Wecare At Murrysville Rehab And Nursing Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of the facility policy, clinical record review and staff interview, it was determined that the facility failed to accurately assess the nutritional status, and failed to update an individualized care plan to address the resident's specific nutritional concerns for two of five residents (Resident R4 and R49) records reviewed.Findings include: Review of facility's policy Nutritional Assessment, dated 6/11/25, indicated as part of the comprehensive assessment, a nutritional assessment, including current nutritional status and risk factors for impaired nutrition, shall be conducted for each resident. The dietitian, in conjunction with the nursing staff and healthcare practioners, will conduct a nutritional assessment for each resident upon admission (within current baseline assessment timeframes) and as indicated by a a change in condition that places the resident at risk for impaired nutrition. Once current conditions and risk factors for impaired nutritional are assessed and analyzed, individual…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical records, and staff and resident interview, it was determined that the facility failed to ensure Total Parenteral Nutrition (TPN) was administered consistent with professional standards of practice and in accordance with physician orders for one of three residents (R96). Findings include: Review of the facility policy Parenteral Nutrition dated 6/11/25, indicated the purpose of PN is to provide guidelines for the safe and aseptic administration of partial nutrition to residents who have a need for supplemental nutrition. (PN or TPN is a sterile pharmacy-prepared form of nutrition that is delivered through an intravenous route.) A physician's order is necessary for this treatment. The PN order should include the formula, total volume and rate of administration. Review of the admission record indicated Resident R96 admitted to the facility on [DATE], with the diagnoses of persistent small bowel obstructions (SBOs), small bowel mesenteric desmoid tumor (an abnormal mass…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical records, and staff interview it was determined that the facility failed to provide trauma survivors with trauma informed care to eliminate or mitigate triggers that may cause re-traumatization of the resident for one of two residents (Resident R9).Findings include: Review of facility policy Trauma Informed Care and Culturally Competent Care dated 6/11/25, indicated: purpose: To address the needs of trauma survivors and/or re-traumatization. Trauma informed care is an approach to delivering care that involves understanding, recognizing and responding to the effects of all types of trauma. A trauma informed approach to care delivery recognizes the widespread impact and signs and symptoms of trauma in residents, and incorporates knowledge about trauma into care plans, policies, procedures and practices to avoid re-traumatization. Trigger is a psychological stimulus that prompts recall of a previous traumatic event , even if the stimulus itself is not traumatic 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 facility policy, clinical record review, observation, and staff interview, it was determined that the facility failed to use proper hand washing to prevent cross contamination during a dressing change for one of three residents (Resident R11). Findings include: Review of the facility policy Handwashing/Hand Hygiene dated 6/11/25, indicated use alcohol-based hand rub containing at least 62% alcohol and/or soap and water before handling clean or soiled dressings, gauze pads, etc.; After handling used dressings, contaminated equipment, etc.; The use of gloves does not replace hand washing/hand hygiene. Review of the facility policy Wound Care dated 6/11/25, indicated wash and dry hands thoroughly. Put on clean gloves, loosen tape and remove dressing. Pull glove over dressing and discard into appropriate receptacle. Wash and dry hands thoroughly. Review of the admission record indicated Resident R11 admitted to the facility on [DATE]. Review of Resident R11's MDS dated [DATE], indicated the diagnoses 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 observations and staff interviews, it was determined that the facility failed to make certain that equipment was in safe operating condition for one of three shower chairs (Resident R82).Findings include: Review of the facility policy Assistive Devices and Equipment dated 6/11/25, indicated device condition and equipment are maintained on schedule and according to manufacturer's instructions. Defective or worn devices are discarded or repaired. Review of the admission record indicated Resident R82 admitted to the facility on [DATE]. Review of Resident R82's Minimum Data Set (MDS- a periodic assessment of care needs dated 12/29/25, indicated the diagnoses of dementia (a general term for loss of memory, language, problem solving and other thinking abilities that are severe enough to interfere with daily life), Parkinson's Disease (disorder of the nervous system that results in tremors), and Bipolar (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs).…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility documents, facility policy, clinical records, and staff interviews, it was determined that the facility failed to conduct a thorough investigation of an allegation of abuse for one of two residents (Resident R1).Findings include: Review of facility Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating policy dated 5/30/25, indicated all reports of resident abuse, neglect, exploitation or theft/misappropriation of resident property are reported to local, state and federal agencies and thoroughly investigated by facility management. Findings of all investigations are documented and reported. Review of the clinical record indicated Resident R1 was admitted to the facility on [DATE]. Review of Resident R1's Minimum Data Set (MDS - a periodic assessment of care needs) dated 12/8/25, indicated diagnoses of depression, chronic obstructive pulmonary disease (COPD, a group of progressive lung disorders characterized by increasing breathlessness), and heart failure (a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, observations and staff interview it was determined that the facility failed to provide a clean, safe, comfortable, and homelike environment for eight of 15 resident rooms (Rooms 114, 116, 119, 122, 139, 140, 143, and 144). Findings include: Review of facility Homelike Environment policy dated 5/30/25, indicated residents are provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible. During a tour of the facility on 11/4/25, from 11:30 a.m. to 12:00 p.m. with the Nursing Home Administrator (NHA), Director of Nursing, Assistant Director of Nursing, and the Regional Maintenance Director Employee E1 the following were observed: Resident room [ROOM NUMBER]'s bathroom had stained, grime tiles around the toilet and the plaster behind the toilet was chipped and stained dark brown. Resident room [ROOM NUMBER]'s bathroom had stained, grime tiles around the toilet and the plaster behind the toilet was chipped…

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 complete a significant change Minimum Data Set (MDS- assessments completed indicating a change in condition of a resident requiring change in care) assessment for one of two residents (Residents R1). Findings include: Review of the Resident Assessment Instrument 3.0 User's Manual (reference used to complete an MDS) effective October 2024, indicated that the facility must conduct a comprehensive assessment of a resident within 14 days after the facility determines, or should have determined, that there has been a significant change in the resident's physical or mental condition. Review of the clinical record revealed that Resident R1 was admitted to the facility on [DATE]. Review of Resident R1's quarterly MDS dated [DATE], indicated diagnoses of high blood pressure, difficulty swallowing, and dementia (a group of symptoms that affects memory, thinking and interferes with daily life). Review of physician order dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of resident clinical records, and staff interview, it was determined the facility failed to ensure the coordination of hospice services with facility services to meet the needs of each resident for end of life care for one of two residents (Resident R1).Findings include: Review of the clinical record revealed that Resident R1 was admitted to the facility on [DATE]. Review of Resident R1's quarterly MDS dated [DATE], indicated diagnoses of high blood pressure, difficulty swallowing, and dementia (a group of symptoms that affects memory, thinking and interferes with daily life). Review of physician order dated 8/1/25, indicated Resident R3 was admitted under hospice services. Review of Resident R1's current comprehensive care plan failed to indicate a plan of care by the facility that displayed the coordination of hospice services by failing to include contact information for the hospice agency and how to access the hospice's 24 hour on-call system. During an interview on 9/9/25, at 2:55 p.m. the…

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

Based on review of facility policies, clinical records, and staff interviews, it was determined that the facility failed to develop a comprehensive care plan that included specific and individualized interventions to address the care needs of residents for one of six residents (Resident R1) reviewed, relating to wandering/elopement.Findings include: Review of facility policy Care Plans, Comprehensive Person-Centered dated 5/30/35, indicated a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implement for each resident. Care plan interventions are chosen only after data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents conditions change. Review of facility policy Wandering and Elopement dated 5/30/25, indicated the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical records, facility documents, and staff interviews, it was determined that the facility failed to provide adequate supervision resulting in an elopement (resident exits to an unsupervised or unauthorized area without the facility's knowledge) for one of six residents (Resident R1).Findings include: Review of facility policy Wandering and Elopement dated 5/30/25, indicated the facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents. Elopement risk screenings with be completed on residents upon admission, re-admission, quarterly, significant change in status, and as needed. Review of the Resident Assessment Instrument 3.0 User's Manual effective October 2023, indicated that a Brief Interview for Mental Status (BIMS) is a screening test that aides in detecting cognitive impairment. The BIMS total score suggests the following distributions:13-15: cognitively…

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

Based on review of facility policy, resident and staff interviews, and group interviews, it was determined that the facility failed to have sufficient nursing staff to provide nursing and related services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of ten out of ten residents during group. Findings Include: Review of the facility policy Resident Rights dated 2/12/25, indicated all residents will be treated with kindness, respect, and dignity. Residents have the right to a dignified existence, Review of the facility Facility Assessment Tool dated 1/1/25, indicated the nursing facility will conduct, document, and annually review a facility-wide assessment, which includes both their resident population and the resources the facility needs to care for their residents. The purpose of the assessment is to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. Use this assessment to make decisions about your direct care staff needs. Facility needs are reviewed daily, 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 a review of facility policies, observations and staff interviews it was determined that the facility failed to properly label and date food products in one of two nursing unit pantries (Rose Dining Room) which created the potential for food borne illness. Findings Include: During an observation in the [NAME] Dining Room, resident refrigerator, on 3/28/25, at 10:25 a.m. the following items were found with no label, name, or date; a glass bowl containing cucumber salad, a plastic container of Chinese food, a plastic container with pumpkin pie, a plastic container of spaghetti and meatballs that had a fuzzy, green substance on top, and a cardboard container of rice. During an interview on 3/28/25, at 10:34 a.m. Registered Nurse Supervisor Employee E14 confirmed the above observation, and that the facility failed to properly label and date food in one of two nursing unit pantries (Rose Dining Room) which created the potential for food borne illness. 28 Pa. Code 201.14(a)Responsibility of licensee. 28 Pa. Code 201.18(b)(1) Management. 28 Pa. code 211.12 (d)(3) Nursing Services.

