Hillcrest Rehabilitation & Healthcare Center

Based on review of facility policy, facility in-service documentation, personnel files, and staff interviews, it was determined that the facility failed to provide training on Quality Assurance and Performance Improvement (QAPI) for five of five staff members (Nurse Aide (NA) Employee E4, NA Employee E5, Registered Nurse (RN) Employee E6, Licensed Practical Nurse (LPN) Employee E7, and NA Employee E8).Findings include: Review of facility policy In-Service Training Program, Nurse Aide dated 1/15/26, indicated all nurse aide personnel participate in regularly scheduled in-service training classes. Insofar as practical, notice of in-service training classes, their time, place, date, etc., are posted on the employee bulletin board at least seven (7) days prior to the scheduled class. All training classes attended by the employee are entered on the respective employee's Record of In-Service by the department supervisor or other person(s) as designated by the supervisor. Review of NA Employee E4's personnel file indicated a date of hire on 3/20/24. Review of NA Employee E4's personnel…

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, facility in-service documentation, personnel files, and staff interviews, it was determined that the facility failed to provide training on Infection Control for five of five staff members (Nurse Aide (NA) Employee E4, NA Employee E5, Registered Nurse (RN) Employee E6, Licensed Practical Nurse (LPN) Employee E7, and NA Employee E8).Findings include: Review of facility policy In-Service Training Program, Nurse Aide dated 1/15/26, indicated all nurse aide personnel participate in regularly scheduled in-service training classes. Insofar as practical, notice of in-service training classes, their time, place, date, etc., are posted on the employee bulletin board at least seven (7) days prior to the scheduled class. All training classes attended by the employee are entered on the respective employee's Record of In-Service by the department supervisor or other person(s) as designated by the supervisor. Review of NA Employee E4's personnel file indicated a date of hire on 3/20/24. Review of NA Employee E4's personnel file did not include credible annual…

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, facility in-service documentation, personnel files, and staff interviews, it was determined that the facility failed to provide training on Compliance and Ethics for five of five staff members (Nurse Aide (NA) Employee E4, NA Employee E5, Registered Nurse (RN) Employee E6, Licensed Practical Nurse (LPN) Employee E7, and NA Employee E8).Findings include: Review of facility policy In-Service Training Program, Nurse Aide dated 1/15/26, indicated all nurse aide personnel participate in regularly scheduled in-service training classes. Insofar as practical, notice of in-service training classes, their time, place, date, etc., are posted on the employee bulletin board at least seven (7) days prior to the scheduled class. All training classes attended by the employee are entered on the respective employee's Record of In-Service by the department supervisor or other person(s) as designated by the supervisor. Review of NA Employee E4's personnel file indicated a date of hire on 3/20/24. Review of NA Employee E4's personnel file did not include credible…

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, facility in-service documentation, personnel files, and staff interviews, it was determined that the facility failed to provide training on Dementia Management and Resident Abuse Prevention for five of five staff members (Nurse Aide (NA) Employee E4, NA Employee E5, Registered Nurse (RN) Employee E6, Licensed Practical Nurse (LPN) Employee E7, and NA Employee E8) and failed to ensure that three of three sampled Nurse Aides received a minimum of 12 hours of in-service education per year (NA Employee E4, NA Employee E5, and NA Employee E8).Findings include: Review of facility policy In-Service Training Program, Nurse Aide dated 1/15/26, indicated all nurse aide personnel participate in regularly scheduled in-service training classes. Annual in-services are no less than 12 hours per employment year. Insofar as practical, notice of in-service training classes, their time, place, date, etc., are posted on the employee bulletin board at least seven (7) days prior to the scheduled class. All training classes attended by the employee are entered on 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, facility in-service documentation, personnel files, and staff interviews, it was determined that the facility failed to provide training on Behavioral Health for five of five staff members (Nurse Aide (NA) Employee E4, NA Employee E5, Registered Nurse (RN) Employee E6, Licensed Practical Nurse (LPN) Employee E7, and NA Employee E8).Findings include: Review of facility policy In-Service Training Program, Nurse Aide dated 1/15/26, indicated all nurse aide personnel participate in regularly scheduled in-service training classes. Insofar as practical, notice of in-service training classes, their time, place, date, etc., are posted on the employee bulletin board at least seven (7) days prior to the scheduled class. All training classes attended by the employee are entered on the respective employee's Record of In-Service by the department supervisor or other person(s) as designated by the supervisor. Review of NA Employee E4's personnel file indicated a date of hire on 3/20/24. Review of NA Employee E4's personnel file did not include credible annual…

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, clinical record review, and staff interviews, it was determined that the facility failed to provide medications as ordered by the physician and ensure the physician was appropriately notified of missed medication doses for one of three residents reviewed (Resident R21).Findings include: Review of the facility Medication Ordering and Receiving Pharmacy last reviewed 1/15/26, indicated emergency pharmacy service is available on a 24-hour basis. Emergency needs for medications are met by using the facility's approved emergency supply or by special order from the provider pharmacy. The provider pharmacy supplies emergency medications including emergency drugs, antibiotics, controlled substances and products for infusion in limited quantities in sealed containers or automatic dispensing system (ADS). The ordered medication is obtained either from the emergency box or ADS, from the provider pharmacy or a back up pharmacy that is determined by the provider pharmacy. Review of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of the Resident Assessment Instrument (RAI) User's Manual, clinical record review, and staff interview, it was determined that the facility failed to ensure Minimum Data Set (MDS - a periodic assessment of care needs) assessments accurately reflected the resident's status for one of five residents (Residents R5).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 2025, indicated the following instructions:O0110K1, Hospice care: code residents identified as being in a hospice program for terminally ill persons where an array of services is provided for the palliation and management of terminal illness and related conditions. Review of the clinical record revealed Resident R5 was admitted to the facility on [DATE]. Review of Resident R5's MDS dated [DATE], indicated diagnoses of high blood pressure, anxiety, and history of…

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

Based on review of facility documents, facility policy, clinical records, and staff interviews, it was determined that the facility failed to ensure that a resident's care plan was updated and revised to reflect the resident's specific care needs for one of three residents (Residents R47).Findings include: Review of facility policy Care Plans, Comprehensive Person-Centered last reviewed 1/15/26, indicated assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. Review of Resident R47's clinical record indicated an admission date of 6/15/24. Review of R47's Minimum Data Set (MDS - a periodic assessment of care needs) dated 2/10/26, indicated the diagnosis of hypertension (high blood pressure), chronic obstructive pulmonary disease (COPD- restricts breathing), and hyperlipidemia (high fats in the blood). Review of Resident R47's physician order dated 12/24/25, indicated Azithromycin Oral Tablet 250 milligram. Give 1 tablet by mouth one time a day every Monday, Wednesday and Friday for Prophylaxis…

