Woodhaven Health & Rehab Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of facility documents, clinical record review, and staff interview, it was determined that the facility failed to provide appropriate care and services to two of five residents (Resident R10 and R11).Findings include: Review of facility policy Activities of Daily Living (ADLs), Supporting dated 6/1/25, indicated residents will be provided with care, treatment, and services as appropriate to maintain or improve their ability to carry out activities of daily living. Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene.Review of the Resident Assessment Instrument 3.0 User's Manual effective October 2025, Section G: Functional Abilities defined dependent as Dependent - Helper does ALL of the effort. Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the resident to complete the activity.Review of the clinical…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of clinical records and staff interviews, it was determined that the facility failed to provide treatment and services related to heart failure (a progressive heart disease that affects pumping action of the heart muscles) for one of three residents (Resident R1).Findings Include:Review of the Unites States National Library of Medicine information Heart Failure dated 3/11/25, indicated symptoms of heart failure can include: Shortness of breath. Fatigue or weakness. Coughing. Swelling and weight gain from fluid in the ankles, lower legs, or abdomen. Difficulty sleeping when lying flat. Nausea and loss of appetite. Swelling in the veins of your neck. Needing to urinate often. 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 6/18/25, included diagnoses of atrial fibrillation (disease of the heart characterized by irregular and often faster heartbeat), chronic obstructive…

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 the clinical record, physician documents, and staff interviews, it was determined that the facility failed to make certain residents with intellectual disabilities receive appropriate services for one of three residents (Resident R2).Based on review of clinical records, and staff interview it was determined that the facility failed to make certain residents receive appropriate treatment and services for highest practicable mental and psychosocial services for one of three residents (Resident R28). Findings include: Review of the Resident Assessment Instrument 3.0 User's Manual effective October 2023, 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 indicated Resident R2 was initially admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS,…

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 the clinical record, physician records, documents, and staff interviews, it was determined that the facility failed to schedule ordered appointments and failed to provide transportation for one of three residents (Resident R2). Findings include: Review of the United States Food and Drug Administration product information dated January 2021, indicated that Faslodex (fulvestrant) is an injectable medication for the treatment of advanced breast cancer. Not taking Faslodex for hormone receptor-positive (HR+), HER2-negative advanced or metastatic breast cancer can lead to the cancer progressing more quickly or returning sooner, potentially lowering the chances of extending life and improving symptoms. Review of the Resident Assessment Instrument 3.0 User's Manual effective October 2023, 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:…

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

Based on review of the Resident Assessment Instrument User's Manual, clinical records, and staff interviews, it was determined that the facility failed to make certain that comprehensive Minimum Data Set (MDS - periodic assessment of care needs) assessments were accurate and fully completed for five of twenty-six residents (Resident R14, R22, R25, R36, and R80). Findings include: The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which gives instructions for completing Minimum Data Set Assessments dated October 2024, indicated in: Section C: Cognitive Patterns, Question C0100 Should Brief Interview for Mental Status Be Conducted? (BIMS) should be coded as 0 if the resident is rarely/never understood, or it should be coded 1, and the BIMS assessment should be completed if the resident is at least sometimes understood. Section D: Mood, Question D0100 Should Resident Mood Interview Be Conducted? should be coded as 0 if the resident is rarely/never understood, and or it should be coded 1, and the assessment should be completed if the resident is at least…

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 the facility failed to develop and implement comprehensive care plans for resident and care needs for five of twelve residents (Resident R14, R22, R43, R73 and R85). Findings include: Review of the facility policy Comprehensive Care Plan dated 1/1/25, indicated an interdisciplinary plan of care will be established for every resident and updated in accordance with State, and Federal requirements and on an as needed basis. Review of the clinical record indicated Resident R14 was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS-periodic assessment of resident care needs) dated 4/8/25, included diagnoses of diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time), cerebral infarction due to unspecified occlusion or stenosis of right posterior cerebral artery (a stroke caused by a blockage or narrowing of a blood vessel in the brain, where the specific cause…

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, clinical records, and staff interview, it was determined that the facility failed to ensure that the Activities Director accurately completed, and/or directed or delegated the accurate completion of the activities component of the comprehensive assessment and failed to attempt to obtain information on resident preferences from family, significant others, or staff interviews for residents with severe cognitive impairment for 28 of 28 residents (Residents R8, R13, R14, R15, R16, R24, R29, R42, R45, R54, R59, R62, R65, R66, R72, R73, R81, R82, R88, R90, R91, R93, R96, R206, R210, R211, R310, and R311). 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 2024, indicated that a BIMS (Brief Interview of Mental Status) is a brief screener that aids in detecting cognitive impairment. Scores from a BIMS assessment suggests the following…