Based on review of facility policy, observation, and staff interview, it was determined that the facility failed to follow established procedures of water storage to ensure that water is available to essential areas when there is a loss of normal water supply for two of two nursing wings (East Wing, and [NAME] Wing) Findings include: Review of the facility policy Disaster Manual dated 2/12/25, indicated that the food service department will continue to provide essential functions at the time of a disaster. In the event of an emergency, which prohibits use of internal water sources, alternate potable (drinking water) water sources are available. Water I available in the Boiler room and storage room. The facility is storing one gallon per day for three days plus an additional 50 gallons for staff and volunteers. An agreement is in place for additional water. Upon entering facility on 3/24/25, resident census was 85. This census would require the facility to maintain a minimum of 255 gallons of drinkable water on hand in case of an emergency for residents. During a tour of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility documents, facility policy, clinical records, and staff interviews, it was determined that the facility failed to implement written policies and procedures to ensure complete and thorough investigations of allegations of abuse and neglect for four of five residents (Resident R14, R44, R46, and R286). Findings include: Review of facility policy Abuse and Neglect - Clinical Protocol dated 2/12/25, indicated neglect means the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. Review of the clinical record indicated Resident R14 was admitted to the facility on [DATE]. Review of Resident R14's Minimum Data Set (MDS - a periodic assessment of care needs) dated 3/19/25, indicated diagnoses of high blood pressure, depression, and cerebral palsy (group of disorders that affect a person's ability to move and maintain balance and posture). During a review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical record review, reports submitted to the State, and staff interview, it was determined that the facility failed to report allegations of abuse and neglect in the required time frame for four of five residents (Resident R14, R44, R46, and R286). Findings include: Review of facility policy Abuse and Neglect - Clinical Protocol dated 2/12/25, indicated neglect means the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. Review of the clinical record indicated Resident R14 was admitted to the facility on [DATE]. Review of Resident R14's Minimum Data Set (MDS - a periodic assessment of care needs) dated 3/19/25, indicated diagnoses of high blood pressure, depression, and cerebral palsy (group of disorders that affect a person's ability to move and maintain balance and posture). During a review of facility provided documents, labeled…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility documents, facility policy, clinical records, and staff interview, it was determined that the facility failed to conduct thorough investigations of allegations of abuse neglect for four of five residents (Resident R14, R44, R46, and R286). Findings include: Review of facility policy Abuse and Neglect - Clinical Protocol dated 2/12/25, indicated neglect means the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. Review of the clinical record indicated Resident R14 was admitted to the facility on [DATE]. Review of Resident R14's Minimum Data Set (MDS - a periodic assessment of care needs) dated 3/19/25, indicated diagnoses of high blood pressure, depression, and cerebral palsy (group of disorders that affect a person's ability to move and maintain balance and posture). During a review of facility provided documents, labeled Complaint/Grievance…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to make certain that the necessary resident information was communicated to the receiving health care provider for three of three residents sampled with facility-initiated transfers (Residents R22, R45, and R58). Findings include: Review of facility policy Transfer or Discharge Documentation dated 2/12/25, indicated should a resident be transferred or discharged for any reason, the following information will be communicated to the receiving facility or provider: - The basis for the transfer or discharge - Contact information of the practitioner responsible for the care of the resident - Resident representative information including contact information - Advance directive information - All special instructions or precautions for ongoing care, as appropriate - All other necessary information including a copy of the residents discharge summary, and any other documentation, as applicable, 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 the Resident Assessment Instrument User's Manual, clinical records, and staff interview, it was determined that the facility failed to make certain that comprehensive Minimum Data Set assessments were completed in the required time frame for three of three residents reviewed (Residents R45, R48, and R54). Findings include: Review of the Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which provides instructions and guidelines for completing required Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2024, indicated that an admission MDS assessment was to be completed no later than 14 calendar days following admission (admission date plus 13 calendar days), and an annual MDS assessment was to be completed no later than the Assessment Reference Date (ARD) plus 14 calendar days. Resident R45 had an annual ARD of 8/10/24, and was due to be completed 8/24/24. The MDS was signed as completed on 9/10/24, 17 days after the due date. Resident R48 had an annual ARD of 8/24/24, and 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 Resident Assessment Instrument User's Manual, clinical records, and staff interview, it was determined that the facility failed to make certain that quarterly Minimum Data Set assessments were completed within the required time frame for four of four residents (Residents R2, R8, R23, and R41). Findings include: Review of the Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which provides instructions and guidelines for completing required Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2024, indicated that quarterly MDS assessments were to be completed no later than 14 calendar days after the Assessment Reference Date (ARD). Resident R2 had a quarterly ARD of 8/2/24, and was due to be completed 8/16/24. The MDS was signed as completed on 9/4/24, 19 days after the due date. Resident R8 had a quarterly ARD of 8/16/24, and was due to be completed 8/30/24. The MDS was signed as completed on 9/8/24, nine days after the due date. Resident R23 had a quarterly ARD of 8/8/24,…