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 and staff interviews, it was determined that the facility failed to obtain physician orders for management of hypoglycemia (low blood sugar) and hyperglycemia (high blood sugar) for one of two residents (Resident R64) and failed to procure complete physician's orders for one of two residents (Resident R47).Findings include: Review of the facility policy Nursing Care of the Resident with Diabetes Mellitus last reviewed 1/15/26, indicated the purpose of this guideline is to help the resident control his/her diabetes with diet, exercise and insulin as ordered, Prevent recurrent hyperglycemia (blood sugar above target levels) and hypoglycemia (blood sugar below target levels). Review of the facility policy Antibiotic Stewardship last reviewed 1/15/26, indicated antibiotics will be prescribed and administered to residents under the guidance of the facilities antibiotic stewardship program. If an antibiotic is indicated, prescribers will provide complete antibiotic orders including…

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, observations, clinical record review, and staff interview, it was determined that the facility failed to conduct ongoing accurate assessments to ensure that bedrails were used to meet residents' needs and the risks associated with bedrail usage for two of five residents (Residents R3 and R7).Findings include: Review of facility policy Proper use of Bed Rails dated 1/15/26, indicated the resident assessment must assess the resident's risk from using bed rails. The resident assessment should assess the resident's risk of entrapment between the mattress and bed rail or in the bed rail itself. A nurse assigned to the resident will complete reassessments in accordance with the facility's assessment schedule, but not less than quarterly, upon a significant change in status, or a change in the type of bed/mattress/rail. Review of the clinical record revealed Resident R3 was admitted to the facility on [DATE]. Review of Resident R3's Minimum Data Set (MDS - a periodic assessment 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 review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to provide evidence medication regimen reviews (MRRs) were reviewed by the resident's attending physician monthly for two of five residents (Residents R3 and R8).Findings include: Review of facility policy Medication Regimen Review (Monthly Report) dated 1/15/26, indicated the consultant pharmacist performs a comprehensive medication regimen review (MRR) at least monthly. The MRR includes evaluating the resident's response to medication therapy to determine that the resident maintains the highest practicable level of functioning and prevents or minimizes adverse consequences to medication therapy. Findings and recommendations are reported to the director of nursing, the attending physician, the medical director and if appropriate the administrator. Physician accepts and acts upon suggestion or rejects and provides an explanation for disagreeing. Review of the clinical record 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to make certain that an influenza immunization was offered to one of five residents (Resident R65).Findings include: Review of facility policy Influenza Vaccine dated 1/15/26, indicated all residents and employees who have no medical contraindications to the vaccine will be offered the influenza vaccine annually to encourage and promote the benefits associated with the vaccinations against influenza. Between October 1st and March 31st each year, the influenza vaccine shall be offered to residents and employees, unless the vaccine is medically contraindicated or the resident or employee has already been immunized. For those who receive the vaccine, the date of vaccination, lot number, expiration date, person administering, and the site of vaccination will be documented in the resident's medical record. A resident's refusal of the vaccine shall be documented on the Informed Consent for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility documentation, observations, and staff interview, it was determined that the facility failed to make certain that equipment was in safe operating condition for one of two crash carts (East Hall Crash Cart).Findings include: Review of a facility document Basic Crash Cart Checklist indicated licensed nurse or designee completes checklist items against contents of crash cart (a cart maintained with equipment used in cardiac and respiratory emergencies) weekly and submits to the Director of Nursing (DON) upon completion. Items include an ambu mask and bag (a handheld device that delivers ventilation to patients who are not breathing). During an observation on [DATE], at 12:44 p.m. of the East Hall Crash Cart reveled the following:Two (2) ambu bags and masks, expired [DATE]. During an interview on [DATE], at 12:50 p.m. the DON confirmed the above observation and that the facility failed to make certain equipment was in safe operation condition for the East Hall Crash Cart. 28 Pa. Code:…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility documents, facility policy, clinical record review, and staff interviews, it was determined that the facility failed to provide care and services needed for residents to attain or maintain the highest practicable physical, mental, and psychosocial well-being for one of three residents (Resident R1).Findings include: Review of facility policy Neurological Assessment last reviewed 2/20/25, indicated the purpose of the policy is to provide guidelines for a neurological assessment following an unwitnessed fall or subsequent to a fall with a suspected head injury. It was indicated to perform neurological checks with the frequency as ordered or per falls protocol. Document the date and time the procedure was performed, the name and title of the individual(s) who performed the procedure, all assessment data obtained, and the signature and title of the person recording the data. Review of the facility's undated Neurological Check Flowsheet indicated to document the date and time of each…

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, clinical record review, and interviews with staff, it was determined that the facility failed to ensure that residents are free of significant medication errors for one of five residents reviewed (Resident R1).Findings include: Review of facility policy Administering Medications dated 2/20/25, indicated medications are administered in a safe and timely manner, and as prescribed. The individual administering the medication checks the label THREE (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication. Review of the clinical record indicated Resident R1 was admitted to the facility on [DATE]. Review of Resident R1's Minimum Data Set (MDS - a periodic assessment of care needs) dated 10/17/25, indicated diagnoses of anemia (too little iron in the blood), high blood pressure, and Diabetes Mellitus (a metabolic disorder in which the body has high sugar levels for prolonged periods 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 review of facility policy, clinical record, observations, and interviews with staff and residents, the facility failed to provide appropriate care and treatment for a wound for one of four residents (Resident R1).Findings: Review of the facility Dressings, Dry/Clean policy last reviewed 2/20/25, indicated it is the facility's policy to verify that there is a physician order for wound care. Review the resident's care plan, current orders, and diagnoses to determine the if there are special resident needs. Check the treatment record. The date and time the dressing was changed, and the name and title (or initials) of the individuals changing the dressing, and the type of dressing used and wound care given must be documented in the resident's medical record. Review of the clinical record indicated Resident R1 was admitted to the facility on [DATE], with diagnoses of high blood pressure, diabetes (high sugar in the blood) and anxiety. During an interview and observation on 10/6/25, at 9:21 a.m. Resident R1…

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, clinical record review, and staff interview, it was determined that the facility failed to provide Activity of Daily Living (ADL) assistance for three of five residents (Residents R1, R2, and R3).Findings include: Based on review of facility policy Activities of Daily Living (ADLs), Supporting dated 2/20/25, indicated residents will be provided with care, treatment, and services as appropriate to maintain or improve their ability to carry out activities of daily living. Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. Review of the clinical record indicated Resident R1 was admitted to the facility on [DATE]. Review of Resident R1's Minimum Data Set (MDS - a periodic assessment of care needs) dated 5/19/25, indicted diagnoses of Cerebral Palsy (group of disorders that affect a person's ability to move and maintain balance and posture), anxiety,…

