Horsham Center For Jewish Life

Based on a review of facility policies, clinical records, and interviews with staff, it was determined that the facility failed to promptly inform the resident's representative of a significant change in the resident's condition and hospital transfer. This failure affected one of three residents reviewed (Resident R1).Review of the facility policy titled Change in a Resident's Condition or Status, dated February 2024, indicated that the facility is required to notify the resident and/or the resident's representative of any significant change in condition, including transfer to the hospital.Review of the resident's clinical record revealed that Resident R1 legally designated her family member as Power of Attorney, dated August 1, 2023.Review of the medical provider notes for Resident R1 dated January 9, 2025, at 9:31 a.m., documented: Patient seen and examined at request for changing condition. Aide reports noticing large amounts of blood on the floor, wheelchair, and bathroom floor. Upon immediate evaluation, patient resting in bed; gown covered with blood, dried blood on sheets,…

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 provided documentation, review of policy and interview with staff, it was determined that facility did not ensure to report the results of all investigations within five working days to the administrator or his/her designated representative and to other officials in accordance with State law for two of seven residents reviewed (Resident R1, R9). Review of facility's policy 'Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating,' revised September 2024, indicates that all reports of resident abuse, neglect, exploitation, or theft/misappropriation of resident property are reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported. Review of Resident R1's clinical record revealed she was admitted to facility on July 21, 2025 and discharged on August 8, 2025. R1 had a medical history of chronic obstructive pulmonary disease, asthma, and malignant neoplasm of upper lobe/right bronchus or lung.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.

Based on observations, resident and staff interviews, it was determined that the facility failed to provide food and drink that were served at palatable temperatures for one of 5 residents reviewed. (Resident R10) Findings include: Observation on December 22, 2025 at 09:20 a.m. of resident trays transported from kitchen to nursing unit using open carts.Observations during a test tray conducted with the Food Service Director, Employee E7, on December 22, 2025 at 09:35 a.m. revealed eggs registered 116 degree Fahrenheit (F), coffee 123 degree Fahrenheit (F), orange juice 51 degree Fahrenheit (F), chocolate milk 46 degree Fahrenheit (F).Follow-up interview with the Food Service Director, on December 22, 2025 at 9:35 a.m. confirmed that these food items were outside the acceptable temperature range and therefore not palatable.28 Pa. Code 201.14(a) Responsibility of licensee28 Pa. Code 201.18(b)(3) Management

Based on staff interviews and the review of facility documentation, it was determined that the facility failed to ensure that a complete and thorough investigation was conducted for bruises of unknown origin for 1 out of 1 residents reviewed (Resident R4).Findings include:Review of the facility policy, Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating with a revision date of September 2024 indicated that all allegations are thoroughly investigated to the best of the facility's ability. The policy also indicated that the individual conducting the investigation reviews documentation and evidence; reviews the resident's medical records; interviews the person(s) reporting the incident, and interviews available staff members (on all shifts) who have had contact with the resident during the period of the alleged incident. Review of Resident R4's October 2025 physician orders included the diagnoses of cerebral infarction (a type of stroke); anxiety (a feeling of worry, nervousness, or unease about something with an uncertain outcome); depression (a mood…

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 interviews it was determined that the facility failed to ensure each resident is provided with the necessary behavioral health care in a timely manner to attain or maintain the highest practicable mental and psychosocial well-being for one of five resident records reviewed (Resident R1).Findings Include: Review of care plan for Resident R1 dated August 4, 2025, revealed that the resident was at risk to be verbally aggressive (yelling/cursing when redirected) related to dementia. Interventions included, Psychiatric/Psychogeriatric consult as indicated.Review of clinical record for Resident R1 dated July 1, 2025, revealed that the resident noted to be agitated, resident was going into other residents' rooms, several attempts were made to redirect the resident, and it was unsuccessful. Staff remained with resident for supervision, and the residents were not cooperative with therapy.Review of physician progress note dated July 9, 2025, revealed that staff reported patient had wandering and some inappropriate behaviors. Some agitation was noted…