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

Based on review of clinical records and staff interview, it was determined that the facility failed to provide documentation of medication regimen reviews (MRR) completed at least monthly for two of five residents (Resident R22 and R34). This was identified as past non-compliance. Finding include: On 7/2/25, the MRRs for Residents R22 and R34 were requested, for the months of January through June 2025. On 7/3/25, the facility provided information that the Quality Assurance and Performance Improvement (QAPI) program members had identified that pharmacy recommendations were not being completed timely. Review of the performance improvement plan developed on 4/24/25, included: -The Director of Nursing (DON) will begin to receive all pharmacy reports and recommendations. -Medical Records staff will ensure any recommendations that re received are handed directly to the ADON (Assistant Director of Nursing) or the DON. -Once the recommendation is received, it will be reviewed by a physician and returned. The ADON/DON will review and complete adjustments as necessary. -Audits will be…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on 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 two of sixteen residents (Resident R 21 and R312). Findings include: Review of the facility Resident Rights and Facility Responsibilities policy last reviewed 6/1/25, indicated it the facility's policy to comply with all Residents Rights. A listing of Resident and Facility Responsibilities for the specific state of residence, and federal rights will be provided to the resident/resident representative upon admission and when requested. Review of the clinical record indicated Resident R21 was originally admitted to the facility on [DATE], and most recently readmitted on [DATE]. Review of the Minimum Data Set (MDS - a periodic assessment of care needs) dated 6/17/25, included diagnoses of heart failure (a progressive heart disease that affects pumping action of the heart muscles) and dementia (a group of symptoms that affects…

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

Based on observations and staff interviews, it was determined, the facility failed to display written information on applying for Medicare and Medicaid benefits and receiving refunds for previous payments covered by Medicare and Medicaid as required, on two of two nursing floors (First Floor and Second Floor). Findings include: During observations completed on 7/3/25, of the First Floor and Second Floor nursing units, failed to include information on how to apply for Medicare and Medicaid benefits and receiving refunds for previous payments covered by Medicare and Medicaid. During observations and an interview with the Nursing Home Administrator (NHA), on 7/3/25, at approximately 8:23 a.m., the NHA confirmed that the facility failed to display written information on applying for Medicare and Medicaid benefits and receiving refunds for previous payments covered by Medicare and Medicaid as required, on two of two nursing floors (First Floor and Second Floor). 28 Pa. Code: 201.14(a)Responsibility of licensee. 28 Pa. Code: 201.18(e) Management.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical record review, and staff interviews, it was determined that the facility failed to properly monitor weight and nutrition status by failing to obtain weights or act upon weight changes for four of twelve residents (Residents R14, R36, R66, and R94). Finding include: Review of the facility policy, Resident Policy dated 6/1/25, and 1/1/25, indicated it is the policy of the facility to obtain weights routinely in order to monitor nutritional health over time. Each resident's weight will be determined upon admission/readmission to the facility, weekly for the first four weeks after admission/readmission, and monthly or more often if risk is identified, or as ordered. Review of Resident R14's admission record indicated she was admitted to the facility on [DATE]. Review of Resident R14's Minimum Data Set (MDS-periodic assessment of care needs) assessment dated [DATE], included diagnoses of diabetes (a metabolic disorder in which the body has high sugar levels for prolonged…

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, observations and staff interviews, it was determined that the facility failed to provide appropriate respiratory care and maintain oxygen equipment for one of three sampled residents (Resident R203). Findings include: The facility policy Oxygen Administration (all routes) Policy last reviewed 6/1/25 and 1/1/25, indicated licensed clinicians with demonstrated competence will administer oxygen via the specified route as ordered by a provider. In an emergency situation, clinicians may administer oxygen and obtain a provider's order as soon as practicably possible after patient stabilization or transfer. Review of Resident R203's admission record indicated she was admitted on [DATE]. Review of Resident R203's Minimum Data Set (MDS -a periodic assessment of resident care needs) dated 6/18/25, indicated that she had diagnoses that included diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time), COPD (Chronic…

