Locust Grove Retirement Village

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and resident and staff interview, it was determined that the facility failed to provide bathing assistance for a resident dependent on staff assistance for five of seven residents reviewed for activities of daily living (Residents 33, 39, 47, 52, and 63). Findings include: Interview with Resident 33 on May 1, 2024, at 9:52 AM revealed she is to get showered on Tuesdays and Fridays, during the day, and she doesn't refuse them, but stated she had a fracture and maybe that's why she wasn't getting them. Clinical record review for Resident 33 did reveal the resident had sustained a fracture in her leg in March 2024, and was scheduled to receive showers on Tuesdays and Fridays on the 2-10:00 PM shift and as needed. A review of Resident 33's bathing records for April 2024, revealed the resident was totally dependent on staff for bathing, and did receive a shower on April 2 and April 9, 2024, on her scheduled shower days after her fracture, but had only received a bed bath on April 5,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, review of facility documents, and resident, family member, and staff interview, it was determined that the facility failed to have sufficient nursing staff to meet resident's needs for four of 24 residents reviewed (Resident 28, 33, 52, and 64). Findings include: A review of a facility complaint/grievance form dated March 6, 2024, noted a resident concern regarding call bell response times. The investigation to the concern was noted as completed on March 25, 2024, by a registered nurse, and indicated, Call bell response times have increased due to staffing shortages, response times are monitored and while it is found to have increased response time, it is not because staff are choosing to not respond it is simply because that are extremely busy. The concern form had not yet been noted as resolved as of May 3, 2024. Facility nurse staffing was reviewed for the week of March 22 - March 28, 2024, which included the March 25, 2024, date the grievance investigation was completed and…

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

Based on observation, review of select policies and procedures, and staff interview, it was determined that the facility failed to secure medications and biologicals on one of two nursing units (One, Two, Three Hall nursing unit). Findings include: Review of the policy entitled Storage and Expiration of Medications, Biologicals, Syringes, and Needles, last reviewed on March 29, 2024, indicates that the facility should ensure that all medications and biologicals, including treatment items, are securely stored in a locked cabinet/cart or in a medication room that is inaccessible by residents and visitors. The policy indicates that the facility should ensure that medications and biologicals are stored at appropriate recommended temperatures. Observation of the One, Two, Three hall nursing unit on April 30, 2024, at 9:45 AM revealed medications laying on the counter to include Zofran (anti-nausea medication), Celexa (treats major depression), Buspar (treats anxiety), Incruse Ellipta inhaler (used to treat chronic lung conditions), and a bottle of liquid Keppra (used to treat seizures).…

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

Based on review of select facility policies and procedures, observation, clinical record review, and resident and staff interview, it was determined that the facility failed to implement appropriate enhanced barrier transmission-based precautions on two of two nursing units (400, and 100/200/300 nursing unit; Residents 65, 74, 231, and 232). Findings include: Review of the memo entitled Enhanced Barrier Precautions (EBP, gown and glove use) in Nursing Homes to Prevent the Spread of Multi-drug Resistant Organisms released by the Center for Medicaid and Medicare Services (CMS) on March 20, 2024, with an implementation date of April 1, 2024, revealed that nursing care facilities are to use EBP for residents with chronic wounds or indwelling medical devices (i.e., indwelling urinary catheters) during high-contact resident care activities regardless of their multidrug-resistant organism status. High-contact activity would include things like dressing, transferring, changing linens, providing hygiene, changing briefs, wound care, or device care. Review of the CDC (Centers for Disease…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff interview, it was determined that the facility failed to establish clear and consistent resident's wishes regarding advance directives (written instruction, such as a living will or durable power of attorney, relating to the provision of healthcare, for a time when a resident may be incapacitated and not able to make decisions) for one of one resident reviewed (Resident 16). Findings include: Review of Resident 16's clinical record revealed that the facility admitted her on February 26, 2024. A physician's order dated February 26, 2024, indicated that Resident 16 was to be a full code, which would include CPR (cardiopulmonary resuscitation). Review of a POLST (Physician Orders for Life Sustaining Treatment, a document for specific medical orders to be honored by health care workers during a medical crisis) form signed by Resident 16's responsible party on [DATE], indicated that she wished for Resident 16 to be a DNR (Do Not Resuscitate, not to perform cardiopulmonary…

