Embassy Of Woodland Park

Based on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to flush an intravenous catheter (a thin tube inserted into a vein to administer medications and/or fluids) per facility policy for one of 35 residents reviewed (Resident 34). Findings include:The facility's policy regarding intravenous catheter flushing, dated March 13, 2025, indicated that catheters were to be flushed at regular intervals to maintain patency, before and after administration of medications. Staff were to use only preservative free 0.9 % sodium chloride for saline flushes (a mixture of water and salt, with a salt concentration of 0.9%).An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 34, dated September 26, 2025, revealed that the resident was cognitively impaired, required assistance for care needs, received an antibiotic and intravenous medications, and had a diagnosis that included Osteomyelitis (an infection of the bone).Physician's orders for Resident 34,…

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

Based on clinical record review and staff interview, it was determined that the facility failed to ensure that residents were assessed and received trauma-informed care to eliminate or mitigate triggers for residents with the diagnosis of Post Traumatic Stress Disorder (PTSD) (a mental and behavioral disorder that develops related to a terrifying event) for one of 35 residents reviewed (Resident 8).Findings include: A Quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 8, dated November 3, 2025, indicated that the resident was cognitively impaired, was dependent on staff for daily care needs, and had diagnoses that included depression, anxiety, and PTSD. A review of Resident 46's care plan, dated August 13, 2024, indicated that the resident had PTSD, anxiety, and Traumatic Brain Injury. There was no documented evidence the facility identified Resident 8's specific triggers that could re-traumatize the resident or implement measures as to how facility staff could prevent or minimize triggers from occurring.…

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

Based on review of the facility's plans of correction for previous surveys, and the results of the current survey, it was determined that the facility's Quality Assurance Performance Improvement (QAPI) committee failed to correct quality deficiencies and ensure that plans to improve the delivery of care and services effectively addressed recurring deficiencies.Findings include: The facility's deficiencies and plan of corrections for an annual survey ending October 3, 2024, revealed that the facility developed plans of correction that included quality assurance systems to ensure that the facility-maintained compliance with cited nursing home regulations. The results of the current survey, ending December 4, 2025, identified repeated deficiencies related to a homelike environment and safe and sanitary food storage. The facility's plan of correction for a deficiency regarding a homelike environment cited during the survey ending October 3, 2024, revealed that the facility would complete audits and report the results of the audits to the QAPI committee for review. The results of the…

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

Based on review of facility policies and observations, as well as staff interviews, it was determined that the facility failed to serve food items at appetizing temperatures.The facility's current policy regarding food temperatures, dated March 13, 2025, indicated that the serving temperature of hot food at point of service should have a temperature of greater than or equal to 120 degrees Fahrenheit (F).The menu for Monday, August 19, 2025, revealed that the lunch meal included baked fish, broccoli rice casserole, seasoned broccoli, and frosted cake. Observations in the main kitchen service area on August 19, 2025, revealed that the food cart to the 100 unit left the main kitchen at 11:54 a.m. and arrived on the 100 unit at 11:55 a.m. Trays were passed to the residents in their rooms and the last resident was served at 12:08 p.m. At 12:08 p.m. the temperature of the seasoned broccoli was 111.0 degrees F. The broccoli was lukewarm and did not taste appetizing. Interview with the Dietary Manager on August 19, 2025 at the time of the observation confirmed that the broccoli should have…

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

Based on a review of clinical records, as well as staff interviews, it was determined that the facility failed to ensure that the resident's representative was notified about a change in condition for one of three residents reviewed (Resident 3).Findings include: An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 3, dated May 28, 2025, revealed that the resident was cognitively intact, required maximum assistance from staff for daily care needs, and had a diagnosis of a stroke.A nursing note for Resident 3, dated May 26, 2025, at 5:47 a.m., revealed that the resident was found on the floor in front of her wheelchair and was attempting to get herself off of the floor. There was no documented evidence in Resident 3's clinical record to indicate that her emergency contact was notified of the fall until May 29, 2025, at 8:54 a.m. (three days later).Interview with the Director of Nursing on July 7, 2025, at 10:26 a.m. confirmed that Resident 3's emergency contact was not notified until three days after the fall but…

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

Based on review of facility policy and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that residents received care and treatment in accordance with professional standards of practice, by failing to ensure that physician's orders were followed for one of five residents reviewed (Resident 4). Findings include: The facility's policy regarding medication administration, dated March 13, 2025, indicated that medications are to be administered by licensed nurses in accordance with professional standards. Staff are to compare the medication source (bubble pack, vial, etc) with the Medication Administration Record (MAR) to verify the resident name, medication name, form, dose, route, and time. The staff are to observe resident consumption of the medication. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 4, dated February 2, 2025, indicated that the resident was cognitively impaired, required assistance from staff for daily care needs, and had constipation and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to store medication appropriately for one of five residents reviewed (Resident 4). Findings include: The facility's policy regarding medication administration, dated March 13, 2025, indicated that medications are to be administered by licensed nurses in accordance with professional standards. Staff are to compare the medication source (bubble pack, vial, etc) with the Medication Administration Record (MAR) to verify the resident name, medication name, form, dose, route, and time. The staff are to observe resident consumption of the medication. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 4, dated February 2, 2025, indicated that the resident was cognitively impaired, required assistance from staff for daily care needs, and had constipation and dementia. A care plan for Resident 4, dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of facility policy and the facility's written menus, as well as observations and staff and resident interviews, it was determined that the facility failed to follow their planned menu. Findings include: A facility policy, dated March 15, 2024, indicated that menus shall be written in advance and followed. Any menu substitutions shall be made in an emergency situation only and recorded on the substitution log. An interview with a group of residents on October 1, 2024, indicated that the kitchen does not always serve what is on the menu. Observations of the kitchen on September 30, 2024, at 9:58 a.m. revealed that staff were preparing meatloaf, mashed potatoes, mixed vegetables (carrots, green beans, and wax beans), and vanilla cake for lunch. The facility's written and printed menu for the lunch meal on September 30, 2024, revealed that the residents were to receive meatloaf, mashed potatoes, Brussels sprouts, berry-topped yellow cake, coffee/tea, dinner roll, and margarine. Observations of the…

