Edison Manor Nursing & Rehabilitation Center

Based on review of facility policy and documents, and resident and staff interviews, it was determined that the facility failed to ensure that the residents are able to voice their concerns at the meetings, and that the meeting concerns are recorded for timely follow-up and resolutions to resident concerns for seven of seven Resident Council attendants (Residents R9, R14, R56, R62, R67, R73, and R85). Findings include: Review of a facility policy entitled Resident Council Policy dated 9/2024, indicated that the Life Enrichment Director or designee may attend the Resident Council Meeting to act as a liaison between the group and the facility if requested by the Council. Any additional facility personnel will attend the meeting upon request of the residents. The Activity Director will attempt to accommodate the resident recommendations to the extent practicable and provide follow-up to the Resident Council. Resident Council will document minutes of each meeting along with attendance on the Resident Council Meeting Minutes Form. Resident issues or concerns will be documented on the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, staff and resident interviews and observations, it was determined that the facility failed to provide adequate housekeeping services to maintain a clean and sanitary environment for 14 of 94 resident rooms (Rooms 207, 209, 210, 217, 220, 223, 224, 226, 303, 307, 310, 319, 321, and 325 ), and for one of two dining rooms. Findings include: Facility policy, General/Routine Environmental Cleaning and Disinfection Policy dated 9/2024, revealed proper cleaning and disinfecting of environmental surfaces is necessary to break the chain of infection. Cleaning refers to the removal of visible soil from surfaces through the physical action of scrubbing with detergents/surfactants and rinsing with water. Process for Environmental cleaning and disinfection includes: working from clean to dirty; working from top to bottom. Cleaning and disinfection of environmental surfaces immediately if surface(s) are visibly soiled. Daily cleaning and disinfection for high touch surfaces in resident…

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

Based on resident interviews and observations, it was determined that the facility failed to provide sufficient nursing staff to promote the physical and mental well-being and meet the needs of nine of 24 residents interviewed (Residents R149, R19, R226, R9, R56, R67, R62, R73, and R85). Findings include: During interviews on 1/06/25, from 10:05 a.m. through 1:00 p.m. revealed that Residents R149, R19 and R226 expressed concerns of poor call bell response times, indicating that they often had to wait nearly an hour after activating the call bell, to have their needs met. Obervations on 1/06/25, at 2:17 p.m. revealed an activated call light for Resident R226. The call light remained unaddressed until 2:30 p.m. During interview at 2:25 p.m., Resident R226 stated they activated the call light as they had been left on a bedpan which was causing considerable discomfort while waiting for assistance. At this time, staff members were observed seated at the nursing station where the call bell system was alarming audibly and visually lighted. Interviews during the Resident Council meeting 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 review of facility policy, observations, and staff interviews, it was determined that the facility failed to follow acceptable infection control practices regarding enhanced barrier precautions (EBP) for two of two resident units (200 and 300 units). Findings include: A facility policy, Transmission-Based Precautions and Isolation Policy, dated 9/2024, revealed Enhanced Barrier Precautions (EBP) - EBP are intended to prevent transmission of multi-drug resistant organisms (MDROs) via contaminated hands and clothing of healthcare workers to high risk residents. EBP are indicated for high contact care activities for residents with chronic wounds and indwelling devices (such as central lines, urinary catheters, and trachs) and for all those colonized or infected with a MDRO currently targeted by the CDC. Other MDROs may be included at the discretion of the facility Infection Control Committee unless required by state guidance. Observations on 1/07/25, at 12:05 p.m. revealed Certified Registered Nurse…

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

Based on review of facility policy and clinical records, and staff interview, it was determined that the facility failed to comprehensively assess pressure ulcers/injuries (injury to skin and underlying tissue resulting from prolonged pressure on the skin) for one of 21 residents reviewed (Resident R42). Findings include: A facility policy Pressure Injury Prevention and Treatment Policy dated 9/2024, revealed Residents admitted with existing pressure injuries will receive necessary treatment and services, consistent with professional standards of practice, to promote healing and prevent infection. New pressure injuries will not develop unless the individual's clinical condition demonstrates that they were unavoidable. Pressure injuries identified will be assessed initially and at least weekly thereafter, until closed. All assessments will include the following elements: Location and stage [Stage one-nonblanchable redness of an area. Stage Two-shallow open ulcer with a red or pink wound bed without slough or bruising. Stage Three-full thickness tissue loss, subcutaneous fat may be…

