Mount Carmel Senior Living Community

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, observation, and family and staff interview, it was determined that the facility failed to ensure a dependent resident received assistance with activities of daily living for two of three residents reviewed for activities of daily living concerns (Resident 63 and 66). Findings include: Interview with Resident 66's daughter on June 15, 2026, at 12:05 PM revealed that family visited Resident 66 on Mother's Day (May 10, 2026) and found that no staff assisted her mother to eat lunch and that she appeared in a group activity disheveled and undignified. Resident 66's daughter stated that her mother was dependent on staff to feed her. Review of a plan of care initiated by the facility on May 10, 2023, to address Resident 66's ADL (activities of daily living) Self Care Performance Deficit revealed interventions that included: Bath/Shower schedule: Mondays and Thursdays evening shift (3:00 PM to 11:00 PM or 2:00 PM to 10:00 PM); Resident 66 preferred showersBathing: The resident required…

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

Based on observation, clinical record review, and resident and staff interview, it was determined that the facility failed to provide the highest practicable care related to alteration in skin integrity for one of two residents reviewed for skin concerns (Resident 16) and ordered medication parameters for one of one resident reviewed (Resident 78).Findings include: Interview with Resident 16 on June 14, 2026, at 3:19 PM revealed that she had broken skin under her stomach and under her breasts that is red. Resident 16 stated that staff do not apply treatment to the area every day. Observation of Resident 16 on June 16, 2026, at 10:51 AM with Employee 8 (registered nurse) revealed that the skin under Resident 16's bilateral breasts and bilateral inguinal areas (groin) was reddened with white substance over the areas. Interview with Employee 8 on the date and time of the observation confirmed that staff applied a treatment of a white substance under her breasts and in her inguinal areas. Resident 16 stated that not all staff had her lay down to best apply the treatment to her bilateral…

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

Based on clinical record review and staff interview it was determined that the facility failed to implement a fall prevention intervention for one of five residents reviewed for fall concerns (Resident 15).Findings include: Clinical record review for Resident 15 revealed admission nursing documentation dated April 29, 2026, at 4:51 PM that Resident 15 was hospitalized after falling from a standing position and sustaining left frontal and parietal bone (frontal and parietal bones form the front and top lateral portions of the skull) fractures, multicompartmental intercranial hemorrhage (bleeding that extends into more than one anatomical compartment of the brain), and left inferior and superior pubic rami fractures (fractures of the front of the pelvic bone). A plan of care initiated by the facility upon Resident 15's admission, dated April 29, 2026, to address his risk for falls, revealed interventions that included to be sure the resident's call light was within reach and encourage Resident 15 to use it for assistance as needed. Provide a prompt response to all requests 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 observation and staff interview it was determined that the facility failed to ensure the application of supplemental oxygen per the physician's order for one of one resident reviewed for oxygen concerns (Resident 35).Findings include: Observation of Resident 35 on June 15, 2026, at 10:12 AM revealed supplemental oxygen in use via a room concentrator (machine that draws in room air and condenses the oxygen saturation of the room air to administer supplemental oxygen at 90 percent or higher through a nasal cannula (NC, a flexible tubing with prongs at one end that insert into the nares) set at less than one liter per minute. Clinical record review for Resident 35 revealed an active physician's order for staff to administer supplemental oxygen at two liters per minute via nasal cannula continuously every shift. Observation of Resident 35 on June 16, 2026, at 10:34 AM revealed his supplemental oxygen again set at approximately one liter per minute. Interview with Employee 8 (registered nurse) on June 16, 2026, at 10:36 AM confirmed that Resident 35's active physician order for…

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

Based on clinical record review and staff interview, it was determined that the facility failed to develop and implement an individualized person-centered care plan to address dementia and cognitive loss displayed by one of one resident reviewed (Resident 11).Findings include: Clinical record review for Resident 11 revealed the facility admitted her on April 3, 2026, with a diagnosis including Dementia (loss of memory, language, problem-solving, and other thinking abilities that interfere with daily life). A review of Resident 11's current care plan (an outline of an individual's health needs, specific care requirements, and the actions necessary to achieve desired health outcomes) entitled, Impaired cognitive function/dementia or impaired thought processes related to dementia revealed general basic interventions such as cueing and reorienting, reporting changes to the physician, provide activities that accommodate needs. There was no indication that the facility had implemented an individualized person-centered care plan to address the residents' specific dementia and cognitive…

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

Based on review of select facility policies and procedures, clinical record review, and staff interview, it was determined that the facility failed to ensure that the resident's attending physician addressed and responded appropriately to consultant pharmacy recommendations for two of five residents reviewed (Residents 12 and 36). Findings include: The facility policy entitled, Consultant Pharmacist Reports, Medication Regimen Review (Monthly Report) last reviewed without changes on May 20, 2026, revealed that the consultant pharmacist performs a comprehensive medication regimen review (MRR) at least monthly. Findings and recommendations are reported to the Director of Nursing, the attending physician, the medical director, and if appropriate the administrator. The findings are faxed or emailed within 72 hours to the Director of Nursing or designee and documented and stored with the other consultant pharmacist recommendations in the resident's chart. The consultant pharmacist's evaluation includes, but is not limited to, reviewing the following: A written diagnosis, indication, or…