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

Based on observation, and staff interviews, it was determined that the facility failed to provide a resident environment free of potential accidental hazards in four out of six resident care areas (Zone 1, Zone 2, Zone 4, and Zone 5). Findings include: During an observation on 3/24/25, at 11:40 a.m. in Zone 5, Resident R31 was observed sitting in her wheelchair without leg rests, and her feet resting on the floor, when Nurse Aide (NA) Employee E15 pushed Resident R31 in her wheelchair towards the [NAME] Dining Room. During an interview on 3/24/25, at 11:41 a.m. NA Employee E15 confirmed that Resident R31 did not have leg rests on her wheelchair while she was being transported. During an observation on 3/24/25, at 11:50 a.m. in Zone 1 Resident R11 was observed being pushed into the Main Dining Room by an unidentified employee without leg rests on her wheelchair. During an observation on 3/25/25, at 10:21 a.m. in Zone 1, Resident R16 was observed being pushed in her wheelchair without leg rests by Housekeeping Employee E16 into the Main Dining Room. During an interview on 3/25/25, at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical records and staff interview, it was determined that the facility failed to provide documentation that medication regimen reviews (MRR) were completed for four of six residents (Residents R6, R22, R45, and R76). Findings include: Review of facility policy Drug Regimen Review dated 2/12/25, indicated Drug Regimen Reviews shall be conducted by the consultant pharmacist at least monthly. Any irregularities noted by the pharmacist during this review shall be documented on a separate, written report that is sent to the facility and list, at a minimum, the resident's name, the relevant drug, and the irregularity the pharmacist identified. Review of the clinical record revealed that Resident R6 was admitted to the facility on [DATE]. Review of Resident R6's MDS (Minimum Data Set, periodic assessment of resident care needs) dated 2/27/25, indicated diagnoses of high blood pressure, Alzheimer's disease (a type of brain disorder that causes problems with memory, thinking and behavior), 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 a review of facility policies, observations, and resident and staff interviews, it was determined that the facility failed to provide therapeutic meal selections for residents with diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time) and resident preferences for eight of twelve months. Findings include: Review of facility policy Therapeutic Diets dated 2/12/25, indicated that therapeutic diets are prescribed by the attending physician to support the resident's treatment and plan of care and in accordance with his or her goals and preferences. Review of facility Diet Manual indicated that the facility offers a Low- Concentrated Sweets (LCS) diet which indicated that food containing high amounts of concentrated sugar, such as syrup, jelly, honey, desserts, etc. are replaced with sugar free/reduced calorie products, served in a smaller portion or eliminated. Review of the American Diabetes Association Understanding Carbs (carbohydrates-sugar molecules in foods) indicated that residents with diabetes should try to eat less of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical record review, observations, and staff interview, it was determined that the facility failed to prevent the potential spread of infection for two of two residents in isolation precautions (Resident R25, and R66), and failed to maintain proper infection control practices related to care of indwelling urinary catheters (tube inserted in the bladder to drain urine) for one of three residents (Resident R187). Findings include: Review of facility policy Isolation - Categories of Transmission-Based Precautions dated 2/12/25, indicated contact precautions are implemented for residents known or suspected to be infected with microorganisms that can be transmitted by direct contact with the resident or indirect contact with environmental surfaces or resident-care items in the resident's environment. Staff and visitors wear gloves (clean, non-sterile) and a disposable gown upon entering the room. The gloves and gown are removed before leaving the room and hand hygiene is…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and staff interview it was determined that the facility failed to maintain essential PTAC (a ductless self-contained air conditioning and heating unit that plugs directly into an electrical outlet, providing climate control for individual rooms) units for seven rooms on the east and west wings (room [ROOM NUMBER], 123, 127, 146, 147, 148, and 156). Findings include: Review of facility policy Homelike Environment dated 2/12/25, indicated residents are provided with a safe, clean, comfortable and homelike environment that includes comfortable and safe temperatures. During a tour of the facility, with the Nursing Home Administrator (NHA), on 3/25/25, at 10:45 a.m. observations of the following were observed: East Wing: room [ROOM NUMBER] - PTAC was not in working order room [ROOM NUMBER] - PTAC was not in working order West Wing: room [ROOM NUMBER] - PTAC was not in working order room [ROOM NUMBER] - PTAC was not in working order room [ROOM NUMBER] - PTAC was not in working order room [ROOM…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, observations and staff interview, it was determined that the facility failed to maintain an effective call system for four rooms on East and [NAME] wing (room [ROOM NUMBER], 147, 148, and 158) Findings include: During a tour, with the Nursing Home Administer (NHA), on 3/25/25, at 10:48 a.m. an observation was made that included the following: East Wing: room [ROOM NUMBER] - call light not in working order West Wing: room [ROOM NUMBER] - call light not in working order room [ROOM NUMBER] - call light not in working order room [ROOM NUMBER] - call light not in working order During an interview on 3/25/25, at 11:07 a.m. the NHA confirmed that the facility failed to maintain an effective call system for four rooms on East and [NAME] wing (room [ROOM NUMBER], 147, 148, and 158). 28 Pa. Code 201.14 (a) Responsibility of licensee 28 Pa. Code 201.18 (b) (1) Management

Based on review of facility policy, facility documents and staff interviews, it was determined that the facility failed to provide Communication training to five of five direct care facility staff reviewed (Employees E3, E4, E5, E6, and E7). Finding include: Review of the facility policy In-service Training dated 1/16/25, indicated all staff must participate in initial orientation and annual in-service training. During an interview on 3/26/25, at 9:45 a.m. Human Resources Director Employee E8 stated that the facility was bought 8/1/24, and he has no records from the previous human resources manager. Review of facility education documents for the year 2024 revealed the following concerns: Review of Nurse Aide (NA) Employee E3's facility provided information did not include training on effective communication. Review of NA Employee E4's facility provided information did not include training on effective communication. Review of NA Employee E5's facility provided information did not include training on effective communication. Review of NA Employee E6's facility provided information…

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, facility documents, and staff interview, it was determined that the facility failed to provide training on Resident Rights for five of five staff members (Employee E3, E4, E5, E6, and E7). Findings include: Review of the facility policy In-service Training dated 1/16/25, indicated all staff must participate in initial orientation and annual in-service training. During an interview on 3/26/25, at 9:45 a.m. Human Resources Director Employee E8 stated that the facility was bought 8/1/24, and he has no records from the previous human resources manager. Review of facility education documents for the year 2024, revealed the following concerns: Review of Nurse Aide (NA) Employee E3's facility provided information did not include training on resident rights. Review of NA Employee E4's facility provided information did not include training on resident rights. Review of NA Employee E5's facility provided information did not include training on resident rights. Review of NA Employee E6's facility provided information did not include training on 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 review of facility policy, facility documents, and staff interview, it was determined that the facility failed to provide training on Quality Assurance and Performance Improvement (QAPI) for five of five staff members (Employee E3, E4, E5, E6, and E7). Findings include: Review of the facility policy In-service Training dated 1/16/25, indicated all staff must participate in initial orientation and annual in-service training. During an interview on 3/26/25, at 9:45 a.m. Human Resources Director Employee E8 stated that the facility was bought 8/1/24, and he has no records from the previous human resources manager. Review of facility education documents for the year 2024, revealed the following concerns: Review of Nurse Aide (NA) Employee E3's facility provided information did not include training on QAPI. Review of NA Employee E4's facility provided information did not include training on QAPI. Review of NA Employee E5's facility provided information did not include training on QAPI. Review of NA Employee E6's facility provided information did not include training on QAPI.…

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, facility documents and staff interviews, it was determined that the facility failed to provide Behavioral Health training to five of five direct care facility staff reviewed (Employees E3, E4, E5, E6, and E7). Finding include: Review of the facility policy In-service Training dated 1/16/25, indicated all staff must participate in initial orientation and annual in-service training. During an interview on 3/26/25, at 9:45 a.m. Human Resources Director Employee E8 stated that the facility was bought 8/1/24, and he has no records from the previous human resources manager. Review of facility education documents for the year 2024, revealed the following concerns: Review of Nurse Aide (NA) Employee E3's facility provided information did not include training on behavioral health. Review of NA Employee E4's facility provided information did not include training on behavioral health. Review of NA Employee E5's facility provided information did not include training on behavioral health. Review of NA Employee E6's facility provided information did not include…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, resident records, observation, and staff interview it was determined that the facility failed to uphold the privacy and dignity of two of four residents reviewed utilizing an indwelling urinary catheter (foley - a thin rubber tube inserted either through the urethra or suprapubic [abdomen] to allow for bladder drainage) for two of four residents (Residents R12 and R187). Findings include: Review of the facility policy Resident Rights last reviewed 2/12/25, indicated that employees shall treat residents with kindness, respect, and dignity. Resident rights include the right to a dignified existence. Review of the clinical record indicated Resident R12 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident R12's Minimum Data Set (MDS - a periodic assessment of care needs) dated 2/24/25, indicated diagnoses of high blood pressure, hyperlipidemia (high levels of fat in the blood), and neurogenic bladder (bladder problems due to disease or injury of 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 observations, and staff interview it was determined that the facility failed to have complete contact information for State Long-Term Care Ombudsman program posted at the facility. Findings include: During an observation, in the front lobby area, there was a poster with Ombudsman contact information which only consisted of the county of the Ombudsman and the phone number, and did not have Ombudsman name, address, or email address listed. During an interview on 3/28/25, at 10:29 a.m. the Nursing Home Administrator confirmed that the facility failed to post the Ombudsman's name, address, and email address as required. 28 Pa. Code: 201.14(a)Responsibility of licensee. 28 Pa. Code: 201.18(b)(3) Management.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, resident grievances for 90 days, clinical records, and resident and staff interviews, it was determined that the facility failed to effectively resolve, in a timely manner, a grievance in relation to concerns documented via Grievance procedure and complete the reports in their entirety for one of five grievances reviewed (R58), failed to provide grievance forms, and failed to post an updated policy and procedure that included the current grievance officer name in an accessible location (Front lobby area). Findings include: Review of facility policy, Resident Rights dated 2/12/25, indicated that the facility will treat all residents with kindness, respect and dignity. Residents have the right to voice grievances to the facility, or other agency that hears grievances, without discrimination or reprisal and without fear of discrimination or reprisal. Residents have the right to have the facility respond to his or her grievance. Review of facility policy, Grievance Policy and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical record review, and staff interviews, it was determined that the facility failed to ensure that residents were free from neglect for one of three residents reviewed (Resident R46). Finding include: Review of facility policy Abuse and Neglect - Clinical Protocol dated 2/12/25, indicated neglect means the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. Review of the clinical record indicated Resident R46 was admitted to the facility on [DATE]. Review of Resident R46's Minimum Data Set (MDS - a periodic assessment of resident care needs) dated 2/7/25, indicated diagnoses of high blood pressure, depression, and repeated falls. Review of a physician order dated 3/18/25, indicated to apply Triple Antibiotic External Ointment to skin tear to right elbow every day shift for impaired skin integrity for 7 days. Cleanse skin tear with NSS…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policies and clinical records, observations and staff interviews it was determined that the facility failed to identify a bolster (a long, thick cushion) as a possible restraint, failed to assess the functional status of the individual resident to determine if the use of a bolster is a restraint, and failed to obtain physician's order for the use of a bolster for one of two residents (Resident R70.) Findings include: The facility policy Use of Restraints last reviewed 2/12/25, indicated that restraints shall only be used for the safety and well-being of the resident(s) and only after other alternatives have been tried unsuccessfully. When the use of restraints is indicated, the least restrictive alternative will be used for the least amount of time necessary, and the ongoing reevaluation for the need for restraint will be documented. Physical Restraints are defined as any manual method or physical or mechanical device, material, or equipment attached or adjacent to the resident's body…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of Resident Assessment Instrument (RAI) User's Manual, clinical records, and staff interviews, it was determined that the facility failed to ensure that Minimum Data Set (MDs - a periodic assessment of care needs) assessments accurately reflected the resident's status for two of two residents (Residents R39 and R45). 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, indicated the following instructions: - K0300 Weight Loss: code 2, yes if the resident has experienced a weight loss of 5% or more in the past 30 days or 10% or more in the last 180 days, and the weight loss was note planned and prescribed by a physician. - K0710A Proportion of Total Calories the Resident Received through Parental or Tube Feeding: review intake records within the last 7 days to determine actual intake through parental or tube feeding…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical record review, and staff interviews, it was determined that the facility failed to make certain that residents were provided appropriate treatment and care for one of four residents (Resident R12). Findings include: Review of facility policy Administering Medications dated 2/12/25, indicated medications are administered in accordance with prescriber order, including any required time frame. The Centers for Disease Control defines diabetes as: Diabetes Mellitus is a chronic (long-lasting) health condition that affects how your body turns food into energy. Most of the food you eat is broken down into sugar (also called glucose) and released into your bloodstream. When your blood sugar goes up, it signals your pancreas to release insulin. Insulin acts like a key to let the blood sugar into your body's cells for use as energy. If you have diabetes, your body either doesn't make enough insulin or can't use the insulin it makes as well as it should. When there isn't enough…

