Gardens At Orangeville, The

Based on observations and resident and staff interviews, it was determined the facility failed to provide services to maintain a clean and homelike environment for one out of two nursing units (West Unit), including issues reported by two of seven sampled residents (Residents 5 and 6) and one resident representative (Resident 2's representative). Findings include: An observation conducted on June 4, 2025, at 10:45 AM in Resident 2's bathroom revealed a strong, musty urine odor. During an interview at that time, Resident 2's representative expressed concerns regarding the persistent smell of urine in the resident's bathroom. She reported that although the odor subsides temporarily following cleaning, it returns shortly thereafter. The representative stated that the recurring odor is unacceptable and affects the living experience of her family member. A follow-up observation at 1:20 PM that same day confirmed that the strong, musty urine odor remained present in Resident 2's bathroom. During a facility tour on June 4, 2025, live and dead insects were observed throughout the [NAME]…

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 provide nursing services consistent with professional standards of quality to ensure that licensed nurses properly evaluated and provided nursing care according to physician orders for one resident (Resident A1) out of 8 residents reviewed. According to the Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.11 (a)(1)(2)(4) indicates that the registered nurse was to collect complete ongoing data to determine nursing care needs, analyze the health status of individuals and compare the data with the norm when determining nursing care needs, and carry out nursing care actions that promote, maintain, and restore the well-being of individuals. The Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.145 Functions of the Licensed Practical Nurse (LPN) (a) The LPN is prepared to function as a member of the health-care team by…

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

Based on staff interview, a review of personnel files and employee credentials, it was determined the facility failed to ensure the full-time director of food and nutrition services, who was not a qualified dietitian or other clinically qualified nutrition professional, received frequently scheduled consultations from a qualified dietitian or other clinically qualified nutritional professional. Findings include: According to current federal regulatory guidance the facility must employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, taking into consideration resident assessments, individual plans of care and the number, acuity, and diagnoses of the facility's resident population in accordance with the facility assessment. In the absence of a full-time qualified dietitian the director of food and nutrition services the facility must designate a person to serve as the director of food and nutrition services. (i) The director of food and nutrition services must at a minimum meet one of the following…

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 resident and staff interviews, it was determined the facility failed to provide care in a manner that promotes each resident's quality of life by failing to respond timely to residents' requests for assistance, including experiences reported by one resident out of the 19 residents sampled (Resident 42) and experiences reported by four out of the five residents during a resident group interview (Residents 4, 15, 36, and 52). Findings include: A clinical record review revealed Resident 42 was admitted to the facility on [DATE], with diagnoses that include chronic kidney disease (gradual loss of kidney function) and fibromyalgia (a chronic disorder that causes pain and tenderness throughout the body, as well as fatigue and trouble sleeping). A review of a quarterly Minimum Data Set assessment (MDS-a federally mandated standardized assessment process conducted periodically to plan resident care) dated November 20, 2024, revealed that Resident 42 is cognitively intact with 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 observations and resident and staff interviews, it was determined the facility failed to provide services to maintain a clean and homelike environment for two out of three nursing units (100 and 200 Halls). Findings include: An observation on December 3, 2024, at 10:42 AM revealed room [ROOM NUMBER]'s bathroom with brown stains on the floor to the left of the toilet. The inner bathroom doorframe was also observed with similar brown stains. An observation on December 3, 2024, at 1:09 PM revealed room [ROOM NUMBER] contained a window air conditioning unit with a large build-up of dust and fuzz on the intake vent. Several black, round-shaped substances build-ups were observed on the airflow fins. An observation on December 3, 2024, at 1:38 PM revealed room [ROOM NUMBER] the bed located by the window had a white sheet with tan stains. Garbage and paper debris were observed on the floor on both sides of the bed. An observation on December 4, 2024, at 9:30 AM revealed the floor trim board had multiple stained…