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

Based on observation, review of facility documents, and resident and staff interview, it was determined that the facility failed to provide palatable food items and menu items as indicated for one of eight residents reviewed (Resident 73).Findings include: Interview with Resident 73 on June 14, 2026, at 1:43 PM, revealed that lunch had just been served. On the resident's bed was a plate of food with breaded chicken, noodles, and mixed vegetables. The resident indicated that the chicken and noodles were gross and that the chicken was dry and hard. Concurrent observation of the chicken revealed it was difficult to cut, and although the breading on the chicken felt very damp, the chicken was very dry to the touch, and the noodles were mushy and over cooked. The resident continued to indicate that they did not receive the meal that was listed on their provided menu because they were on a liberal renal diet (a flexible diet designed for patients with kidney disease), and that this happened all the time. Upon review of a facility menu the resident had in their room, the food items 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 facility meal schedule, observation, and resident and staff interview, it was determined that the facility failed to ensure that meals were served at regularly scheduled times in accordance with resident needs on one of four nursing units (Oak Nursing Unit; Residents 6, 30, and 78).Findings include: Review of the facility's Resident Council meeting minutes dated June 2, 2026, at 1:58 PM revealed that the residents indicated concerns related to meal trays arriving late. Review of facility grievances revealed the following grievances related to late meals: grievance dated February 5, May 2, and May 3, 2026, for Resident 30. Interview with Resident 78 on June 15, 2026, at 8:47 AM revealed that meals are frequently late. A follow-up interview with Resident 78 on June 16, 2026, at 1:05 PM revealed that meals can be up to 40 minutes late on some days. An interview with Resident 6 on June 15, 2026, at 9:50 AM revealed concerns related to lunch being served late. Observation of the Oak Nursing Unit on June 14, 2026, at 11:53 AM revealed a posted sign in the hallway…

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

Based on clinical record review and staff interview, it was determined that the facility failed to ensure complete and accurate clinical documentation for 1 of 24 residents reviewed (Resident 30).Findings include: Clinical record review for Resident 30 revealed a current physician order dated August 18, 2025, for bilateral floor mats when in bed. A quarterly Minimum Data Set Assessment (MDS, an assessment completed at specific intervals to determine care needs) dated May 26, 2026, revealed that facility staff assessed Resident 30 as having a BIMS (Brief Interview for Mental Status) of 00, which indicated severe cognitive impairment. The current task list (located in the electronic health record where staff document specific care related events for a resident) for Resident 30 revealed a safety device - bilateral floor mats when in bed with a frequency of every shift. A review of the task documentation for Resident 30 for April 2026, May 2026, and June 2026, revealed the following dates where there was no documentation (left blank) to indicate that staff had addressed the floor mats:…

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

Based on a review of select facility policies and procedures, clinical record review, and staff and resident interview, it was determined that the facility failed to ensure that contracted hospice services met professional standards of practice and timeliness of services for one of one resident reviewed for hospice concerns (Resident 15). Findings include: Review of the facility's current contract with the hospice services provider revealed hospice shall furnish to the facility at the time of the patient's admission, a copy of the patient's plan of care, medical history, advance directive, DNR (do not resuscitate) status, and request for service signed by the patient or authorized representative of the patient and shall specify the general inpatient care or respite care services to be provided by the facility. Hospice shall promptly communicate orally or in writing any changes in the plan of care to the facility. The patient care coordinator/designee shall coordinate the general inpatient care or respite care provided to the patient by reviewing the plan of care and updating 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 observation and staff interview, it was determined that the facility failed to store food and maintain food service equipment in accordance with professional standards for food service safety in the facility's main kitchen, and two of two nursing unit pantries (Oak/[NAME] and Marble/Maple). Findings include: An observation in the facility's main kitchen on July 15, 2025, at 9:22 AM revealed the following: Open wire rack shelving was observed in the walk-in cooler near the beverage station. Multiple wire shelves were observed rusty with the exterior finish worn off. The lower shelves located six to eight inches from the floor with food products stored on them contained no barrier from the potential for mop water splash or sweeping debris from the floor. A black plastic tub was observed on the lower shelf in the same walk-in cooler with multiple clear plastic bags of unidentified meat. The tub was full of a clear liquid. Employee 6, dietary manager, indicated the bags contained chicken thighs, which were…

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

Based on clinical record review and staff interview, it was determined that the facility failed to ensure that the resident and/or their representative received written notice of transfer for one of five residents reviewed for hospitalizations (Resident 41); and written notice of the facility bed-hold policy at the time of transfer for three of five residents reviewed for hospitalization (Residents 9, 11, 41).Findings include: Clinical record review for Resident 41 revealed nursing documentation dated June 6, 2025, at 2:22 PM that Resident 41 wanted to go to the hospital due to rectal pain. Nursing documentation dated June 6, 2025, at 2:35 PM revealed that staff called emergency medical services (911). Hospital documentation dated June 6, 2025, confirmed that Resident 41 presented to the emergency department for evaluation of rectal pain. There was no documented evidence that the facility provided Resident 41 or her responsible party with written information regarding the facility’s bed-hold policy. There was no documented evidence that the facility provided a written transfer…