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, facility policies and documentation and staff interview, it was determined facility did not ensure adequate supervision and assistance to prevent accidents during a mechanical lift transfer for one of two residents reviewed (Resident R2). Review of facility policy title Lifting Machine, Using a Mechanical, revised July 2017, revealed that at least two (2) nursing staff are needed to safely move a resident with a mechanical lift, when possible.A review of Resident R2's clinical record revealed that he was admitted to the facility on [DATE], with diagnosis of chronic obstructive pulmonary disease (an ongoing lung condition caused by damage to the lungs).A review of Resident R2's allegation of abuse incident investigation report revealed that on June 18, 2025, Employee E13, nurse aide, was providing care to Resident R2 using a sit to stand lift. The report indicated that Employee E13 was by herself when she lifted the resident and transported him into the bathroom and bumped…

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, observations, and resident and staff interviews, it was determined that the facility failed to provide food and drink that was palatable and served at the proper temperature. Findings include: Interview with Resident R80 on June 16, 2025 at 11:23am revealed that food does not taste good. Interview with Resident R230 on June 16, 2025 at 1:07pm revealed that food does not taste good and is not cooked to right temperatures, tends to be overdone or underdone depending on the dish. Interview conducted with Resident R137, during dining on June 16, 2025, at 1:27 p.m. revealed that the food was cold. During a group interview on June 18, 2025, at 10:03 p.m. when food was brought up and all the residents agreed that there were problems with the food. Residents R33, R110, and R230, stated that last week, chicken was served partially raw with visible blood. Observations during a test tray conducted with the Dietitian, Employee E9, on June 18, 2025, at 1:01 p.m. revealed pasta registered at 107.6 degrees Fahrenheit (F); green beans registered at 102.5…

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

Based on observations; review of clinical records, policies, and procedures; and staff interviews; it was determined that the facility failed to ensure that a resident was free from physical restraints for one out of 35 residents reviewed (Resident R156). Findings include: Review of Resident R156's clinical record revealed that the resident was admitted in the facility on June 1, 2024, with diagnoses including Unspecified Dementia, Unspecified Severity, Without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance, and Anxiety (Dementia is the loss of cognitive functioning - thinking, remembering, and reasoning - to such an extent that it interferes with a person's daily life and activities), Parkinson's Disease with Dyskinesia (neurological disorder that primarily affects movement, causing symptoms like tremors, stiffness, and slowness of movement), Anxiety Disorder (Anxiety disorders are a group of mental health conditions characterized by excessive, persistent, and uncontrollable feelings of worry and fear), and Depression (major loss of interest in pleasurable…

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

Based on observations, review of facility policies, clinical record reviews and interviews with staff, it was determined that the facility failed to ensure appropriate enteral feeding practices related to labeling for one of two residents reviewed for tube feeding (Resident R299). Findings include: Review of physician order for Resident R299, dated April 27, 2025, indicated, one time a day Administer Jevity 1.5 @50 ml/hr until total volume of 500 ml daily has infused . Observations on June 18, 2025, at 1:37 p.m. in Resident R299's room, revealed that the bottle of Jevity 1.5 Enteral Feed was dated June 10, 2025. Follow-up interview with the unit manager, Employee E11 at 1:39 p.m. confirmed the above-mentioned finding. Continued interview revealed that the enteral feed bottle must be discarded every 24 hours. 28 Pa Code 211.10(c) Resident care policies 28 Pa Code 211.12(d)(3)(5) Nursing services

Based on observed, clinical record review and staff interview, it was determined that the facility failed to provide appropriate respiratory care and services for one of 35 residents reviewed (R205). Findings include: Review of physician order for Resident R205 indicated an order dated March 9, 2025; Check and change Oxygen tubing weekly and as needed, every night shift, every Saturday per protocol; date the Oxygen tubing. Review of physician order for Residnet R205 indicated an order dated May 8, 2025; Oxygen at two Litters, to keep SPO2 (pulse oxygen level) greater than 90, Every Shift for Shortness of Breath. Observation conducted on June 17, 2025, at 10:37 a.m., revealed that Resident R205 was disconnected from Oxygen tube, although the Oxygen Concentrator was running, and while the oxygen tubing was laying on the floor. At the time of the finding the same was confirmed with a Licensed Nurse, Employee E7. 28 Pa Code 211.10(c) Resident care policies 28 Pa Code 211.12(d)(5) Nursing services