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 the Resident Assessment Instrument (RAI) and staff interview, it was determined the facility failed to ensure the Minimum Data Set Assessments (MDS - a federally mandated standardized assessment conducted at specific intervals to plan resident care) accurately reflected the status of two residents out of 19 sampled (Residents 53 and 70). Findings included: A review of Resident 53's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses which included Alzheimer's disease. A current physician order initially dated December 3, 2021, noted an order for Apixaban (an anticoagulant medication also known as a blood thinner) 5 mg by mouth twice daily for history of thrombosis (formation of a blood clot inside a blood vessel) and embolism (traveling blood clot). Review of Resident 53's October 2024 and November 2024 Medication Administration Records revealed Apixaban 5 mg was administered twice daily as ordered by the physician. 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 a review of clinical records, select facility investigative reports, and staff interviews, it was determined the facility failed to implement effective safety measures to prevent an injury during transfer for one out of the 19 sampled residents (Resident 43). Findings include: A clinical record review revealed Resident 43 was admitted to the facility on [DATE], with diagnoses that include dementia (a condition characterized by the loss of cognitive functioning such as thinking, remembering, and reasoning, to such an extent that it interferes with a person's daily life and activities) and osteoporosis (a bone disease that develops when bone mineral density and bone mass decrease, or when the structure and strength of bone change). A review of a quarterly Minimum Data Set assessment (MDS-a federally mandated standardized assessment process conducted periodically to plan resident care) dated August 20, 2024, revealed that Resident 43 is severely cognitively impaired with a BIMS score of 03 (Brief 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of clinical records, select facility policy, and staff interview it was determined the facility failed to ensure that physician ordered intravenous (giving medication or fluid through a needle or tube inserted into a vein) antibiotics were administered as prescribed for two residents out of two sampled (Residents CR1 and 122). Findings include: Review of a facility policy titled Administering Medications last reviewed by the facility on February 1, 2024, indicated that medications are administered in a safe and timely manner, and as prescribed. Only persons licensed or permitted by the state to prepare, administer, and document the administration of medications may do so. Medications must be administered in accordance with the orders, including any required time frame. Medications must be administered within one hour of their prescribed time unless otherwise specified. The individual administering the medication must document such in the eMAR (electronic medication administration) system after…

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 the attending physician failed to act upon pharmacist identified irregularities in the medication regimen of one of 19 residents sampled (Resident 22). Findings include: A review of Resident 22's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses which included bipolar disorder (a serious mental illness that causes unusual shifts in mood, ranging from extreme highs to extreme lows and schizoaffective disorder (a mental health condition that is marked by symptoms such as hallucinations and delusions and mood disorder symptoms such as depression). A review of an October 2024 Note to Attending Physician/Prescriber revealed the consultant pharmacist indicated the resident's order for Depakote ER 250mg (medication used to stabilize mood) was to be reviewed for a gradual dose reduction. Further review revealed the resident's attending physician failed to write an appropriate response to the pharmacy…

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 provide nursing services consistent with professional standards of quality to ensure that licensed nurses properly evaluated and provided nursing care for one resident (Resident 1) out of 5 residents reviewed. According to the Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.11 (a)(1)(2)(4) indicates that the registered nurse was to collect complete ongoing data to determine nursing care needs, analyze the health status of individuals and compare the data with the norm when determining nursing care needs, and carry out nursing care actions that promote, maintain, and restore the well-being of individuals. The Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.145 Functions of the Licensed Practical Nurse (LPN) (a) The LPN is prepared to function as a member of the health-care team by exercising sound judgement based 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 clinical record review and staff interview, it was determined that the facility failed to provide adequate supervision to monitor one resident's whereabouts and activities to prevent access to potential accident hazards for one of eight sampled residents. (Resident A1) Findings include: A review of clinical record revealed that Resident A1 was admitted [DATE], with diagnoses that included fracture of the femur. Review of the resident's current care plan revealed that Resident A1 was at risk to elope and an intervention was for staff to apply a wander guard (a bracelet like device that is placed on an extremity that assisted with the location of a resident who may wander). Review of resident A1's nursing progress notes since admission April 3, 2024, revealed the resident had displayed consistent behaviors of exit seeking, was repeatedly attempting to self-transfer and was to have increased visual supervision. During an interview with Employee 1 (nurse aide) during the survey of May 30, 2024, she stated…