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

Based on clinical record review and staff interview, it was determined that the facility failed to identify triggers related to a resident's diagnosis of Post-Traumatic Stress Disorder, to provide culturally, competent, trauma-informed care, and to eliminate or mitigate re-traumatization for two of two residents reviewed for mood and behaviors (Residents 9 and 63).Findings include: Clinical record review for Resident 9 revealed a diagnosis of Post Traumatic Stress Disorder (PTSD, a mental and behavioral disorder that develops related to a terrifying event) since his admission to the facility on November 27, 2023. Review of Resident 9's care plan revealed that there were no identified triggers (everyday situations that cause a person to re-experience the traumatic event as if it was reoccurring) or interventions to alleviate individualized triggers. There was no documented evidence that the facility completed a trauma assessment on Resident 9 regarding his PTSD diagnosis. Review of Resident 63's clinical record revealed that the facility initiated a diagnosis of PTSD on November 7,…

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 employee education records and staff interview, it was determined that the facility failed to ensure that nurse aides received 12 hours of in-service training annually for three of three nurse aides reviewed (Employees 2, 3, and 4). Findings include: Review of the active nurse aide hire list revealed that Employee 2, nurse aide, was hired on May 3, 2018. There was no documented evidence that Employee 2 completed 12 hours of in-service training annually. Employee 2 only had six hours of in-service training since January 2025. Employee 3, nurse aide, was hired by the facility on May 3, 2018. There was no documented evidence that Employee 3 completed 12 hours of in-service training annually. Employee 3 only had six hours of in-service training since January 2025. Employee 4, nurse aide, was hired by the facility on June 21, 2021. There was no documented evidence that Employee 4 completed 12 hours of in-service training annually. Employee 4 only had six hours of in-service training since January 2025. Interview with the Director of Nursing on July 17, 2025, at 11:40…

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

Based on observation and staff interview, it was determined that the facility failed to maintain confidentiality of residents' personal health information for four of four previous surveys reviewed that were located in one of one survey results binder (main lobby of facility). Findings include: Observation of a seating area located in the main lobby of the facility on July 15, 2025, at 10:55 AM revealed a binder that contained the results of the most recent surveys of the facility conducted by Federal or State surveyors and any plan of correction in effect with respect to the facility. Review of the contents of the binders revealed that the facility placed the full health survey letters and complaint deficiency letters (letters sent to administration after a survey) along with the Statement of Deficiencies (Form CMS-2567) into the binder. The deficiency letters also noted the specific resident identifiers and associated resident names used for any cited deficiencies in the Statement of Deficiencies. The binder contained the following deficiency letters with the resident identifiers…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff and resident interview, it was determined that the facility failed to ensure a resident's medication regime was free from potentially unnecessary medication for one of five residents reviewed for medication review (Resident 2). Findings include: Clinical record review for Resident 2 revealed her medication regime included the use of the antipsychotic medication, Loxapine Succinate, 10 milligrams daily, since her admission on [DATE], for a diagnosis of unspecified schizophrenia (serious mental health condition that affects how people think, feel and behave. It may result in a mix of hallucinations, delusions, and disorganized thinking and behavior. Review of progress notes from the facility's consulting psychiatric provider dated January 10, 2025, January 20, 2025, February 10, 2025, and April 28, 2025, revealed that Resident 2 had a history of depression for which she took the antidepressant medication, Fluoxetine, and that, pt (patient) with chronic psych illness,…

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

Based on clinical record review and staff interview, it was determined that the facility failed to ensure assessments accurately reflected a resident's status for one of three closed records reviewed (Resident 113).Findings include: Clinical record review for Resident 113 revealed a Discharge Return Not Anticipated Medicare MDS (Minimum Data Set, an assessment tool completed at specific intervals to determine resident care needs) dated June 30, 2025, in which facility staff assessed the resident as being discharged to a short-term general hospital. Further closed clinical record review for Resident 113 revealed the resident had signed out of the facility against medical advice and was not discharged to a hospital on June 30, 2025. Interview with Employee 10, Registered Nurse Assessment Coordinator (RNAC), on July 17, 2025, at 10:37 AM confirmed the MDS did not accurately reflect Resident 113's discharge status. The above information was reviewed with the Director of Nursing on July 17, 2025, at 2:00 PM. 483.20(g) Accuracy of AssessmentsPreviously cited 8/23/24 28 Pa. Code…

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

Based on clinical record review, observation, and staff interview, it was determined that the facility failed to revise a resident's comprehensive care plan for one of 21 residents reviewed (Resident 11).Findings include: Clinical record review for Resident 11 revealed a significant change MDS (Minimum Data Set, an assessment tool completed at specific intervals to determine resident care needs) dated June 26, 2025. The MDS indicated the resident was assessed as receiving oxygen therapy. A current physician's order for Resident 11 noted supplemental oxygen at two liters per minute (LPM) via nasal cannula (a type of medical tubing to deliver supplemental oxygen to the nose) every shift for shortness of breath; check oxygen saturation (a non-invasive measurement of the amount of oxygen in the blood usually measured through a medical device placed on a finger) every shift to keep saturation above 90 percent. Resident 11's current care plan revealed the resident is on oxygen therapy related to ineffective gas exchange. An intervention dated June 25, 2025, included oxygen settings that…