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

Based on a review of facility policy, facility documents and staff interviews, it was determined that the facility failed to document the date the grievance was received, a summary statement of the resident's grievance, steps taken to investigate the grievance, a summary of findings/conclusions regarding the resident's grievance, whether the grievance was confirmed or not confirmed, corrective actions implemented, and the date of written decision issued for one of one resident's (Resident R1) allegation of neglect. (Resident R1) Findings include: A review of facility Grievance/Complaints, Filing policy dated 2/20/25. revealed upon receiving a resident grievance or complaint the facility Grievance Officer will submit a written report of the findings of the Administrator. A review of a facility reported document dated 4/5/25, to the State Agency contained an allegation of neglect by Resident R1. The report contained evidence that Resident R1 made an allegation that facility staff allowed her to lay on the floor for an hour after a fall. A review of facility Grievance Log for the month…

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, documents, resident and staff interviews, it was determined that the facility failed to implement an abuse/neglect policy that thoroughly investigated allegations for one of one event with allegations of neglect. (4/5/25). Findings include: A review of facility Abuse Investigation and Reporting policy dated 2/20/25, indicated all parties will be interviewed to obtain information regarding the allegation, all witness statements will be obtained in writing with signature and date of the witness, at the completion documents will be completed and reviewed with the Administrator. A review of facility documents dated 4/5/25, submitted to the State Agency revealed that Resident R1 voiced a concern that staff allowed her to remain on the floor for an hour after sustaining a fall. A review of facility witness statements failed to provide a written document of witness statements obtained of the resident and her roommate which created an incomplete investigation. A review of facility documents revealed that the facility failure to follow the guidance 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 a review of facility policies, documents and resident and staff interviews, it was determined that the facility failed to provide evidence that an alleged allegation of neglect for one of one event (4/5/25), was thoroughly investigated as required. Findings include: A review of facility Abuse, Investigation, and Reporting' policy dated 2/20/25, indicated that all allegations of abuse/neglect will be thoroughly investigated by Administration. A review of facility documents dated 4/5/25, submitted to the State Agency revealed that Resident R1 voiced a concern that staff allowed her to remain on the floor for an hour after sustaining a fall. A review of the facility's investigation of Resident R1's allegation of neglect revealed the following: * The facility failed to complete documentation of the resident's grievance. * The facility failed to interview the resident and her roommate which created an incomplete and inaccurate conclusion of the facility not identifying alleged perpetrators. * The facility failed to properly investigate the resident's allegation of neglect which…

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, observations and staff interview, it was determined the facility failed to properly date and store food products in a manner to prevent foodborne illness in the main kitchen (Main Kitchen). Findings include: The facility Food Receiving and Storage policy last reviewed 2/20/25, indicated that foods shall be received and stored in a manner that complies with safe food handling practices. During observations on 3/3/25, at 9:12 a.m. the dry storage room was found with two opened packages of dried pasta open and not dated. During observation on 3/3/25, at 9:14 a.m. the walk-in-cooler was found with a meal cart holding a metal tray. Observed on top of the tray was cooked ground meat. Next to the cooked ground meat was an open and undated bag of raw chicken. During an interview on 3/3/25, at 1:48 p.m. Dietary Manager Employee E7 confirmed that the facility failed to properly date and store food products in a manner to prevent foodborne illness in the main kitchen. 28 Pa. Code: 201.14(a) Responsibility of licensee 28 Pa. Code: 201.18(b)(1) Management.…

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, clinical records and staff interviews, it was determined that the facility failed to conduct care plan conferences and failed to ensure a resident or resident representative was notified in advance of care conference meetings for four of four residents (Resident R12, R36, and R39). Findings include: The facility Resident participation-assessments and care plans policy dated 2/20/25, indicated that the resident and his or her representative are encouraged to participate in the resident's assessment and in the development of the resident's care plan. A seven day notice of the care plan conference is provided to the resident and his or her representative. The Social Services director is responsible for notifying the resident or representative and for maintaining records of such notices. Review of Resident R12's admission record indicated she was originally admitted on [DATE]. Review of Resident R12's MDS assessment (Minimum Data Set assessment: MDS -a periodic assessment 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.

Review of facility policy and documentation, resident and staff interviews revealed that the facility failed to to document and include followup from four of four months and resident council meeting for four of four months and failed to have/offer resident council meetings for two of four months. Findings include: Review of facility policy Grievances/Complaints, Filing dated 2/20/25, indicated: All grievances, complaints, or recommendations stemming from resident or family groups concerning issues of resident care in the facilities will be considered. Actions on such issues will be responded ot in writing, including a rationale for the response. Review of resident council minutes for October and November 2024 indicated that staff went room to room instead of having a resident group. During an interview on 3/4/25, at 10:15 a.m. Residents indicated that they did not have a resident group for two months in October and November 2024. Residents indicated that they do not get feedback or response to concerns from resident group. During an interview on 3/7/25, at 11:19 a.m Nursing Home…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to conduct an initial Enabler/Assist Rail/ Device Evaluation assessment for one of three residents (Resident R30), and failed to compete ongoing accurate assessments to ensure that enabler/side rail assist bars were used to meet residents' needs and the risks associated with enabler bar/side rail assist bar usage for three of three residents (R7, R8, and R30). Findings include: Review of the facility Proper Use of Bed Rails dated 2/20/25, indicated an assessment will be made to determine the resident ' s symptoms, risk of entrapment and reason for using side rails. When used for mobility or transfer, an assessment will include a review of the resident ' s: a. Bed mobility. b. Ability to change positions, transfer to and from bed or chair, and to stand and toilet. c. Risk of entrapment from the use of side rails; and d. That the bed ' s dimensions are appropriate for the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical record review and staff interview it was determined that the facility failed to investigate, and report an allegation of abuse and or neglect for one of three residents reviewed (Resident R24). Findings include: Faiclity policy Identifying Types of Abuse dated 2/20/25, indicated Neglect/Deprivation of Goods and services by Staff - Neglect ids the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm,pain,mental anguish, or emotional distress. Review of Resident R24 clinical record indicate the were admitted on [DATE]. Review of Resident R24 MDS (minimum data set - a periodic assessment of resident needs) dated 2/2/25, indicated diagnosis of atrial fibration ( irregular and often very rapid heart rhythm), chf (heart failure occurs when the heart muscle doesn't pump blood as well as it should) Review of Resident R24 clinical record progress notes indicated 3/1/2025, nursing note…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of facility policy, clinical records, and staff interview, it was determined that the facility failed to develop a baseline care plan for pain management one of three residents (Resident R223). Findings include: Review of facility policy Baseline Care Plans dated 2/20/25, indicated a baseline plan of care to meet the residents immediate needs and provide instruction needed to provide effective and person-centered care shall be developed for each resident within forty-eight hours of admission. Review of the clinical record revealed Resident R223 was admitted to the facility on [DATE], with diagnoses of fracture of shaft of right tibia and fibula, pain in right ankle and joints of right foot, and idiopathic progressive neuropathy (nerve damage that interferes with the function of the peripheral nervous system (PNS) when the cause can't be determined.) During an interview on 3/3/25, at 12:36 p.m. Resident R223 stated he has pain and receives medication for pain management. It was indicated he has…