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, a review of facility's planned menus and concerns/grievances lodged with the facility and resident and staff interviews it was determined that the facility failed to plan menus that accommodate residents' food preferences, to the extent possible, to increase resident satisfaction with meals for residents which included four residents of 15 residents reviewed (Resident B2, B3, B4, and B5). Findings included: A review of the facility's grievance log dated March 26, 2024, revealed that Resident B2 lodged a concern regarding the lack of variety on the facility's planned menu. Resident B5 lodged a concern with that there are too many eggs served at breakfast. An interview with the dietary manager on April 16, 2024, at 10:15 a.m., revealed that the facility's cycle menus were developed and adjusted by the facility's corporate dietitian. The dietary manager revealed that residents in the facility expressed their feelings that that their preferences aren't always being considered in the development of the menus for their facility. During an interview with Residents…

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 interviews, it was determined that the facility failed to afford a resident the right to participate in the resident's treatment and health care decision making, including the right to refuse specific treatment, for one resident out of 15 reviewed. (Resident B1) Findings included: According to long term care regulatory requirements a resident has the right to select or refuse specific treatments options before the care plan is instituted, based on the information provided as required under §483.10(c)(1), (4)-(5), F552. A review of Resident B1's clinical record revealed that the resident was admitted to the facility on [DATE], with diagnoses that included type two diabetes [is a condition that results from insufficient production of insulin, causing high blood sugar], cirrhosis of the liver [is a degenerative disease of the liver resulting in scarring and liver failure], and major depressive disorder. A review of Resident B1' s Annual MDS (Minimum Data Set - a federally…

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 grievances lodged with the facility, observations and staff and resident interview, it was determined that the facility failed to provide housekeeping services to maintain a clean and orderly environment for residents, including Residents B2 and B3. Findings include: A review of a grievance that roommates, Residents B2 and B3, lodged with the facility dated March 26, 2024, revealed that the residents expressed their concerns that their room is not thoroughly cleaned, especially on the weekends. During interviews with the two cognitively intact residents, Resident B2 and Resident B3, on April 16, 2024, at 10:40 a.m., the residents stated that their bathroom is not always cleaned and that the windows and window treatments in their room are very dirty. Observations conducted on April 16, 2024, at 10:55 a.m., revealed that the bathroom, inside of resident room [ROOM NUMBER], there was a strong smell of urine, a soiled rag laying on the floor in front of the toilet, and the floor felt sticky. 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 a review of clinical records and the Resident Assessment Instrument and staff interview, it was determined that the facility failed to ensure that the Minimum Data Set Assessments (MDS - a federally mandated standardized assessment conducted at specific intervals to plan resident care) accurately reflected the status of one resident out of 13 sampled (Resident 62). Findings included: A review of Resident 62's clinical record revealed she was admitted [DATE], with diagnosis to include vertigo, osteoarthritis, gastro-esophageal reflux disease (GERD), and diabetes. A review of the residents' plan of care, date initiated February 12, 2024, indicated that's her wishes were to return home after completion of her therapeutic stay. A Social Service note dated February 12, 2024, at 10:11 PM revealed that Resident 62's goal was to be rehabilitated and return to the community, back to her daughter's home. A review of an Activities progress note dated February 15, 2024, at 11:28 AM, indicated that the resident'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 observation and staff interview it was determined that the facility failed to maintain an environment free of potential accident hazards and obstacles to safe mobility, assistance devices, on one of three nursing units (200 hall). Findings include: An observation of the 200-nursing unit, on April 16, 2024, at approximately 10:35 AM revealed that one side of the hallway from resident room [ROOM NUMBER] to 207, was lined with mechanical lifts, linen carts, soiled linen and trash hampers, and wheelchairs. These items obstructed access to the corridor handrails on that side of the hallway, which are to be used for resident ambulation or mobility assistance. A second observation of the 200-nursing unit, on April 16, 2024, at approximately 10:50 AM revealed that one side of the hallway from resident room [ROOM NUMBER] to 207, was lined with mechanical lifts, linen carts, soiled linen and trash hampers, and wheelchairs. These items obstructed access to the corridor handrails on that side of the hallway, which…