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

Based on review of select facility policies and procedures, clinical record review, and family and staff interview, it was determined that the facility failed to ensure reasonable care for the protection of the resident's property for one of 18 residents reviewed (Resident 228). Findings include: The facility policy entitled, Personal Items Inventory, last reviewed without changes on March 29, 2024, revealed that the facility's procedure included: Enter the resident's name, room number, medical record number, and the date of inventory on the Inventory of Personal Effects Identify articles as listed, indicating quantity and presence with a check (x) Describe items of specific value. Describe color and size. Do not indicate type of metal or stone Sign Inventory of Personal Effects sheet: signature of resident or responsible party/date; signature of nurse/date; If resident or responsible party is unable to sign, two facility personnel (one being a nurse) are to sign the inventory on admission Telephone interview with Resident 228's husband on April 30, 2024, at 12:13 PM revealed that…

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

Based on a review of select facility policies and procedures, employee personnel record review, and staff interview, it was determined that the facility failed to obtain attestation of Pennsylvania residency as required for one of five personnel records reviewed (Employee 3). Findings include: In accordance with Act 13 Elder Abuse Mandatory Reporting and Act 169 Criminal Background Checks, nursing facilities are required to obtain a criminal background check on all newly hired employees. Facilities are required to obtain the Pennsylvania State Police (PSP) background check within 30 days of hire on all prospective employees. If the applicant has not been a Pennsylvania resident for the two years before application, they will need to have a PSP criminal history background check completed and an FBI Background Check. The facility policy entitled, Abuse, Neglect, Exploitation, and Misappropriation, last reviewed without changes on March 29, 2024, revealed that persons applying for employment will be screened for a history of abuse, neglect, exploitation, or misappropriation 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 clinical record review and staff, resident, and family interview, it was determined that the facility failed to provide the resident and their representative a summary of the baseline care plan for two of 24 residents reviewed (Residents 228 and 231). Findings include: Interview with Resident 228's husband on April 30, 2024, at 12:27 PM revealed that he believed the facility's contracted hospice provider staff were organizing his wife's care. Resident 228's husband was not aware of the frequency of visits completed by hospice staff. Review of the facility's CMS-802 (form used to list all current residents and pertinent care categories) revealed that Resident 228 received hospice services. Clinical record review for Resident 228 revealed that the facility admitted her on April 17, 2024. Review of active physician orders for Resident 228 revealed no evidence that she was to receive services from a hospice provider. Interview with Employee 11 (licensed practical nurse) on May 1, 2024, at 11:14 AM revealed that a baseline care plan form in Resident 228's clinical record…

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

Based on clinical record review and resident and staff interview, it was determined that the facility failed to provide the highest practicable care related to intravenous access and medication administration for one of two residents reviewed for intravenous access concerns (Resident 74); implementation of interventions for one of four residents reviewed for skin conditions (Resident 231); and bowel protocol medications for one of one resident reviewed for constipation concerns (Resident 231). Findings include: Clinical record review for Resident 74 revealed a plan of care initiated by the facility on April 25, 2024, to address antibiotic therapy related to an endocarditis infection (inflammation of the inner lining of the heart chambers and valves; usually caused by a bacterial infection). Interventions listed in the plan of care included: PICC line (PICC, long, thin, tube that is inserted through a vein in the arm and passed through to a larger vein near the heart. The line requires careful care and monitoring for complications including bleeding, infection, and blood clots) and…