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, job descriptions, clinical records, and staff interviews, it was determined that the facility failed to adhere to acceptable standards of practice related to monitoring of Food Service operations, resident interviews, and participation in care plan meetings by the Registered Dietitian for six out of six months ( October 2024, November 2024, December 2024, January 2025, February 2025, and March 2025). Findings include: The Pennsylvania Code, Title 49, Chapter 21, Professional and Vocational Standards: Responsibilities of the Licensed Dietitian/ Nutritionist Section 21.711 Professional Conduct indicated that the Licensed Dietitian/ Nutritionist shall provide information which will enable patients to make their own informed decisions regarding nutrition and dietetic therapy, including the reasonable expectations of the professional relationship. The facility Nutritional assesment policy dated 2/20/25, indicated that as a part of the comprehensive assesment, the nutritional assessment shall be conducted for each resident. The dietitian will conduct…

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, staff, and resident interviews, it was determined that the facility failed to provide Activity of Daily Living (ADL) assistance for one of six residents (Resident R33). Findings include: The facility Activity of Daily Living (ADLs), Supporting policy dated 2/20/25, indicated residents will be provided with care, treatment, and services as appropriate to maintain or improve their ability to carry out ADLS. Residents who are unable to carry out activities of daily living independently will receive the service necessary to maintain good personal hygiene. The facility Bed Bath, Shower/Tub policy dated 2/20/25, indicated the purpose of this policy is to promote cleanliness, provide comfort to the resident. Review of Resident R33's admission record indicated resident was admitted to facility on 4/24/24. Review of Resident R33's MDS assessment (MDS-Minimum Data Set assessment: periodic assessment of resident care needs) dated 1/15/25, indicated diagnoses of high blood pressure,…

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, clinical records, and staff interviews, it was determined that the facility failed to make certain that residents received the necessary services, consistent with professional standards of practice to promote healing and prevent infection for one of four residents (Residents R27). Findings include: Review of the admission record indicated Resident R27 was admitted to the facility on [DATE], with diagnoses of dementia (the loss of cognitive functioning to such an extent that it interferes with a person's daily life and activities), morbid obesity, and muscle weakness. Review of Resident R27's skin evaluation dated 12/27/24, indicated the resident had an unstageable (a type of pressure ulcer that is covered by necrotic tissue or eschar, making it hard to stage and treat) 3cm x 1.5 cm coccyx (tailbone) pressure ulcer. A 5 cm x 9 cm sacrum (a single bone located at the base of the spine)pressure ulcer that was not staged. Two left rear thigh pressure ulcers measuring 0.3cm x 1cm…

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 observations and staff interviews, it was determined that the facility failed to ensure a resident with limited mobility receives appropriate services, equipment, and assistance to maintain or improve mobility for one of three residents (Resident R223). Findings include: Review of Resident R223's admission record indicated he was admitted on [DATE], with diagnoses of fracture of shaft of right tibia and fibula, pain in right ankle and joints of right foot, and idiopathic progressive neuropathy (nerve damage that interferes with the function of the peripheral nervous system (PNS) when the cause can't be determined.) Review of Resident R223's Hospital Discharge summary dated [DATE], indicated the resident was ordered to wear a TLSO brace (brace that limits movement in your spine from the thoracic area (mid back) to your sacrum (low back)) when upright or out of bed. Review of Resident R223's physical therapy notes dated 3/1/25, indicated the resident will 100% return…

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, clinical records, and staff interviews, it was determined that the facility failed to timely assess the nutritional status for one of two residents (Resident R23). Findings include: The facility Nutritional assesment policy dated 2/20/25, indicated that as a part of the comprehensive assesment, the nutritional assessment shall be conducted for each resident. The dietitian will conduct a nutritional assessment for each resident upon admission within current baseline assessment time frames. Review of Resident R23's admission record indicated he was originally admitted on [DATE]. Review of Resident R23's MDS assessment (Minimum Data Set assessment: MDS -a periodic assessment of resident care needs) dated 7/18/24, indicated he had diagnoses that included epilepsy (a long-term disease that causes repeated seizures due to abnormal electrical signals produced by damaged brain cells), dysphagia (difficulty swallowing), hypertension (a condition impacting blood circulation through 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, observations, staff interviews, and clinical record review, it was determined that the facility failed to provide appropriate respiratory care related to oxygen management for two of four residents (Resident R41 and R274). Findings include: A review of the facility policy Oxygen Administration last reviewed on 2/20/25, indicates to provide safe oxygen administration. A review of Resident R41's clinical record indicates an admission date of 7/27/24. A review of R41's Minimum Data Set (MDS-periodic assessment of care needs) dated 12/20/24, indicate the diagnosis of hypertension (high blood pressure), respiratory failure (blood doesn't have enough oxygen), and coronary artery disease (CAD - buildup of plaque in the arteries that reduces the blood flow to the heart). During an observation completed on 3/3/25, at 10: 29 a.m. Resident R41 was in bed, her oxygen was on via nasal canula (thin flexible tube used to deliver oxygen). The oxygen tubing failed to be labeled with a date. Review of Resident 41's physician orders dated 12/15/24, indicate oxygen…

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 record and staff interview it was determined that the facility failed to make certain consistent dialysis communication was maintained for one of two residents (Resident R12). Findings include: Review of Resident R12's admission record indicated she was originally admitted on [DATE]. Review of Resident R12's MDS assessment (Minimum Data Set assessment: MDS -a periodic assessment of resident care needs) dated 8/26/24, indicated diagnoses of depression, renal insufficiency (kidneys are functioning poorly), and diabetes (a group of diseases that affect how the body uses blood sugar (glucose). Review of physician orders dated 2/14/25, indicated Resident R12 attends dialysis on Monday, Wednesday, and Friday each week. Review of Resident R12's clinical record on 3/4/25, failed to include a care plan for dialysis. A review of the clinical record did not include complete communication forms for the month of February and March 2025. There were seven incomplete communication…