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

Based on review of clinical records and facility policy, observations, and staff interviews, it was determined that the facility failed to properly reorder and store medications for two of eight residents reviewed during medication pass observations (Residents R72 and R73). Findings include: Review of the facility policy entitled Medication Shortages/Unavailable Medications last revised 8/01/2024, revealed that upon discovery that facility has an inadequate supply of a medication to administer to a resident, facility staff should immediately initiate action to obtain the medication form the pharmacy. If the medication shortage is discovered at the time of medication administration, facility staff should immediately notify the pharmacy. Resident R72's clinical record revealed an admission date of 7/23/24, with diagnoses that included history of falls, fracture of the left femur, and aftercare for joint replacement therapy. R72 had a physician's order for Oxycodone (pain medication) 5 milligrams (mg) every 6 hours as needed for pain with a start date of 10/14/24, and last administered…

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 and resident interviews, it was determined that the facility failed to provide a homelike environment for residents for two of two nursing care units (Second and Third floor nursing care units). Findings include: Observations on 8/20/2024, between 1:00 p.m. and 1:30 p.m. of the Second and Third floor nursing care units with the Director of Laundry and Housekeeping Services revealed the following: Stock of clean linen on the Second floor nursing care unit revealed four wash cloths and six towels on the clean linen carts and storage closet. Stock of clean linen on the Third floor nursing care unit revealed zero wash cloths and towels on the linen carts and storage closet. Soiled linen rooms on the Second and Third floor nursing care units revealed bagged soiled linens that were stored from the morning and had not been sent to the laundry room for washing. Laundry room revealed clean linen that was ready to be sent back to the nursing care units for the second shift. The stock of towels and wash cloths did not appear to be enough to supply the census of…

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

Based on resident interviews, it was determined that the facility failed to serve food that was palatable for taste and temperature on two of two units for 17 of 18 residents interviewed (Residents R1 through R13, R15, and R24 through R27). Findings include: Upon request, there was no policy provided regarding the expectations/requirements during meal service for timeliness of meal delivery and the palatability of food served to residents. During resident interviews on 7/9/24, during the lunch meal service, 17 of 18 alert and oriented residents interviewed, elicited complaints regarding their meals. Residents R1 through R13, R15, and R24 through R27 expressed frustration that their meals were not palatable because the food was usually cold when delivered by staff, due to the trays sitting in the hall for long periods of time until they are delivered. Additionally, they reported that the food overall was of poor quality and tasted terrible. 28 Pa. Code 201.14(a) Responsibility of licensee

Based on review of facility policies, observations, and staff interviews, it was determined that the facility failed to maintain sanitary food service operations for one of one kitchens. Findings include: Review of facility policy entitled, Dish Machine Use, last reviewed 1/17/2024, revealed Prior to use, verify temperature and/or chemical sanitizer concentration are within specifications provided by the dish machine manufacturer (see note). If requirements are not met, immediately discontinue use of the dish machine and notify the person in charge. Review of facility policy entitled, Storage of refrigerated foods, last reviewed 1/17/2024, revealed All refrigerated items must be stored at least six inches above the floor and eighteen inches from the refrigerator ceiling and sprinkler heads. Store all food/leftovers in covered, approved, food grade containers. Refrigerated, TCS foods, prepared and held for more than 24 hours will be marked to indicate the date the food will be consumed or discarded. Prepared TCS foods will be held a maximum of seven days with the day of preparation…

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

Based on review of facility policy, observations, and staff interviews, it was determined the facility failed to maintain infection control and prevention measures related to laundry services. Findings include: Review of facility policy entitled, General Linen Handling Policy, dated 1/17/24, revealed The facility will handle all used linen as potentially contaminated and will employ standard precautions in handling such linen. Linen will be handled in a manner which reduces the likelihood of contamination. Contaminated laundry/linens will be bagged or contained at the point of use or collection. Leak resistant bags or containers will be used for any linens contaminated with blood or body substances. Observations in the laundry area on 2/07/24, at 10:20 a.m. revealed dirty linen and clothing covered with feces in a large laundry cart that was utilized for a collection device from bags delivered via the laundry chute. Soiled wash cloths and towels with large amounts of feces were observed in a garbage bag to be discarded related to the large amount of feces on them. An interview with…

