Wecare At Monroeville Rehabilitation And Nsg Ctr

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, observations and staff interviews, it was determined that the facility failed to provide a safe, clean, comfortable, and homelike environment on two of two nursing units (Side 1 and Side 2) and failed to provide clean linens, wash cloths and towels to accommodate the needs of the residents of two of two nursing units (Side 1 and Side 2). Findings included: Review of the facility policy Homelike Environment, last reviewed on 6/1/25, indicated that residents are provided with a clean, comfortable homelike environment and encouraged to use their own belongings. The facility staff and management maximize, the characteristics of the facility that reflect a personalized, homelike setting including a clean, sanitary, and orderly environment including clean bed and bath linens that rea in good condition. During observations on 4/12/26 from 10:40 a.m., through 12:27 p.m., the following was observed: The main hall the ceilings have unfinished drywall and spackling, walls have areas 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.

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 physician of increased or decreased Capillary Blood Glucose (CBG) levels and failed to assess residents of hyperglycemia (high blood glucose) and hypoglycemia (low blood glucose) for three of seven residents (R1, R14, and R77). Findings include: The Centers for Disease Control define diabetes as: Diabetes Mellitus is a chronic (long-lasting) health condition that affects how your body turns food into energy. Most of the food you eat is broken down into sugar (also called glucose) and released into your blood stream. When your blood sugar goes up, it signals your pancreas to release insulin. Insulin acts like a key to let the blood sugar into your body's cells for use as energy. If you have diabetes, your body either doesn't make enough insulin or can't use the insulin it makes as well as it should. When there isn't enough insulin or cells stop responding to insulin, too much blood…

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 consistent dialysis communication was maintained for two of two residents reviewed (Residents R1 and R21).Findings include: Review of the facility policy Dialysis Management (Hemodialysis) dated 1/8/26 with a prior review date of 6/1/25. The policy indicates the facility is to complete Pre-Dialysis information on the communication form and send with resident to dialysis on treatment days, to ensure communication of resident information and coordinate care between Dialysis Center and Facility. Dialysis center personnel to complete Dialysis communication form and return to facility. Dialysis Center may provide their EHR documentation vs manual documentation of treatment on communication form. Upon return from Dialysis Center, review information provided on Dialysis communication form/EHR. Communicate and address as appropriate. Facility to complete post-dialysis information/data 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 facility policy, resident observations, resident group interview, a confidential staff interview and staff interviews, it was determined that the facility failed to have sufficient nursing staff to provide nursing and related services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of twelve of twenty-four residents (Residents R1, R2, R5, R14, R36, R51, R60, and R700 R701, R702 R801, and R802).Findings Include: Review of the facility policy Staffing, Sufficient and Competent Nursing, reviewed on 1/8/26 with a prior review date of 6/1/25, indicated, attaining or maintaining the highest practicable physical, mental, and psychosocial well-being of each resident. Minimum staffing requirements imposed by the state are adhered to when determining staff rations but are not necessarily considered a determination of sufficient and competent staffing. Review of the facility policy Answering the Call Light, reviewed on 1/8/26 with a prior review date of 6/1/25, indicated that each resident is provided with a means to call staff for…

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

Based on review of facility policy, observations, and staff interviews, it was determined that the facility failed to properly secure a medication cart for one of three medication carts currently in use (Cart #1) and failed to properly secure a medication cart while not in use for one of four medication carts (Cart #4). Findings include: Review of the facility policy Storage of Medications dated 6/1/25, indicated drug and biologicals used in the facility are to be in locked compartments under proper temperature. Only persons authorized to prepare and administer medications have access. The nursing staff are responsible for maintaining medication storage. Compartments containing drugs and biologicals are locked when not in use. Unlocked medication carts are not left unattended. During an observation on 4/12/26, at 10:03 a.m., Medication cart #1 was unlocked and unattended in hall. During an interview on 4/12/26, at 10:03 a.m., Registered Nurse Employee E8 confirmed that the facility failed to properly secure one of three medication carts (Cart #1). During an observation on 4/12/26,…

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, observation, and staff interview, it was determined that the facility failed to ensure that care was provided in a manner which maintained resident dignity for five of twenty-three residents (Resident R40, R51, R700, R701, and R702).Findings include: Review of the facility policy Resident Rights reviewed on 1/8/26, with a prior review date of 6/1/25, indicated that federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to a dignified existence be treated with respect, kindness and dignity, be free from abuse, neglect, access to people and services both inside and outside the facility. The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which provides instructions and guidelines for completing required Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2023, indicated that a BIMS (Brief Interview of Mental Status)…

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

Based on review of facility policy, resident council documents, resident group interview, resident interview, and staff interview it was determined that the facility failed to respond to concerns from resident council and failed to respond to concerns in a timely manner for seven out of eight months (August 2025, September 2025, October 2025, November 2025, December 2025, February 2026 and March 2026).Findings include:Review of the facility policy Resident Council dated 1/8/26 with a prior review date of 6/1/25. The policy indicates The purpose of the resident council is to provide a forum for: residents, families and resident representatives to have input in the operation of the facility; discussion of concerns and suggestions for improvement; consensus building and communication between resident and facility staff; and disseminating information and gathering feedback from interested residents. A Resident Council Response Form will be utilized to track issues and their resolution. The quality assurance and performance improvement (QAPI) committee will review information 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, clinical records, and staff interviews, it was determined that the facility failed to conduct a thorough investigation of an injury obtained during care to eliminate possible neglect for one of seven residents (Resident R77).Findings include: Review of the facility policy Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating reviewed 2/18/26, with a previous review date of 1/20/25, indicated the facility will report any resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by management. Findings of all investigations are documented and reported. Review of the facility policy Accidents and Incidents-Investigating and Reporting reviewed 2/18/26, with a previous review date of 1/20/25, indicated all accidents or incidents involving residents, employees, visitors, vendors,…