Based on review of clinical records, staff and resident interviews, it was determined that the facility failed to provide culturally competent, trauma care in accordance with professional standards of practice, accounting for the resident's past experiences and preferences in order to eliminate and/or mitigate triggers that may cause re-traumatization of the resident for one of three residents sampled for behavior. (Resident R130) Findings include: A review of the clinical record revealed that Resident R130 was admitted to the facility, with diagnoses to include post-traumatic stress disorder (PTSD)(a mental health condition that develops after experiencing or witnessing a traumatic event, such as a natural disaster, war, violent crime, or personal loss), anxiety disorder, and bipolar disorder. A quarterly Minimum Data Set assessment (MDS- a federally mandated standardized assessment process conducted at specific intervals to plan resident care) for Resident R130 dated April 8, 2025, Section I, Active Diagnoses, Psychiatric/Mood Disorder, question I6100, indicated the resident has…

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 policies, review of facility documentation, clinical record review and interviews with staff, it was determined that the facility failed to maintain an effective infection control program related with Enhanced Barrier Precautions for one of 14 residents reviewed (R142). Findings include: Review of literature revealed that Enhanced Barrier Precautions are infection control intervention designed to reduce the transmission of novel or Multi-Drug-Resistant Organisms. Enhanced Barrier Precautions require to employ the use of targeted Personal Protective Equipment (PPE) during high contact patient/resident activities. Review of Resident R142's clinical record revealed that the resident was admitted to the facility on [DATE] with the diagnoses of Dependence on Renal Dialysis, and Obstructive and Reflux Uropathy Obstructive Unspecified (Reflux Uropathy Obstructive Unspecified refers to a condition where there's a blockage in the urinary tract that prevents normal urine flow.…

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 make certain that the necessary resident information was communicated to the physician before the resident was discharged against medical advice (AMA) for one of one resident reviewed. (Residents R1). Findings include: Review of Resident R1's clinical record revealed the resident was admitted on [DATE], with the diagnoses of fracture of right lower leg, Parkinson's disease (movement disorder of the nervous system), dysphagia (difficulty swallowing), type 2 diabetes (failure of the body to produce insulin), and lack of coordination,. Review of Resident R1's Minimum Data Set (MDS - a periodic assessment of care needs) dated, November 16, 2024, revealed a Brief Interview for Mental Status (BIMS) of 15 which indicated that the resident was cognitively intact. On January 27, 2025, at 9:02 a.m., an interview was held with the Administrator, Employee E1, and the Director of Nursing, Employee E2, who reported that 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 a review of clinical records and interview with resident and staff, it was determined that the facility did not ensure that routine dental services were provided to residents in a timely manner for one of five clinical records reviewed (Resident R1) . Findings include: Review of Resident R1's clinical record revealed the resident was admitted on [DATE]. A review of the clinical record indicated that Resident R1 had a scheduled appointment on February 27, 2025, at 1:00 p.m. for the extraction of tooth #19. However, the prior dental consultation on February 13, 2025, indicated that R1's Xarelto medication needed to be held for three days before the scheduled procedure. A review of the Medication Administration Record (MAR) for February 23-27, 2025 revealed that Xarelto was administered, with no documentation indicating that it needed to be held for Resident R1 to undergo the scheduled procedure on February 27, 2025. On February 25, 2025, at 2:26 p.m., an interview with the unit manager, Employee E4 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 interview with and review of clinical records, it was determined that the facility failed to ensure timely provision of professional services furnished by outside providers, for one of 5 residents reviewed (Residents R1). Findings include: Review of Resident R1's clinical record revealed the resident was admitted on [DATE], diagnosed with Fracture of Right lower leg, Parkinson's disease (movement disorder of the nervous system) and lack of coordination. Continued review of Resident R1's clinical record revealed that the resident sustained a fall on November 5, 2024, and was diagnosed with distal right fibula fracture. Resident R1 was receiving orthopedic services and had a follow up on December 23, 2024, with a recommendation for follow up in 4 weeks. Resident R1 next follow up appointment was scheduled for February 10, 2025, which resulted in a total of 8 weeks follow up. On February 27, 2025, at 2:26 p.m., an interview was conducted with the Director of Nursing, Employee E2 confirmed that Resident R1…