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 a review of facility policy, clinical record review and staff interview, it was determined that the facility failed to address the resident's specific nutritional interventions for two of two residents (Residents R39 and R45), failed to complete a comprehensive nutritional assessment for two of two residents (Resident R39 and R45), and failed to make certain that significant weight loss was addressed in a timely manner for two of two residents (Resident R39 and R45). Findings include: Review of facility policy Nutritional Assessment, dated 2/12/25, indicated that the dietitian, in conjunction with the nursing staff and healthcare practitioners, will conduct a nutritional assessment for each resident upon admission and as indicated by a change in condition that places the resident at risk for impaired nutrition. The nutritional assessment conducted by the dietitian shall identify at least the following components: - An estimate of calorie, protein, nutrient, and fluid needs - Whether the resident's current…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, resident record review, and staff interviews, it was determined that the facility failed to provide a trauma survivor with trauma informed care to eliminate or mitigate triggers that may cause re-traumatization of the resident for one of two residents (Resident R70). Findings include: Review of facility policy Behavioral Assessment, Intervention and Monitoring dated 22/12/25, indicated that the facility will provide, and residents will receive behavioral health services as needed to attain or maintain the highest practicable physical, mental, and psychosocial well-being in accordance with comprehensive assessment and plan of care. Behavioral symptoms will be identified using facility approved behavioral screening tools and the comprehensive assessment. Review of the clinical record indicated Resident R70 was admitted to the facility on [DATE]. Review of Resident R70's Minimum Data Set (MDS - a periodic assessment of care needs) dated 3/23/25, indicated diagnoses of Post…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to conduct ongoing accurate assessments to ensure that bedrails were used to meet residents' needs and the risks associated with bedrail usage for one of two residents (Resident R40). Findings include: Review of the clinical record indicated Resident R40 was admitted to the facility on [DATE]. Review of Resident R40's Minimum Data Set (MDS - a periodic assessment of care needs) dated 2/1/25, indicated diagnoses of high blood pressure, anxiety, and chronic pain. During an observation on 3/24/25, at 8:58 a.m. two top enabler bars were present on Resident R40's bed. Review of Resident R40s clinical record on 3/26/25, failed to reveal an ongoing assessment for Resident R40's enabler bar usage. During an interview on 3/28/25, at 11:17 a.m. the Director of Nursing (DON) stated that it has now been triggered for Resident R40 to have a quarterly assessment completed for enabler bars.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policies, clinical record review, and staff interview, it was determined that the facility failed to make certain resident medication regimens were free from potentially unnecessary medications for two of six residents (Residents R6 and R45). Findings include: Review of facility policy Antipsychotic Medication Use dated 2/12/25, indicated antipsychotic medications will be prescribed at the lowest possible dosage for the shortest period of time and are subject to gradual dose reduction and re-review. Review of facility policy Drug Regimen Review dated 2/12/25, indicated Drug Regimen Reviews shall be conducted by the consultant pharmacist at least monthly. Any irregularities noted by the pharmacist during this review shall be documented on a separate, written report that is sent to the facility and list, at a minimum, the resident's name, the relevant drug, and the irregularity the pharmacist identified. Review of the clinical record revealed that Resident R6 was admitted to the facility on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy, observation, and staff interviews, it was determined that the facility failed to provide food in a form to meet individuals' needs in one of six residents (Resident R44). Findings include: Review of the facility policy Resident Rights dated 2/12/25, indicated that residents have the right to be notified of his or her medical condition and of any changes in his or her condition. Review of the facility policy Nutritional Assessment dated 2/12/25, indicated an assessment including current nutritional status and risk factors for impaired nutrition, shall be conducted for each resident. Review of the clinical record revealed that Resident R44 was admitted to the facility on [DATE]. Review of Resident R44's MDS (Minimum Data Set, periodic assessment of resident care needs) dated 1/30/25, indicated diagnoses of depression, irritable bowel syndrome, and diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time). During a lunch observation and resident…

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

Based on review of facility policy, newly hired personnel records and staff interviews it was determined that the facility failed to properly screen an employment by completing a state background check prior to hire for two out of five personnel records (Licensed Practical Nurse Employee E1, and Registered Nurse Employee E4). Findings include: The facility Abuse, Neglect, Exploitation, and Misappropriation policy dated 1/11/24, indicated the residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. Conduct employee background checks. The facility Background Checks for Nursing Home Employees policy dated 1/11/24, indicated that the purpose of the background check is to ensure the safety and well-being of all residents and staff by conducting background checks on all potential and current employees. Background checks requirements, Pre-Employment Screening include: - Criminal history check, including national and state records. - Verification of identity through government-issued identification. - Verification of 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 review of facility policy, job descriptions, and staff interviews, it was determined that the facility failed to provide care and services to meet the accepted standards of practice for one of five employees reviewed (Registered Nurse (RN) Employee E4). Findings include: The facility RN job description indicated that licensed personnel have graduated from a State Accredited Educational Institution/Program registered by the State education department. Nursing license is valid for life, unless it is surrendered or revoked, annulled or suspended by the State Board. Registration certificate will authorize licensed personnel to practice nursing and renewed as per state mandate to continue practicing in nursing. Licensed personnel are not legally allowed to practice nursing while registration is expired. Legal/ Ethical- RNS is required to understand legal/ethical professional standards of practice including but not limited to: -Practicing in accordance with legislation affecting nursing practice -Fulfilling…