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

Based on review of facility records and policy, review of clinical records, and the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual 2019 (RAI-assessment guide use to plan the provision of care for residents), observations, and resident and staff interviews, it was determined that the facility failed to ensure that a resident's dignity was maintained for nine of 24 residents reviewed (Residents R1, R11, R13, R26, R36, R44, R48, R66, and R78). Findings include: Review of Resident Rights Inservice provided by the Registered Nurse (RN) Regional Director on 2/07/24, at approximately 11:00 a.m. revealed The Residents' [NAME] of Rights, The Nursing Home Reform Act established the following rights for nursing home residents: The right to be treated with dignity; The right to exercise self-determination; The right to communicate freely; Receive adequate and appropriate care; To be treated with consideration, respect, and dignity; and Participate in community activities, both inside and outside the nursing home. Review of the facility policy, Resident Communication…

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, clinical record review and staff interview, it was determined that the facility failed to complete a discharge summary, which includes a recapitulation of the resident's stay, the resident's discharge status, reconciliation of all medications, and post-discharge plan for two of three closed records reviewed (Resident CR108 and Resident CR159). Findings include: Review of a facility policy dated 1/17/24, entitled Discharge Planning Policy indicated that when a discharge is anticipated, the facility will develop a Discharge Summary that includes summaries of the resident's stay, the resident's status at discharge, medication reconciliation, and summary of the resident's post-discharge plan of care. Resident CR108's closed clinical record revealed an admission date of 11/17/23, with diagnoses that included diabetes (condition related to inadequate insulin and high blood sugars), Chronic Obstructive Pulmonary Disease (COPD - a condition that obstructs air flow in the lungs with symptoms of difficulty breathing, coughing and shortness of breath), 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 documents and clinical records, and the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual 2019 (RAI-assessment guide use to plan the provision of care for residents), observations, and staff interviews, it was determined the facility failed to ensure dependent residents are assisted with meals for two of 24 residents reviewed (Residents R40 and R105). Findings include: No policy was provided regarding the facility's responsibility to ensure a dependent resident receives care/treatment. Review of the Resident Rights Inservice, provided by the Regional Director on 2/07/24, approximately 11:00 a.m. revealed The Residents' [NAME] of Rights, The Nursing Home Reform Act established the following rights for nursing home residents: Receive adequate and appropriate care, Right to Dignity, Respect, and Freedom; and to be treated with consideration, respect, and dignity. Resident R40's clinical record revealed an admission date of 5/02/22, with diagnoses that included acute respiratory failure with hypoxia (caused by a disease or injury 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, clinical records, and the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual 2019 (RAI-assessment guide used to plan the provision of care for residents), observations, and resident and staff interviews, it was determined that the facility failed to ensure medications were administered in accordance with professional standards for one of 24 residents reviewed (Resident R78). Findings include: Review of facility policy, General Dose Preparation and Medication Administration, dated 1/17/24, revealed 1. Facility staff should comply with Facility policy, Applicable Law and the State Operations Manual when administering medications. 3. Dose Preparation: Facility should take all measures required by Facility policy and Applicable Law, including but not limited to the following: 3.10 Facility staff should not leave medications or chemicals unattended. 5. During medication administration, Facility staff should take all measures required by Facility policy and Applicable Law, including, but not limited to the following: 5.10 Observe…

