Harmon House Health & Rehab Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of the Resident Assessment Instrument User's Manual and clinical records, as well as staff interviews, it was determined that the facility failed to complete accurate Minimum Data Set assessments for six of 39 residents reviewed (Residents 18, 30, 61, 66, 77, 79). Findings include: The Resident Assessment Instrument (RAI) User's Manual, which gives instructions for completing Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2024, revealed that Section N0415F1 (antibiotic medication) was to be checked if the resident received an antibiotic medication during the seven-day look-back period. Physician's orders for Resident 18, dated April 24, 2025, included an order for the resident to receive 1 gram of Cefipime (antibiotic) intravenously every eight hours for seven days for a urinary tract infection. The resident's Medication Administration Record (MAR's) for April 2025 revealed that the resident received Cefipime every eight hours…

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, as well as staff interviews, it was determined that the facility failed to ensure that care plans were updated/revised to reflect the resident's specific care needs for three of 39 residents reviewed (Residents 30, 77, 91). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's care needs and abilities) for Resident 30, dated May 29, 2025, indicated that the resident was cognitively impaired, had an indwelling urinary catheter (a thin, flexible tube inserted into the bladder to drain urine), and had diagnoses that included obstructive uropathy (condition where the flow of urine is blocked within the urinary tract). A care plan for Resident 30, dated January 28, 2025, indicated that the resident had urinary incontinence (the involuntary leakage of urine) and staff were to assess her pattern of urination and episodes of incontinence. A care plan, dated May 12, 2025, indicated that the resident required an indwelling urinary catheter, and that staff were to provide catheter care as ordered. A nurse's…

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

Based on review of Pennsylvania's Nursing Practice Act and clinical records, as well as staff interviews, it was determined that the facility failed to clarify a provider's order for treatments for one of 39 residents reviewed (Resident 30). Findings include: The Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.11 (a)(1)(2)(4) indicated that the registered nurse was to collect complete and ongoing data to determine nursing care needs, analyze the health status of individuals and compare the data with the norm when determining nursing care needs, and carry out nursing care actions that promote, maintain and restore the well-being of individuals. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's care needs and abilities) for Resident 30, dated May 29, 2025, indicated that the resident was cognitively impaired, had an indwelling urinary catheter (a thin, flexible tube inserted into the bladder to drain urine), had diagnoses that included obstructive uropathy (condition where the flow of urine was blocked…

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 and clinical record reviews, as well as staff interviews, it was determined that the facility failed to ensure that physician's orders regarding medication administration were followed for one of 39 residents reviewed (Resident 91). This deficiency was cited as past non-compliance. Findings include: The facility policy for medication administration, dated August 14, 2024, indicated that medications are prescribed as ordered by the physician and will be administered by certified healthcare professionals in a behavior consistent with appropriate infection control and standards of practice. A quarterly MDS assessment for Resident 91, dated March 19, 2025, indicated that the resident had moderate cognitive impairment was independent with personal care needs, and had diagnosis that included dementia. Physician's orders for Resident 91 dated June 20, 2024, included for the resident to receive 25 milligrams (mg) of metoprolol tartrate (used to treat high blood pressure) twice a day and to hold the medication if the resident's systolic blood pressure…

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

Based on review of established infection control guidelines, facility policy, and residents' clinical records, as well as staff interviews, it was determined that the facility failed to follow infection control guidelines from the Centers for Medicare/Medicaid Services (CMS) and the Centers for Disease Control (CDC) to reduce the spread of infections and prevent cross-contamination for one of 39 residents reviewed (Resident 76). Findings include: CDC guidance on isolation precautions and Implementation of Personal Protective Equipment (PPE) use in Nursing Homes to Prevent Spread of Multidrug-Resistant Organisms (MDRO's - bacteria that have become resistant to certain antibiotics, and these antibiotics can no longer be used to control or kill the bacteria), dated July 12, 2022, indicates that MDRO transmission is common in skilled nursing facilities, contributing to substantial resident morbidity and mortality and increased healthcare costs. Enhanced Barrier Precautions (EBP) are an infection control intervention designed to reduce transmission of resistant organisms that employs…