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 personnel files, facility documentation, policy review and interviews with staff, it was determined that the facility failed to ensure that nursing staff possessed the required skills to properly care for residents' needs for one out of five personnel files reviewed (Registered Nurse Employees E4). Findings include: The facility RN job description indicated that licensed personnel have graduated from a State Accredited Educational Institution/Program registered by the State education department. Nursing license is valid for life, unless it is surrendered or revoked, annulled or suspended by the State Board. Registration certificate will authorize licensed personnel to practice nursing and renewed as per state mandate to continue practicing in nursing. Licensed personnel are not legally allowed to practice nursing while registration is expired. Legal/ Ethical- RNS is required to understand legal/ethical professional standards of practice including but not limited to: -Practicing in accordance…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, review of facility documentation, and staff interview, it was determined that the facility failed to ensure licensed professional staff held an active license in accordance with state laws for one of five staff members reviewed (Registered Nurse (RN) Employee E4). Findings include: Review of facility policy Background Checks for Nursing Home Employees policy dated [DATE], indicated that the purpose of the background check is to ensure the safety and well-being of all residents and staff by conducting background checks on all potential and current employees. Background checks requirements, Pre-Employment Screening include: - Criminal history check, including national and state records. - Verification of identity through government-issued identification. - Verification of professional licenses, certifications, and qualifications as required for the position. - Monitoring for changes in professional licensure status. The facility Abuse, Neglect, Exploitation, and Misappropriation…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility documentation and interviews with staff it was determined that the facility failed to maintain and implement an effective, quality assurance and performance improvement program that focuses on outcome as required by failing to follow a performance improvement project (PIP) for new hire employee files. Finding include: Review of facility Quality Assurance Assurance policy dated [DATE], indicated that facility is to establish a framework for continuous improvement in the quality of care and services provided. Quality assurance ensures that the facility meets or exceeds regulatory standards, promotes resident satisfaction, and fosters a culture of accountability and excellence. Review of facility provided documentation on [DATE], at 10:02 a.m. indicated a new process for new hire employees were initiated at facility on [DATE]. During an interview on [DATE], at 10:15 a.m. Regional Human Resource (HR) Employee E2 stated I put this initiative together after one of my other buildings that I…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility document, clinical records, and staff interviews, it was determined that the facility failed to notify the resident or resident's representative of the facility bed-hold policy (an agreement for the facility to hold a bed for an agreed upon rate during a hospitalization) for one of two resident hospital transfers (Resident R1). Findings Include: Review of the facility document admission Agreement indicated that before a resident may be transferred to a hospital or for therapeutic leave, the facility is required to provide the facility's Bed Hold Policy to the resident and a family member or Resident Representative. Review of the clinical record indicated Resident R1 was admitted to the facility on [DATE]. Review of Resident R1's Minimum Data Set (MDS - a periodic assessment of care needs) dated 11/1/24, indicated diagnoses of high blood pressure, diabetes (a disorder in which the body has high sugar levels for prolonged periods of time), and difficulty in walking. Review of Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical record reviews and staff interviews, it was determined that the facility failed to initiate a thorough investigation for incident or accidents for one of three residents (Residents R1). Findings include: The facility Accident and Incidents-Investing and Reporting policy dated 1/1/24, indicated all accidents and incidents occuring on the premises must be investigated and reported. Review of clinical record indicated Resident R1 was admitted [DATE], with diagnoses which included diabetes mellitus, rheumatoid arthritis and major depressive disorder. A review of Resident R1's Minimum Data Set (MDS-a periodic assessment of resident care needs), dated 8/11/24, indicated diagnoses remained current. Review of facility provided documents submitted 10/14/24, Resident R1 accidently spilled coffee on his abdomen that was microwaved by another resident. Review of Resident R1's dated 10/14/24 at 10:53 p.m. revealed nurse aide informed nurse that resident had a burn to his abdomen,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy review, clinical and facility record review, facility provided documents and staff interviews, it was determined that the facility failed to provide adequate supervision for one resident resulting in a burn for one of four resident's (Residents R1). Findings include: Review of facility policy Safety and Supervision of residents dated 1/1/24, indicated facility strives to make environment as free hazards as possible Review of the admission Record indicated Resident R1 was admitted to the facility on [DATE]. Review of the Resident Assessment Instrument 3.0 User's Manual effective October 2019, indicated that a Brief Interview for Mental Status (BIMS) is a screening test that aides in detecting cognitive impairment. The BIMS total score suggests the following distributions: 13-15: cognitively intact 8-12: moderately impaired 0-7: severe impairment Review of Resident R1's Minimum Data Set (MDS - a periodic assessment of care needs) dated 8/11/24, indicated the diagnoses of diabetes mellitus,…

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

Based on review of facility documentation and interviews with staff it was determined that the facility failed to maintain and implement an effective, quality assurance and performance improvement program that focuses on outcome as required by failing to implement a QAPI for overall PPD calculation for four days. Finding include: Review of Plan of Correction for PA State tag 5540 indicated: The facility will insure that staffing ratios are met every shift. Outcomes will be reported to the Quality Assurance Performance Improvement Committee for review and recommendations. Review of the Plan of Correction dated 9/3/24, and accepted by the state survey agency on 9/13/24, indicated if the facility projects not to meet staffing ratios on a shift, nursing administration/designee will be responsible . or call extra support staff to assist. Review of staffing sheets from 9/14/24, indicated the following: 9/14/24 - census 84 needed 3.20 had 3.08. 9/15/24 - census 86 needed 3.20 had 2.73. 9/16/24 - census 87 needed 3.20 had 3.02. 9/22/24 - census 89 needed 3.20 had 2.98. During an interview…

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

Based on a review of facility documents, an audit conducted by the State Ombudsman Office and staff interviews, it was determined that the facility failed to notify the State Ombudsman Office of resident transfers and discharges for 28 of 28 months (5/22, 6/22, 7/22, 8/22, 9/22, 10/22, 11/22, 12/22, 1/23, 2/23, 3/23, 4/23, 5/23, 6/23, 7/23, 8/23, 9/23, 10/23, 11/23, 12/23, 1/24, 2/24, 3/24, 4/24, 5/24, 6/24, 7/24, and 8/24) as required. Findings include: A request to review facility documents on 9/12/24, of the facility's compliance in notifying the State Ombudsman Office revealed that the facility failed to provide documented evidence of notifying the State Ombudsman Office of residents transfers and discharges for the time period of 5/22, through 8/24. A review of an audit conducted on 8/1/24, by the State Ombudsman Office revealed that the facility failed to notify the State Ombudsman Office of resident transfers and discharges since 4/22. During an interview on 9/12/24, at 9:00 am Director of Social Services Employee E1 confirmed that she was recently informed of the facility's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of facility policies, resident medical records, facility submitted documents, and staff interviews it was determined that the facility failed to provide adequate supervision to be aware of a resident's departure from the facility for one of six residents (Resident R1). Findings include: A review of facility Safety and Supervision of Residents date 1/1/24, indicated that the facility takes an initialized resident centered approach to resident safety including implementing interventions with adequate supervision. A review of facility Wandering and Elopements policy dated 1/1/24, indicated that the facility implements interventions for at risk resident that show behaviors of wandering and elopement. The facility will implement strategies and interventions documented in the resident's care plan. Review of Resident R1's medical record indicated that the resident was admitted to the facility on [DATE], with the the diagnoses of alcohol dependence, back pain, muscle weakness, and depression Review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and staff interview, it was determined that the facility failed to properly store food and maintain sanitary conditions in the Main Kitchen and the facility failed to properly label and date food products in East nursing unit failed to maintain sanitary conditions which created the potential for cross contamination (1 of 2 units). Findings include: During an observation of the main designated kitchen on 8/20/24, at 9:10 a.m. the following was observed: - Dry Storage: 5 boxes of food products stored on the floor, 6 buckets of dishmachine sanitizer -Walk in freezer- 25 boxes of food stored on the floor During an observation of the main designated kitchen on 8/20/24, at 9:20 a.m. the following was observed: -Juice dispenser nozzles, fuzzy, slimy debris (2) During an observation on the East Nursing Unit on 8:20/24 at 10:30 a.m. the following was observed: -5 food items not labeled or dated, [NAME] milk, green tea, cottage cheese and two plates of leftover food During an interview on 8/20/24 at…

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

Based on staff interviews it was determined that the facility failed to employ a full-time director of food service for the past six out of 31 days (August 2024). Findings include: During a kitchen tour on 8/20/24 at 9:10 a.m. kitchen staff stated the kitchen currently does not have a manager. During an interview on 8/20/24 at 12:30 p.m. the Nursing Home Administrator confirmed that the facility has not had a Dietary Manager since 8/15/24 as required, the Registered Dietitian is approximately two days a month and the Consultant Manager one day per week. 28 Pa. Code 201. 18(e)(1)(6)Management 28 Pa. Code 211. 6(c) Dietary services

Based on a review of facility policies, observations, and staff interviews, it was determined that the facility failed to properly label and date food products, and to properly segregate damage food in the Main Kitchen, creating the potential for food-borne illness. Findings include: Review of facility policy Food Storage, dated 1/1/24, indicated that all foods will be dated at time of receipt and be inventoried using in the FIFO method (first in first out).Damaged, spoiled or recalled products will be segregated and held in a designated area. During an observation and interview on 4/1/24, at 9:15 a.m. in the tray line refrigerator in the Main Kitchen, a tray of cups were filled with juice and covered in plastic but did not have a date on them. Food Service Director (FSD)Employee E13 confirmed that the juices were not labeled and dated. During an observation and interview on 4/1/24, at 9:17 a.m. in the walk-in freezer in the Main Kitchen, a plastic bag of cookie dough was observed without a date, and a plastic bag of bread was observed without a date. FSD Employee E13 confirmed 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 review of facility policy, resident council minutes, group interview, resident interviews, and staff interviews it was determined that the facility failed to respond to resident concerns and grievances identified during resident council minutes for three of three months (January 2024 through March 2024). Findings include: Review of the facility policy Grievances, dated 1/1/24, indicated that the facility will support each resident's right to voice grievances and to assure that after receiving a complaint/grievance, the facility actively seeks a resolution and keeps the resident appropriately appraised of its progress toward resolution. Grievances may include a formal, written grievance process or a resident's verbalized complaint to facility staff. Review of Resident Council Meeting/Food Committee dated 1/4/24, stated: Is your hot food being delivered to you hot? No. Review of Resident Council Meeting/Food Committee dated 2/1/24, stated: Is your hot food being delivered to you hot? Hot foods are coming to the rooms cold but only if they are the last few rooms being served.…