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, and staff interviews it was determined that the facility failed to make certain consistent dialysis communication was maintained for two of three residents (Residents R20 and R61). Findings include: Review of the facility policy Hemodialysis Care Policy dated 1/1/25 and 6/1/25, indicates communication between the dialysis provider and facility staff will occur before and after each hemodialysis treatment and as needed. Pre-dialysis process: document assessment in the Dialysis Communication Tool vital signs, pre-treatment weight (unless performed at dialysis) medication adminstered before treatment, time of last meal, fluid intake and any additional alerts or information. Tool to be sent with resident to dialysis. Post-dialysis process: receive report from dialysis provider and or review Dialysis Communication Tool documentation by dialysis provider. Information post-dialysis will include: vital signs, post-treatment weight (unless to be completed by skilled…

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 facility documents, clinical records, and staff and resident interviews it was determined that the facility failed to ensure the physician reviewed the resident's total program of care for one of eight residents (Resident R36).Findings include:Review of the Facility assessment dated [DATE], previously dated 2/27/25, indicated the facility will ensure resident health and safety by assessing needs and matching those needs to facility staff and other resources. Review of the facility provided, Medical Director's Responsibilities Checklist indicated that the Medical Director (MD Employee E6) will coordinate medical care in the facility and ensure the appropriateness and quality of medical care and medically related care.Review of the clinical record indicated Resident R36 was admitted to the facility on [DATE].Review of the minimum MDS dated [DATE], included diagnoses of dementia (a group of symptoms that affects memory, thinking and interferes with daily life), anemia (too little iron in the body…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, resident clinical records, and staff interviews, it was determined that the facility failed to ensure a resident received appropriate behavioral health services to maintain the highest practicable well-being for one of eight residents (Resident R43). Findings include: The facility Behavior Management Program policy reviewed on 1/1/25 and 6/1/25, includes, the facility will assess and track a behavior(s) that negatively impacts each resident regarding their quality of life. The interdisciplinary team (IDT) will conduct record review. The IDT will review newly identified behaviors during risk rounds to ensure appropriate documentation in in place for new behaviors and/or different behaviors for a resident. The IDT will conduct a clinical record review. The IDT will complete behavior/psychotropic review form and identify the root cause for the behavior utilizing the behavioral management care paths. The resident with identified behaviors will be followed at the weekly resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, resident clinical records, and staff interviews, it was determined that the facility failed to ensure a resident received appropriate behavioral health services to maintain the highest practicable well-being for one of eight residents (Resident R43). Findings include: The facility Behavior Management Program policy reviewed on 1/1/25 and 6/1/25, includes, the facility will assess and track a behavior(s) that negatively impacts each resident regarding their quality of life. The interdisciplinary team (IDT) will conduct record review. The IDT will review newly identified behaviors during risk rounds to ensure appropriate documentation in in place for new behaviors and/or different behaviors for a resident. The IDT will conduct a clinical record review. The IDT will complete behavior/psychotropic review form and identify the root cause for the behavior utilizing the behavioral management care paths. The resident with identified behaviors will be followed at the weekly resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical records, resident, and staff interviews, it was determined that the facility failed to provide sufficient and timely social services to meet the residents needs for one of eight residents (Resident R43). Findings include: Review of the facility's Social Service Job Description indicated the social worker: Plan develop, organize, implement, evaluate, supervise and direct the social services program of the community including coordination with all departments to provide suitable social services. Keep abreast of current federal and stat regulations, as well as professional standards of practice, and make recommendations on changes in policies and procedures to the administrator. Complete assessments and devise, review and revise comprehensive care plans. Ensure that all charted social service progress notes and all documentation is accurate, informative and descriptive of the services provided and of the resident's response to the services Coordinates ancillary services for the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policies, observations, and staff interviews, it was determined that the facility failed to properly store medications and/or biologicals in one of two medication rooms (First Floor Medication Room). Findings include: Review of facility policy Storage and Expiration Dating of Medications and Biologicals dated [DATE], previously dated [DATE], indicated that medications and biologicals that have been retained longer than recommended by manufacturer or supplier guidelines are stored separate from other medications until destroyed. During an observation on [DATE], at 9:25 a.m. of the First Floor Medication Room the following was observed: (4) petroleum gauze dressing with an expiration date of 06/2023 (2) Aquacel Advantage dressing with an expiration date of [DATE] (3) Aquacel Extra dressing with an expiration date of [DATE] (1) tube Zinc Oxide ointment (1 ounce) with an expiration date of 04/2024 (1) Vacutainer Transfer Straw Kit with an expiration date of 01/2025 (5) Puracol Ultra…