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

Based on observation and staff interviews, it was determined that the facility failed to ensure that current and accurate nurse staffing information was posted in the facility at the beginning of each shift. Findings include: Observation conducted on 4/12/26, at approximately 9:15 a.m., revealed that nurse staffing information was posted in the main lobby on the reception desk. At that time, the nurse staffing information had the date of (4/10/26), resident census, and the staffing hours did not accurately reflect the current total number of hours worked for licensed and unlicensed nursing staff directly responsible for resident care per shift for the current date. During an interview with the Nursing Home Administrator (NHA) on 4/12/26, at approximately 11:50 a.m., the NHA confirmed the facility failed to post the required current facility information for staffing hours and the census for 4/12/26.

Based on review of job descriptions, clinical records, and staff interviews, it was determined that the Nursing Home Administrator (NHA) and the Director of Nursing (DON) failed to ensure that water temperatures in resident bathroom hand sinks were maintained at a safe temperature for one of two nursing units observed (First and Second Nursing Units). This failure resulted in a harm to Resident R77 and placed residents on the Second Nursing Unit at risk for serious injury from a burn and resulted in an Immediate Jeopardy situation for 26 of 41 residents. Findings include:Review of the facility-provided Nursing Home Administrator (NHA) job description indicated, The primary purpose of your job is to lead, direct, and manage the overall operations of the community in accordance with policies and procedures and current federal, state and local standards, guidelines and regulations that govern the community. As the Administrator, it is your responsibility to organize, develop, and direct resources to maintain the highest degree of quality care is maintained for each resident at all…

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

Based on observations, family interview, and staff interviews, it was determined that the facility failed to ensure a clean, sanitary, and functional environment in the laundry room.Findings include:During an observation on 4/12/26, at 12:27 p.m., the following was observed: The washing area had two washers; one working washer had the complete front panel of the machine off and was leaking water throughout the washroom onto the floor. There were three dryers, two of which had broken signs on them and the functioning dryer had a brown substance inside the dryer drum. During an interview on 4/12/26, at 12:28 p.m., the Laundry/ Housekeeping Supervisor Employee E1 confirmed that the facility failed to ensure a clean, sanitary, and functional environment in the laundry room. 28 Pa. Code 201.14 (a) Responsibility of licensee. 28 Pa. Code 201.18(b)(1)(3) Management.

Based on facility documents, observations, and staff interviews, it was determined that the facility failed to make certain door alarm systems were regularly tested for functionality. Findings include: Review of the facility Maintenance Manager job description indicated the Maintenance Manager Maintains competency & is tested to be competent in:Machine Maintenance requirementsFire Prevention & SafetyInfection Control/OSHA & CDCFacility Maintenance requirements Review of the facility alarm testing instructions stated:Check delayed egress operation (if applicable)1. Push door release hard for a fraction of a second - door should not open and alarm shouldnot sound2. Apply pressure to the door release for the pre-determined nuisance period setting (normally1-3 seconds)3 Door should go into irreversible unlocking sequenceDoor alarm will soundDoor will automatically open within (15-30 seconds)4 Close door and reset the alarm5 Ensure signs are placed on doors adjacent to the release device that read 'Push until alarmsounds. Door can be opened in 15 seconds.6 Confirm that security panels at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of clinical record review and staff and resident interviews, it was determined that the facility failed to provide prescribed treatment and services related to the care of wounds for two of five residents (Resident R4 and R5).Findings include: Review of the PICO 14 Single Use Negative Pressure Wound Therapy (NPWT) System (device used for wound healing) directions for use indicated that the portable pump is connected to the absorbent adhesive dressing. The dressings have a wear time of up to seven days depending on the amount of fluid from the wound, and the pump has a battery life of 14 days. Review of Resident R4's admission record indicated he was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS - periodic assessment of resident care needs) dated 2/3/26, included diagnoses of heart failure (a progressive heart disease that affects pumping action of the heart muscles) and diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical record review, resident interviews and observations, staff interviews, and it was determined that the facility failed to provide appropriate respiratory care for two of four residents (Resident R2 and R3). Findings include: Review of facility policy Administering Medications 1/8/26, indicated medications are administered in a safe and timely manner, and as prescribed. The policy further stated that the individual administering the medication records in the resident's medical record:-the date and time the medication was administered;-the dosage;-the route of administration;-the injection site (if applicable);-any complaints or symptoms for which the drug was administered;-any results achieved and when those results were observed; and-the signature and title of the person administering the drug. Review of the Resident Assessment Instrument 3.0 User's Manual effective October 2025, indicated that a Brief Interview for Mental Status (BIMS), is a screening test that aides…

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 facility policy review, clinical and facility record review, facility submitted documents, and staff interviews, it was determined that the facility failed to provide adequate supervision to prevent elopement for one of five residents (Resident R1). This was identified as past non-compliance.Findings include: Review of the facility policy Wandering and Elopements dated 1/8/26, indicated the facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining he lest restrictive environment for residents. Review of the Resident Assessment Instrument 3.0 User's Manual effective October 2025, 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 intact8-12: moderately impaired0-7: severe impairment Review of the clinical record revealed Resident R1 was admitted to the facility on [DATE]. Review of the Minimum Data…