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

Based on review of facility policy, observations, resident council group interview, and staff interviews, it was determined that the facility failed to maintain a clean, safe, homelike environment for five out of 12 residents (Resident R33, R25, R70, R80, and Resident R81). Findings include: The facility Resident Environment policy dated 1/1/24, indicated it is the facility policy to provide an environment that is safe, clean, comfortable and homelike. During a resident council group interview on 4/2/24, at 1:00 p.m. two residents voiced that the facility was not clean and homelike. During an observation and interview on 4/4/24, at 9:54 a.m. Resident R70's bathroom baseboard was observed hanging off the wall. Nurse Aide, Employee E2 confirmed Resident R70's bathroom baseboard was hanging off the wall. During an observation and interview on 4/4/24, at 9:57 a.m. Resident R80's bathroom baseboard was observed broken and hanging off the wall. Resident R80's curtain was observed to be dirty. Nurse Aide, Employee E2 confirmed Resident R80's curtains were dirty and the bathroom baseboard…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policies, clinical record reviews and staff interviews, it was determined that the facility failed to initiate a thorough investigation for accidents or incidents included statements for three of five residents (Residents R11, R45, and R76). Findings include: The facility Accidents and Incidents-Investigating and Reporting policy dated 1/1/24, indicated all accidents or incidents occurring on our premises must be investigated and reported to the administrator. Regardless of how minor an accident or incident, injuries of unknown origin, it must be reported to the nursing supervisor and included on the facility 24-hour report. It was indicated a witness statement must be obtained immediately. Review of the clinical record indicated that Resident R11 was admitted to the facility on [DATE], with diagnoses which included bipolar disorder (a serious mental illness characterized by extreme mood swings), anxiety, and developmental disorders of scholastics skills (significant disability of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of clinical records and staff interviews, it was determined that the facility failed to implement a bowel protocol as ordered (Resident R11), notify a physician of abnormal glucose readings (Resident R14), provide necessary care and treatment for Resident R60' s pacemaker, and ensure timely follow-up for a resident's appointment as ordered (Resident R62) for 4 out of 29 residents. (Residents R11, R14, R60, R62) Review of facility's policy, Transfer to Appointment Outside the Facility, policy interpretation dated 1/1/24, indicated the facility will verify that a physician order for an appointment/consult is present. Notify the appropriate office of the appointment by the next business day. Arrange for transportation as appropriate. Enter the appointment on the consultation/appointment log. Review of the facility Bowel Protocol policy dated 1/1/24, indicated it is the facility's policy to prevent constipation. The resident's bowel movements will be monitored daily by 11-7 supervisor. Residents who…