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

Based on clinical record review, observation, and resident and staff interview, it was determined that the facility failed to provide transfer and eating assistance to a dependent resident for one of three residents reviewed for activities of daily living concerns (Resident 41).Findings include: Observation of Resident 41 on July 15, 2025, at 12:33 PM revealed she was in bed. Interview with Resident 41 on the date and time of the observation revealed that she stayed in bed due to physical limitations following her right leg surgery. Resident 41 stated that she was not out of bed yet on this date. During the observation and interview with Resident 41 on July 15, 2025, at 12:50 PM a nurse aide delivered her lunch. The nurse aide obtained assistance from a second staff person to reposition Resident 41 in bed; however, did not ask Resident 41 if she wanted to get out of bed. The nurse aide stayed to feed Resident 41 due to her reported loss of vision. Resident 41, in the presence of the nurse aide, stated that not all staff stay to assist her with her meal. Resident 41 stated that she…

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

Based on clinical record review and staff interview, it was determined that the facility failed to provide the highest practicable care regarding physician ordered treatments and medications for two of 21 residents (Residents 11 and 48).Findings Include: Clinical record review for Resident 11 revealed a diagnosis list that included atrial fibrillation (an irregular and sometimes rapid heart rhythm that can lead to complications such as stroke and heart failure). Review of Resident 11’s current care plan revealed the resident has hypertension (high blood pressure) and an altered cardiovascular status related to atrial fibrillation. A review of the current physician orders for Resident 11 revealed an order dated June 25, 2025, for Metoprolol Succinate ER Extended Release (a medication that is used to treat high blood pressure and/or heartrate) 100 milligrams (mg) give one tablet by mouth one time a day related to unspecified atrial fibrillation. Hold for a systolic blood pressure (SBP, the top number of a blood pressure reading where the heart contracts) less than 100 or apical pulse…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, observation, and resident and staff interview, it was determined that the facility failed to ensure that a resident received proper treatment and assistive devices to maintain hearing abilities for one of one resident reviewed for hearing concerns (Resident 36). Findings include: Interview with Resident 36 on July 15, 2025, at 1:19 PM revealed that he had difficulty hearing. Observation of Resident 36 revealed that he utilized a headphone amplifier device that he removed to answer his mobile phone, which decreased his ability to hear the person on the phone. Resident 36 stated, was just up to the VA (Veterans Administration), they take care of my hearing. Resident 36 denied knowing the status of his hearing aids. Clinical record review of nursing documentation dated March 21, 2025, at 10:38 AM revealed that staff notified Resident 36's daughter that his hearing aid was not working. Staff noted that a filter in the hearing aid was occluded, and that the battery was corroded.…

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

Based on observation, clinical record review, and resident and staff interview, it was determined that the facility failed to ensure a resident's environment remained free from accident hazards for one of five residents reviewed for accident hazards (Resident 83). Findings include: Observation of Resident 83's room on July 16, 2025, at 9:37 AM revealed a countertop wooden block with large scissors and seven knives visible near his television. Interview with Resident 83 on the date and time of the observation confirmed that he leaves his room often during the day to go outside or on leaves of absence, and his room door does not lock. The surveyor reviewed the above concern regarding Resident 83's open storage of knives in his room during an interview with the Nursing Home Administrator and the Director of Nursing on July 16, 2025, at 1:45 PM. Clinical record review for Resident 83 revealed documentation by the business office manager dated July 16, 2025, at 4:55 PM (following the surveyor's questioning) that she and social services staff went to see Resident 83 regarding the block of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff interview, it was determined that the facility failed to develop and implement an individualized person-centered care plan to address dementia and cognitive loss displayed by one of 21 residents reviewed (Resident 7). Findings include: Clinical record review for Resident 7 revealed the resident was admitted on [DATE], with a diagnosis of unspecified dementia (loss of memory, language, problem-solving, and other thinking abilities that interfere with daily life). A review of Resident 7's admission minimum data set (MDS, a form completed at specific intervals to determine care needs) assessment dated [DATE], indicated that facility staff assessed Resident 7 as having a diagnosis of dementia, and a BIMS (brief interview of mental status) score of three indicating severe cognitive impairment. A review of Resident 7's plan of care developed by facility staff revealed alteration in cognition, with general basic interventions such as cueing and reorienting, therapy staff 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 observation and staff interview, it was determined that the facility failed to ensure adequate storage of medications and biologicals on one of four hallways (Maple).Findings include: Observation on July 17, 2025, at 12:00 PM of the Maple Hallway revealed an unlocked treatment cart against a wall, outside a resident's room. Opening drawers in the cart revealed multiple tubes of creams. Continued observation of the cart for five minutes revealed no employee attending the cart, and two residents were moving independently in the hallway. In an interview with the Director of Nursing (DON) on July 17, 2025, at 12:35 PM the unlocked cart was shown to the DON, who confirmed the cart should be locked. 28 Pa. Code 211.12 (c)(d)(1)(5) Nursing services