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

Based on clinical record review, observation, and staff interview, it was determined that the facility failed to assess a blister for one of three residents reviewed (Resident 10). Findings include: Clinical record review for Resident 10 revealed a progress note dated April 10, 2024, at 10:57 AM noting the resident had a blister that opened on his left great lateral toe and the resident had stated he rubbed it on his footboard. It was also noted a longer bed was needed and bacitracin (antibacterial ointment) and a Band-Aid were applied. A follow up progress note dated April 10, 2024, at 3:27 PM noted the resident had a 0.5 cm (centimeter) x 0.5 cm blister that opened on his left great lateral toe and Vaseline and a band aid were applied. A maintenance work order dated April 11, 2024, indicated a longer bed was provided for the resident, and a review of physician orders revealed a treatment order for the resident's toe on April 10, 2024, and changed on April 11, 2024, to apply Vaseline to the area and cover with a band aid. The order was discontinued on April 19, 2024. As of May 1,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff interview, it was determined that the facility failed to provide services to maintain a resident's range of motion for one of three residents reviewed (Residents 39). Findings include: Clinical record review revealed a quarterly MDS (Minimum Data Set, an assessment completed at specific intervals to determine resident care needs) dated September 6, 2023, noting staff assessed Resident 39 as having no upper or lower extremity impairments. Further review of Resident 39's clinical record revealed a significant change MDS assessment dated [DATE], noting nursing staff assessed Resident 39 as having a limited range of motion (ROM, movement of the body to maintain a resident's ability) to his lower extremity. Nursing staff again assessed Resident 39 as having a limited range of motion to his lower extremity on his most recent quarterly MDS assessment dated [DATE]. Review of occupational therapy documentation revealed Resident 39 was discharged from occupational therapy on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff interview, it was determined that the facility failed to implement interventions to maintain acceptable parameters of nutritional status for one of six residents reviewed for nutritional concerns (Resident 233). Findings include: Clinical record review for Resident 233 revealed nursing documentation dated April 23, 2024, at 3:00 PM that indicated the facility admitted him from the hospital after multiple intensive care unit assignments, a history of necrotizing pancreatitis (severe inflammation that causes tissue death in the pancreas organ), and with treatment that had included TPN (total parenteral nutrition, medical intervention that provides all the nutrients and calories a person needs through a vein) since March 8, 2024. The documentation stipulated that Resident 233 was to have TPN from 6:00 PM to 6:00 AM. Nursing documentation dated April 23, 2024, at 7:32 PM, and April 24, 2024, at 8:13 PM revealed that the TPN was not available from the pharmacy for…

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

Based on clinical record review and staff and resident interview, it was determined that the facility failed to identify triggers related to a resident's diagnosis of Post-Traumatic Stress Disorder, to provide culturally, competent, trauma-informed care, and to eliminate or mitigate re-traumatization for one of five residents reviewed for mood/behavior (Resident 3). Findings include: Clinical record review for Resident 3 revealed a diagnosis of Chronic Post Traumatic Stress Disorder (PTSD, a mental and behavioral disorder that develops related to a terrifying event) since October 27, 2023. Review of a social service progress note dated April 7, 2023, 12:22 PM revealed Employee 13 (social worker) reviewed recent behaviors of increased agitation and yelling out, including some verbal abuse towards others. Documentation revealed Resident 3 continues to be significantly confused at baseline and continues medication management for mood and behavior concerns. Employee 13's documentation noted Resident 3 has expressed at times that he has just returned from the war and that he has a…

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

Based on review of select facility policies and procedures, observation, and review of personnel records, it was determined that the facility failed to ensure specific competencies necessary to care for resident needs for one of two residents reviewed for intravenous access concerns (400 hall nursing unit, Resident 74, Employee 7). Findings include: The facility policy entitled, Peripheral Intravenous Catheter Flushing, last reviewed without changes on March 29, 2024, revealed that infusion therapy in the post-acute care facility is performed by licensed nurses according to state law and facility policy. The nurse is responsible and accountable for obtaining and maintaining competence with infusion therapy within his or her scope of practice. Competency validation is documented in accordance with organizational policy. According to, Pennsylvania Code, Title 49, Chapter 21, Functions of the LPN, an LPN (licensed practical nurse) may perform only the IV (intravenous) therapy functions for which the LPN possesses the knowledge, skill, and ability to perform in a safe manner.…