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, staff interview and a review of the facility's assessment it was determined that the facility failed to implement and document a complete facility wide assessment, which identified the specific resources necessary to care for a resident using a LifeVest for eight out of eight months (September 2023 through April 2024 ) Findings include: Review of facility policy Facility Assessment, dated 7/24/23, indicated that the purpose of the assessment is to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. Use this assessment to make decisions about your direct care staff needs, as well as your capabilities to provide services to the residents in the facility. Review of facility Facility Assessment Tool, dated 9/28/23, indicated that the intent of the facility assessment is for the facility to evaluate its resident population and identify the resources needed to provide the necessary person-centered care and services…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy, clinical record review and staff interviews, it was determined the facility failed to notify the physician of a change in condition for one of three residents. (Resident R56) Findings include: Review of facility policy Notification of Changes dated 7/24/23, indicated the facility will immediately inform the resident; consult with the resident's physician; and if known, notify the resident's legal representative or an interested family member when there is: - An accident involving the resident which results in injury and has the potential for requiring physician intervention. - A significant change in the resident ' s physical, mental, or psychosocial status - A need to alter treatment significantly. Review of the clinical record indicated Resident R56 was admitted to the facility on [DATE]. Review of Resident R56's MDS (Minimum Data Set, periodic assessment of resident care needs) dated 3/13/24, indicated diagnoses of heart failure (a progressive heart disease that affects pumping…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, resident record, investigation documents, resident interveiw, and staff interview, it was determined that the facility failed to report allegation of neglect and report an allegation of verbal abuse for two out of four sampled residents (Resident R40 and Resident R69). Findings include: The facility Abuse protection policy dated 1/1/24, indicated that the resident has the right to be free from verbal, sexual, physical, and mental abuse. The facility Abuse reporting and investigation policy dated 1/1/24, indicated that the facility will thoroughly investigate all reports of suspected or alleged abuse. The Department of Health will be notified of the alleged event by the Administrator per regulation. Review of Resident R40's admission record indicated he was admitted on [DATE], with diagnoses that included hypertension (a condition impacting blood circulation through the heart related to poor pressure), diabetes (a metabolic disorder in which the body has high sugar levels for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, resident records, admissions documentation and staff interview it was determined that the facility failed to provide a comprehensive review of resident admission rights and maintain admission documentation for one out of out three sampled records (Resident R4). Finding include: The facility Admissions documents: statement of resident rights last reviewed 1/1/24, indicated that the facility shall protect and promote the rights of each resident. The resident has the right to be informed and participate in his or her treatment. The resident has the right to be informed before or at the time of admission of the facilities policies and procedures. Review of Resident R4 admission record indicated he was admitted on [DATE]. Review of Resident R4 MDS assessment (Minimum Data Set assessment: MDS -a periodic assessment of resident care needs) dated 1/5/24, indicated that he was admitted with diagnosed that included lung cancer, chronic obstructive pulmonary disease (COPD: a disease…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of clinical records, and staff interview, it was determined that the facility failed to ensure that a comprehensive resident care plan was complete for resident care needs related to a Life Vest (a wearable defibrillator designed to protect residents from sudden cardiac death) for one of five residents (Resident R56). Findings include: Review of facility's policy MDS/RAI/Care Planning dated 7/24/23, indicated the resident assessment instrument (RAI) and care planning process provide a tool for an interdisciplinary approach to plan the care of the resident. The purpose of the RAI is to incorporate the identified medical, nursing, nutritional, rehabilitative, and psychosocial needs of each resident into interventions and goals to meet those needs. Review of the clinical record revealed that Resident R56 was admitted to the facility on [DATE]. Review of Resident R56's MDS (Minimum Data Set, periodic assessment of resident care needs) dated 3/13/24, indicated diagnoses of heart failure (a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on the review of facility job descriptions, clinical records, and staff interviews, it was determined that the facility failed to follow standards of professional practice for one of six residents (Resident R25). Findings include: Review of Title 42 Code of Federal Regulations (CFR) §483.709(i) Medical records. In accordance with accepted professional standards and practice, the facility must maintain medical records that are complete, accurately documented, readily accessible, and systematically organized. Review of the facility document Staff Nurse RN (Registered Nurse) Job Description indicated that facility RN must: · Chart nurse's notes in an informative, relevant, concise, and descriptive manner that reflects the care provided to the resident, as well as the resident's response to care. · Develop a nursing care plan, individualizing the care, revises the plan as necessary. · Routinely assesses the total needs of the residents and adjust care plans as needed. · Reviews care plan daily to ensure 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy clinical record review and staff interviews, it was determined that the facility failed to make certain that residents receive assistance with nail care for one of two residents (Resident R53). Findings include: Review of the facility policy Nail Care, last reviewed 1/1/24, indicated that resident's finger nails will be cleaned and trimmed as needed or requested. Review of the clinical record indicated Resident R53 was admitted to the facility on [DATE], with diagnoses of hemiplegia (paralysis of one side of body) affecting the right dominant side, and polyneuropathy (damage to multiple peripheral nerves). Review of Resident R53's MDS assessment (Minimum Data Set- a periodic assessment of resident needs) dated 2/22/24, indicated the diagnoses remained current and that Resident R53 requires assistance with ADL's (activities of daily living). Review of Resident R53's [NAME] (documentation system that enables nurses to write, organize, and easily reference key patient information 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical record review, observation, and staff interview, it was determined that the facility failed to provide services and treatment to prevent further limitations in range of motion for one of two residents who had limitations in range of motion (Resident R81). Findings include: Review of facility policy Resident Screening for Therapy Services Best Practices, dated 1/1/24, indicated that skilled therapy services may be necessary to improve a patient's condition, to maintain the patient's current condition, or to slow further deterioration of the patient's condition. Thus, therapists must document the [NAME] need of the therapy services and support that therapy interventions are reasonable and medically necessary. Walking clinical rounds are conducted to observe positioning for comfort, posture, function, mobility, adaptive equipment use, ability to feed oneself, grooming/hygiene needs, etc. Review of previously established care includes evaluation of wheelchair to ensure…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical records and staff interviews, it was determined that the facility failed to make certain each resident received adequate supervision and assistance to prevent accidents for one of five residents (Resident R11). Findings include: Review of the facility MDS/RAI/Care Planning policy last reviewed 1/1/24, indicated the facility must develop a written plan of care individualized for each resident, which identifies through his/her strengths, problems and needs. Review of Resident R11's admission record indicated Resident R11 was admitted on [DATE]. Review of Resident R11's MDS assessment (Minimum Data Set Assessment: A periodic assessment of resident care needs) dated 2/3/24, indicated she was admitted with the following diagnoses that included bipolar disorder (a serious mental illness characterized by extreme mood swings), anxiety, and developmental disorders of scholastics skills (significant disability of learning that cannot be solely accounted for by mental…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of clinical record, and staff interview, it was determined that the facility failed to ensure a resident was offered sufficient fluid intake to maintain proper hydration and health for one of seven residents (Resident R55). Findings include: Review of the Hydration Guideline policy dated 1/1/24, stated residents will be monitored for decreased oral fluids intake and hydration status. Interventions will be initiated to prevent dehydration. It was indicated the facility must ensure residents sufficient fluid intake to maintain hydration and health. It was indicated the facility staff must offer a variety of fluids based on resident preference. Review of the clinical record revealed that Resident R55 was admitted to the facility on [DATE]. Review of Resident 55's MDS (Minimum Data Set, periodic assessment of resident care needs) dated 3/25/21, indicated diagnoses of constipation, depression, and adult failure to thrive (happens when an older adult has a loss of appetite, eats and drinks less than…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, observations, staff interviews, and clinical record review, it was determined that the facility failed to provide oxygen as ordered for one of four residents (Resident R55). Findings include: Review of undated and unsigned Staff Nurse (RN) job description indicated the Registered Nurse is responsible for the interpretation and execution of physician orders. Review of the clinical record revealed that Resident R55 was admitted to the facility on [DATE]. Review of Resident 55's MDS (Minimum Data Set, periodic assessment of resident care needs) dated 2/21/24, indicated diagnoses of constipation, depression, and adult failure to thrive (happens when an older adult has a loss of appetite, eats and drinks less than usual, loses weight, and is less active than normal). Review of Resident R55's physician's order dated 3/27/24, indicated to administer two liters of oxygen continuously every shift for shortness of breath. During an observation on 4/1/24, at 11:10 a.m. Resident R55 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical record review, resident interview, and staff interviews it was determined that the facility failed to develop and implement a person-centered care plan that supports the behavioral health care needs for one of three residents (Resident R11), and that the facility failed to provide on-going, necessary behavioral healthcare services to a resident to maintain the highest practicable mental and psychosocial well-being for one of three residents (Resident R33), the discontinuation of behavioral healthcare services preceded an attempt of suicide for one resident (Resident R33), and also failed to offer psychiatric services for one resident (Resident R33) after an attempt of suicide. Findings include: Review of the facility MDS/RAI/Care Planning policy last reviewed 1/1/24, indicated the facility must develop a written plan of care individualized for each resident, which identifies through his/her strengths, problems and needs. Review of Title 42 Code of Federal Regulations…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of facility policy, clinical records and staff interviews, it was determined that the facility failed to limit as needed antipsychotic drugs to 14 days for one of five residents (Resident R11). Findings include: Review of the facility Antipsychotic Drugs policy last reviewed 1/1/24, indicated evidence that supports justification of why a drug is being used outside the Guidelines, must be documented in the clinical record. Review of Resident R11's clinical record indicated the resident was admitted to the facility on [DATE], with diagnoses that included bipolar disorder (a serious mental illness characterized by extreme mood swings), anxiety, and developmental disorders of scholastics skills (significant disability of learning that cannot be solely accounted for by mental retardation, visual acuity, or inadequate schooling). A Minimum Data Set Assessment (MDS, a form completed at specific intervals to determine care needs) dated 2/3/24, indicated the diagnoses were current. Review of Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy and clinical record, observation and staff interviews it was determined that the facility failed to make certain that residents are free from significant medication errors for one of three residents (Resident R45). Findings include: Review of the facility's Medication Error policy dated, 1/1/24, indicated medications errors are documented and reported to the attending physician, Director of Nursing, Pharmacy Coordinator, and the facility Quality Assurance/Improvement Committee. Medication errors are any and all errors made in the administration and/or documentation of medications. Review of Resident R45's Minimum Data Set (MDS-periodic review of care needs) dated 3/6/24, indicated the resident was admitted on [DATE], with diagnoses of opiod and alcohol abuse, chronic viral Hepatitis C and major depressive disorder. Review of Resident R45's physician order dated 2/22/24, instructed the nurse to give Suboxone Sublingual Film 4-1 MG, 1 film sublingually every 12 hours 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 the facility failed to obtain laboratory services as ordered for one of two residents reviewed (Resident R55). Findings Include: Review of the facility Transcribing Physician Orders policy dated 1/1/24, indicated physician orders will be transcribed when they are received. It was indicated ordered lab work will be documented in the facility's lab tracking tool, a lab form will be completed listing the ordered test, and diagnostic studies will be called to the appropriate diagnostic service for scheduling and noted in the nursing progress notes. Review of Resident R55's Follow-Up summary dated 3/25/23, completed by Nurse Practitioner (NP) Employee E23 indicated the resident was seen for follow up for pneumonia. It was indicated the resident's Blood Urea Nitrogen (a common blood test that reveals important information about how well your kidneys are working) and Creatine (a waste product in your blood that comes from muscle wear and tear, blood levels are checked to assess kidney function.) levels were slightly…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of clinical records, and staff interview it was determined that the facility failed to ensure that a resident's physician was notified about abnormal laboratory test results for one of two residents (Resident R60). Findings include: Review of facility policy Notification of Changes dated 7/24/23, indicated the facility will immediately inform the resident; consult with the resident ' s physician; and if known, notify the resident's legal representative or an interested family member when there is: - An accident involving the resident which results in injury and has the potential for requiring physician intervention. - A significant change in the resident's physical, mental, or psychosocial status - A need to alter treatment significantly. Review of the clinical record indicated Resident R60 was admitted to the facility on [DATE]. Review of Resident R60's MDS (Minimum Data Set, periodic assessment of resident care needs) dated 1/10/24, indicated diagnoses of heart failure (a progressive heart…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy, observations, and staff interviews it was determined that the facility failed to provide adaptive feeding devices for one of three residents (Resident R55). Findings include: Review of the facility policy Flow of Care dated 1/1/224, indicated care will be provided to residents, as needed 24-hours a day to attain and maintain the highest level of functioning. Review of the clinical record indicated Resident R55 was admitted to the facility on [DATE], with diagnoses of anxiety, depression, and adult failure to thrive (happens when an older adult has a loss of appetite, eats and drinks less than usual, loses weight, and is less active than normal). Review of the Minimum Data Set (MDS, periodic assessment of resident care needs) dated 2/21/24, indicated the diagnoses were current. Review of Resident R55's physician order dated 2/19/24, indicated to provide red foam built up utensils for all meals. Review of Resident R55's care plan dated 2/20/24, indicated the resident is to use red foam…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on the review of facility job descriptions, clinical records, and staff interviews, it was determined that the facility failed to maintain and complete accurate documentation for one of six residents (Resident R25). Findings include: Review of Title 42 Code of Federal Regulations (CFR) §483.709(i) Medical records. In accordance with accepted professional standards and practice, the facility must maintain medical records that are complete, accurately documented, readily accessible, and systematically organized. Review of the facility document Staff Nurse RN (Registered Nurse) Job Description indicated that facility RN must: · Chart nurse's notes in an informative, relevant, concise, and descriptive manner that reflects the care provided to the resident, as well as the resident's response to care. · Develop a nursing care plan, individualizing the care, revises the plan as necessary. · Routinely assesses the total needs of the residents and adjust care plans as needed. · Reviews care plan daily to ensure…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, resident record and staff interview it was determined that the facility failed to establish a written agreement with a Medicare-certified hospice provider prior to the start of hospice services for one of two sampled resident records (Resident R59). Findings include: The facility Hospice care last reviewed 1/1/24, indicated that all hospice services are provided under contractual arrangement. Complete details outlining the responsibilities of the facility and the hospice agency are contained in this agreement. A copy of this agreement is on file in the business office. Review of Resident R59's admission record indicated he was admitted on [DATE]. Review of Resident R59's MDS assessment (Minimum Data Set assessment: MDS -a periodic assessment of resident care needs) dated 1/11/24, with diagnoses that included lewy body dementia (a progressive form of dementia associated with protein deposits to the nervous system impacting memory, mood, and movement), anxiety disorder (a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical record review and staff interview, it was determined that the facility failed to implement procedures to prevent the development and transmission of communicable diseases and infections for three of 11 residents. (Resident R55, R60, and R63) Findings include: A review of the facility 'COVID-19 Testing Schedule policy dated 1/1/24, indicated that residents, regardless of vaccination status, with signs or symptoms must be tested. A review of the facility policies Isolation Procedure: Resident placement in transmission-based precautions dated 1/1/24, indicated transmission-based precautions (airborne, contact, droplet) will be implemented when indicated by suspicion or presence of infectious disease. Review of Resident R55's progress note dated 3/14/24, indicated the resident complained of a non-productive cough. Lung sounds with rhonchi (an abnormal breathing sound caused when air passes through accumulated fluids or secretions in lungs) and wheezes. 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 facility policies and clinical records and staff interview, it was determined that the facility failed to make certain that medical records on each resident are complete and accurately documented for three of six residents (Resident R2, R3, and CR1). Review of facility policy Flow of Care dated 7/24/23, indicated the provision of targeted care needs shall be documented on Care Tracker/Point of Care/ADL Flow Records (clinical documents). Review of the admission record indicated Resident R2 admitted to the facility on [DATE]. Review of Resident R2's Minimum Data Set (MDS- a periodic assessment of care needs) dated 11/6/23, indicated the diagnoses of high blood pressure, diabetes (too much sugar), and muscle weakness. Review of Resident R2's Documentation Survey Report v2 dated December 2023 indicated the following: Morning care , bed mobility, bowel and bladder, morning oral care, personal hygiene, pressure relieving device to chair, pressure relieving device to bed, toilet use, or amount eaten…