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 and staff interviews it was determined the facility failed to ensure equipment was in safe operating condition for two of two crash carts (carts maintained with equipment used in emergencies, 100-Hall and 2-Hall) and two of two facility dryers. Review of the facility policy, Emergency Procedure - Cardiopulmonary Resuscitation dated [DATE], previously dated [DATE], indicated, Maintain equipment and supplies necessary for CPR/BLS (cardiopulmonary resuscitation / basic life support) in the facility at all times.Findings include:During an observation of the 100-Hall crash cart on [DATE], at approximately 10:00 a.m. revealed the following items missing from per the inventory on the Emergency Cart Daily Checklist:Blank code bookBand-aids(2) needles with syringesGownsMasksGoggles or face shieldAlcohol based hand rubAmbu-bag(2) 14 French suction kits(2) Christmas tree adaptersNon-rebreather maskNasal canulaReview of the 100-Hall Emergency Cart Checklist for [DATE] revealed the crash cart was not…

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

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 physicians of increased capillary blood glucose (CBG) levels for four of six residents (Resident R1, R2, R3, and R4).The Centers for Disease Control indicated hyperglycemia is blood glucose greater than 125 mg/dL (milligrams per deciliter) while fasting (not eating for at least eight hours, or a blood glucose greater than 180 mg/dL one to two hours after eating. If hyperglycemia is left untreated for long periods of time, it can damage nerves, blood vessels, tissues and organs. Review of the facility policy, Diabetes - Clinical Protocol dated 1/8/26, previously dated 6/1/25, indicated, The physician will order appropriate interventions, which may include:Treatment of underlying conditions causing impaired glucose tolerance;Physical activity, diet and lifestyle modifications, where feasible and accepted by the resident;Oral hypoglycemia agents; and/orInsulin (an injectable medication 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 a review of facility policy and records and staff interviews, it was determined that the facility failed to ensure that facility nursing personnel maintain current CPR (cardiopulmonary resuscitation) certification for Healthcare Providers through a CPR provider whose training includes a hands-on session either in a physical or virtual instructor-led setting in accordance with accepted national standards for three of 27 licensed nurses (Licensed Practical Nurse (LPN) Employees E10 and E11, and Registered Nurse (RN) Employee E14).Review of the facility policy, Emergency Procedure - Cardiopulmonary Resuscitation dated [DATE], previously dated [DATE], indicated Obtain and/or maintain American Red Cross or American Heart Association certification in Basic Life Support (BLS) / Cardiopulmonary Resuscitation (CPR).On [DATE], the Nursing Home Administrator (NHA) provided a list of 14 currently employed LPNs and 13 currently employed RNs.Review of the CPR certification cards for LPN Employees E10 and E11, and RN…

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 and records and staff interviews, it was determined that the facility failed to maintain documentation that facility nursing personnel have current education and certification to provide basic life support, including CPR (cardiopulmonary resuscitation), to a resident requiring such emergency care prior to the arrival of emergency medical personnel and subject to related physician orders and the resident's advance directives for 15 of 27 licensed nurses (Licensed Practical Nurse (LPN) Employees E1, E2, E3, E4, E5, E6, E7, E8, E9, E12, and Registered Nurse (RN) Employees E13, E15, E16, E17, and E18).Review of the facility policy, Emergency Procedure - Cardiopulmonary Resuscitation dated [DATE], previously dated [DATE], indicated that personnel have completed training on the initiation of cardiopulmonary resuscitation (CPR) and basic life support (BLS), including defibrillation, for victims of sudden cardiac arrest (unexpected cessation of heart pumping, causing an immediate…

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 and staff interviews, it was determined that the facility failed to develop, implement, and maintain an effective training program, including additional training topics based on the resident population or outcome of the facility assessment for eight of nine staff members sampled (Employees E19, E20, E21, E22, E24, E25, E26, and E27).Findings include: Review of the United States National Institute of Health: National Heart, Lung, and Blood Institute document, Cardiac Arrest: Causes and Risk Factors dated [DATE], indicated that Heart problems are the most important risk factors for cardiac arrest. Included in the examples of heart conditions that can precipitate cardiac arrest were: Coronary artery disease (CAD, damage or disease in the heart's major blood vessels)Abnormal heart rhythms (arrhythmia, dysrhythmia)Atrial fibrillation (disease of the heart characterized by irregular and often faster heartbeat)Angina (chest pain from not enough blood flow to the heart…

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

Based on review of facility policy, observations, and staff interview, it was determined that the facility failed to make certain that medical supplies were properly stored and/or disposed of for two of two crash carts (carts maintained with equipment used in emergencies, 100-Hall and 2-Hall).Findings include: Review of the facility policy Storage of Medications dated 1/8/26, previously dated 6/1/25, indicated that discontinued, outdated, or deteriorated drugs are returned to the dispensing pharmacy or destroyed. During an observation on 2/2/26, at approximately 11:00 a.m., of the 100-Hall crash cart revealed the following:(1) Yankauer catheter with sterile packaging open.(1) box of acetaminophen suppositories with an expiration date of 12/2024.(1) bottle of 0.9% sodium chloride solution with an expiration date of 5/18/24.(1) I.V. start kit with an expiration date of 4/30/24.(1) I.V. start kit with an expiration date of 9/7/25.(1) concentrator mask with tubing with an expiration date of 03/2025.(1) package of connection tubing with an expiration date of 06/2012.(1) box of glucose…