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, interview with residents and staff, it was determined that the facility did not provide sufficient nursing staff at all times to provide nursing and related services to meet the resident's needs for 12 out of 35 residents reviewed (Resident R180, R46, R155, R247, R75, R78, R137, R32, R134, R11, R161 and R7) Findings include: Review of facility's policy 'Call System, Residents,' revised September 2022, indicates that calls for assistance are answered in a timely fashion. Observations on Tuesday, February 4, 2025, on D3 unit, revealed call bell light on appeared at 9:45 a.m., room#304. Continued observation on D3 unit, revealed call bell light still on at 10:16 am, room#304. Interview with Resident R180, in room [ROOM NUMBER], on February 4, 2025, at 10:30 am, revealed that late call bell response time is common and he believes nurse aides quit or left to another unit. Interview with Resident R217, on February 4, 2025, unit D3, at 11:15 a.m. Interview with Resident R15, unit D2, on February…

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, resident and staff interviews, it was determined that the facility failed to provide food and drink that was palatable and served at palatable temperatures for 15 of 35 residents reviewed (Residents R114, R55, R406, R10, R268, R204, R31, R18, R285, R407, R22, R221, R182, R28 and R118). Findings include: Interview with Resident R114 on February 4, 2025, at 9:55 a.m. revealed that the food is always served cold. Interview with Resident R55 on February 4, 2025, at 9:59 a.m. revealed that he does not care for the food, it is just not good, they could do a lot better. Interview with Resident R406 February 4, 2025, at 10:03 a.m. revealed that the food does not taste good, and it is not always hot enough. Interview with Resident R268 February 4, 2025, at 10:06 a.m. revealed the food is cold, especially the scrambled eggs. He stated that the kitchen staff say it is hot when it leaves the kitchen but it takes too long to be delivered. He said that he doesn't like that the meat is served only at night and at lunch it is too much starch and cheese, not good for 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 clinical record review and interview with staff, it was determined that the facility did not ensure that care plans were updated in a timely manner for one of 35 records reviewed related to resident's behaviors of dislodging a peg tube (Resident R237). Findings include: Review of facility undated policy, titled Care Plans, Comprehensive Person- Centered dated in March 2022 indicated that 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 implemented for each resident. Assessment of resident's are ongoing, and care plans are revised as information about the residents and the residents' conditions changes. Review of clinical documentation revealed that Resident R237 was admitted to the facility on [DATE], and had diagnoses of benign neoplasm of stomach, Alzheimer's disease (progressive degenerative disease of the brain), Gastrostomy status, unspecified protein-calorie…

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 interview with residents, interview with staff, and review of clinical records, it was determined that facility failed to obtained a consultation with an especialist and administered insulin medications as ordered by the physican for two of 35 residents reviewed. (Resident R40 and Resident R94) Findings include: Review of Resident R40's clinical record, revealed medical history of multiple sclerosis (slow progressive disease of the cenetal nervous system), paraplegia (paralysis on the lower half of the body), lymphedema (condition of localized swelling caused by a compromised lymphatic system) and muscle weakness. Interview with Resident R40 on Tuesday, on February 4, 2025, at 11:00 a.m., revealed that she has not seen a lymphedema specialist after communicating her preference with nursing staff over past seven months. Review of Resident R40's clinical record revealed an active physician order, obtained on August 31, 2024, for lymphedema therapy consult. Further review of Resident R40's clinical record revealed physician note, dated January 23, 2025, at 3:15 p.m.,…

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, record review, and staff interviews, it was determined the facility failed to provide respiratory care/oxygen services consistent with professional standards of practice for three of 35 residents reviewed (Residents R406, R18, and R114). Findings include: Review of Resident 406's clinical record revealed diagnoses including Chronic Respiratory Failure with hypoxia (the lungs cannot adequately oxygenate the blood, leading to low oxygen levels). Review of Resident 406's clinial record failed to reveal a physician's order for oxygen therapy. Observations conducted of Resident R406's room on February 4, 2025, at 10:30 a.m. revealed Resident 406 was wearing his/her oxygen and the filter on the concentrator contained an abundance of grey, fuzz substance. Review of Resident R18's clinical record revealed diagnoses including Chronic Respiratory Failure with hypoxia (the lungs cannot adequately oxygenate the blood, leading to low oxygen levels). Further review of Resident R18's clinical record revealed a September 29, 2024, physician's order for oxygen at 2 litters per…