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

Based on clinical record review and staff interview, it was determined that the facility failed to develop and implement individualized person-centered care plans to address dementia and cognitive loss displayed by one of two residents reviewed (Resident 3). Findings include: Clinical record review for Resident 3 revealed the facility admitted him on September 17, 2021. A diagnosis of dementia (loss of memory, language, problem-solving, and other thinking abilities that interfere with daily life) was added on November 29, 2022. A review of Resident 3's most recent annual Minimum Data Set Assessment (MDS, a form completed at specific intervals to determine care needs) dated August 15, 2023, indicated that the facility assessed Resident 3 as having a diagnosis of dementia. The facility determined that a care plan for dementia and cognitive loss would be developed. A review of Resident 3's care plan revealed that there was no indication that the facility had developed and implemented a person-centered care plan to address the resident's dementia and cognitive loss. Interview with…

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

Based on clinical record review and staff interview, it was determined that the facility failed to ensure a resident's medication regime was free from potentially unnecessary medications for one of five residents reviewed for medication regime review (Resident 3). Findings include: Clinical record review revealed that the facility admitted Resident 3 on September 17, 2021. Resident 3's clinical record revealed a physician's order for Seroquel (an antipsychotic medication) 25 milligrams (mg) every 24 hours as needed (PRN) for agitation on September 20, 2023. Review of the consultant pharmacist's recommendation dated September 22, 2023, revealed Resident 3 has a PRN order for Seroquel without a stop date. The consultant pharmacist requested the facility discontinue Resident 3's PRN Seroquel or add a stop date that does not exceed 14 days from initiation. If the PRN antipsychotic cannot be discontinued at this time, the prescriber should directly examine the resident to determine if the antipsychotic is still needed and document the specific condition being treated before issuing a new…

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

Based on review of select facility policies and procedures, observation, and staff interview, it was determined that the facility failed to ensure a medication error rate below five percent (100/200/300 hall nursing unit, Residents 62 and 15). Findings include: The facility's medication error rate was 6.67 percent based on 30 medication opportunities with two medication errors. The facility policy entitled, Medication - Oral Administration Of, last reviewed without changes on March 29, 2024, revealed that staff should compare the medication unit/dose label against the MAR prior to returning the medication container or card to the medication cart or disposing of the empty container; and prior to supporting the resident to accept and ingest the medication. The policy did not include the expectation of nursing staff when there are specific instructions printed on the pharmacy label such as, give with food, or give with a meal. Review of the facility's mealtimes revealed that the 100 Hall receives the breakfast meal at 7:15 AM. Observation of a medication administration pass on the 100…

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

Based on clinical record review and staff interview, it was determined that the facility failed to provide the highest practicable care regarding physician ordered pain medications for one of five residents reviewed (Resident 53). Findings include: Review of Physiopedia's and Wikipedia's definition of the numeric pain rating scale (parameters) from zero to 10 indicated that no pain was identified as zero, mild pain was identified as one to three, moderate pain was identified as four to six, and severe pain was identified as seven to 10. Clinical record review for Resident 53 revealed physician's orders for the following pain medications: Ordered on June 17, 2023, Tylenol (for mild pain) 325 milligrams (mg) 2 tablets by mouth (PO) every 6 hours as needed (PRN) for mild pain. Ordered on June 19, 2023, and discontinued on June 27, 2023, Tramadol (for moderate pain) 50 mg PO every 8 hours PRN for moderate pain. Review of Resident 53's June, July, and August 2023 MAR (medication administration record, a form to document medication administration) revealed the following: Staff…

