional standards of practice, in a manner to prevent contamination or infection. Administer medication as ordered in accordance with manufacturer's specifications. Observation of a medication administration pass on October 31, 2023, at 9:01 AM revealed Employee 1, licensed practical nurse, preparing to administer Insulin Aspart (an injectable insulin to treat diabetes) two units to Resident 11. Employee 1 administered the Insulin Aspart to Resident 11 one hour and 15 minutes after she was served her breakfast.…

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 staff interview, it was determined that the facility failed to store food items and maintain equipment in a safe and sanitary manner in the facility's main kitchen. Findings include: A tour of the facility's main kitchen with Employee 7 (Interim General Manager of the Kitchen) on October 31, 2023, at 9:10 AM revealed the following: A meat slicer was covered with dust. The dry goods storage area had the following open items that were not labeled with open dates: bag of cream of wheat, a bag of noodles, a bag of thick and easy thickener. There was a large plastic storage container with a white product that Employee 7 identified as flour. There was no label or dates on the product. The oven, steamer, and hot holder appliances had a build-up of dust and debris on the top of each unit. The hot holder had various hot pads that Employee 7 identified as clean. The hot pads had various stains on them. The spice storage area had a large container of parsley flakes and a box of corn starch that were both open with no open date on the products. There were multiple brown…

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, observation, and staff interview, it was determined that the facility failed to implement measures to prevent the potential spread of infections for one of five residents reviewed for infections (Resident 7) and the main laundry unit of the facility. Findings include: Review of an annual MDS (minimum data set, an assessment tool design to direct the plan of care) for Resident 7 dated August 16, 2023, revealed that the resident was always incontinent (loss of bladder control) of urine. Review of a report of a urine culture for Resident 7 dated August 27, 2023, indicated the resident had under 100,000 colonies/milliliter Escherichia coli ESBL (extended spectrum beta lactamase, chemicals produced due to certain type of bacteria, a person infected with ESBL can be a carrier and spread the bacteria to others, which is difficult to treat with antibiotics) producing organism. The report indicated the person may require isolation (special precautions to prevent the spread of infection) and directed the facility to contact…

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

Based on clinical record review, observation, and resident and staff interview, it was determined that the facility failed to accommodate resident needs regarding the accessibility to a call bell for one of 28 residents reviewed (Resident 62). Findings include: Interview and observation with Resident 62 on October 31, 2023, at 2:00 PM revealed the resident was sitting in a motorized wheelchair that she can operate on the window side of the bed. The call bell was on the other side of the bed at the head of the bed on the floor. Resident 62 said she would not be able to reach the call bell to pull it off the floor. Resident 62 said that she asked for a clip for the call bell and bed remote as they often fall on the floor. Interview and observation with Resident 62 on November 1, 2023, at 8:43 AM revealed the resident was in bed eating breakfast. The call bell was hanging over the right side of the bedrail out of the resident's reach. Concurrently, the surveyor found Employee 5, nurse aide, in the hallway and informed her the call bell was out of reach. On return to Resident 62's room,…

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 store supplemental oxygen equipment per professional standards of practice for one of six residents reviewed (Resident 114). Findings include: A review of current physician orders for Resident 114 revealed an order dated August 24, 2023, that noted oxygen via nasal cannula (medical tubing with two nasal prongs used to deliver supplemental oxygen into the nose) at two liters per minute to keep the resident's oxygen saturation above 90 percent. Another physician order dated August 24, 2023, instructed staff to change the oxygen equipment every Thursday on night shift for infection control purposes change oxygen equipment every Thursday on 11-7 every night shift every Thu for infection control. The current care plan for Resident 114 revealed the resident has a potential for an altered respiratory status / difficulty breathing / shortness of breath related to the medical history. An intervention is to administer oxygen as ordered. Observation on October 31, 2023, at 11:16 AM…

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 assess the resident for the need for side rails and risk of side rail entrapment for one of three residents reviewed (Resident 28). Findings include: Observation and interview on November 1, 2023, at 11:05 AM revealed Resident 28 had enabler bars (side rails) on both sides of the bed. Resident 28 indicated that he uses the bars to move in bed and help him get out of bed. A safety risk evaluation dated May 12, 2023, revealed the facility assessed Resident 28 as not needing side rails. There was no documented evidence in Resident 28's clinical record to indicate that the facility assessed the resident as having the need for side rails and assessed for entrapment risks. Interview with Employee 3, registered nurse consultant, on November 3, 2023, at 8:30 AM confirmed the above findings for Resident 28 and indicated that the staff completing the assessment did not realize that enabler bars were side rails. 28 Pa. Code 211.12 (d)(1)(3)(5) Nursing services

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of clinical records and staff interview, it was determined that the facility failed to develop and implement an individualized person-centered plan to address dementia symptoms displayed by two of four residents reviewed (Residents 107 and 124). Findings include: Review of Resident 107's clinical record revealed that the facility admitted her on July 21, 2023. The facility implemented a diagnosis of unspecified dementia on August 10, 2023. Documentation along with the diagnosis indicated that Resident 107 scored an 18 out of 30 on the St. Louis University Mental Status Examination (SLUMS test, a tool used to screen for various types of dementia). Resident 107's score of 18 out of 30 indicated dementia. A physician progress note dated August 14, 2023, indicated that Resident 107's primary diagnosis was Dementia in Alzheimer's disease with delirium. A Minimum Data Set Assessment (MDS, a form completed at specific intervals to determine care needs) dated May 27, 2023, indicated that 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, staff interview, and review of dietary purchase orders and invoices, it was determined that the facility failed to ensure effective management and execution of the duties and responsibilities of the facility's food and nutrition department to provide enough food in accordance with physician ordered dietary needs for one of six residents reviewed (Resident 3). Findings include: Review of Resident 3's clinical record revealed a physician's order dated March 14, 2023, for the facility to provide her with a gluten free diet. Interview with Employee 2, licensed practical nurse, on August 23, 2023, at 9:15 AM revealed that Resident 3 did not get the breakfast she usually gets every morning. Employee 2 indicated she usually gets two pieces of gluten free toast every morning but stated that the kitchen ran out of the gluten free bread. Interview with Employee 3, dietary manager, on August 23, 2023, at 11:30 AM revealed that the facility ran out of Resident 2's bread starting on August 21, 2023, and that dietary staff did not inform her that the gluten free…

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.