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, and resident and staff interview, it was determined that the facility failed to assure full visual privacy for one of 32 residents reviewed (Resident 11).Findings include: Observation of Resident 11 in his room on July 17, 2025, at 9:15 AM revealed that the privacy curtain did not extend around the bottom of the bed, preventing full visual privacy. Upon entering the room with Employe 5, Licensed Practical Nurse, to observe a medication pass for Resident 11's roommate, Resident 11 was receiving a brief change. Employee 5 waited until Resident 11 was no longer exposed before walking past, but he was observed in bed, uncovered, wearing only a brief and in a state of undress. Further observation revealed that the curtain was not large enough to extend around the bottom portion of Resident 11's bed. Interview with Resident 11 on July 17, 2025, at 11:15 AM revealed that the curtain has not extended around the bed since their admission on [DATE]. The surveyor discussed the above findings with 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 observation and staff interview, it was determined that the facility failed to provide a clean, comfortable, and homelike environment on four of four nursing units reviewed ([NAME]; Oak: Resident 6; Marble: Resident 3; and Maple: Resident 1). Findings include: Observation on March 18, 2024, at 8:30 AM of the [NAME] nursing unit shower room revealed rust around the two doors to the left as you entered the shower room. The second door to the left as you entered the shower room was warped and splintered at the bottom. The floor had a brown substance and loose particles of dirt on it. The first shower stall had a black substance on the floor of the shower and on the wall tiles, and two shower chairs located in this stall were dirty around the base. The second shower stall had a black substance on the floor and wall tiles, the shower curtain was dirty around the bottom, and ripped, two shower chairs located in the stall were dirty, grab bars in the shower were noted to have rust on them, and the drain in 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 observation and staff and resident interview, it was determined that the facility failed to implement enhanced barrier precautions for one of eight residents reviewed (Resident 2). Findings include: Review of the Centers for Medicare and Medicaid Services (CMS) memo entitled, Enhanced Barrier Precautions in Nursing Homes, dated March 20, 2024, revealed that nursing care facilities are to use enhanced barrier precautions (EBP, gown and glove use) for residents with chronic wounds or indwelling medical devices (i.e., indwelling urinary catheters) during high-contact resident care activities regardless of their multidrug-resistant organism status. High-contact activity would include things like dressing, transferring, changing linens, providing hygiene, changing briefs, wound care, or device care. Interview with Resident 2 on March 18, 2025, at 9:13 AM, revealed that she had an indwelling urinary catheter (tube inserted into the bladder to drain urine). Observation of Resident 2's room door on the date and time of the interview revealed a sign to inform staff and visitors that…

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

Based on a review of select facility policies and procedures, clinical record review, and staff and resident interview, it was determined that the facility failed to provide the highest practicable care regarding physician ordered blood sugar assessments and insulin administration for five of nine residents reviewed (Residents 1, 2, 3, 8, and 9). Findings include: The facility policy entitled, Insulin Administration, last reviewed without changes on January 17, 2024, revealed that the purpose of the policy is to provide guidelines for the safe administration of insulin to residents with diabetes (high blood sugar). The nursing staff will have access to specific instructions (from the manufacturer if appropriate) on all forms of insulin delivery system(s) prior to their use. Characteristics and types of insulin note that the three key characteristics of insulin are the onset of action, peak effects, and the duration of effects. Rapid-acting insulin has an onset time of 10 to 15 minutes. The policy did not include instructions regarding the administration of insulin per professional…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and resident and staff interview, it was determined that the facility failed to provide bathing support for a resident requiring staff assistance for three of 10 residents sampled for activities of daily living (Residents 6, 5, and 7). Findings include: Clinical record review for Resident 6 revealed her most recent annual MDS (Minimum Data Set, an assessment completed at specific interval to determine care needs) dated November 15, 2024, noted staff assessed her as requiring supervision/touching assistance (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity. Assistance may be provided throughout the activity or intermittently) for bathing. Clinical record for Resident 6 revealed her preference for bathing is to receive a shower/bed bath on Mondays and Thursdays. Review of Task documentation (electronic system of nurse aide documentation of activities of daily living care) for the last 30 days revealed nursing staff…

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

Based on clinical record review, review of select facility policies and procedures, and staff interview, it was determined that the facility failed to promote the healing of pressure ulcers for one of one resident reviewed for pressure ulcer concerns (Resident CR1). Findings include: The facility's current policy entitled Skin and Wound Management System, revealed it is the policy to identify and assess residents with wounds and/or pressure ulcers, as well as those at risk for skin compromise. Ongoing monitoring and evaluation are then provided to ensure optimal resident outcomes. An assessment of skin integrity is to be performed on each resident upon admission by completing a head-to-toe physical evaluation of skin condition and a risk evaluation for predicting pressure will be used to determine risk status, such as the Braden or Norton Scale. Ongoing weekly evaluations of resident skin will be completed and documented in Point Click Care. Closed clinical record review for Resident CR1 revealed the facility admitted him on September 6, 2024. Review of Resident CR1's initial…

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 observation and staff interviews, it was determined that the facility failed to serve food timely and at a palatable temperature on four of four resident hallways (Maple, Marble, Oak, and [NAME] hallways). Findings include: Observation of the posted meal serving times revealed the residents would receive their lunch trays at the following times: Early trays at 11:45 AM Marble Hall at 12:00 PM Oak Hall at 12:10 PM [NAME] Hall at 12:18 PM Maple Hall at 12:35 PM Observation of lunch meal on October 10, 2024, revealed that the meal carts arrived on the resident hallways at the following times: Early trays arrived at 12:30 PM (45 minutes late) Marble Hall trays arrived at 1:20 PM (an hour and 20 minutes late) [NAME] Hall trays arrived at 1:00 PM (42 minutes late) Oak Hall trays arrived at 1:35 PM (an hour and 25 minutes late) Maple Hall trays arrived at 1:42 PM (an hour and seven minutes late) Observation of meal service on the Maple Hall on October 10, 2024, at 12:30 PM revealed that the early tray cart…