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 policies and clinical records, as well as staff interviews, it was determined that the facility failed to develop comprehensive care plans that included specific and individualized interventions to address resident care needs for one of six residents reviewed (Resident 5). Findings include: The facility's policy regarding comprehensive care planning, dated August 14, 2024, revealed that the facility will develop a comprehensive person-centered care plan for each resident that includes measurable goals and timetables to meet the resident's medical, nursing, mental, and psychosocial needs identified in the comprehensive assessment. A quarterly Minimum Data Set (MDS) assessment (a mandatory assessment of a resident's abilities and care needs) for Resident 5, dated March 14, 2025, revealed that the resident was understood, could understand others, had an indwelling catheter (a flexible tube inserted into the bladder to drain urine), had diagnoses that included a wound infection, Multiple Sclerosis (MS - a disease that causes breakdown of the protective covering of…

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

Based on review of manufacturer's directions and clinical records, as well as observations and staff interviews, it was determined that the facility failed to provide care and treatment in accordance with professional standards of practice, by failing to follow physician's orders for one of six residents reviewed (Resident 2). Findings include: Manufacturer's direction for use of diclofenac sodium topical gel 1 percent (a nonsteroidal anti-inflammatory drug (NSAID) used to treat mild-to-moderate pain), undated, revealed: Important: Use the dosing card that is inside the diclofenac sodium topical gel carton to correctly measure each dose. The dosing card is re-usable. Do not throw the dosing card away. For each upper body area (hand, wrist, or elbow), squeeze out 2.25 inches (two grams) and apply. For each lower body area (foot, ankle, or knee), squeeze out 4.5 inches (four grams) and apply. An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 2, dated March 7, 2025, revealed that the resident was understood, 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 established infection control guidelines, facility policy, and residents' clinical records, as well as observations and staff interviews, it was determined that the facility failed to follow infection control guidelines from the Centers for Medicare/Medicaid Services (CMS) and the Centers for Disease Control (CDC) to reduce the spread of infections and prevent cross-contamination, and failed to ensure that proper infection control practices were performed during care for one of six residents reviewed (Resident 5). Findings include: CDC guidance on isolation precautions and Implementation of Personal Protective Equipment (PPE) use in Nursing Homes to Prevent Spread of Multidrug-Resistant Organisms (MDRO's - bacteria that have become resistant to certain antibiotics, and these antibiotics can no longer be used to control or kill the bacteria), dated July 12, 2022, indicates that MDRO transmission is common in skilled nursing facilities, contributing to substantial resident morbidity and mortality and increased healthcare costs. Enhanced Barrier Precautions (EBP's)…

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

Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to maintain the confidentiality of residents' medical information for two of seven residents reviewed (Residents 6, 7). The deficiency is being cited as past non-compliance. Findings include: The facility's policy regarding privacy, dated January 22, 2024, indicated that the facility could only use and disclose protected health information as permitted or required under HIPAA (Health Insurance Portability and Accountability Act) rules. A facility investigation, dated September 15, 2024, revealed that Resident 6's health information was provided to Resident 1's family member, who then presented the information to Resident 1's outside physician. Upon return to the facility, the family member again asked for Resident 1's health information and was provided a copy of Resident 7's health information instead. Interview with the Nursing Home Administrator on October 2, 2024, at 2:58 p.m. confirmed that Resident 6 and 7's health information was provided to Resident 1's…

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

Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that clinical records were complete and accurately documented for one of four residents reviewed (Resident 1). This deficiency was cited as past noncompliance. Findings include: The facility's policy regarding condom catheters (a urine collection device that fits like a condom over the penis, but also has a tube that goes to a collection bag strapped to the leg), dated August 14, 2023, indicated that condom catheters will be changed daily and as needed. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated May 8, 2024, revealed that the resident was understood, could understand others, had an external catheter, had diagnoses that included Multiple Sclerosis (a chronic disease of the central nervous system), and quadriplegia (a condition where all four limbs experience paralysis). A care plan for the resident, dated April 3, 2024, revealed that the resident required 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 clinical record reviews and staff interviews, it was determined that the facility failed to notify the resident and legal guardian in writing regarding the reason for hospitalization for seven of 45 residents reviewed (Residents 6, 7, 53, 58, 72, 73, 86). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 6, dated April 17, 2024, indicated that the resident was cognitively intact, required assistance from staff for her daily care needs, and had diagnoses that included diabetes. A nursing note for Resident 6, dated August 6, 2024, at 8:26 p.m., revealed that the resident was sent to the hospital per his request because he felt something was wrong. There was no documented evidence that a written notice of Resident 6's transfer to the hospital was provided to the resident's responsible party regarding the reason for transfer. A quarterly MDS assessment for Resident 7, dated May 29, 2024, indicated that the 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 Resident Assessment Instrument User's Manual and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that comprehensive admission and annual Minimum Data Set assessments were completed in the required time frame for five of 45 residents reviewed (Residents 12, 53, 65, 69, 77). The deficiency was cited as past non-compliance Findings include: 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 an admission MDS assessment was to be completed no later than 14 days following admission, that the Assessment Reference Date (ARD - the last day of an assessment's look-back period) must be set within 366 days after the ARD of the previous comprehensive assessment, and that the assessment was to be completed no later than 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 the Resident Assessment Instrument Manual and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that quarterly Minimum Data Set assessments were completed within the required timeframe for five of 65 residents reviewed (Residents 2, 17, 47, 59, 72). The deficiency is being cited as past non-compliance. Findings include: The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which provides instructions and guidelines for completing Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2023, indicated that the assessment reference date (ARD - the last day of the assessment's look-back period) of a quarterly MDS assessment must be no more than 92 days after the ARD of the most recent assessment of any type, and the assessment was to be completed no later than the ARD plus 14 calendar days. A quarterly MDS assessment for Resident 2, with an ARD of March 13, 2024, was due to be completed by March 27, 2024, but was not signed as…