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

Based on staff interview and a review of employee qualifications it was determined that the facility failed to employ a full-time qualified director of food and nutrition services manager in the absence of a full-time qualified dietitian. Findings include: Current regulatory guidance requires that if a qualified dietitian or other clinically qualified nutrition professional is not employed full-time, the facility must designate a person to serve as the director of food and nutrition services. The director of food and nutrition services must at a minimum meet one of the following qualifications- (A) A certified dietary manager; or (B) A certified food service manager; or (C) Has similar national certification for food service management and safety from a national certifying body; or D) Has an associate's or higher degree in food service management or in hospitality, if the course study includes food service or restaurant management, from an accredited institution of higher learning; or (E) Has 2 or more years of experience in the position of director of food and nutrition services 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 observation and staff interview, it was determined that the facility failed to maintain acceptable practices for the storage and service of food to prevent the potential for contamination and microbial growth in food, which increased the risk of food-borne illness. Findings include: Food safety and inspection standards for safe food handling indicate that everything that comes in contact with food must be kept clean and food that is mishandled can lead to foodborne illness. Safe steps in food handling, cooking, and storage are essential in preventing foodborne illness. You cannot always see, smell, or taste harmful bacteria that may cause illness according to the USDA (The United States Department of Agriculture, also known as the Agriculture Department, is the U.S. federal executive department responsible for developing and executing federal laws related to food). Review of a facility General Food Preparation and Handling Policy last reviewed July 1, 2023, indicated that meats, fish, and poultry are defrosted under safe thawing practices: in the refrigerator in a drip…

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, the minutes from resident group meeting and grievances filed with the facility, and resident and staff interviews, it was determined that the facility failed to provide care in a manner and environment that promotes each resident's quality of life by failing to respond timely to residents' requests for assistance, including experiences reported by four alert and oriented residents out of four interviewed during a group meeting (Residents 7, 26, 47, and 48), grievances filed by residents (Residents 32, 44, and 72) and two out of 20 residents sampled (Residents 30 and 44). Findings include: A review of grievances filed with the facility dated September 26, 2023, revealed that Resident 44 reported that it takesa while for the nurse aides to respond to her call bell when she rings it for assistance. A review of the minutes from the Residents' Council meeting dated November 21, 2023, revealed that residents in attendance raised concerns that staff are not answering their call…

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 grievances filed with the facility (Residents 26, 44, 45, and 228) and the minutes from resident group meeting, observations, and resident and staff interview, it was determined that the facility failed to provide housekeeping services and maintenance services to maintain a clean and comfortable environment on three of the three nursing units (Units 100, 200, and 300). Findings include: A review of grievances filed with the facility revealed a grievance dated September 19, 2023, indicating that Resident 45's room was not cleaned. The resident's family raised concerns on behalf of the resident regarding the presence of cobwebs with spiders in the resident's closet, dirty window screens, and dirt in the corners of the resident's room. A grievance dated September 26, 2023, revealed that Residents 26 and 44 expressed concerns with garbage cans in their bedrooms and bathrooms not being emptied. A review of the minutes from the Residents Council meeting dated October 26, 2023, revealed residents…

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 select facility policy/protocol and clinical records and staff interview it was determined that the facility failed to provide nursing services consistent with professional standards of practice by failing to follow physician orders for bowel protocol to promote normal bowel activity for one resident (Resident 18) and for the consistent application of prescribed therapeutic devices and preventative measures, skin sleeves and legs rests with foot buddy, for one resident out of 20 sampled (Resident 62). Findings include: According to the American Academy of Family Physicians {The American Academy of Family Physicians is one of the largest medical organizations in the US founded to promote the science and art of family medicine}the primary goal of constipation management should be symptom improvement, and the secondary goal should be the passage of soft, formed stool without straining at least three times per week). The facility policy titled Bowel Protocol, last reviewed by the facility, July…

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, clinical record reviews, and staff interviews, it was determined that the facility failed to ensure that residents received appropriate treatment and services to prevent potential complications for residents with indwelling catheters for two out of the 20 residents sampled (Residents 11 and 30). Findings include: Department of Health & Human Services, USA. Centers for Disease Control and Prevention, Guideline for Prevention of Catheter-Associated Urinary Tract Infections 2009, last updated June 6, 2019, III Proper Techniques for Urinary Catheter Maintenance, B. Maintain unobstructed urine flow. 2. Keep the collecting bag below the level of the bladder at all times. Do not rest the bag on the floor. A review of facility policy titled Urinary Catheter Care, reviewed by the facility on July 1, 2023, revealed that it is the facility's policy to prevent catheter-associated urinary tract infections. The policy indicates that if breaks in aseptic technique, disconnection, or leakage occur,…