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 provided documentation, it was determined that facility did not ensure nurse aides had completed annual performance evaluation for three out of nine nurse aides reviewed (Employee E11, E12, E13) Findings include: Review of facility policy 'Performance Evaluations,' revised September 2020, indicates that a performance evaluation will be completed on each employee at the conclusion of his/her 90-day probationary period, and at least annually thereafter. Request to review nurse aide performance evaluations on Wednesday, February 5, 2025, at 12:05 p.m. revealed facility was unable to provide completed performance evaluation for nurse aide, Employees E11 and E12. Request to review additional nurse aide performance evaluations on Friday, February 7, 2025, at 11:15 a.m., revealed facility was unable to provide completed performance evaluation for nurse aide, Employee E13. 28 Pa Code 211.12(d)(1) Nursing services 28 Pa Code 211.12(d)(5) Nursing services

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff interview, it was determined that the facility failed to develop and implement an individualized person-centered care plan to address a resident's dementia care needs for one of 35 residents reviewed (Resident R46). Findings Include: Reviewed facility dementia policy title Dementia Clinical Protocol dated in November 2018 states that treatment/management for the individual with confirmed dementia, the IDT team will identify a resident-centered care plan to maximized remain function and quality of life. Review of the admission sheet of Resident R46, revealed that Resident R46 was admitted to the facility on [DATE], with the diagnosis of Dementia (Dementia is not a specific disease but is rather a general term for the impaired ability to remember, think, or make decisions that interferes with doing everyday activities). Review of Minimun Data Set (MDS- assessment of resident care needs) revealed that Resident R46 received antipsychotic (Antipsychotic medications have 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 upon review of resident records and interviews with staff it was determined that the facility failed to maintain ongoing communication between the facility and a dialysis provider that was completed and/or available for review for three of three residents receiving dialysis (Resident R104, R139 and R230). Findings include Resident R104 was admitted to the facility on [DATE], diagnosed with end state renal disease and was ordered to receive hemodialysis three times a week on Tuesday, Thursday and Fridays. Hospital records revealed Resident R104 presented to the emergency on December 19, 2024, with right upper extremity erythema edema, cellulitis/abscess with purulent drainage (thick milky foul smelling drainage commonly called pus) from his fistula site, also with nonocclusive right brachial DVT (blood clot) and was placed on Vancomycin (an antibiotic used for severe infections). The correspondence/communication between the facility and dialysis center during that time period was either incomplete or not…

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 provided documentation and interview with staff, it was determined that facility did not ensure required in-services training was provided for one nurse aide out of nine nurse aides reviewed (Employee E14) Findings include: Review of facility policy 'In-Service Training, Nurse Aide,' revised August 2022, indicates that in-service training is based on the outcome of the annual performance review, annual in-services: are no less than 12 hours per employment year. Request to review regular in-service education for nurse aides, on Wednesday, February 5, 2025, at 12:05 pm, revealed facility unable to provide completed in-service education for nurse aide, Employee E14. 28 Pa Code 201.19(7) Personnel policies and procedures 28 Pa Code 201.20(d) Staff development

Based on review of facility records, job descriptions, and staff interviews, it was determined that the Nursing Home Administrator (NHA) and the Director of Nursing (DON) did not effectively manage the facility to ensure that the resident's environment was free of accident hazards, and failed to ensure hazardous materials were not accessible to a resident. This failure resulted in Resident R1 able to obtaining a disposable razor and cutting her/his wrist. The facility's failure placed Resident R1 who had a history of suicidal ideation at risk for serious injury and resulted in Immediate Jeopardy situation. Findings include: Review of the job description for the Nursing Home Administrator (NHA) revealed that The primary purpose of the job position is to manage the Facility in accordance with current applicable federal, state, and local standards, guidelines, and regulations that govern long-term care facilities. To follow all facility policies and apply them uniformly to all employees. To ensure the highest degree of quality care is provided to our residents at all times. As…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interviews, the review of the clinical record and facility documents, it was determined that the facility failed to ensure that the physician was notified regarding a resident's verbal threats of wanting to kill herself, and failed to ensure that the physician was notified when the resident reported to nursing staff that she ingested 25-30 milligrams of Tylenol for 1 out of 3 residents reviewed (Resident R1). Findings include: Review of the facility policy, Change in Condition, with a revision date of February 2021 indicted that the nurse will notify the resident's attending physician or physician on call for reasons that include, but not limited to the following: discovery of injuries of an unknown source; the refusal of treatment or medication two or more consecutive times, an accident or incident involving the resident and a significant change in a resident's physician/emotional/mental condition. Review of the policy also indicated that the resident's representative will also be notified.…