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 documents, observations, and staff interviews, it was determined that the governing body failed to implement policies regarding the management of the operation of the facility by failing to align facility policies with Centers for Medicare and Medicaid Services requirements.Findings include: Review of the facility policy, Governing Body dated [DATE], previously dated [DATE], indicated, The Governing Body is, to the extent required by applicable law, responsible for establishing and implementing policies regarding management and operation of the Facility. Review of S483.24(a)(3) Personnel provide basic life support, including CPR (cardiopulmonary resuscitation), to a resident requiring such emergency care prior to the arrival of emergency medical personnel and subject to related physician orders and the resident's advance directives indicated, Ensure staff maintain current CPR certification for healthcare providers through a CPR provider whose training includes hands-on practice 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 the review of facility policy, observations, clinical records, and staff interviews, it was determined that the facility failed to appropriately document wound care orders and treatments for four of seven residents (Residents R5, R6, R7, and R8).Findings include: Review of the Facility Assessment dated 1/23/26, indicated in the Common Diagnoses that the facility would provide care for skin ulcers and injuries. Review of the facility policy, Charting and Documentation dated 1/8/26, previously dated 6/1/25, indicated All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. The medical record should facility communication between the interdisciplinary team regarding the resident's condition and response to care. Review of the facility policy, Wound Care dated 1/8/26, previously dated 6/1/25, indicated that the date and time wound care was given…

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 develop and implement a baseline care plan to include instructions needed to provide effective and person-centered care of the resident for ten of ten residents reviewed (Resident R1, R2, R3, R4, R5, R6, R7, R8, R9, and R10).Findings include: Review of the facility policy Care Plans, Comprehensive Person-Centered dated 6/1/25, indicated, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the residents physical, psychosocial, and functional needs is developed and implemented for each resident. Review of Resident R1's clinical record reviewed that the resident was admitted to the facility on [DATE]. Review of Resident R1's facility diagnosis list included Alzheimer's disease (a type of brain disorder that causes problems with memory, thinking and behavior) and bipolar disorder (mental illness that causes unusual shifts in a person's mood, energy, activity…

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 resident and staff interviews, it was determined that the facility failed to make accessible grievance boxes to residents in two of two locations (front hallway and rear hallway).Findings include: The Centers for Medicare & Medicaid Services (CMS) does not specify exact height requirements for grievance boxes in skilled nursing facilities. However, CMS mandates that grievance procedures be accessible to all residents, including those with disabilities, in compliance with the Americans with Disabilities Act (ADA). In Pennsylvania, the Department of Health incorporates by reference the federal requirements outlined in 42 CFR Part 483, Subpart B, which pertains to long-term care facilities. These regulations emphasize the importance of accessibility but do not provide additional specifications regarding grievance box placement. To ensure accessibility, the ADA Standards for Accessible Design recommend that operable parts, such as slots on grievance boxes, be mounted between 15 and 48 inches above the floor. This range accommodates…

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

Based on observations and staff interviews, it was determined that the facility failed to provide a clean and homelike environment on two of two nursing units and for seven of twelve residents.Findings include: Review of the facility policy Homelike Environment dated 6/1/25, indicated in part, The facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include clean bed and bath linens that are in good condition. Review of information submitted to the Pennsylvania Department of Health on 12/22/25, indicated that Resident R21 had vomited under his bed on 12/18/25, and the dried vomit remained under his bed on 12/22/25. During an interview on 12/22/25, at 12:59 p.m. the Nursing Home Administrator confirmed that Resident R21's room had not been cleaned of the vomit from 12/18/25. During an observation on 12/22/25, at 1:50 p.m. Resident R20's room was noted to have food on the floor with a smell of urine. During an observation of Resident R24's room revealed blood 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 documentation, clinical records, and staff interviews it was determined the facility failed to document and/or follow-up on concerns/grievances presented by staff and residents for five of five residents (Resident R11, R12, R13, R14, and R15).Findings include: Review of facility, Grievance Policy dated 6/1/25, indicated the facility is committed to maintaining transparent, fair, and accessible grievance process. Every grievance will be addressed promptly and appropriately, in accordance with federal and state regulations. Residents and their representative must be assured that: They can submit grievances orally or in writing; Their concerns will be investigated and responded to promptly; They will not face discrimination, reprisal, or retaliation; They will receive written notice of grievance outcomes within required timeframes. Review of a grievance filed by Resident R11 on 11/19/25, reported a concern related to not receiving showers. The form section that indicated if the resident/resident representative was informed of the resolution and the name 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 protect residents from verbal and emotional abuse and/or neglect for three of twelve residents (Resident R15, R23, and R25).Findings include: Review of the facility policy, Abuse and Neglect - Clinical Protocol dated 6/1/25, defined abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish and neglect as 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 the clinical record indicated Resident R15 was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS - periodic assessment of resident care needs) dated 10/10/25, included diagnoses of dementia (a group of symptoms that affects memory, thinking and interferes with daily life)…

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 and resident and staff interviews, it was it was determined that the facility failed to follow physician's orders for four of five residents (Resident R16, R17, R18, and R19).Findings include:Review of Resident R16's admission record indicated she was admitted to the facility on [DATE].Review of the Minimum Data Set (MDS - periodic assessment of resident care needs) dated 9/30/25, included diagnoses of heart failure (a progressive heart disease that affects pumping action of the heart muscles) and hemiplegia (paralysis on one side of the body).Review of an active physician order dated 4/3/24, indicated Resident R16 should have a left protective sleeve and left resting hand splint, to be worn every day, day shift, as tolerated.Review of an active physician order dated 10/29/24, indicated Resident R16 should have a left an Isotoner glove to her left hand daily.Review of Resident R16's plan of care for self-care deficit and skin integrity last reviewed on 10/8/25, both indicated Resident R16…