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

Based on clinical record review and staff interview, it was determined that the facility failed to provide services to maintain a resident's range of motion for three of four residents reviewed (Residents 16, 30, and 50). Findings include: Clinical record review for Resident 16 revealed a current care plan for staff to provide a restorative nursing program (RNP) to maintain the resident's range of motion (ROM, movement of the body to maintain a resident's ability) to ambulate for 20 feet with a rolling walker with assist of one and use of a gait belt. Review of task documentation for Resident 16 revealed that staff did not document completion or documented NA (Not Applicable) of the restorative task on the following dates: Day Shift: June 15, 25; July 1, 9; August 1, 2, 3, 4, and 6, 2024 Evening Shift: June 13, 22; July 15, 20; August 18, 2024 Staff documented several refusals by Resident 16 throughout June, July, and August 2024. There was no facility documentation that identified this CLOF (current level of function). Clinical record review for Resident 30 revealed a therapy…

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

Based on clinical record review, review of facility documentation, and staff interview, it was determined that the facility failed to implement interventions to prevent falls and injuries for two of five residents reviewed for falls (Resident 16 and 103). Findings include: Clinical record review for Resident 16 revealed that the facility requested a therapy screen as a result of a fall on May 22, 2024. Physical and occupational therapy staff screened Resident 16 on May 23, 2024. Occupational therapy (OT) staff recommended patient in heavily supervised areas when OOB (out of bed) to prevent falls. There was no documentation available that indicated the facility implemented OT's recommendation dated May 23, 2024. Review of facility and nursing documentation revealed that Resident 16 fell and sustained injuries on the following dates: On July 14, 2024, at 2:44 PM Resident 16 was found in her room on her knees on the right side of the bed with her elbows resting on her wheelchair. Resident 16 was last observed by staff in her wheelchair. Resident 16 sustained a 1.0-centimeter (cm) by…

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

Based on review of select facility policies and procedures, clinical record review, observation, and resident and staff interview, it was determined that the facility failed to assess the entrapment risk of assist bar (side rail) use for eight of nine residents reviewed for accident concerns (Residents 23, 24, 26, 30, 37, 50, 51, and 78) Findings include: The facility policy titled, Enabler Bar Protocol, last reviewed without changes on January 17, 2024, revealed that it is the purpose of the facility to assist the resident in attaining and maintaining his or her highest practicable level of physical and psychosocial well-being. Some of the procedures regarding the use of enabler bars included the following: The Bed System Measurement Device Test, form will be completed upon admission or when initiated, and with any change in bed and/or mattress. If any zones do not pass the above test, the bed and/or mattress will be taken out of use immediately. The facility will complete the Bed System Measurement Device Test form upon admission, when initiated, and with any change in bed and/or…

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

Based on employee personnel review and staff interview, it was determined that the facility failed to complete a performance evaluation of each nurse aide at least once every 12 months for three of three nurse aides reviewed (Employees 10, 11, and 12). Findings include: The facility noted the following hire dates for three employees reviewed for performance evaluations: Employee 10's hire date of February 15, 2007 Employee 11's hire date of May 23, 2023 Employee 12's hire date of October 21, 2020. A request to review the annual performance evaluations revealed no documented evidence that the facility is completing the evaluations at least once every 12 months. Interview with the Nursing Home Administrator on August 23, 2024, at 12:40 PM confirmed that performance evaluations were not completed on the three employees. 28 Pa. Code 201.19 (2) Personnel policies and procedures

Based on review of the facility's arbitration agreements and staff interview, it was determined that the facility's arbitration agreements failed to ensure a neutral and fair arbitration process by ensuring the selection of a neutral arbitrator for three of three residents reviewed with a signed arbitration agreement (Residents 39, 52, and 103). Findings include: Review of a Mandatory Binding Arbitration Agreement (an agreement that the resident/resident's responsible party and the facility will resolve legal disputes through binding arbitration, waiving their right to a trial) signed by Resident 39's responsible party on March 28, 2023, revealed that the document stipulated that, All Arbitrations shall be administered by (name of arbitrator services company, which the facility utilized). The document also stipulated that if, . (name of arbitrator services company, which the facility utilized), is unable or unwilling to handle the Arbitration, the parties will work in good faith to agree on an alternative neutral arbitration service, and if the parties cannot reach an agreement…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of select facility policies and procedures, observation, clinical record review, and staff and resident interview, it was determined that the facility failed to ensure the implementation of isolation precautions for two of three residents reviewed for transmission based precautions (Residents 28 and 30); implement enhanced barrier precautions for two of three residents reviewed for enhanced barrier precautions (Residents 103 and 107); enforce restriction-to-work guidelines for one of two staff that tested positive for COVID-19 (Employee 5); implement measures to monitor and prevent the growth of opportunistic pathogens within the facility's water system; and ensure an environment free from the potential spread of infection on one of four resident hallways (Maple hall, Resident 29). Findings include: Review of the Centers for Medicare and Medicaid Services (CMS) memo entitled, Enhanced Barrier Precautions in Nursing Homes, dated March 20, 2024, revealed that nursing care facilities are to use…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of select facility policies and procedures, clinical record review, and staff and family interview, it was determined that the facility failed to ensure all residents who consented to the COVID-19 vaccine received the vaccine for three of five residents reviewed for immunizations (Residents 26, 28, and 107). Findings include: The facility policy entitled, Coronavirus Disease (COVID-19) - Infection Prevention and Control Measures, last reviewed without changes on January 17, 2024, revealed that the facility follows infection prevention and control (IPC) practices recommended by the Centers for Disease Control and Prevention to prevent the transmission of COVID-19 within the facility. Measures include encouraging staff, residents, and visitors to remain up to date with all COVID-19 vaccine doses. The CDC (Centers for Disease Control) recommendations for COVID-19 vaccines (https://www.cdc.gov/vaccines/covid-19/downloads/COVID-19-immunization-schedule-ages-6months-older.pdf) indicate that for people…