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 interviews, review of clinical records, it was determined that the facility failed to ensure comprehensive person-centered plan of care for a resident with a history of passive suicidal ideation (thoughts of wanting to die or thinking one would be better off dead) for 1 out of 3 residents reviewed (Resident R1). Findngs include: Review of the facility policy, Care Plans, Comprehensive Person-Centered with a revision date of March 2022 indicated that assessments of residents are ongoing and care plans are revised as information about the resident and the resident's conditions change. Review of the August 2024 physician orders for Resident R1 included the diagnoses of hypertension (high blood pressure); chronic kidney disease (a gradual loss of kidney function that can lead to kidney failure); cerebral infarction (a stroke); muscle weakness; anxiety (excessive, persistent and uncontrollable worry and fear about everyday situations) and depression (a mood disorder that cause persistent feelings of sadness and loss of interest). Review of the resident's annual Minimum Data Set…

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, review of facility policy, and review of the clinical record, it was determined that the facility failed to ensure that resident's medications were administered in a timely manner for 1 out of 3 residents reviewed (Resident R2). Findings include: Review of the facility policy, Administering Medications, with a revision date of April 2019, indicated that medication administration times are determined by resident need and benefit, not staff convenience, and includes the following factors that are considered: -enhancing optimal therapeutic effect of the medication -preventing potential medication or food interactions; and -honoring resident choices and preferences, consistent with his or her care plan Continued review of the facility policy indicated that medications are administered within one hour of their prescribed time, unless otherwise specified (for example, before and after meal orders). Review of the physician orders for Resident R2 indicated that the resident was admitted into the facility on July 13, 2024 for rehabilitation services with diagnoses…

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, facility documentation and interviews with staff, it was determined that the Nursing Home Administrator and the Director of Nursing failed to effectively manage the facility regarding the suicide attempt of one of three residents reviewed (Resident R1). Findings include: Review of the job description of the Nursing Home Administrator (NHA) indicated that the primary purpose of the job description is to manage the facility in accordance with current applicable federal, state, and local standards, guidelines and regulations that govern long term care facilities. Review of the job description of the Director of Nursing (DON) included organizing and directing administration, nursing services and resident care, in addition to developing, organizing, implementing and evaluating and directing the day-to-day functions of the Nursing Services Department, it programs and activities. Review of the August 2024 physician orders for Resident R1 included the diagnoses of hypertension…

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 clinical record and facility documentation, it was determined that the facility failed to ensure complete and accurate documentation related to a resident's mental health status for 1 out of 3 residents reviewed (Resident R1). Findings include: Review of the August 2024 physician orders for Resident R1 included the diagnoses of hypertension (high blood pressure); chronic kidney disease (a gradual loss of kidney function that can lead to kidney failure); cerebral infarction (a stroke); muscle weakness; anxiety (excessive, persistent and uncontrollable worry and fear about everyday situations) and depression (a mood disorder that cause persistent feelings of sadness and loss of interest). Review of the resident's annual Minimum Data Set Assessment (MDS-a periodic assessment of a resident's needs) dated July 23, 2024 indicated that the resident was assessed with a BIMS (Brief Interview of Mental Status) score of 15, which indicated that the resident was cognitively intact. Review of a note written by the psychologist dated April 2, 2024, at 12:21 p.m. documented…

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

Based on observation, review of clinical records, and interviews with residents and staff, it was determined that the facility failed to maintain sufficient nursing staff levels to provide nursing care and services for three of 35 residents reviewed (Residents R135, R123 and R138 ). Findings include: Review of facility's policy Answering the Call Light revised September 2022, the purpose of this procedure is to ensure timely response to the resident's request and needs. Answer the resident call system within 5-15 minutes. An interview with Resident R135 on March 18, 2024, at 1:17 p.m. revealed that many times they must wait a long time to get change because they are short staff with nursing aides day and night shifts. Daily shift has two nurse aides and night shift has one nurse aide for 27 residents on D2 unit. An interview with Resident R123 on March 18, 2024, at 12:49 p.m. revealed that it a one hour waiting time to get your call bell answered because it one nurse aide only for 13 residents. An interview with Registered Nurse, unit manger, Employee E16, on March 18, 2024, at 1:20…