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, resident, and staff interviews, it was determined that the facility failed to assess and care plan for self-administration of medications for three of twelve residents (Residents R1, R2, and R3). Findings include: Review of the facility policy General Dose Preparation and Medication Administration dated 6/7/24, indicated to observe resident consumption of medication. During an observation on 3/14/25, at 10:08 a.m. Resident R1 was reclined in bed. On her over-bed table a medicine cup was observed on its side, with one pill still in it and another pill on the over-bed table. During an observation on 3/14/25, at 10:08 a.m. Resident R2 was reclined in bed. On her over-bed table a medicine cup was observed with one pill still in. During an observation on 3/14/25, at 2:06 p.m. a pill was observed on the floor or Resident R3's room. Review of the clinical records for Resident R1, R2, and R3 failed to reveal an assessment for the self-administration of medications or a plan of care developed for self-administration of medications. 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.

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 16 of 22 residents (Residents R1, R2, R4, R5, R6, R7, R8, R9, R10, R11, R12, R13, R14, R15, R16, R17). Findings Include: Review of the facility policy Resident Communication and Call Light Policy dated 6/27/24, indicated staff will respond to call lights promptly. During an observation on 3/14/25, at 9:59 a.m. Resident R4 room smelled strongly of urine and Resident R4 had messy, unkempt hair. During an interview on 3/14/25, at 1:02 a.m. Resident R5 was observed to have messy, unkempt hair. During an interview on 3/14/25, at 10:03 a.m. Resident R6, when asked if call lights took a long time to be answered stated, Sometimes it takes a long time. Resident R6 further stated his medications have been 30-90 minutes late. During an interview with Residents R1 and Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy, observation, clinical record review, and staff interview, it was determined that the facility failed to make certain that residents are free of significant medication errors for one of four residents (Resident R7). Findings include: Review of facility policy General Dose Preparation and Medication Administration reviewed 6/27/24, indicated that prior to administration of medication, facility staff should take all measures required by facility policy and applicable law, including, but not limited to: Verify each time a medication is administered that it is the correct medication, at the correct dose, at the correct route, at the correct rate, at the correct time, for the correct resident. Review of the National Library of Medicine information dated , indicated insulin aspart is an injectable medication used to treat diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time). It further stated, If you are using insulin aspart suspension to treat…

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 the family of a change in condition in a timely manner for one of nineteen residents (Resident R1). Findings include: Review of the facility policy Resident Change in Condition Policy dated 6/27/24, indicated the responsible party or guardian is to be notified when there has been a significant change in the resident's physical condition. Review of the clinical record indicated that Resident R1 was admitted to the facility on [DATE], with diagnoses that included peripheral vascular disease (a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs) and type 2 diabetes mellitus (condition in which the body has trouble controlling blood sugar) with diabetic neuropathy (complication that can cause nerve damage in the hands and feet). Review of the Minimum Data Set (MDS - a periodic assessment of care needs) dated 1/21/25, indicated the diagnoses remain current.…

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, personnel records, clinical records and activity calendars, and staff interview, it was determined that the facility failed to ensure that the Activities Department had a qualified director to oversee the activities program. Findings include: Review of the Life Enrichment Director job description indicated the qualifications were as required by State and Federal Regulations. Review of Life Enrichment Director Employee E2's personnel record indicated she was hired on 12/27/23. Review of Life Enrichment Director Employee E2's personnel record did not include evidence that Life Enrichment Director Employee E2 had proper qualifications as a Life Enrichment Director. The personnel record did not include education in therapeutic services, education as a social worker or occupational therapist, or a background in recreational services. Further review of resident records and facility activity calendars since Life Enrichment Director Employee E2 hire date, indicated she has been performing this job without any required oversight from an employee qualified…

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 provide the opportunity to formulate an advance directive (written instructions such as a living will or durable power of attorney for health care for when the individual is incapacitated) for two of five residents reviewed (Resident R38,R57). Findings Include: A review of the facility policy Advanced Directives on 1/1/2024, indicated the facility will comply with the requirements related to maintaining written policies and procedures regarding advance directives, including provisions to inform and provide written information to all adult residents concerning the right to accept or refuse medical or surgical treatment and formulate an advance directive. A review of the medical record indicated Resident R38 was admitted to the facility on [DATE], with diagnoses that included diabetes(high blood sugar), high blood pressure, congestive heart failure(chronic condition in which the heart doesn't…