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 upon clinical record review, and staff interview, it was determined that the facility failed to ensure that any irregularities submitted in the medication regiment reviews (MRR) by pharmacy were reviewed by a physician for one out of four residents (Resident R12). Findings include: Review of the facility Medication Regimen Review (Monthly Report) policy last review 2/20/25, indicated the consultant pharmacist performs a comprehensive medication regimen review (MRR) at least monthly. The MRR includes evaluating the resident's response to medication therapy to determine that the resident maintains the highest practicable level of functioning and precents or minimizes adverse consequences related to medication therapy. The physician accepts and acts upon suggestion or rejects and provides explanation for disagreeing. Review of Resident R12's admission record indicated she was originally admitted on [DATE]. Review of Resident R12's MDS assessment (Minimum Data Set assessment: MDS -a periodic assessment 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 review of facility policy, clinical record review, and staff interview it was determined that the facility failed to make certain that residents are free from significant medication errors for one of five residents (Resident R27). Findings include: Review of the facility Administering Medications last reviewed 2/20/25, indicated medications are administered in a safe manner. If a dosage is believed to be inappropriate or excessive for a resident, or a medication has been identified as having potential adverse consequences for the resident or is suspected of being associated with adverse consequences, the person preparing or administering the medication will contact the prescriber, the resident's attending physician or the facility's medical director to discuss the concerns. Review of manufactures guidelines for Divalproex Sodium (also known as Depakote, medication used to treat seizures and mental/mood disorders) indicated: the maximum recommended dosage is 60 milligram/kilogram/day. It was indicated…

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, observations and staff interview it was determined that the facility failed to date opened medications and properly store medications in one of five medication carts observed (two East Hall) and properly store/label medication in one of two medication rooms (two East) and medications found unsecured at resident's bedside for one of six residents (Residents R31). Findings include: Review of facility policy Storage of Medications dated 2/20/25, indicated the facility shall store all drugs and biologicals in a safe, secure, and orderly manner. Drugs for external use, as well as poisons, shall be clearly marked as such, and shall be stored separately from other medications. Drugs shall be stored in an orderly manner in cabinets, drawers, carts, or automatic dispensing systems. Each resident ' s medications shall be assigned to an individual cubicle, drawer, or other holding area to prevent the possibility of mixing medications of several residents. Review of the facility policy Administering Medications dated 2/20/25, indicates the expiration/beyond…

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 record, and staff interviews it was determined that the facility failed to identify and or review a change in dietary recommendations for one of three residents (Resident R17). Findings include: Review of facility policy Therapy Evaluation dated 2/20/25, indicated An initial evaluation of a resident's past and current medical and functional status is required prior to the initiation of treatment. Information regarding a resident's level of function must be documented. Review of clinical record indicated Resident R17 was admitted on [DATE]. Review of clinical record MDS (minimum data set - a periodic assessment of resident needs) dated 12/31/24, indicated diagnosis of COPD ( an ongoing lung condition caused by damages to the lungs) and unspecified dementia (a condition in which person loses the ability to think, remember,learn, make decisions, and solve problems). Review of Resident R17 clinical record indicated progress notes: 1/27/2025 12:03 *Nursing Note Note Text: Resident c/o…

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

Based on facility policy review, review of Quality Assurance attendance records, and staff interview, it was determined that the facility failed to conduct Quality Assessment and Assurance (QAA) meetings at least quarterly for one of four quarterly meeting (June 2024 thru September 2024). Findings Include: The facility Quality Assurance Performance improvement plan last reviewed 2/20/25, indicated that the facility staff practice is to schedule monthly QAPI meetings to ensure regulatory compliance for quarterly meetings. Review of Quality Assurance attendance records dated 2024, did not include quarterly sign in documents from 5/13/24 to 10/24/24. During an interview on 3/7/25, at 12:05 p.m. the Nursing Home Administrator (NHA) confirmed that the facility failed to conduct Quality Assessment and Assurance (QAA) meetings at least quarterly with all of the required committee members as required. 28 Pa Code: 201.18(e )(1)(2)(3)(4) Management.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, resident clinical records, observation, and staff interviews, it was determined that the facility failed to implement infection control monitoring and management during a COVID-19 outbreak for three of three residents (Resident R12, R33, and R36), and the facility failed to ensure that proper infection control practices were followed during medication administration for one of three residents reviewed (Resident R274). Finding include: The facility policy Administering Medications last reviewed 2/20/25, indicates staff follows established facility infection control procedures (e.g., handwashing, antiseptic technique, gloves, isolation precautions, etc.) for the administration of medications, as applicable. Review of facility policy SARS-CoV-2 Management last reviewed 2/20/25, indicated the facility follows current guidelines and recommendations for managing COVID-19 in the facility. Anyone with even mild symptoms of COVID-19 (fatigue, headache, sore throat, fever, chills,…

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, clinical record review, and staff interviews, it was determined that the facility failed to make certain that residents were provided appropriate treatment and care for one of three residents (Residents R1). Findings include: Review of facility policy Resident Rights, indicated basic rights to all residents of this facility. Resident to be notified of his or her medical condition and of any changes in his or her condition. Be informed of, and participate in, his or her care planning and treatment. Review of facility policy Medication and Treatment Orders, indicated orders for treatments will be consistent with principles of safe and effective order writing. Review of Resident R1's clinical record indicated the resident was admitted to the facility on [DATE]. Review of Resident R1's MDS dated [DATE], indicated diagnoses of high blood pressure, arthritis, and coronary artery disease (damage or disease in the heart's major blood vessels). Review of Resident R1's physician orders…

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

Based on review of clinical records and staff interview, it was determined that the facility failed to inform a resident's representative in advance of the proposed care, including the risk and benefits of the prescribed medication for one of three sampled residents (Resident R1). Findings include: Review of Resident R1's MDS assessment (MDS-Minimum Data Set assessment: periodic assessment of resident care needs), dated 9/24/24, indicated she had diagnoses included chronic kidney disease, dementia (chronic condition that causes a decline in mental abilities, such as thinking, remembering, and reasoning, that interferes with daily life. It's not a normal part of aging, but it's more common) and diabetes mellitus. Further review of the MDS indicated the resident's BIMS (Brief Interview for Mental Status assessment was 4 indicating severe impairment. Review of the Resident Assessment Instrument 3.0 User's Manual effective October 2019, indicated that a Brief Interview for Mental Status (BIMS) is a screening test that aides in detecting cognitive impairment. The BIMS total score…

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 resident records, admission documentation and staff interview, it was determined that the facility failed to maintain admission documentation for one of six residents (Resident R1). Findings include: Review of Resident R1's MDS assessment (MDS-Minimum Data Set assessment: periodic assessment of resident care needs), dated 9/24/24, indicated she had diagnoses included chronic kidney disease, dementia (chronic condition that causes a decline in mental abilities, such as thinking, remembering, and reasoning, that interferes with daily life. It's not a normal part of aging, but it's more common) and diabetes mellitus. Review of the Resident Assessment Instrument 3.0 User's Manual effective October 2019, indicated that a Brief Interview for Mental Status (BIMS) is a screening test that aides in detecting cognitive impairment. The BIMS total score suggests the following distributions: 13-15: cognitively intact 8-12: moderately impaired 0-7: severe impairment Review of Resident R1's admission MDS assessment (Minimum Data Set assessment MDS- a periodic assessment 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 a review of facility documents, and staff interviews, it was determined that the facility failed to employ staff with the required skills and competencies to carry out the daily functions of the Dietary Department (Food Service Director Employee E9) for six of twelve months. Findings include: A review of facility document Dietary Supervisor Job Description indicated that a qualified candidate must have successful completion of a reputable course in food service operation, or a college degree in culinary arts management. During an interview on 5/13/24, at 9:45 a.m. Food Service Director Employee E9 stated that he started at the facility in November 2023, and did not possess qualifications of a certified dietary manger or have any related degrees. During an interview on 5/13/23, at 3:00 p.m. Nursing Home Administrator (NHA) confirmed that Food Service Director Employee E9 failed to meet the state agency requirements for a food service director. 28Pa. Code: 211.6(c)(d) Dietary services.