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, resident observations, resident and staff interviews, information submitted to the Pennsylvania Department of Health (PADOH, Resident Council minutes, and grievance review, it was determined that the facility failed to have sufficient nursing staff to provide nursing and related services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of 16 of 35 residents (Residents R1, R5, R11, R12, R13, R14, R15, R16, R17, R20, R22, R26, R27, R30, R31, and R32).Findings Include: Review of the facility policy, Answering the Call Light dated 6/1/25, indicated, The purpose of this procedure is to ensure timely responses to the resident's requests and needs. Review of the facility policy, Activities of Daily Living, (ADL), Supporting dated 6/1/25, indicated, 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. During an observation on 12/22/25, at approximately 1:19 p.m. Resident R1 was noted…

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 implement policies and procedures to report possible neglect of one of three residents (Resident R23).Findings include: Review of facility policy Abuse, Neglect, Exploitation or Misappropriation Reporting and Investigating dated 6/1/25, indicated The administrator or the individual making the allegation immediately reports his or her suspicion to the following persons or agencies: The state licensing/certification agency responsible for surveying/licensing the facility.The local/state ombudsman.The resident's representative.Adult protective services (where state law provides jurisdiction in long-term care).Law enforcement officials.The residents attending physician.The facility medical director. Immediately is defined as: Within two hours of an allegation involving abuse or result in serious bodily injury; or Within 24 hours of an allegation that does not involve abuse or result in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy, clinical record review, and resident and staff interview it was determined the facility failed to obtain laboratory services as ordered for one of three residents (Resident R13).Findings Include: Review of the facility policy, Laboratory Testing and Result Management dated 6/1/25, indicated, The facility shall ensure that laboratory tests are obtained, processed., reviewed, and acted upon in a timely manner by qualified staff. Review of the clinical record revealed that Resident R13 was admitted to the facility on [DATE]. Review of Resident R13's Minimum Data Set (MDS, periodic assessment of resident care needs) dated 12/1/25, included diagnoses of chronic kidney disease (gradual loss of -kidney function), heart failure (a progressive heart disease that affects pumping action of the heart muscles), and high blood pressure. Review of the plan of care dated 4/8/25, included a care of plan for psoriasis (a chronic skin condition that causes red, itchy, scaly patches). Review 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, observations and staff interview, it was determined that the facility failed to determine if it was safe to self-administer medications for one of five residents (Resident R1).Findings include: Review of the facility policy, Self-Administration of Drugs dated 6/1/25, indicated, If a resident chooses to self-administer medication, he/she will be assessed for the ability to exercise this right safely and accurately. Review of the clinical record indicated Resident R1 was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS - periodic assessment of resident care needs dated included diagnoses of diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time) and dementia (a group of symptoms that affects memory, thinking and interferes with daily life). Review of Section C: Cognitive Patterns indicated Resident R1 had moderate cognitive impairment. Review of Resident R1's plan of care updated 10/3/25, failed to include…

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, resident, and staff interviews, it was determined that the facility failed to provide a safe, clean, comfortable, and homelike environment for three of ten residents as required (Residents R1, R2, and R3) on two of two nursing units side one and side two. Findings included:Review of the facility policy Homelike Environment dated 6/1/25, indicated in part The facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include clean bed and bath linens that are in good condition. During an interview on 7/31/25, at approximately 10:00 a.m. Resident R1 verbalized frustration with the lack of linen at the facility. They always run out of sheets and bath towels, sometimes I have an accident in bed and the staff have to run all over the building to try and find linen it can take an hour. Sometimes you can't get new sheets on your bed after your shower because there isn't any available. During an interview on 7/31/25, at approximately…

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

Based on observations, review of facility documentation, resident, and staff interviews, it was determined that the facility failed to make certain that fresh drinking water was consistently readily accessible to residents to promote adequate hydration, meet resident preferences, and maintain their comfort for three of ten residents (Residents R1, R2, and R3).Findings include:The U.S. National Academies of Sciences, Engineering, and Medicine suggests adequate daily fluid intake for men: 3,700 mL (milliliter) per day and women: 2,700 mL per day.A review of the facility current Certified Nursing Assistant Job Description indicated Keep residents' water pitchers clean and filled with fresh water (on each shift), and within easy reach of the resident. During an interview and observation on 7/31/25, at approximately 10:00 a.m., Resident R1 was asked by the surveyor if drinking water was provided. Resident R1 stated; they are supposed to bring it three times a day and that never happens. You usually have to ask for water if you want it. You can't get ice because the ice machines are…

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

Based on observations, review of facility documentation, and staff interviews, it was determined that the facility failed to make certain that equipment was in safe operating condition for one of one AEDs (Automatic External Defibrillators).Findings include:Review of facility policy Automatic External Defibrillator, Use and Care of dated 6/1/25, indicated; Keep a spare battery and adhesive pads in the case, as instructed. Record the expiration date of the battery and the pads on the maintenance log or tag. Check the device and perform maintenance tasks, as directed. Document checks, maintenance steps and date performed on maintenance log and store log with the device.During an observation on 7/31/25, approximately 1:00 p.m. with the Director of Nursing (DON) of the Automatic External Defibrillator (AED, a portable electronic device that can automatically diagnoses and treat the life-threatening heart rhythms) located at the Nursing Station (Side 2) revealed the last AED audit date of 10/8/2020. During an interview on 7/31/25, at approximately 3:15 p.m. RN Employee E1 stated, I…