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

Based on clinical record review, observation, and staff interview, it was determined that the facility failed to accommodate resident needs regarding the accessibility of a call bell for one of 22 residents reviewed (Resident 74). Findings include: Clinical record review for Resident 74 revealed a diagnoses list that included unsteadiness on their feet, muscle weakness, abnormalities of gait and mobility, and dementia. A current care plan for Resident 74 revealed the resident is at risk for falls. An intervention listed on the care plan included to be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. Another intervention noted the resident needs a safe environment that included a working and reachable call light. Observation of Resident 74 on August 22, 2024, at 9:00 AM and 10:47 AM revealed the resident was in bed. The call bell was not within reach and located on the floor with the cord stuck under the wheel of the bed. Employee 9, nurse aide, was advised of the findings for Resident 74 on August 22, 2024, at 10:50 AM and…

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

Based on review of select facility policies and procedures, clinical record review, and staff and resident interview, it was determined that the facility failed to ensure a resident's right to choose activities consistent with her interests for one of 22 residents reviewed (Resident 100). Findings include: The facility policy entitled, Smoking Policy, last reviewed without changes on January 17, 2024, revealed that on admission, the Safe Smoking Assessment Form must be completed on any resident requesting to smoke. Upon completion of the assessment form, the individualized care plan will be completed to reflect the appropriate interventions for each resident. The designated smoking area for residents is outside the front entrance door near the provided receptacles. Interview with Resident 100 on August 21, 2024, at 9:40 AM revealed that she was told that she could not go outside, unless someone was with her, even though she believed that she had no issues with safety. Resident 100 stated that she smoked cigarettes before her admission to the facility and was not told that smoking…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff interview, it was determined that the facility failed to establish clear and consistent resident wishes regarding advance directives for three of 33 residents reviewed (Residents 16, 101, and 102). Findings include: Clinical record review for Resident 102 revealed a POLST (Physician Orders for Life-Sustaining Treatment, a document for specific medical orders to be honored by health care workers during a medical crisis) in the resident's record dated [DATE], indicating it was the resident's wish to have CPR (cardiopulmonary resuscitation, a lifesaving procedure performed when the heart stops beating). Further review of Resident 102's clinical record revealed a physician's order dated [DATE], indicating Resident 102 was a DNR (do not resuscitate, no lifesaving procedures performed when the heart stops beating). Resident 102's physician orders for life sustaining treatment did not match the wishes indicated on Resident 102's POLST. There was no evidence of any discussion or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident observation and interview and staff interview, it was determined that the facility failed to ensure assessments accurately reflected a resident's status for one of 22 residents reviewed (Resident 23). Findings include: Interview with Resident 23 on August 21, 2024, at 10:30 AM revealed that she had not received the services of a professional dental provider, in a while. Resident 23 stated that she had broken and missing teeth. Resident 23 was reluctant to smile for the surveyor and stated that she was embarrassed of the condition of her teeth. Review of an admission MDS (Minimum Data Set, an assessment tool completed at specific intervals to determine resident care needs) dated January 17, 2024, revealed that staff assessed Resident 23 had no teeth (was edentulous). The assessment indicated that Resident 23 had no obvious or likely cavities or broken natural teeth. The assessment triggered staff to develop a plan of care due to Resident 23's edentulous status. There was no evidence in Resident…