Based on review of facility policies, observations and staff interview, it was determined the facility failed to properly date and store food products, and maintain clean equipment in a manner to prevent foodborne illness in the main kitchen. Findings include: Review of facility policy Food Receiving and Storage dated 3/4/24, indicated foods shall be received and stored in a manner that complies with safe food handling practices. Review of facility policy Sanitization, dated 3/4/24, indicated that the food service area is maintained in a clean and sanitary manner. During observation and interview in the dry storage room on 5/13/24, at 9:58 a.m. opened packages of macaroni, spaghetti, and egg noodles were noted to have not been dated. Food Service Director (FSD) Employee E9 confirmed that the facility failed to properly label and date opened food packages to prevent foodborne illness. During observation on 5/14/24, at 11:17 a.m. a fan that was pointed towards the tray line, was covered in a gray, fuzzy substance. During an interview on 5/14/24, at 11:20 a.m. FSD Employee E9 confirmed…

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 make certain that the necessary resident information was communicated to the receiving health care provider for three out of five residents sampled with facility-initiated transfers (Residents R16, R24, and, R212). The findings include: Review of Resident R16's clinical record indicated the resident was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses of COPD, (chronic obstructive pulmonary disease- a group of progressive lung disorders characterized by increasing breathlessness), high blood pressure, and heart failure (a progressive heart disease that affects pumping action of the heart muscles. This causes fatigue, shortness of breath.) Review of Resident R16's clinical record revealed that the resident was transferred to the hospital on [DATE], and returned to the facility on [DATE]. Review of Resident R16's clinical record revealed no documented evidence that the facility had…

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 resident clinical records, and staff interviews, it was determined that the facility failed to provide a transfer notice to a representative of the Office of the Long-Term Care Ombudsman Division for three of four residents (Resident R16, R24, and R212). Findings Include: A review of the facility policy Transfer and Discharge-30 day reviewed 3/4/24, indicated that the a copy of the transfer and discharge notice will be sent to the Office of the State Long-Term Care Ombudsman. Review of Resident R16's clinical record indicated the resident was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses of COPD, (chronic obstructive pulmonary disease- a group of progressive lung disorders characterized by increasing breathlessness), high blood pressure, and heart failure (a progressive heart disease that affects pumping action of the heart muscles. This causes fatigue, shortness of breath.) Review of Resident R16's clinical record revealed that the resident 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 review of facility policy, clinical records, and staff interviews, it was determined that the facility failed to notify the resident or resident's representative of the facility bed-hold policy (an agreement for the facility to hold a bed for an agreed upon rate during a hospitalization) for three of four resident hospital transfers (Residents R16, R24, and R212). Findings Include: Review of the facility policy Leave Day-Bed Hold Policy dated 3/4/24, indicated that the facility establish procedures that ensure residents and/or responsible parties are properly informed of bed hold options, potential financial obligations, and processes to be followed in order to guarantee a bed upon the resident's return to the facility should a resident need to be absent from the facility for a period of time for hospitalization or other medical or therapeutic leave. Notification of bed hold options is required each time a resident will be absent from the facility for hospitalizations. Review of Resident R16's clinical…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical record review, and staff interviews, it was determined that the facility failed to develop and implement comprehensive care plans to meet care needs for three of ten residents (Residents R21, R25, R34). Findings include: Review of facility policy Care Planning - Interdisciplinary Team dated 3/4/24, indicated the facility's care planning/interdisciplinary team is responsible for the development of an individualized comprehensive care plan for each resident. The care plan is based on the resident's comprehensive assessment. Review of Title 42 Code of Federal Regulations (CFR) §483.21 - Comprehensive Care Plans, the facility must develop and implement a comprehensive care plan for each resident that includes measurable objectives, and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment, and must be culturally competent and trauma informed. Review of the clinical record indicated 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of facility provided documentation and staff interview, it was determined the facility failed to issue an accurate Skilled Nursing Facility Advanced Beneficiary Notice form (SNF ABN CMS-10055) for one of three residents (Resident R163). Findings include: Review of the Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN CMS-10055) form provides information to residents/resident representatives that skilled nursing services may not be paid by Medicare and so that the resident/resident representative can decide if they wish to continue receiving skilled nursing services and assume financial responsibility. Review of Resident R163's clinical record documented the resident was admitted to the facility on [DATE], and readmitted [DATE], and remained in the facility until 3/14/24. Review of the facility provided Beneficiary Notice list, which includes residents who were discharged from Medicare Part A with benefit days remaining, and remained in the facility indicated Resident R163's last…

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, facility documents, clinical records, and resident and staff interviews, it was determined that the facility failed to make certain residents were free from neglect for one of eight residents (Resident R49). Findings include: Review of facility policy Identifying Types of Abuse dated 3/4/24, indicated neglect is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary. It was indicated neglect occurs when the facility is aware of, or should have been aware of goods and services that a resident requires, but the facility fails to provide them. Review of the facility policy Resident Rights dated 3/4/24, stated residents will be free from neglect. Review of admission record indicated Resident R49 was admitted to the facility on [DATE]. Resident R49's care plan initiated 10/2/22, indicated the resident is at risk for alteration in skin integrity. Interventions indicated to observe for changes in skin condition…

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, resident record review, observation, and staff interviews it was determined the facility failed to prevent the misappropriation of resident medications for one of three residents (Resident R112). Findings include: Review of the facility policy Resident Rights dated 3/4/24, stated residents will be free from abuse, neglect, misappropriation of property, and exploitation. Review of facility policy titled Controlled Substances last reviewed 3/4/24, informed the facility complies with all laws, regulations, and other requirements related to handling, storage, disposal, and documentation of controlled medications (listed as Scheduled II-IV of the Comprehensive Drug Abuse Prevention Program and Control Act of 1976.) Controlled substances are counted upon delivery. If the count is correct, an individual resident controlled substance record is made for each resident who will be receiving a controlled substance. This record contains the name of the resident, quantity received,…

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

Based on review of facility policy, newly hired personnel records and staff interviews it was determined that the facility failed to conduct a current FBI (Federal Bureau of Investigation) background check on an employee prior to her date of hire for one out of five personnel records (Licensed Practical Nurse Employee E3). Findings include: The facility Abuse Prevention Program policy dated 3/4/24, indicated that the resident has the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms. The facility Background Check Procedures policy dated 3/4/24, indicated that facility conducts employment background screening checks on all applicants, to include current employees as needed, in compliance with Federal and State requirements and regulations. All offers of employment are contingent upon clear results of a thorough criminal…