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, PAHAN (Pennsylvania Health Alert Network) infection control guidance, select facility policies, and staff interview, it was determined that the facility failed to initiate necessary infection control precautions for cohorting a resident positive for COVID-19 to prevent the spread of the SARS-CoV-2 virus to uninfected resident. This failure placed the uninfected resident at risk to their health due to the likelihood of contracting the virus by continuing to reside in the same room as the infected resident and resulted in 1 resident out of three sampled being infected with COVID-19 (Resident 58) while residing with COVID positive roommate (Resident 20), and failed to maintain infection control practices related to reduce the potential for infections for one (Resident 8) out of four sampled residents with an indwelling urinary Foley catheter (flexible tube which is placed in the bladder to drain urine) and failed to ensure that infection control practices were implemented 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 select facility policy and clinical records, and staff interview, it was determined that the facility failed to timely consult with the physician and notify the resident's interested representative of a change in condition for one resident out of 20 sampled (Resident 64). Findings include: A review of the facility's policy Change in a Resident's Condition or Status last reviewed by the facility July 1, 2023, indicated that the facility shall promptly notify the resident, his or her attending physician, and representative (sponsor) of changes in the resident's medical/mental condition and /or status. A review of the clinical record revealed Resident 64 was admitted to the facility on [DATE], with diagnoses that included Alzheimer's disease, muscle weakness, history of falling, and dementia. The resident's clinical record identified a resident representative. A review of an admission BIMS (brief interview for mental status - a tool to assess cognitive status) report dated October 31, 2023,…

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 facility's abuse policy, select investigative reports and clinical records, and resident and staff interview, it was determined that the facility failed to ensure that three residents were free from verbal abuse out of 20 residents sampled (Resident 67, Resident CR1, and Resident CR2) Findings include: Review of facility policy titled Abuse Policy that was last reviewed by the facility July 1, 2023, revealed that the resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. The facility must not use verbal, mental, sexual, or physical abuse, corporal punishment or involuntary seclusion. Residents must not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff or other agencies serving the resident, family members or legal guardians, friends or other individuals. The facility defined abuse as the willful infliction of injury, unreasonable confinement,…

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 provide restorative nursing services planned to maintain mobility and functional abilities of one of 11 residents sampled (Resident 10). Findings included: A review of the clinical record of Resident 10 revealed admission to the facility on January 12, 2023, with diagnoses to include congestive heart failure (weakness of the heart that leads to build-up of fluid in the lungs and surrounding body tissues), unsteadiness on feet and difficulty walking. A review of Resident 10's Physical Therapy Discharge summary dated [DATE], indicated that the resident was to receive Restorative Nursing Program (RNP) for ambulation. The discharge summary indicated that the ambulation program was established, and staff trained for the resident to ambulate 100 feet with rolling walker with assist of one person. A review of the physician's order dated December 27, 2023, revealed an order for RNP ambulation 100 feet with rolling walker…

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, a review of clinical records, investigative reports, and information provided by the facility, and staff interview it was determined that the facility failed to use safe technique while positioning a resident and assure the presence of planned and prescribed preventative measures to prevent minor injury to one resident out of 13 sampled (Resident 1) and maintain an environment free of potential accident hazards. Findings include: A review of Resident 1's clinical record revealed that the resident had diagnoses to include cerebral infarction (stroke), right sided hemiplegia and hemiparesis (weakness or paralysis), gastro-esophageal reflux disease (GERD), and osteoporosis (bone softening, weakening). A quarterly Minimum Data Set assessment (MDS - a federally mandated standardized assessment process conducted at specific intervals to plan resident care) dated December 6, 2023, indicated that the resident was severely cognitively impaired with a BIMS (brief interview to assess cognitive status) score of 3 (0 - 7 represents severe cognitive impairment) and 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 clinical records and staff interviews it was determined that the facility failed to provide person-centered care as prescribed to meet the current clinical needs, failed to ensure the ready availability of prescribed emergency supplies, and failed to follow physician orders for management of a PICC line [(Percutaneously Inserted Central Catheter) for one resident out of 20 sampled residents (Resident 8). Findings include: A review of clinical records revealed Resident 8 was admitted to the facility on [DATE], with diagnoses to include sepsis (a condition in which the immune system has a dangerous reaction to an infection), and urinary tract infection, and ESBL (Extended Spectrum Beta Lactamase, a bacteria resistant to most antibiotics) in the urine. Review of Resident 8's hospital record, Procedure Note for Interventional Radiology, dated December 18, 2023, revealed that the resident underwent a procedure for a single lumen PICC placement in her right arm . Catheter total length…