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, observations, and staff interviews it was determined that the facility failed to store drugs and biologicals in a safe, secure, and orderly manner for one of four nursing medication carts (100 Hall) and failed to label multi-dose vials and check expiration dates for two of four nursing medication carts (100 and 200 Hall). Finding include: Review of facility policy Administering Medications dated [DATE], indicated during administration of medications, the medication cart is kept closed and locked when out of site of the medication nurse or aide. The policy also states the expiration/beyond use date on the medication label is checked prior to administering. When opening a multi-dose container, the date opened is recorded on the container. During an observation and staff interview on [DATE] at approximately 8:43 a.m. the Side 1-Front 100 Hallway medication cart was left open and computer screen visible with patient information with no nurse or aide at cart. During an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy, clinical record review and staff interviews, it was determined that the facility failed to complete education regarding, Coronavirus Disease (COVID) vaccination for three of five residents (R9, R18, R50), influenza vaccination education for two of five residents (R32, R50) and pneumococcal vaccination education for five of five residents (R9, R18, R32, R36, R50). Finding include: Review of the facility policy Coronavirus Disease (COVID-19)-Vaccination of Residents policy dated 6/1/25, indicated before the COVID-19 vaccine is offered, the resident is provided with education regarding the benefits, risks, and potential side effects associated with the vaccine. Review of the facility policy Influenza Vaccine dated 6/1/25, indicated the resident (or resident's legal representative) or employee will be provided information and education regarding the benefits and potential side effects of the influenza vaccine. Provision of such education shall be documented in the resident's/employee'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 and documents, clinical record review, and staff interviews, it was determined that the facility failed to make certain that showers and baths were provided for three of five residents (Resident R1, R2, and R3). Findings include: Review of facility policy Activities of Daily Living (ADL), Supporting reviewed 1/22/25, indicated resident will be provided with care, treatment and services as appropriate to maintain activities of daily living. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, including appropriate support and assistance with hygiene/bathing. Review of the clinical record indicated Resident R1 was admitted to the facility on [DATE], with diagnoses that included diabetes, right ankle foot ulcer, and morbid obesity. Review of the Minimum Data Set (MDS - comprehensive, standardized assessment of each resident's functional capabilities and health needs) dated 4/14/25, indicated the diagnoses remain current 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, clinical records, and staff interview, it was determined that the facility failed to notify resident representative and/or medical providers of a newly ordered medication or a change in condition for three of seven residents (Resident R10, R11, and R2). Findings include: Review of the policy Next of Kin Notification for Medication Changes, dated 1/22/25, indicated the interdisciplinary team shall notify the next of kin or designated responsible party/HCP (healthcare proxy)/POA (power of attorney) of medication changes for residents in a timely manner to promote informed decision-making and continuity of care. Review of the Resident Assessment Instrument 3.0 User's Manual effective October 2024, 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 R10'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, clinical records and staff interviews, it was determined that the facility failed to notify physicians of increased and decreased Capillary Blood Glucose (CBG) levels for four of eight residents (Residents R7, R18, R19, and R20). Findings: Review of the facility policy, Diabetes - Clinical Protocol dated 1/22/25, indicated, The physician will order desired parameters for monitoring and reporting information related to blood sugar management. The staff will incorporate such parameters into the Medication Administration Record (MAR) and care plan. Review of the clinical record revealed Resident R7 was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS, periodic assessment of resident care needs) dated 3/7/25, included diagnoses of coronary artery disease (damage or disease in the heart's major blood vessels) and diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time) Review of Resident R7's care plan initiated…

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, observation, and interviews with staff, it was determined that the facility failed to make certain residents were provided necessary treatment and services, consistent with professional standards of practice, for a pressure ulcer (PU/PIs- injuries to skin and underlying tissue resulting from prolonged pressure on the skin) for two of five residents (Resident R4 and R5). Findings include: Review of the facility policy Pressure Ulcer/Skin Breakdown - Clinical Protocol last reviewed 1/22/25, indicated the physician will order pertinent wound treatments. Review of the clinical record revealed that Resident R4 was initially admitted to the facility 6/2/22, and readmitted on [DATE]. Review of Resident R4's Minimum Data Set (MDS, periodic assessment of resident care needs) dated 3/4/25, included diagnoses of heart failure (a progressive heart disease that affects pumping action of the heart muscles), arthritis (inflammation of one or more joints, causing pain 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 facility policy review, clinical record review, resident, and staff interviews, it was determined that the facility failed to provide colostomy care and services consistent with professional standards of practice for two of two residents (Resident R5 and R6). Findings include: Review of facility policy Colostomy/Ileostomy Care dated 1/22/25, indicated for staff to review the resident's care plan. Review of Resident R5's clinical admission record indicated that resident was initially admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident R5's Minimum Data Set (MDS, periodic assessment of care needs) dated 2/3/25, included diagnoses of diabetes, Ogilvie's syndrome (dilation of the colon in the absence of an anatomic lesion that obstructs the flow of intestinal contents), and the presence of pressure ulcers. Section H: Bladder and Bowel indicated the presence of an ostomy. Review of Resident R5's physician order dated 10/22/24, indicated Colostomy Appliance: Change wafer…