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 document notification of changes in conditions for three of six residents (Resident R1, R2, and R3). Findings include: Review of the facility, Resident Change of Condition Policy last reviewed 1/1/24, indicated the family/responsible party will be notified when there has been a accident or incident involving the resident, a discovery of an injury, a reaction to medication or treatment, a significant change in the resident's physical/emotional/mental condition, a need to alter the resident's medical treatment including a change in provider orders, when there is a consistent refusal of treatment or medications, and a need to transfer the resident to the emergency room and/or admission to the hospital. Review of the clinical record revealed that Resident R1 was originally admitted to the facility on [DATE], and readmitted on [DATE]. Review of the Minimum Data Set (MDS - periodic assessment of care…

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

Based on a review of facility policy, resident record, observation, resident interview and staff interview, it was determined the facility failed to provide necessary services to maintain adequate grooming and personal hygiene for ten of 18 residents (Resident R1, R2, R3, R4, R5, R6, R7, R8, R9, and R10). Findings include: Based on review of facility policy titled Resident Bath/Showering/Scheduling Policy dated 1/1/24, indicated residents will be bathed or showered according to their preferences in order to maintain health hygiene and skin condition. During in observation on 4/19/24, at 11:40 a.m. Resident R4 was noted to be seated in a wheelchair in the hallway, with unkempt hair and long facial hair. During an interview and observation on 4/19/24, at 11:43 a.m. Resident R5 confirmed that she had filed a grievance on 3/28/24, related to not receiving showers. Resident R5 stated she has missed multiple showers, and would like at least one per week adding, I don't want to look like a hag, just because I'm in a place like this. During an observation on 4/19/24, at 11:48 a.m. 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 nursing unit observations, resident observations, and resident 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 18 of 23 residents (Resident R1, R2, R3, R4, R5, R6, R7, R8, R9, R10, R11, R12, R13, R14, R15, R16, R17, and R18). Findings include: During an interview on 3/8/24, at 9:50 a.m., when asked if there were enough nursing staff to care for the residents Resident R1 stated, I have to wait forever and ever for an aide. They gather out in the halls and they ignore the call lights. Sometimes I'm wet from 8:30 on. They just lolly-gag. I don't get no showers, are you kidding? I get a bed bath, swish swish. I'm just here. When asked about call light response, Resident R1 stated, I have to lay on the light, and I mean lay on the light. They don't answer. We have to holler. During an interview and observation on 3/8/24, at 10:00 a.m., when asked if there were enough nursing staff to care 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 an observation and staff interview it was determined that the facility failed to maintain a clean and sanitary enviornment in the Main Kitchen. (Main Kitchen) Findings include: During an observation of the Main Kitchen on 2/13/24 at 10:15 am the following was revealed: the baseboards around the kitchen floor contain a build up of debris, the floor in the kitchen and storeroom had a build up of dirt and grime, the burners on the range top contained a food and debris, the steamtable wells contained dirty water, the steamtable well edges contained a build up of dirt and debris, the top of convection ovens contained a build up of dust, the convection ovens contained a build up of a brown substance on the doors and inside the ovens, the soap dispenser at the hand wash sink was empty. During an interview on 2/13/24, at 10:30 am Food Service Director Employee E1 confirmed that the facility failed to maintain the Main Kitchen in a clean and sanitary condition. Pa Code: 211.6 (c)(d)(f) Dietary services.