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 and clinical records, as well as staff interviews, it was determined that the facility failed to follow physician's orders for four of 45 residents reviewed (Residents 17, 37, 40, 46) Findings include: The facility's policy regarding medication administration, dated August 14, 2023, indicated that during medication administration, facility staff should take all measures required by facility policy and applicable law, document the administration of controlled substances in accordance with applicable law and observe the resident's consumption of the medication(s), and document necessary medication administration/treatment information on appropriate forms. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 17, dated May 22, 2024, revealed that the resident was understood, could understand others, was cognitively impaired, and was independent for care. Physician's orders for Resident 17, dated May 8, 2024, included orders for the resident to have full head-to-toe assessment…

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

Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to maintain accountability for controlled medications (drugs with the potential to be abused) for two of 45 residents reviewed (Residents 24, 55). Findings include: The facility's policy regarding medication administration, dated August 14, 2023, indicated that during medication administration, facility staff should take all measures required by facility policy and applicable law, document the administration of controlled substances in accordance with applicable law, observe the resident's consumption of the medication(s), and document necessary medication administration/treatment information on appropriate forms. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 24, dated May 16, 2024, revealed that the resident was cognitively intact, had pain frequently, received pain medication routinely and as needed, and received an opioid (a controlled pain medication). Physician's orders 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 and clinical records, observations, and staff interviews, it was determined that the facility failed to provide reasonable accommodation of a resident's needs by failing to ensure that the call bell was within reach for one of 45 residents reviewed (Resident 8). Findings include: An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 8, dated June 10, 2024, indicated that the resident was understood and could understand, and she required maximum assistance for transfers and toileting. The resident's current care plan indicated that the resident had decreased mobility and that staff were to ensure the call bell was within reach. A facility policy for call light policy, dated August 14, 2023, revealed that call light will be within easy reach. Observations of Resident 8 on June 24, 2024, at 11:38 a.m. revealed that the resident was lying in bed, and the call bell was hanging off the back of the bed onto the floor and was not within her reach. Interview with Licensed Practical Nurse…

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 and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that a resident's physician was notified in a timely manner about a change in condition for one of 45 residents reviewed (Resident 52). Findings include: The facility's policy regarding resident medication rights, dated August 14, 2023, revealed that the facility should notify physician of a resident's refusal of medications for more than 24 hours. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 52, dated May 7, 2024, indicated that the resident was understood and could understand, was cognitively impaired, was dependent on staff's assistance for care, and was receiving an antidepressant. Physician's orders for Resident 52, dated June 23, 2023, included an order for 10 mg Lexapro (a medication to treat depression and anxiety) daily. Electronic Medical Records for Resident 52 for June 2024 revealed that the resident refused medication on June 1, 2, 3, 4, 17, and 18,…

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 and clinical records, as well as staff interviews, it was determined that the facility failed to complete accurate comprehensive Minimum Data Set assessments for two of 45 residents reviewed (Residents 38, 73). Findings include: The RAI User's Manual, dated October 2023, revealed that Section 16100 psychiatric/mood disorder was to be coded for post-traumatic stress disorder if the resident was diagnosed with that any time during the seven-day look-back period. A quarterly MDS assessment for Resident 38, dated, June 4, 2024, revealed that Section I16100 was coded, indicating that the resident had a diagnosis of post-traumatic stress disorder. A social service note, dated May 31, 2024, at 6:59 a.m., indicated that the resident never experienced or witnessed a life threatening or traumatic event. Interview with the Registered Nurse Assessment Coordinator (RNAC - a registered nurse who is responsible for the completion of MDS assessments) on June 27, 2024, at 1:19 p.m. confirmed that section I16100 of Resident 38's…