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

Based on review of facility policy, observations and staff interview, it was determined that the facility failed to label multi-dose containers of tuberculin solution (used to test for the disease tuberculosis) with the date they were opened in one of two medication storage rooms (Third Floor medication room). Findings include: Review of a facility policy entitled, Storage and Expiration dating of Medication, Biologicals dated January 2022, indicated that staff should record the date opened on the primary medication container when the medication has a shortened expiration date once opened. The packaging for the tuberculin solution indicated that any unused solution was to be discarded after 28 days once opened. Observation on 2/05/24, at 12:32 p.m. of the Third Floor medication room refrigerator revealed an opened multi-dose vial of tuberculin solution without a date when it was opened. At that time, Licensed Practical Nurse (LPN) Employee E6 confirmed that the multi-dose vial of tuberculin solution did not identify an open date. The LPN was able to confirm at that time that 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 clinical record review and resident and staff interview, it was determined that the facility failed to schedule an appointment for outside services for one of 24 residents reviewed in a timely manner (Resident R99). Findings include: Resident R99's clinical record revealed an admission date of 10/27/2023, with diagnoses that inlcuded cervical (neck) spinal problems, difficulty walking, muscle weakness, cervical spinal fusion and pain disorder. During an interview on 2/6/2024, at 1:55 p.m. Resident R99 revealed that facility staff were to schedule an appointment within one week of admission with an orthopedic surgeon (medical doctor that focuses on bones, muscles, joints, and nerves) specializing in spinal care, but that they failed to make the appointment until nearly a month after admission, prolonging their stay at the facility. Resident R99's clinical record also contained hospital discharge/admission orders which directed the facility to make an appointment with an orthopedic surgeon specializing in…

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

Based on a review of facility policy and clinical records, and review of the Long Term Care Facility Resident Assessment Instrument 3.0 User's Manual 2019 (RAI-assessment guide used to plan the provision of care for residents), and resident and staff interviews, it was determined that the facility failed to provide a bath/shower as resident preference for six of six residents reviewed (Residents R1, R2, R4, R5, R6, and R7). Findings include: Review of facility policy, Resident Bath Showering/Scheduling Policy dated 1/17/23, revealed Residents will be bathed or showered according to their preferences in order to maintain healthy hygiene and skin condition. Staff who have demonstrated competence may bathe the resident via shower, tub bath, whirlpool bath, or bed bath. Bed linens will be changed on baths days and as needed, but minimally once weekly. (A) Each resident will be asked about his/her bathing preferences upon admission (type of bath, preferred days and times). (B) Each resident will be scheduled to receive bathing a minimum of two times per week unless they prefer less…

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 clinical records, resident and staff interviews, and observations, it was determined that the facility failed to ensure residents receive the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, for two of two resident bathing rooms observed (Floors 2 and 3). Findings include: No water temperature policy for bathing was provided by the facility. Review of Resident R2's clinical record revealed an admission date of 9/28/21, with diagnoses that included presence of left artificial elbow joint, history of falling, muscle weakness, and other reduced mobility. During an interview on 1/10/24, at 11:45 a.m. Resident R2 indicated he/she does not receive showers often, but when he/she does, the water is hot, then cold, making the shower a horrible experience. Resident R2 indicated he/she received a shower earlier in the day and the water temperature went from hot to cold and stayed cold for the rest of the shower. Resident R2 indicated he/she told staff to stop and give him/her a bed bath, because he/she…

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

Based on review of facility records and policy, review of clinical record, and resident representative and staff interviews, it was determined the facility failed to provide residents with medically related social services related to the grievance process, and psychosocial services for one of ten residents interviewed (Resident representative R1). Findings include: Review of facility documentation Job Description for a Social Worker on 1/11/24, revealed that the primary purpose of the job position is to assist in planning, organizing, implementing, evaluating, and directing the overall operation of our facility's Social Services Department in accordance with current federal, state, and local standards, guidelines and regulations, our established policies and procedures, and as may be directed by the Director of Social Services and/or Administrator, to assure that the medically related emotional and social needs of the resident are met/maintained on an individual basis. Essential function, duties, and responsibilities include: participate in discharge planning, development and…