Based on review of facility documents, observations and staff interviews it was determined that the facility failed to meet the physical, mental and psychosocial well being of the residents failing to provide beautician services to residents desiring to have hair grooming services and failed to notify the residents of a proper fee structure for beautician services for residents covered by Medicare and Medicaid insurance providers for eight of eight months. (7/23, 8/23, 9/23, 10/23, 11/23, 12/23, 1/24, and 2/24) . Finding include: Federal Regulation 483.10(f)(11) (i) indicates Services included in Medicare or Medicaid payment. During the course of a covered Medicare or Medicaid stay, facilities must not charge a resident for the following categories of items and services: (E) Routine personal hygiene items and services as required to meet the needs of residents, including, but not limited to, hair hygiene supplies, comb, brush, bath soap hair and nail services, bathing assistance, and basic personal laundry. During observations resident's personal grooming on 2/13/24, it was revealed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of facility policies, documents, resident medical records and staff interviews it was determined that the facility failed to administer medications to six of six residents (Resident R5, R6, R7, R8, R9, and R10) in accordance with physician orders and follow through to make certain that the facility corrected the causes for the medication errors. Findings include: A review of policy Medication Administration Times dated 1/1/24, indicated that the facility should ensure that authorized personnel, administer medications according to times of administration as determined by Facility's pharmacy committee and/or Physician/Prescriber, A review of Resident R5's medical record indicated that the resident was readmitted to the facility on [DATE], with the diagnosis of congestive heart failure, diabetes, dementia, depression, history of falls, prostate cancer and high blood pressure. A review of facility documents indicated that Resident R5's medications were not entered into the facility's medication…

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 standardized recipes and staff interviews, it was determined that the facility failed to properly prepare flavorful, palatable food products by failing to follow facility standardized recipes for the lunch meal on 2/13/24. (lunch meal 2/13/24). Findings include: During an observation of the lunch meal on 2/13/24, at 12 :20 pm the following was revealed: *the resident tray card indicated cheese stuffed shells, the facility served cheese stuffed shells with a meat sauce, * the resident tray card indicated Italian green beans, the facility served a heated marinated three bean salad that consisted of green beans, yellow beans and kidney beans in a vinegar dressing. * the resident tray card indicated beef taco, the facility served the taco wrapped in aluminum foil which caused the taco shell to be soggy and mushy. A review of the facility's standardized recipes revealed the following: * Cheese stuffed shell. A review of the recipe revealed that the cheese stuffed shells where to be heated and then served topped with a marinara sauce. The facility…

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

Based on observations and staff interviews it was determined that the facility failed to provide accurate meal trays for four of 10 residents ( Resident R1, R2, R3 and R4). Findings include: During an observation on 2/13/24, at 12:10 pm for tray accuracy during the lunch meal the following was revealed: Resident R1's tray card indicated that the resident was to receive double portion of the entree. Upon auditing Resident R1's lunch meal tray it was determined that the facility failed to provide Resident R1 with double portions of the lunch meal entree. Resident R2's tray card indicated that the resident was to receive 8 ounces of 2% milk. Upon auditing Resident R2's lunch meal tray it was determined that the facility failed to provide Resident R2 with 8 ounces of 2% milk. Resident R3's tray card indicated that the resident selected not to receive the Italian green beans vegetable offered on the menu. Upon auditing Resident R3's lunch meal tray it was determined that the facility failed to follow Resident R3's preference and served the resident a three bean salad medley. 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 observations and staff interviews it was determined that the facility failed to follow the displayed menu for the lunch meal on 2/13/24 as required. (lunch meal 2/13/24). Findings include: During an observation on 2/13/24, at 9:00 a.m., of the displayed menu on the bulletin board located at the entrance to the second floor nursing unit it was revealed that the menu for the lunch meal consisted of fried chicken, mashed potatoes, spinach, and cobbler. The alternate menu selection consisted of salisbury steak. During an observation on 2/13/24, at 9:05 a.m., displayed on the Activities Department's bulletin board outlining the daily activities for 2/13/24, also contained menu selection information that included the lunch menu consisted of fried chicken. During an observation on 2/13/24, at 11:45 a.m., of the lunch meal tray line operations it was revealed that the menu selections being served to the residents consisted of stuffed shells with meat sauce, Italian green beans, and garlic bread. The alternate menu selection consisted of beef taco and corn. During an interview on…

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

Based on resident, and staff interviews it was determined that the facility failed to provide a dignified dining experience for the Thanksgiving Holiday meal (Thanksgiving Holiday Meal). Findings include: During resident interviews on 12/13/23, Residents R2 and R3 revealed that the facility served the Thanksgiving Holiday meal using disposable styrofoam containers which they determined to not in the spirit of the holiday. During an interview on 12/13/23, at 11:30 am Food Service Director Employee E1 confirmed that the facility utilized disposable styrofoam containers to serve the resident's their Thanksgiving Holiday meal which failed to provide a dignified dining experience. PA Code: 201.29(j) Resident Rights