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

Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that an IV (intravenous - in the vein) dressing change was done as per facility policy for one of 45 residents reviewed (Resident 4). Findings include: The facility's policy regarding changing the dressing (a transparent barrier) of midline catheters (a thin tube inserted into a vein and used long-term for the administration of fluids and/or medications), dated August 14, 2023, indicated that midline catheter dressings were to be changed weekly and when the integrity of the dressing became compromised (wet, loose or soiled). In addition, the facility policy indicated that staff were to assess the midline insertion site with each medication administration. The catheter insertion site is a potential entry site for bacteria that may cause a catheter-related infection. A quarterly Minimum data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 4, dated May 18, 2024, revealed that the resident was moderately…

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 policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that residents received oxygen as ordered by the physician for two of 45 residents reviewed (Residents 8, 70). Findings include: The facility's policy regarding oxygen therapy, dated August 14, 2023, indicated that oxygen was to be administered in accordance with physician's orders. An admission Minimum data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 8, dated June 10, 2024, revealed that the resident was understood and understood others, cognitively intact, had diagnoses that included asthma and respiratory failure, and had shortness of breath related to her current condition. Physician's orders for Resident 8, dated June 10, 2024, included an order for the resident to receive continuous oxygen at a flow rate of 2 liters per minute via nasal cannula (tubes that deliver oxygen into the nostrils). Observations of Resident 8 on June 24, 2024, at 11:44 a.m.; June 25, 2024, at 8:15…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of policies, as well as observations and staff interviews, it was determined that the facility failed to ensure that medications remained properly secured in one of four medication carts reviewed (lower level medication cart) and failed to discard expired in-use stock medications. The facility's policy regarding medication administration, dated [DATE], indicated that the purpose was to provide a method for the safe, accurate administration of oral medications to residents. Observations of the lower level medication cart on [DATE], at 9:17 a.m. revealed that it was unlocked and unattended. The medication cart was facing room [ROOM NUMBER] while the nurse was administering medications to residents in that room. However, the door was shut to the room, which blocked the nurses direct view of the medication cart. Observations of the top drawer of the lower level medication cart on [DATE], at 9:29 a.m. revealed an undated/unmarked medication cup that contained one small, round yellow tablet; one small…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of policies, observations, and staff interviews, it was determined that the facility failed to ensure that food was prepared and served under sanitary conditions, in accordance with professional standards for food service safety. Findings include: The facility's policy regarding food and nutrition services, dated August 14, 2023, indicated that employees will wear a clean, appropriate hairnet/hair restraint, and that beards and facial hair will be contained. Observations in the main kitchen on June 25, 2024, at 1:50 p.m. revealed that Dietary Aide 4 did not have a beard guard covering his beard. Interview with the Dietary Manager on June 25, 2024, at 1:55 p.m. confirmed that Dietary Aide 4 did not have a beard guard on to cover his beard and should have. Observations of sanitizer on June 26, 2024, at 1:15 p.m. revealed that the sanitizer level in the three-compartment sink was 500 parts per million (ppm). A review of the three-compartment sink sanitizer log revealed that the sanitizer level was…

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 facility's plans of correction for previous surveys, and the results of the current survey, it was determined that the facility's Quality Assurance Performance Improvement (QAPI) committee failed to maintain compliance with nursing home regulations and ensure that plans to improve the delivery of care and services effectively addressed recurring deficiencies. Findings include: The facility's deficiencies and plans of correction for State Survey and Certification (Department of Health) surveys ending September 18 and October 25, 2023, and July 27, 2023, revealed that the facility developed plans of correction that included quality assurance systems with audits to ensure that the facility maintained compliance with cited nursing home regulations. The results of the audits were to be reported to the QAPI committee for review. The results of the current survey, ending June 27, 2024, identified repeated deficiencies regarding notification of the physician, quality of care, issues with intravenous therapy, preventing issues with the accountability of controlled…