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

Based on staff interviews and review of facility documentation, it was determined that the facility failed to ensure that nurse aides received an annual performance evaluation for three of five employees reviewed (Employees 13, 14, and 15). The findings include: On August 4, 2023, at 9:00 AM the surveyor requested from the Nursing Home Administrator the most recent annual performance evaluations for Employees 13, 14, and 15. Three of the five annual performance evaluations were not provided. Interview with the Director of nursing on August 4, 2023, at 10:05 AM confirmed that the facility did not have completed evaluations for Employees 13, 14, or 15 in their personnel file. Interview with the Nursing Home Administrator on August 4, 2023, at 11:45 AM confirmed that Employees 13, 14 and 15 were employed by the facility for the past 12 months and should have had a performance evaluation completed. 28 Pa. Code 201.19 Personnel policies and procedures

Based on observation and staff interview, it was determined that the facility failed to maintain equipment in a safe and sanitary condition in the facility's main kitchen and store food items in a safe and sanitary manner in a facility dining room located between the 200 and 300 Nursing Units. Findings included: Initial tour of the facility's main kitchen on August 1, 2023, between 9:50 AM and 10:30 AM with Employee 12, Dietary Manager, revealed the following: The entire length of the water drainage pipe from the ice machine to the floor drain was covered in a black colored mold-like substance. Observation of a facility dining room located between the 200 and 300 Nursing Units on August 2, 2023, at 12:00 PM and August 4, 2023, at 9:25 AM revealed the following: A pantry area in the dining room contained multiple plastic spoons unsecured in a drawer. They were stored on top of an open pack of personal cleaning cloths. The cloths had a large dried, brown colored stain on the top of the package. There was an accumulation of debris and crumbs in the bottom of the drawer. A second drawer…

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

Based on clinical record review, review of facility documents, and staff and resident interview, it was determined that the facility failed to protect the rights of a resident to be free from neglect by not providing the services necessary to avoid a fall out of bed resulting in injury for one of one resident reviewed for neglect related to a fall (Resident 60). Findings include: Clinical record review for Resident 60 revealed a nursing progress note dated July 13, 2023, at 9:53 PM that indicated he was witnessed by staff to roll out of bed onto the floor. The note indicated that he landed on the floor face first and that he denied pain other than his knees. His knees were red from laying on the floor and he had an abrasion on his left elbow. Further clinical record review for Resident 60 revealed a nursing progress note date July 13, 2023, at 10:09 PM that revealed a nurse aide was performing incontinence care on him and had him propped on his left side holding himself up with his right hand. The nurse aide turned his head for a second and the resident rolled onto the floor. The…

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

Based on review of select facility policies and procedures, employee personnel records, and staff interview, it was determined that the facility failed to implement its established abuse prohibition policy regarding criminal background checks and abuse training for two of five newly hired employees reviewed (Employees 1 and 3). Findings include: The facility policy entitled, Abuse, Neglect, Exploitation, and Misappropriation, last reviewed without changes on March 16, 2023, revealed that screening procedures included persons applying for employment with the facility would be screened, which would include, but not be limited to, criminal background checks. Training procedures included that employees of the facility would receive education and training on resident rights, resident abuse, and abuse reporting during orientation and annually thereafter. Review of the list provided by the facility of newly hired employees for the past four months revealed that the facility hired Employee 1 (licensed practical nurse) on May 17, 2023. A review of Employee 1's personnel file revealed no…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, observation, and family, resident, and staff interview, it was determined that the facility failed to ensure assessments accurately reflected residents' status for three of 18 residents reviewed (Residents 17, 39, and 33). Findings include: Clinical record review for Resident 17 revealed a quarterly MDS assessment (MDS, Minimum Data Set, an assessment tool completed at specific intervals to determine resident care needs) dated February 8, 2023, that assessed her as the following: Independent after setup help for bed mobility Independent for transfers between surfaces Supervision after setup help for toileting An annual MDS dated [DATE], assessed that Resident 17 declined to the following status: The physical assistance of one person and supervision for bed mobility The physical assistance of one person and supervision for transfers between surfaces The physical assistance of one person and supervision for toileting Interview with Employee 4 (registered nurse assessment…