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 Resident Assessment Instrument (RAI) User's Manual, clinical records, and staff interviews, it was determined that the facility failed to ensure that MDS assessments accurately reflected the resident's status for one of six residents (Resident R25). 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 the following instructions: -Observation (Look-Back, Assessment) Period is the time period over which the resident's condition or status is captured by the MDS assessment. Most MDS items themselves require an observation period, such as 7 or 14 days, depending on the item. Since a day begins at 12:00 a.m. and ends at 11:59 p.m., the observation period must also cover this time period. A standard 7-day look-back period counts back from and includes the Assessment Reference Date (ARD+6 previous days). Review…

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, clinical record review, and staff interview, it was determined that the facility failed to ensure that a resident and a resident's representative was provided a summary of their completed baseline care plan for two of six residents (Resident R21 and R33). Findings include: Review of the facility policy Careplans-Baseline, last reviewed 4/3/24, indicated that a baseline plan of care to meet the resident's immediate needs shall be developed for each resident within forty-eight hours of admission. The resident and their representative will be provided a summary of the baseline care plan. Review of Resident R21's clinical record indicated the resident was admitted to the facility on [DATE]. Review of Resident R21's MDS (Minimum Data Set, periodic assessment of resident care needs) dated 4/18/24, indicated diagnoses of depression, dysphasia (difficulty swallowing), and schizoaffective disorder (a mental disorder in which a person experiences a combination of schizophrenia and mood…

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, observation, and staff interviews, it was determined that the facility failed to follow physician orders for one of eight residents (Resident R49). Findings include: Review of admission record indicated Resident R49 was admitted to the facility on [DATE]. Resident R49's care plan initiated 10/2/22, indicated the resident is at risk for alteration in skin integrity. Interventions indicated to observe for changes in skin condition and report abnormalities and administer treatment per physician orders. Review of Resident R49's Minimum Data Set (MDS- periodic assessment of care needs), dated 4/29/24, indicated the diagnoses of dementia (a group of symptoms that affects memory, thinking and interferes with daily life), high blood pressure, and anxiety. Review of Resident R49's physician order dated 5/12/24, indicated to cleanse right hand with normal saline (wound cleanser), pat dry, apply TAO (Triple Antibiotic Ointment) and cover with bordered gauze every shift for skin tear.…

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 and staff interviews, it was determined that the facility failed to change an indwelling catheter (insertion of a tube into the bladder to drain urine) as ordered for one of three residents (Resident R14), and failed to obtain a valid medical diagnosis for an indwelling urinary catheter and develop and implement a comprehensive plan of care related to urinary catheter usage for one of three residents (Resident R52). Findings include: Review of Title 42 Code of Federal Regulations (CFR) §483.25(e) Incontinence indicated if the facility provides care for a resident with an indwelling catheter, in collaboration with the medical director and director of nurses, and based upon current professional standards of practice, resident care policies and procedures must be developed and implemented that address catheter care and services, including but not limited to: timely and appropriate assessments related to the indication for use of an indwelling catheter; identification 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 policy, observations, interviews, and clinical record review, it was determined that the facility failed to provide appropriate respiratory care for one of four residents (Residents R16). Findings include: Review of facility policy Oxygen Administration dated 3/4/24, indicated to check the mask, tank, and humidifying jar to be sure they are in good working order. Be sure there is water in the humidifying jar and that the water level is high enough that the water bubbles as oxygen flows through. Periodically re-check the water level in humidifying jar. Review of the clinical record indicated that Resident R16 was admitted to the facility on [DATE], with diagnosis of COPD, (chronic obstructive pulmonary disease- a group of progressive lung disorders characterized by increasing breathlessness), high blood pressure, and heart failure (a progressive heart disease that affects pumping action of the heart muscles. This causes fatigue, shortness of breath.) Review of Resident R16'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 facility policy, resident record review, and staff interviews, it was determined that the facility failed to provide a trauma survivor with trauma informed care to eliminate or mitigate triggers that may cause re-traumatization of the resident for one of two residents (Resident R34). Findings include: Review of facility policy Trauma Informed Care dated 3/4/24, indicated the facility will deliver care and services which, in addition to meeting professional standards, are delivered using approaches which are culturally-competent and account for experiences and preferences, and address the needs of trauma survivors by minimizing triggers and/or re-traumatization. Facilities should use a multi-pronged approach to identifying a resident's history of trauma, this would include asking the resident about triggers that may be stressors or may prompt recall of a previous traumatic event. Facilities must identify triggers which may re-traumatize residents with a history of trauma. The facility should…

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, observations, and staff interviews, the facility failed to ensure residents with dementia receive the appropriate treatment and services to attain or maintain their highest practicable physical, mental, and psychosocial well-being for two of four residents reviewed (Resident R1 and R49). Findings include: Review of federal guidance §483.40(b)(3) a resident who displays or is diagnosed with dementia, receives the appropriate treatment and services to attain or maintain his or her highest practicable physical, mental, and psychosocial well-being. The regulations associated with medication management include consideration of: o Indication and clinical need for medication; o Dose (including duplicate therapy); o Duration; o Adequate monitoring for efficacy and adverse consequences; and o Preventing, identifying, and responding to adverse consequences. Review of the facility Dementia-Clinical Protocol reviewed 3/4/24, indicated the interdisciplinary [NAME] will identify and document…

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 the physician responded timely pharmacy medication recommendations for one out of five sampled residents (Resident R49). Findings include: The facility Medication Regimen Review policy dated 8/17/23, indicated the consultant pharmacist will conduct Medication Regimen Review (MRR) and will make recommendations based on the information available in the resident's health record. If an irregularity does not require urgent action, it should be addressed before the consultant pharmacist's next monthly MRR. The facility should alert the Medical Director when MRR's are not addressed by the attending physician in a timely manner. Review of admission record indicated Resident R49 was admitted to the facility on [DATE]. Review of Resident R49's Minimum Data Set (MDS- periodic assessment of care needs), dated 4/29/24, indicated the diagnoses of dementia (a group of symptoms that affects…

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 a medication regime was free from potentially unnecessary medication for two of five residents (Resident R21 and R25). Findings include: Review of the facility policy Psychotropic Medication Use dated 3/4/24, indicated residents will not receive medications that are not clinically indicated to treat a specific condition. Review of Resident R21's clinical record indicated the resident was admitted to the facility on [DATE]. Review of Resident R21's MDS (Minimum Data Set - assessment of a resident's abilities and care needs) dated 4/18/24, indicated diagnoses of depression, dysphasia (difficulty swallowing), and schizoaffective disorder (a mental disorder in which a person experiences a combination of schizophrenia and mood disorder symptoms). Review of Resident R21's care plan dated 4/15/24, indicated to evaluate effectiveness and side effects of medication for possible decrease/elimination of psychotropic…