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 interviews it was determined that the facility failed to develop and implement an interdisciplinary plan and approaches for direct care staff to use in managing dementia related behaviors for one resident out of five sampled residents (Resident 64). Findings include: A review of the clinical record revealed Resident 64 was admitted to the facility on [DATE], with diagnoses that included Alzheimer's disease, muscle weakness, history of falling, and dementia. A review of an admission BIMS (brief interview for mental status - a tool to assess cognitive status) report dated October 31, 2023, indicated that the resident was severely cognitively impaired with a BIMS score of 0. Resident 64's care plan initiated October 31, 2023, revealed that the resident had a progressive decline in intellectual functioning characterized by deficit in memory, judgment, decision making and thought process related to Alzheimer's and Dementia. The resident's goal was that the resident will…

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 a staff interview, it was determined that the facility failed to ensure that the resident's drug regimen was free of unnecessary antibiotic drugs for one out of 20 residents sampled (Resident 11). Findings included: A clinical record review revealed that Resident 11 was admitted to the facility on [DATE], with diagnoses to include dementia and obstructive and reflux uropathy (urine is not able to drain through the urinary tract). A nursing progress note dated September 28, 2023, at 12:50 PM revealed that the certified nurse practitioner was made aware of the resident's increased confusion, suprapubic pain, and exit-seeking behaviors. The note indicated that the nurse practitioner ordered lab work, blood cultures, and urinalysis. A physician order dated September 28, 2023, at 3:00 PM for Resident 11 to have a urinalysis and culture and sensitivity (a test to determine the type of organisms in the urinary tract and antibiotic treatments that are effective to treat specific…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of select facility policy, clinical records, and a staff interview, it was determined that the facility failed to offer and/or provide pneumococcal immunization for residents including one of the five residents sampled for immunizations (Resident 61). Findings include: A review of facility policy titled Pneumococcal Vaccine, reviewed by the facility on July 1, 2023, revealed that it is the facility's policy to offer pneumococcal vaccines to aid in preventing pneumonia or pneumococcal infections. The policy indicates that the administration of pneumococcal vaccines or re-vaccinations will be made in accordance with current Centers for Disease Control and Prevention (CDC) recommendations at the time of vaccination. A review of the CDC's Pneumococcal Vaccination: Summary of Who and When to Vaccinate, September 22, 2023, indicates for adults [AGE] years of age or older who only received PCV13 and don't have an immunocompromising condition, cochlear implant, or cerebrospinal fluid leak: Give 1 dose…

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 select investigative reports and staff interviews, it was determined that the facility failed to provide care necessary to prevent complications with a gastric feeding tube for one resident out of three sampled (Resident CR1). Findings include: Review of Resident CR1's clinical record revealed that the resident was admitted to the facility on [DATE], with diagnoses, which included dysphagia (difficulty swallowing) and gastrostomy status (a gastrostomy tube inserted into his stomach). The resident had an admission physician order for Nutren 1.5 Enteral Liquid (liquid feeding formula) Give 60 milliliters per hour (ml/hr) via PEG-Tube (tube that is placed directly into the stomach through an abdominal wall incision for administration of food, fluids, and medications. The most common type is a percutaneous endoscopic gastrostomy {PEG} tube) every shift, and a bolus water flush 200 ml every 4 hours for hydration. The order also noted that the staff were to check the resident'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.