Based on observations and staff interviews it was determined that the facility failed to meet the physical, mental and psychosocial well being of the residents by failing to provide beautician services for residents desiring hair grooming services for six months (7/23, 8/23, 9/23, 10/23, 11/23, and 12/23). Findings include: During observations of resident's personal grooming on 12/13/23, it was revealed that residents were in need of beautician services such as hair cuts and hair styling. During an interview on 12/13/23, at 8:55 am the Nursing Home Administrator confirmed that the facility had failed to provide beautician services since 7/1/23. PA Code: 211.10(d) Resident Care Policies

Based on a review of the facilities four week cycle menu, observations, and resident and staff interviews it was determined that the facility failed to approve the four week cycle menu prior to implementation (Week one, Week Two, Week Three, and Week Four) and provide food products as listed on the menu for the lunch meal on 12/13/23. (Lunch meal 12/13/23). Findings include: A review of facility policy Food and Nutrition Services Menus and Diets adopted for the period of January 1, 2023 to December 31, 2023 indicated that menus menu planning will be completed two weeks in advance of service. A Registered Dietitian (RD) will approve all menus. Posted menus shall indicate any menu substitutions in a timely manner. During an observation on 12/13/23, at 11:30 am it was revealed that the menus failed to provide evidence of the RD approving the menu for implementation by signing and dating the reviewed and approved menus. During an interview on 12/13/23, at 11:35 am the Food Service Director Employee E1 confirmed that the facility failed to make certain that the RD approved the Four Week…

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

Based on a review of facility policies, documents, observations, test tray audits, and staff interviews, it was determined that the facility failed to to serve food products at palatable temperatures for the lunch meal on 12/13/23. (lunch meal 12/13/23) Findings include: A review of facility policy Food and Nutrition Services Food Production and Safety adopted for the period of January 1, 2023 to December 31, 2023 indicated that Hot foods may not fall be low 135°F (farenheit) while holding after cooking. Hot foods should be palatable at the time of delivery. The temperature of potentially hazardous cold foods must be served at 41° F or below. A review of facility document Dining Observation/Test Tray form indicated that cold food is served at a maximum temperature of 41° F and Hot food is served at a minimum of 135°F. During an observation of a test tray audit conducted by Food Service Manager Employee E1 on 12/13/23 at 1:10 pm food temperatures were as follows: Corn Chowder 133.9°F Fish Taco 106°F Salsa 74.8°F Churro 110°F Chicken tender 110°F French Fries 108°F Coffee 132°F 2%…

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 record review and staff interview, it was determined the facility failed to notify the physician of a change in condition for one of six residents. (Resident R1) Findings include: Review of the face sheet indicated Resident R1 was admitted to the facility 4/28/23. Review of Resident R1's minimum Data Set (MDS-a periodic assessment of care needs) dated 8/5/23, indicated the diagnoses of stroke ( blood flow to the brain is blocked), hypertension (force of the blood against the artery walls is too high), peripheral vascular disease (slow and progressive circulation disorder) and diabetes mellitus (amount of sugar in the blood is elevated). Review of Resident R1's physcian orders dated 10/13/23 NPO, Enteral feeding Diabetisource AC 75 ml/hr x 18 hours via enteral tube. Review of Resident R1's progress notes indicated on 8/31/23, at 2:32 p.m. that feeding tube was sucking into stomach. Review of Resident R1's progress notes indicated on 9/1/23, at 12:39 a.m. that feeding retracted back into stomach, only approximately one inch of tube showing, RN Supervisor…

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 dish machine temperature logs dated from May 2023 through July 2023, and staff interviews, it was determined that the facility failed to store foods in a sanitary manner to prevent the potential for food borne illness, maintain a sanitary environment in the main kitchen, failed to maintain necessary equipment in proper functioning order and failed to make certain the dish machine was running at proper temperatures. Findings include: During an observation on 8/31/23, at 8:50 a.m., the following was observed in the main kitchen: A small milk cooler in front of the food trayline area had a foam cup of crackers uncovered, a plastic milk crate with several packages of unopened cookies, a cloth apron and two bananas, and inside the cooler was a cup of pudding with a spoon in it sitting on top of a tray over cartons of milk with seven cups of pudding and applesauce undated. A cart was placed beside the milk cooler with a staff cup of coffee on top shelf of the cart and a foam container with a half eaten breakfast sandwich on the bottom shelf . 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.