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

Based on review of clinical records, observations, and staff interviews, it was determined that the facility failed to follow physician orders for one of four residents reviewed (Resident R3). Findings include: Resident's R3's clinical record revealed an admission date of 5/17/23, with diagnoses that included urinary tract infection, neuromuscular dysfunction of the bladder (a urinary condition involving bladder control due to a brain, spinal cord or nerve problem), diabetes mellitus (a disease that affects how blood sugar is regulated in the blood), and chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe). Review of Resident R3's Medication Administration Record (MAR) revealed a physician order with start date of 5/18/23, for Anoro Ellipta (umeclidinium-vilanterol--medicines to treat Chronic Obstructive Pulmonary Disease [COPD-progressive lung disease]) blister with device; 62.5-25 microgram (mcg)/actuation one puff, inhale orally one time a day for wheezing. Observation of the 2 [NAME] Medication Cart on 1/09/24, 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 review of facility records, observations, and staff interviews, it was determined that the facility failed to ensure nursing staff possessed the training to properly care for resident's needs for one of 21 days reviewed (12/29/23). Findings include: Review of the Job Description for Charge Nurse RN/LPNLVN, dated 11/25/23, for RN Employee E4, and 11/27/23, for RN Employee E5 indicated the primary purpose of your job position is to provide direct nursing care to the residents, and to supervise the day-day nursing activities performed by nursing assistants. Such supervision must be in accordance with current federal, state, and local standards, guidelines, and regulations that govern our facility, and as may be required by the Director of Nursing Services or Nurse Supervisor to ensure that the highest degree of quality care is maintained at all times. As Charge Nurse you are delegated the administrative authority, responsibility, and accountability necessary for carrying out your assigned duties. You are responsible for the independent supervision of the delivery of care to 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.

Based on review of clinical records, observations, and staff interviews, it was determined that the facility failed to ensure medical records on each resident were accurately documented for one of four residents reviewed (Resident R3). Findings include: Resident's R3's clinical record revealed an admission date of 5/17/23, with diagnoses that included urinary tract infection, neuromuscular dysfunction of the bladder (a urinary condition involving bladder control due to a brain, spinal cord or nerve problem), diabetes mellitus (a disease that affects how blood sugar is regulated in the blood), and chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe). Review of Resident R3's Medication Administration Record (MAR) revealed a physician order with start date of 5/18/23, for Anoro Ellipta (umeclidinium-vilanterol--medicines to treat Chronic Obstructive Pulmonary Disease [COPD-progressive lung disease]) blister with device; 62.5-25 microgram (mcg)/actuation one puff, inhale orally one time a day for wheezing. Observation of…

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

Based on review of facility policies, observations, and staff interviews, it was determined that the facility failed to follow proper sanitation procedures for the dish machine operation and maintaining kitchen equipment and failed to ensure all staff wore proper hair restraints in one of one main kitchens. Findings include: Review of the facility policy entitled, Dish Machine Use dated 1/17/23 revealed Prior to use verify temperature and/or chemical sanitizer concentration are within specifications provided by the dish machine manufacturer . The chemical sanitizer concentration testing results were to be within a range of 10-200 parts per million (ppm). Review of the facility policy entitled, Employee Sanitary Practices dated 1/17/23, revealed Food Nutritional Service staff are required to wear hair restraints .should cover all hair on the head and/or face while in the food preparation area. Observations on 11/13/23, 9:35 a.m. revealed the following in the main kitchen: Observation of the dish machine operation area revealed that there were two large stand up fans with dust 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 observations and interviews with residents and staff, it was determined that the facility failed to serve food that was palatable and at proper temperatures. Findings include: Observations on 8/16/2023, at 11:40 a.m. of the lunch meal service revealed the meal was pizza and green beans. Observations also revealed that the meal trays were prepared and placed on the service racks to be transported to the nursing care units for distribution. The plates had lids on the tops covering the food, but the thermal plate warmer bases were not being used. During an interview with the Kitchen Manager/Cook on 8/16/2023, at 11:50 a.m. it was confirmed that the thermal plate warmer bases were not used because they were understaffed in the kitchen and forgot to turn on the warmer, it takes about 25 minutes to heat up the bases for use. During an interview on 8/16/2023, at 12:15 p.m. the Regional Dietary Manager confirmed that the thermal plate warmer bases should be used for the meals to be kept warm until distribution to the residents on the nursing care units. During interviews with…

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

Based on observations and staff interview, it was determined that the facility failed to provide a clean and homelike resident environment on one of two resident care nursing units observed (Second Floor). Findings include: Observations on 8/16/2023, at approximately 12:30 p.m. and 2:30 p.m. of the Long Hall corridor on the Second Floor nursing care unit revealed a soiled linen hamper with linen in the hamper with no lid or cover on the hamper. Interview with the Nursing Home Administrator and the Director of Maintenance and Housekeeping on 8/16/2023, at about 3:00 p.m. confirmed that all soiled linen hampers were to be covered when not in use in the corridors. 28 Pa. Code 201.18(b)(3) Management