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

Based on clinical record review and staff interview, it was determined that the facility failed to provide the highest practicable care regarding physician ordered vital signs for one of 24 residents reviewed (Resident 78). Findings include: Clinical record review for Resident 78 revealed a physician's order dated July 17, 2023, that staff were to complete vital signs (blood pressure, pulse, respirations, and temperature) every shift. Review of Resident 78's clinical documentation revealed that staff did not complete Resident 78's vital signs on the following dates and shifts: July 31, 2023, day shift July 29, 30, and 31, 2023, evening shift July 26, 27, 29, 30, and 31, 2023, night shift August 1 and 2, 2023, night shift The surveyor reviewed the above information during an interview on August 3, 2023, at 2:30 PM with the Nursing Home Administrator and Director of Nursing. 483.25 Quality of Care Previously cited 8/12/22 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing services

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of select facility policies and procedures, clinical record review, observation, and resident and staff interview, it was determined that the facility failed to implement treatment and services to prevent development and promote healing of pressure ulcers for two of two residents reviewed for pressure ulcer concerns (Residents 2 and 54). Findings include: The facility policy entitled, Pressure Injury Record, last reviewed without changes on March 16, 2023, revealed that it is the facility's policy to document the presence of skin impairment/new skin impairment related to pressure when first observed and weekly thereafter until the site is resolved. The procedure included to enter the size of the pressure injury, the tissue type and color, and a description of the wound edges, drainage, and surrounding area. The facility policy entitled, Skin and Wound, last reviewed without changes on March 16, 2023, revealed that it is the facility's policy to provide a system for identifying risk, 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 review of select facility policies and procedures, review of personnel files, and staff interview, it was determined that the facility failed to ensure an individual completed required retraining for one of five personnel records reviewed (Employee 2). Findings include: The facility policy entitled, Abuse, Neglect, Exploitation, and Misappropriation, last reviewed without changes on March 16, 2023, revealed that persons applying for employment with the facility will be screened which includes, but is not limited to, employment history. Department of Health, Nurse Aide Enrolling and Testing, stipulates that a Pennsylvania nurse aide registry will lapse if an individual does not work providing nursing related services for 24 months or more. Review of Employee 2's (nurse aide) personnel file revealed the facility hired her on June 6, 2023. The personnel file included a work history that ended, 2021. The information did not include a month or specific date. Review of reference checks obtained by the facility revealed that staff failed to complete the dates of employment 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 review of select facility policies and procedures, clinical record review, and resident and staff interview, it was determined that the facility failed to assist a resident to obtain routine dental services for one of four residents reviewed for dental concerns (Resident 75). Findings include: The facility policy entitled, Dentist, last reviewed without changes on March 16, 2023, revealed that the facility will assist a resident in obtaining routine and emergency dental care. The facility will provide Medicaid residents services and routine services covered under the State plan at no charge. If any resident of the facility is unable to pay for needed dental services, the facility will attempt to find alternative funding sources or alternative service delivery systems to ensure the resident maintains his/her highest practicable level of well-being. Interview with Resident 75 on August 2, 2023, at 9:45 AM revealed that she was edentulous (without natural teeth) but was not wearing her dentures that she…

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

Based on clinical record review and resident and staff interview, it was determined that the facility failed to ensure accurate clinical record documentation for one of 18 residents reviewed (Resident 13). Findings include: Interview with Resident 13 on August 1, 2023, at 12:41 PM revealed that he had natural teeth; however, he believed that he had not been evaluated by a dentist this year. Resident 13 could not remember the last time that a dental professional evaluated the condition of his teeth. Clinical record review for Resident 13 revealed documentation by the facility's consulting dentist dated January 31, 2023, that indicated Resident 13 had decay, was missing several teeth, and had several retained roots. The documentation indicated that x-rays were taken and that any treatment needs were noted. The same document noted that the extractions of six teeth were, Planned. There was no evidence in Resident 13's clinical record of any further professional dental services in the six months since the January 31, 2023, appointment. The surveyor requested evidence of any professional…

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.