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 policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that proper infection control practices and techniques were followed during the administration of medications. Findings include: The facility's policy regarding hand hygiene and medication administration through certain routes, dated August 14, 2024, indicated that staff were to perform hand hygiene prior to administering medications and specifically prior to eye drop administration. Physician's orders for Resident 15, dated July 6, 2023, included an order for the resident to receive Restasis (medication for dry eyes) one drop in each eye twice a day. Observations during medication administration on June 26, 2024, at 8:52 a.m. revealed that Licensed Practical Nurse 2 prepared Resident 15's medications and without performing hand hygiene she administered the resident her po (by mouth) medications. Then without performing hand hygiene once again, she administered the resident her eye drops. Interview with Licensed Practical Nurse 2 on…

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

Based on review of facility policies, resident interviews, observations, and staff interviews, it was determined that the facility failed to serve food items at appetizing temperatures. Findings Include: The facility's policy regarding food temperatures, dated, August 14, 2023, revealed that all hot items may not fall below 135 Fahrenheit (F) while holding after cooking. Hot foot should be at least 135 degrees F when plated and be palatable at point of delivery. Observations of the lunch meal service on October 25, 2023, revealed that the fourth and last cart containing a test tray left the kitchen at 11:24 a.m. and arrived on the short hall at 11:26 a.m. Trays were passed to the residents in the dining area across from the nurses' station at 11:26 a.m. Trays were passed to the residents in their rooms at 11:26 a.m. and the last resident was served at 11:30 a.m. The test tray was removed from the cart at 11:31 a.m. and the temperature of the coffee was 135 degrees F, the pork ribs were 133 degrees F, and the potato cubes were 105 degrees F. The coffee and potatoes were lukewarm 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 policies, as well as observations and staff interviews, it was determined that the facility failed to distribute and serve food in accordance with professional standards for food service safety by failing to ensure that dietary staff wore gloves on their hands with long false fingernails while serving food. Findings include: The facility's policy regarding dress and personal hygiene, dated August 14, 2023, indicated that fingernails should be clean and trimmed. Polished or false nails are not allowed in the food service area unless gloves are worn. Observations in the kitchen on October 25, 2023, at 10:45 a.m. during the lunch meal revealed that Dietary Aide 1 was plating food items, had false fingernails that were longer than one inch, and she was not wearing gloves. Interview with the Dietary Manager on October 25, 2023, at 12:09 p.m. confirmed that the dietary aide should have worn gloves while serving food and that her nails should have been trimmed. 28 Pa. Code 211.6(f) Dietary services.

Based on clinical record reviews and staff interviews, it was determined that the facility failed to ensure that the resident's physician was notified timely about the unavailability of a medication for three of five residents reviewed (Residents 2, 3, 5). This deficiency was cited as past non-compliance. Findings include: An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 2, dated July 17, 2023, revealed that the resident was cognitively intact, required extensive assistance from staff for his daily care tasks, and had a diagnosis which included diabetes, high blood pressure, GERD (gastro-esophageal reflux disease), hyperlipidemia (high lipids), and schizophrenia (disorder that affects a person's ability to think, feel, and behave clearly). Physician's orders for Resident 2, dated June 29, 2023, included orders for the resident to receive 10 milligrams (mg) of aripiprazole (antipsychotic) once a day, 200 micrograms (mcg) aerosol inhaler of Asmanex (used to treat breathing problems) two puffs twice a day, 20…

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 policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that physician's orders for medications were followed for three of five residents reviewed (Residents 2, 3, 5). This deficiency was cited as past non-compliance. Findings include: The facility's policy regarding medication administration, dated May 12, 2023, indicated that the facility would ensure that authorized personnel, as determined by applicable law, administer medications according to times of administration as determined by the facility's pharmacy committee and/or physician/prescriber. An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 2, dated July 17, 2023, revealed that the resident was cognitively intact, required extensive assistance from staff for his daily care tasks, and had a diagnosis which included diabetes, high blood pressure, GERD (gastro-esophageal reflux disease), hyperlipidemia (high lipids), and schizophrenia (disorder that affects a person's ability 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.

Based on review of policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that medication was obtained and provided as ordered by the physician for three of five residents reviewed (Residents 2, 3, 5). This deficiency was cited as past non-compliance. Findings include: The facility's policy regarding medication administration, dated May 12, 2023, indicated that the facility would ensure that authorized personnel, as determined by applicable law, administer medications according to times of administration as determined by the facility's pharmacy committee and/or physician/ prescriber. An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 2, dated July 17, 2023, revealed that the resident was cognitively intact, required extensive assistance from staff for his daily care tasks, and had a diagnosis which included diabetes, high blood pressure, GERD (gastro-esophageal reflux disease), hyperlipidemia (high lipids), and schizophrenia (disorder…

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.