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 the minutes from Resident Council meetings and grievances filed with the facility, resident interviews and staff interviews, it was determined that the facility failed to put forth efforts to sustain resolution and prevent continued resident complaints expressed during Resident Council meetings for three of three months. (November 2023, December 2023, and January 2024). Findings Include: Review of resident council meeting minutes from 11/2/23, indicated that the residents in attendance voiced complaints regarding the following: -call bells not being answered -staff wearing ear buds and being on the phone during resident care -snacks not being passed out -staff being loud in hallways late at night and early in the mornings -trays not being picked up after meals -ice water not being passed on daylight and evening shift Review of resident council meeting minutes from 12/7/23, indicated that the residents in attendance voiced complaints regarding the following: -call bells not being answered -staff wearing ear buds and being on the phone during resident care -snacks…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy, observations and staff interviews, it was determined that the facility failed to provide personal privacy during showers for one of three residents (Resident R1). Findings include: Review of the facility policy Resident Rights last reviewed on 7/24/23, indicated the facility will protect and promote the rights of each resident, including privacy and confidentiality. The facility shall implement written policies and procedures setting for the right of residents for the protection and preservation of dignity. Review of admission record indicated Resident R1 admitted to the facility on [DATE]. Review of Resident R1's Minimum Data Set (MDS- a periodic assessment of care needs) dated 12/19/23, indicated the diagnoses of high blood pressure, diabetes (too much sugar in the blood), and amputation of left toes (surgically removed). Review of Resident R1's care plan dated 11/13/23, indicated physical functioning deficit related to self-care impairment. Resident refuses showers at times.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of the grievance policy and clinical records, staff and resident interviews, it was determined that the facility failed to resolve a grievance related no privacy during showers for one of three residents (Resident R1). Findings include: Review of facility policy Grievances/Concerns - Residents, Resident Representatives, Family Members, or Resident Advocates dated 7/24/23, indicated Grievances/Complaints will be handled promptly with the intent to have a satisfactory resolution in place within a reasonable expected time frame from the date of the concern, typically five days. Review of admission record indicated Resident R1 admitted to the facility on [DATE]. Review of Resident R1's Minimum Data Set (MDS- a periodic assessment of care needs) dated 12/19/23, indicated the diagnoses of high blood pressure, diabetes (too much sugar in the blood), and amputation of left toes (surgically removed). Review of Resident R1's care plan dated 11/13/23, indicated physical functioning deficit related to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical records and staff interviews, it was determined that the facility failed to make certain call bells were in reach for four of eight residents (R4, R5, R6, and R7) as required. Based on policy review, staff and resident interview, observations, and staff interview, it was determined that the facility failed to make certain call bells were in reach for four of eight residents observed (Resident R4, R5, R6, and R7). Findings include: The facility policy Call Light Response dated 7/24/23, indicated a call bell or alternative device will be placed within the reach of each resident while in their room, toilet or bathing area. Review of admission record indicated R4 admitted to the facility on [DATE]. Review of R4's Minimum Data Set (MDS- a periodic assessment of care needs) dated 11/30/23, indicated the diagnoses of high blood pressure, diabetes (too much sugar), and Alzheimer's Disease (a progressive disease that destroys memory and other important mental functions).…

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 it was determined that the facility failed to employ a full-time qualified dietary services supervisor in the absence of a full-time qualified dietitian. Findings include: During a kitchen tour on 12/27/23 at 2:15 p.m. Dietary Manager Employee E1 stated that she was not certified and was not in classes to obtain a certification. During an interview on 12/27/23 at 2:30 p.m. Employee E1 stated the Registered Dietitian (RD) is part-time and only works approximately 15 hours per week. During an interview on 12/27/23 at 4:00 p.m. Nursing Home Administrator confirmed the facility's Dietary Manager is not qualitfied as required and the RD is part-time. 28 Pa. Code 201.18(e)(1)(6)Management 28 Pa. Code 211. 6(c)Dietary Services

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical record review, observation, and resident and staff interview, it was determined that the facility failed to provide care and services to maintain personal hygiene by failing to provide scheduled showers for four of eight residents (Residents R1, R2, R3, and R4). Findings include: A review of facility policy Flow of Care dated 7/24/23, indicated that the flow of care is to be implemented on a continuous basis to promote quality of life with the resident and the provision of targeted care needs shall be documented on Care Tracker/Point of Care/ADL Flow Records (electronic documentation in resident's medical record). Residents are to have two bath/showers per week unless the resident states otherwise. A review of the clinical record indicated that Resident R1 was admitted to the facility on [DATE]. A review of Resident R1's Minimum Data Set (MDS - a periodic assessment of resident care needs) dated 9/8/23, indicated diagnoses of hypertension (high blood pressure 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of clinical records and staff interview, it was determined that the facility failed to notify the family or responsible party for a change in room assignment for three of six residents (Resident R1, R2, and R3). Findings included: A review of the policy Notification of Resident's Responsible Party last reviewed 7/24/23, indicated that prior to making a room change or roommate assignment, all persons involved in the change/assignment, such as residents and their representatives, will be notified. Review of clinical record indicated that Resident R1 was admitted to the facility on [DATE], with diagnosis that included right femur fracture and depression. Review of Resident R1's Minimum Data Set, MDS (periodic assessment of needs) completed on 6/19/23, indicated those diagnoses remain current. Review of Resident R1's clinical record indicated that resident was transferred to a different room on 7/5/23. Review of record did not indicate that a resident representative was notified of either room…

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 employee personnel files and staff interviews, it was determined that the facility failed to complete State criminal background check prior to the date of hire for one out of three reviewed personnel records (Activities Assistant Employee E2). Findings include: In accordance with Act 13 Elder Abuse Mandatory Reporting and Act 169 Criminal Background Checks, nursing facilities are required to obtain a criminal background check on all newly hired employees. Facilities are required to obtain the Pennsylvania State Police background check within 30 days of hire on all prospective employees. Review of Activities Assistant Employee E2 ' s personnel record indicated that the date of hire was 8/25/23. Review of Activities Assistant Employee E2 ' s personnel record did not include a State criminal background check. During an interview on 9/20/23, at 1:34 p.m., the Nursing Home Administrator confirmed that the facility failed to complete a State criminal background check prior to the date of hire for Activities Assistant Employee E2 as required. 28 Pa Code 201.18 (e)(1)…

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