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, resident observations, resident and staff interviews, and grievance review, it was determined that the facility failed to have sufficient nursing staff to provide nursing and related services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of ten of 18 residents (Residents R4, R5, R12, R13, R14, R15, R16, R17, R18, and R19). Findings Include: Review of the facility policy Answering the Call Light dated 1/22/25, indicated staff will ensure timely responses to the resident's requests and needs. During an observation on 3/26/25, at 3:39 p.m. the call light for Residents R19 was alarming. At this time, six nursing staff members were noted to be seated at the nursing station, without responding. When staff observed the surveyor noting the time, Nurse Aide Employee E13 responded to the call light. During an interview on 3/27/25, at 11:10 a.m. Resident R5 when asked if he felt the facility maintained enough staff, Resident R5 responded, No. Resident R5 stated that call light response time can be long, 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 the review of facility policy, observations, clinical records, and staff interviews, it was determined that the facility failed to appropriately document physician notification for three of eight residents (Residents R7, R8, and R9). Findings include: Review of the facility policy, Charting and Documentation dated 1/22/25, indicated All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. The medical record should facility communication between the interdisciplinary team regarding the resident's condition and response to care. Review of a physician order for Resident R7 dated 6/26/24, indicated, Hypoglycemia Protocol Observe Sign/Symptoms of hypoglycemia as needed if blood glucose is less than 70 mg/dl or ordered low parameter follow Hypoglycemia protocol. NOTIFY md (Doctor of Medicine) > 400 BLOOD SUGAR. ADDITION OF PROGRESS NOTE. Review of Resident R7's blood sugar record revealed the following: 1/23/25, at 5:40…

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 documentation, cited deficiencies from previous surveys, review of plan of correction documentation, and staff interview, it was determined that the facility's Quality Assurance and Performance Improvement (QAPI) program failed to correct previously cited deficiencies. This has the potential to affect 18 of 91 residents. Findings include: Review of the facility policy, Quality Assurance and Performance Improvement (QAPI) Program dated 1/22/25, indicated objectives of the QAPI program include providing a means to establish and implement performance improvement projects to correct identified negative or problematic indicators and to establish systems through which to monitor and evaluate corrective actions. The facility's deficiencies and plan of correction for the State Survey and Certification (Department of Health) survey ending 2/28/24, revealed the facility developed a plan of correction that included quality assurance systems to ensure the facility maintained compliance with cited nursing home regulations. Review of the plan of correction 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.

Based on review of facility documents, observations and staff interview, it was determined that the facility failed to maintain an effective call system for three of five restrooms accessible to residents. Findings include: Review of the Facility Assessment dated 1/1/25, indicated that listed under the Physical Environment resources was a nurse call system. During an observation on 3/27/25, at 9:38 a.m. the staff restroom across from the 200-Unit nursing station was observed unlocked, with the door open. Observation of the restroom revealed no emergency call light or call cord attached for emergency use. During an observation on 3/28/25, at approximately 1:00 p.m. the two staff restrooms across from the Activities room were observed unlocked, with the doors open. Observation of the restrooms revealed no emergency call light or call cord attached for emergency use. During an interview on 3/28/25, at approximately 1:00 p.m. the Nursing Home Administrator confirmed the restrooms were unlocked, which allowed access by residents, and confirmed that no call lights were available 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 a review facility policy, clinical records, and staff interviews, it was determined that the facility failed to assure that licensed nurses displayed the appropriate competencies and skills sets to provide nursing services for one of two residents (Resident R11). Findings include: Review of the facility policy, Management of Hypoglycemia (low blood sugar) dated 1/22/25, indicated that Level 3 hypoglycemia is when a resident has altered mental status and/or physical status requiring assistance for the treatment of hypoglycemia. In the actions listed to take include: 1. Call 911 (in accordance with resident ' s advance directives); 2. Administer glucagon (emergency injectable medicine used to treat severe hypoglycemia); 3. Notify the provider immediately ' Review of the Facility Assessment dated 1/1/25, indicated the facility is able to provide care for residents with diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time). Review of the 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.

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 physicians of increased and decreased Capillary Blood Glucose (CBG) levels and failed to assess residents for hyperglycemia (high blood glucose) and hypoglycemia (low blood glucose), for 8 of 19 Residents (Residents R3, R9, R54, R55, R59, R61, R66, R187). Findings: Review of the clinical record revealed Resident R3 was admitted to the facility on [DATE], with diagnoses that included diabetes, high blood pressure, and depression. Review of the Minimum Data Set (MDS - a mandated assessment of a resident's abilities and care needs) dated 5/6/24, indicated the diagnoses remain current. Review of a physician order dated 10/12/23, revealed Novolog (fast-acting insulin that starts to work about 15 minutes after injection, peaks in about 1 hour, and keeps working for 2 to 4 hours) insulin, 8 units three times a day. On 4/10/24, Lantus (long-acting type of insulin that works slowly, over about…

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 make certain that medical supplies were properly stored and/or disposed of in one of two supply rooms (100-Unit supply room ). Findings include: Review of the facility policy Storage of Medications dated 6/1/23, indicated medications are and biologicals are stored safely, securely, and properly, following manufacturer's recommendations. During an observation of the 100-Unit supply room on 6/27/24, at approximately 9:17 a.m. the following was observed: (6) boxes Shiley disposable inner trach cannulas, with expiration of 4/20/21 and 8/31/19. (2) boxes of wound irrigation trays, with expiration of 12/23. (6) boxes of 3ml syringes (100 count), with expiration of 10/18/23. (3) urethral catheter, with an expiration date of 6/28/23. (4) intravenous fluid administration sets, with an expiration date of 10/13/23. (1) box of mini-bore IV extension sets, with expiration of 10/30/23 (6 bags in box had prior resident's names). (1) box vacutainers, with an expiration date 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 facility policy review, clinical and facility record review, facility submitted documents, and staff interviews, it was determined that the facility failed to provide adequate supervision to prevent elopement for one of seven residents (Resident R1). This was identified as past non-compliance. Review of the facility policy Resident Elopement dated 6/1/23, indicated cognitively impaired residents at risk for elopement will be appropriately monitored to reduce the potential for injury. Elopement is defined as a resident leaving the physical structure of the facility without knowledge of facility staff. Review of the clinical record revealed Resident R1 was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS - periodic assessment of resident care needs) dated 2/20/24, included diagnoses of diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time), chronic obstructive pulmonary disease (COPD, a group of progressive lung disorders characterized…