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

Based on observation and interviews with staff and residents, it was determined that the facility did not employ sufficient staff to carry out the functions of food and nutrition services and that meals were served timely in one of three dining rooms (Second floor). Findings include: Observation of lunch meal service on March 18, 2024 at 12:15 p.m. revealed eighteen residents seated in the dining room waiting for lunch. All residents were offered a beverage. At 12:30 p.m., Food Service staff, Employee E17 pushed a cart into the dining room with eight bowls of soup. Seven residents were seated at a table and only one resident received a bowl of soup. At 12:45 p.m., Employee E17 pushed in a cart of eight more bowls of soup. At 12:55 p.m. the final resident received a bowl of soup. Resident R134 stated the soup is not hot. Employee E17, picked up the bowl of soup and went into the pantry where she reheated the soup in the microwave. She brought the soup out to Resident R134 who stated, yes, the soup was hot It's fine. Again, Employee E117 came from the pantry with eight entrees 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 of the Food and Nutrition Services, reviews of policies and procedures and food committee meeting minutes, and interviews with residents, it was determined that the facility failed to ensure that each resident received foods and beverages that were palatable and at safe and appetizing temperatures for five of 35 residents reviewed (Residents R123, R11, R134, R135 and R69) and in two of six nursing units. (D2 second floor, and B2 second floor Findings include: A review of facility documentation titled HACCP Daily Tasty Panel Chart log on March 21, 2024, stated that recommended serving temperatures to ensures hot or cold food at of consumption: soup, sauces, gravies, vegetables 160 degrees Fahrenheit (F) to 180 degrees Fahrenheit (F), meat, poultry, seafood and eggs 145 degrees Fahrenheit (F) to 165 degrees Fahrenheit (F), and cold food below 40 degrees Fahrenheit (F) and other entrees 160 degrees Fahrenheit (F). A review of facility policy title Food Holding Temperature Requirements: states that food temperatures should be taken prior to service 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.

Based on observations, review of facility policy and interviews with residents, it was determined the facility failed to implement a resident's care plan related showers to one of ten residents reviewed. (Resident R1) Findings Include: Review of facility policy titled Activities of Daily Living (ADLs), Supporting states Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Review of Resident R1's clinical record revealed the following diagnoses Cerebral infarction (a disruption of blood flow to the brain due to problems with the blood vessels that supply it), Muscle Weakness, Abnormalities of gait, Hemiplegia (paralysis of one side of the body), Fibromyalgia (a chronic (long-lasting) disorder that causes pain and tenderness throughout the body, as well as fatigue and trouble sleeping). Review of Resident R1's quarterly Minimum Data Set (MDS- assessment date September 9, 2023 of resident care needs) revealed a BIMS (Brief Interview for Mental Status) score of 15 indicating…

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 determined the facility failed to develop a comprehensive care plan related to one residents required assistants with activities of daily living for one of four resident records reviewed (Resident R1). Findings include: Review of the facility policy titled, Care Plans, Comprehensive Person- Centered revised December 2016 indicated care plans will include measurable objectives and timeframes, describe the services that are to be furnished to attain or maintain the residents highest practicable physical mental and psychosocial well-being. Review of Resident R1's clinical record revealed an admission date of July 12, 2023 diagnosed with Multiple Sclerosis, (a chronic disease of the central nervous system) polyneuropathy (malfunction of multiple nerves throughout the body), and muscle weakness. Review of Resident R1's admissions MDS (an assessment of resident needs) dated July 17, 2023 indicated the resident had impairments to one side of her upper body and both sides of her lower extremities and required extensive assistance 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 policies, clinical record review and interviews with staff, it was determined that the facility failed to maintain intravenous (IV) devices in accordance with professional standards of practice for one of four resident records reviewed (Resident R2) Findings include: Review of facility policy, Peripheral IV Dressing Changes revised on April 2016, revealed the purpose of the policy was to prevent catheter related infections associated with contaminated, loosened, or soiled catheter-site dressings. The policy continues to state the IV dressing should be changes every 5-7 days and to document the date, time, type of dressing, reason for dressing change, any complications, interventions related to insertion cite and/or surrounding area and the resident's response to the procedure. Review of Resident R2's clinical record revealed the resident was admitted on [DATE], diagnosed with right shoulder septic arthritis, and received intravenous antibiotics, Cefepime and Vancomycin via 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.