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

Based on clinical record review and staff interview, it was determined that the facility failed to provide the highest practicable care regarding physician ordered medications for two of 22 residents reviewed (Residents 51 and 72). Findings include: Review of the current physician orders for Resident 51 dated May 21, 2024, instructed staff to monitor for side effects (that included constipation) of anti-anxiety medications. The other order instructed staff to monitor for side effects (that included constipation) of anti-depressant medications. Clinical record review for Resident 51 revealed a current care plan that revealed the resident has an alteration in gastrointestinal status. An intervention included to administer medications as ordered and observe for/document side effects and effectiveness. Clinical record review for Resident 51 revealed the following physician orders to promote bowel movements: Dulcolax Oral Tablet (a laxative medication used to relieve constipation) delayed release 5 milligrams (mg) give one tablet by mouth as needed for constipation every three days 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 observation, clinical record review, and staff interview, it was determined that the facility failed to provide respiratory care consistent with professional standards of practice with the administration of supplemental oxygen for two of four residents reviewed for oxygen use (Residents 78 and 35). Findings include: An observation of Resident 78 on August 20, 2024, at 12:55 PM revealed the resident in bed with oxygen being administered via a nasal cannula (tubing piece inserted into the nostrils to administer supplemental oxygen). There was no evidence of any date on the resident oxygen tubing, or bag that hung on the side of the resident's oxygen concentrator where the tubing was attached to indicate when the tubing was placed there. There was no evidence in Resident 78's clinical record to indicate when the resident's oxygen tubing and nasal cannula was changed. An observation of Resident 35 on August 21, 2024, at 11:40 AM revealed the resident in bed with oxygen being administered via nasal cannula. There was no date on the oxygen tubing or oxygen concentrator 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 staff interview and clinical record review, it was determined that the facility failed to ensure that a medication was available in a timely manner for 3 of 3 residents reviewed for medication availability concerns (Residents 57, 24, and 50). Findings include: Clinical record review for Resident 57 revealed a physician's order dated March 14, 2024, indicating the resident was to receive phenobarbital tablets (a medication used to prevent and control seizures) every 12 hours for a diagnosis of unspecified convulsions. A review of Resident 57's August 2024, medication administration record (MAR) revealed Resident 57 did not receive the morning or evening dose of the phenobarbital on August 9, 2024. Further clinical record review revealed a nursing medication administration note dated August 9, 2024, at 8:11 AM noting that the resident's phenobarbital was not administered due to it being unavailable and awaiting delivery from the pharmacy. An additional nursing medication administration note dated August 9, 2024, at 8:59 PM noted the resident's evening dose of phenobarbital…

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

Based on observation, clinical record review, and staff interview, it was determined that the facility failed to ensure a medication error rate below five percent (Resident 91). Findings include: The facility's medication error rate was 6.06 percent based on 33 medication opportunities with two medication errors. Observation of a medication administration pass on August 20, 2024, at 10:02 AM revealed that Employee 1, licensed practical nurse, administered Dulera 200 mcg (micrograms) - 5 milligrams (mg) per actuation (puff), one puff orally to Resident 91. Employee 1 did not instruct and ensure Resident 91 rinsed her mouth with water after the administration. Further medication administration observation with Employee 1 revealed that she administered Spiriva Respimat Inhalation Aerosol solution 2.5 mcg per actuation (puff), two puffs orally to Resident 91. Employee 1 did not instruct and ensure Resident 91 rinsed her mouth with water after the administration. Clinical record review for Resident 91 revealed the following current physician orders: Dulera 200 mcg - 5 mg per actuation,…

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

Based on clinical record review and staff interview, it was determined that the facility failed to notify the responsible party of a resident's change in condition requiring interventions for one of five residents reviewed (Resident CR1). Findings include: Closed clinical record review for Resident CR1 revealed a progress note dated November 28, 2023, at 8:47 AM that indicated she was coughing with her meal, pocketing food, and a speech therapy consult was initiated. Review of the speech therapy screen completed on November 28, 2023, and signed by the speech therapist on November 29, 2023, at 11:30 AM, revealed that Resident CR1 was pocketing food, but she was not medically appropriate for skilled treatment due to increased lethargy (unusual decrease in consciousness/alertness). The speech therapist indicated to downgrade Resident CR1's diet to puree (smooth with no lumps) texture with nectar thick (easily to pour and are comparable to heavy syrup found in canned fruit) liquids. Further clinical record review revealed a nursing progress note dated November 29, 2024, at 5:26 AM that…

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

Based on observation and staff interview, it was determined that the facility failed to provide a clean, comfortable, and homelike environment on one of four nursing units reviewed (Maple Nursing Unit, Resident 1). Findings include: Observation of Resident 1's room on the Maple Nursing Unit on January 19, 2024, at 11:10 AM and 12:19 PM revealed the following: A significant accumulation of crumbs and debris under the bed especially near the foot of the bed. The perimeter of the floor where it met the wall near the egress door to the room had an accumulation of crumbs and debris. The floor mat next to the bed was covered with dirty footprints and had several white stains on it. There was a plastic bag filled with rocks that was propped against the door to keep it open. Resident 1's scoot chair had a significant accumulation of debris under the cushion of the chair. The above information was reviewed in a meeting with the Director of Nursing and Assistant Director of Nursing on January 19, 2024, at 4:05 PM. 28 Pa. Code 201.18(b)(3)(e)(2.1) Management

Based on clinical record review, observation, and staff interview, it was determined that the facility failed to accurately document the nutritional status and ensure appropriate adaptive equipment was utilized for one of one resident reviewed for nutrition concerns (Resident 1). Findings include: A current diagnoses list for Resident 1 included a history of dysphagia oral phase (a type of swallowing disorder) and feeding difficulties. A current physician's order for Resident 1 dated September 20, 2023, was to initiate dependent for feeding and other orders dated October 12, 2023, was to initiate a tall blue lidded cup with a straw at all meals and an early tray for all meals per family request. Clinical record review for Resident 1 revealed a current care plan that noted nutritional concerns related to the resident's history, therapeutic diet, and varied intake. An intervention noted was to utilize adaptive equipment that included a tall cup with lid and straw. Clinical documentation for Resident 1 revealed an MDS (Minimum Data Set, an assessment tool completed at specific…

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.