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, observation, and staff interviews, it was determined that the facility failed to date opened medications and properly store medications in one of two medication carts (West Assignment). Findings include: Review of facility policy Storage of Medications dated 3/4/24, indicated medications are stored safely, securely, and properly, following manufacture's recommendations or those of the supplier. Review of Title 42 Code of Federal Regulations (CFR) §483.45(g) Labeling of Drugs and Biologicals indicated if a multi-dose vial has been opened of accessed (e.g., needle-punctured), the vial should be dated and discarded within 28 days unless the manufacturer specifies a different (shorter or longer) date for that opened vial. During an observation on 5/15/24, at 9:16 a.m. of the [NAME] Assignment medication cart indicated the following medications stored in one compartment without individual packaging or separation from other residents medications: - Resident R10's Lantus (prefilled pen to inject long acting insulin under the skin) pen not in a box or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of facility policy, clinical records, and resident and staff interviews it was determined that the facility failed to ensure that emergency dental care was provided for one of two residents (Resident R19). Findings include: Review of facility policy Dental Services, dated 3/4/24, indicated that routine and emergency dental services are available to meet the resident's oral health services in accordance with the resident's assessment and plan of care. Social Services representatives will assist residents with appointments, transportation arrangements, and reimbursement of dental services under the state plan, if eligible. Review of the clinical record revealed that Resident R19 was admitted to the facility on [DATE]. Review of Resident 19's MDS (Minimum Data Set, periodic assessment of resident care needs) dated 4/8/24, indicated diagnoses of high blood pressure, dementia (neuro-cognitive disorder impacting reasoning, judgment, and memory), and mild intellectual disabilities. Review of 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 facility documents, employee education records, and staff interview, it was determined that the facility failed to provide training on effective communication for one of five direct care staff members (Nurse Aide Employee E10). Findings include: Review of the Nurse Aide Job Description, indicated that nurse aide employees shall participate in required trainings and complete all related clinical competencies. Review of Nurse Aide (NA) Employee E10's facility provided staff list indicated she was hired on 3/9/81. Review of NA Employee E10's training record for 3/9/23, through 3/9/24, did not include training on effective communication. During an interview on 5/16/24, at 2:42 p.m. Assistant Director of Nursing (ADON)Employee E11 confirmed that the facility failed to provide training on effective communication for one of five staff members. 28 Pa Code: 201.14 (a) Responsibility of licensee. 28 Pa Code: 201.18 (b)(1) Management. 28 Pa Code: 201.20 (a)(c) Staff development.

Based on review of facility documents, employee education records, and staff interview, it was determined that the facility failed to provide training on QAPI (Quality Assurance and Performance Improvement) for five of five staff members (Employees E10, E12, E13, E14. E15). Findings include: Review of the Nursing Home Administrator (NHA) Job Description dated 9/1/23, indicated that the NHA will ensure all compliance with required trainings and in-services. Review of Nurse Aide (NA) Employee E10's facility provided staff list indicated she was hired on 3/9/81. Review of NA Employee E10's training record for 3/9/23, through 3/9/24, did not include training on QAPI. Review of Licensed Practical Nurse (LPN) Employee E12's facility provided staff list indicated she was hired on 2/4/02. Review of LPN Employee E12's training record for 2/4/23, through 2/4/24, did not include training on QAPI. Review of NA Employee E13's facility provided staff list indicated she was hired on 5/3/17. Review of NA Employee E13's training record for 5/3/23, through 5/3/24, did not include training on QAPI.…

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 documents, employee education records, and staff interview, it was determined that the facility failed to provide training on behavioral health for one of five staff members (Nurse Aide Employee E10). Findings include: Review of the Facility Assessment dated 3/4/24, indicated staff training/education and competencies will be completed during general orientation upon hire, and annually. Education listed included, but not limited to: -Alzheimer's disease and related disorders -Dementia Care Review of Nurse Aide (NA) Employee E10's facility provided staff list indicated she was hired on 3/9/81. Review of NA Employee E10's training record for 3/9/23, through 3/9/24, did not include training on behavioral health. During an interview on 5/16/24, at 2:42 p.m. Assistant Director of Nursing Employee E11 confirmed that the facility failed to provide training on behavioral health for one of five staff members. 28 Pa Code: 201.14 (a) Responsibility of licensee. 28 Pa Code: 201.18 (b)(1) Management. 28 Pa Code: 201.20 (a)(c) Staff development.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to perform accurate post-fall documentation for two of five residents (Resident R2 and R3) and failed to ensure that a resident received neurological assessments after an incident involving a fall for one of five residents (Resident R1). Findings include: Review of facility policy Assessing Falls and Their Causes dated 3/4/24, indicated if a resident has just fallen, or is found on the floor without a witness to the event, evaluate for possible injuries to the head, neck, spine, and extremities. Observe for delayed complications of a fall for approximately 48 hours after an observed or suspected fall, and document findings in the medical record. When a resident falls, the following information should be recorded in the resident's medical record: the condition in which the resident was found, assessment data, including vital signs and any obvious injuries, interventions, notification of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical record review, and staff interviews, it was determined that the facility failed to make certain that residents were provided appropriate post-fall care for one of five residents (Resident R1). Findings include: Review of facility policy Assessing Falls and Their Causes dated 2/1/23, indicated that if a resident has just fallen, or is found on the floor without a witness to the event, evaluate for possible injuries to the head, neck, spine, and extremities. If there is evidence of an injury, provide appropriate first aid and/or obtain medical treatment immediately. If an assessment rules out significant injury, help the resident to a comfortable sitting, lying, or standing position, and then document relevant details. Review of the clinical record indicated that Resident R1 was admitted to the facility on [DATE]. Review of Resident R1's Minimum Data Set (MDS - periodic assessment of care needs) dated 9/25/23, indicated diagnoses of hypertension (high blood pressure),…

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, clinical record review, and staff interview, it was determined that the facility failed to prevent injury during bed mobility, resulting in a fall that required transfer to the hospital for one of five residents (Resident R1). Findings include: Review of facility policy Accidents and Incidents - Investigating and Reporting dated 2/1/23, indicated the Nurse Supervisor/Charge Nurse and/or the department director or supervisor shall promptly initiate and document investigation of the accident or incident. Review of facility policy Assessing Falls and Their Causes dated 2/1/23, indicated that if a resident has just fallen, or is found on the floor without a witness to the event, evaluate for possible injuries to the head, neck, spine, and extremities. If there is evidence of an injury, provide appropriate first aid and/or obtain medical treatment immediately. If an assessment rules out significant injury, help the resident to a comfortable sitting, lying, or standing position, 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.