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, grievance reviews, facility provided documents, resident records, and resident and staff interviews, it was determined the facility failed to protect residents from misappropriation of resident property for three of three residents (Residents R2, R3 and R5). Findings include: Review of facility policy titled Abuse: Protection from Abuse last reviewed 6/1/23, informed the resident has right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, involuntary seclusion, neglect, and misappropriation of property. Misappropriation is defined as the deliberate misplacement, exploitation, or wrongful (temporary or permanent) use of resident's belongings or funds without the resident's consent. Our facility is committed to protecting our residents from abuse by anyone including, but not necessarily limited to: facility staff, other residents, consultants, volunteers, staff members from other agencies providing services to our residents, family members, legal…

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, observations, resident record review, and resident and staff interviews, it was determined the facility failed to provide a safe, clean, comfortable and homelike environment for one of four residents (Resident R2). Findings include: Based on a review of facility policy titled Environmental Services, Clean, Safe and Orderly Environment last reviewed 6/1/23, informed the exterior and interior of the facility will be maintained in clean, safe and orderly manner. Based on review of facility policy titled Maintenance Administration last reviewed 6/1/23, informed the maintenance department will maintain documentation to evidence preventative safety measures are implemented, maintain a log with daily checks, and makes rounds daily. Review of Resident R2's record indicated the resident was admitted to the facility on [DATE]. Current diagnoses included Parkinson's disease (a central nervous system disorder that affects movement), schizoaffective disorder (a mental health 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.

Based on a review of facility documents and staff interviews, it was determined that the facility failed to ensure that the residents were aware of unrestricted visitation. Findings include: During an observation on 1/6/24, at 9:30 a.m. a stack of papers titled Family/Visitor Information were placed on the table with the visitor sign-in book. On this document was the following information: Visitor Information: Visitation Hours: -Monday - Friday 8AM-8PM (Enter through the front doors) -Saturday & Sunday 8AM-8PM (front doors lock at 1:00 PM; use ambulance entrance after hours). Further review of the document failed to reveal information relating the availability of 24 hour visitation. During an interview on 1/6/23, at approximately 2:30 p.m. the Nursing Home Administrator confirmed that the facility failed to ensure that the residents were aware of unrestricted visitation. 28 Pa. Code 201.29(a) Resident Rights.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of clinical records, observations, and staff interview, it was determined that the facility failed to provide prescribed treatment and services related to the care of pressure ulcers for five of nine residents (Resident R1, R2, R3, R4, and R5). Findings include: Review of the clinical record indicated Resident R1 was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS - periodic assessment of care needs) dated 12/3/23, included the diagnoses of Myelodysplastic syndrome (group of cancers where immature blood cells do not mature or become healthy blood cells) and lymphedema (the build-up of fluid in soft body tissues) high blood pressure. Review of Section GG: Functional Abilities and Goals indicated that Resident R1 had range of motion impairments of one upper and one lower extremity. Review of Section M: Skin Conditions, indicated Resident R1 had three Stage II pressure ulcers (partial-thickness skin loss with exposed middle layer of skin). Review of a physician's order dated…

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, personnel records, and staff interview, it was determined that the facility failed to employ a qualified social worker for one of two employees (Employee E1). Findings include: Review of the facility policy Social Services Administration dated 6/1/23, indicated the following: A qualified social worker is defined as an individual who meets, at a minimum, one of the following qualifications: 1. A bachelor's degree in social work, or 2. A bachelor's degree in human services field. 3. A bachelor's degree in social work or a bachelor's degree in a human services field including but not limited to sociology, special education, rehabilitation and counseling, and psychology. 4. One year of supervised social work experience in a health setting working directly with individuals. Review of the facility provided job description for the Social Services Director included the educational requirement of a bachelor's degree in social work or a related field. Review of the personnel record for Social Services Director (SSD) Employee E3 revealed that SSD…

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 staff interview and facility documents, it was determined that the facility failed to provide training on behavioral health for 16 of 38 staff members reviewed (E1, E2, E3, E4, E5, E6, E7, E8, E9, E10, E11, E12, E13, E14, E15, and E16). Findings Include: Review of the facility policy Staff Development dated 6/1/23, indicated All employees receive Inservice annually and as needed. Annual training will include Psychosocial Needs, Dementia, Trauma Informed Care, and Substance Use Disorder. During nine staff interviews conducted on 11/19/23, between 1:00 p.m. and 3:00 p.m. the following was indicated: Nurse Aides (NA) Employees E1 and E2 stated they had just begun working at the facility within the previous few days, and had not been provided behavioral health or dementia training from the facility. Licensed Practical Nurse (LPN) Employee E3 stated she had received dementia training at a previous facility she worked at, but not from the current facility. LPN Employee E4 stated she had not received behavioral health or dementia training from the facility. NA Employee…

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.