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

Based on review of facility policy, observations, and staff interviews, it was determined that the facility failed to prepare and store food in accordance with professional standards for food service safety. Findings include: A facility policy for food storage, dated March 15, 2024, revealed that all items being stored in the freezer must be labeled, dated, and sealed in the same manner and may be stored for the period of time per Hazardous Analysis Critical Control Point (HACCP - a systematic approach to the identification, evaluation, and control of food safety hazards) guidelines. Dry storage items must be six inches off the floor. Observations of the main kitchen during the initial tour on September 30, 2024, at 9:55 a.m. revealed that there were two cardboard boxes of coffee on the floor stacked one on top of the other. Observations in the three-door freezer on September 30, 2024, at 9:58 a.m. revealed a box with approximately two thirds of a chocolate cake that was not dated, labeled, or sealed. Interview with Dietary Director on September 30, 2024, at 10:08 a.m. confirmed…

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 policies, as well as observations and staff interviews, it was determined that the facility failed to maintain a clean and homelike environment for two of 38 residents reviewed (Residents 1, 39). Findings include: The facility's policy regarding cleaning and disinfecting, dated March 15, 2024, indicated that the facility was to provide a safe, comfortable, homelike environment. A quarterly Minimum data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated September 3, 2024, revealed that the resident was cognitively intact, required staff assistance for care needs, used a wheelchair, and had diagnoses that included cerebral palsy (CP - neurological disorder that affects a person's ability to move, balance, and maintain posture.) Observations on September 30, 2024, at 1:24 p.m. revealed that the resident was sitting in his electric wheelchair in his room. The carpet in his room was black and worn. An interview with the resident at the time revealed that he felt that the carpet was very dirty, and that the…

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

Based on review of policies and personnel files, as well as staff interviews, it was determined that the facility failed to ensure that the status of nursing licenses were checked with the State Board of Nursing for two of two nurses reviewed (Registered Nurse 1, Licensed Practical Nurse 2) and failed to complete a Nurse Aide Registry verification for one of three nurse aides reviewed (Nurse Aide 3). Findings include: The facility's policy regarding abuse prevention, dated March 15, 2024, indicated that the facility conducted background checks and will not knowingly employ or otherwise engage any individual who has disciplinary action in effect against his or her professional license by a state licensure board or registry as a result of a finding of abuse, neglect, exploitation, mistreatment of residents, or misappropriation of resident property. The personnel file for Registered Nurse 1 revealed a start date of April 21, 2024. However, there was no documented evidence until October 2, 2024, that his license was verified with the State Board prior to him working. The personnel file…

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 policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to develop care plans for one of 38 residents reviewed (Resident 61). Findings include: The facility's policy regarding the development of care plans, dated March 15, 2024, indicated that the facility will develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective person-centered care of the residents and meet professional standards of quality care. A significant change Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 61, dated September 6, 2024, indicated that the resident was cognitively intact, required assistance from staff for her daily care needs, and was frequently incontinent (two or more episodes of bowel incontinence, but at least one continent bowel movement) of bowel. Task records for the month of September 2024 were reviewed and indicated that Resident 61 did have two or more bowel incontinence episode weekly.…

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

Based on review of facility policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to revise/update care plans for two of 38 residents reviewed (Residents 39, 61). Findings include: The facility's policy regarding care plans, dated March 15, 2024, indicated that nurses and interdisciplinary team members were responsible for updating the resident's care plan to reflect changes in the resident's status. A significant change Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 39, dated September 24, 2024, indicated that the resident was cognitively intact, required assistance from staff for her daily care needs, and had diagnoses that included, heart failure, and chronic pain. Physician's orders for Resident 39, dated March 11, 2024, included an order for morphine sulfate solution (20 mg/ml), give one ml by mouth every eight hours for chronic pain. Physician's orders for Resident 39, dated May 1, 2024, included an order for morphine sulfate solution (20 mg/ml),…

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 investigation reports, as well as staff interviews, it was determined that the facility failed to ensure that the residents' environment remained free of accident hazards for residents for one of 38 residents reviewed (Resident 55). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 55, dated August 9, 2024, revealed that the resident was cognitively intact. An elopement risk for the resident, dated August 10, 2024, revealed that the resident was an elopement risk and that she required a Wanderguard bracelet (an electronic device that alarms when near the exit door). A nursing note for Resident 55, dated December 12, 2023, at 3:18 p.m. revealed that the resident was visualized exiting the building. She had a history of verbalizing her desire to go home. Wanderguards had been attempted in the past; however, she usually removes them. A nursing note for Resident 55, dated July 19, 2024, revealed that the resident was found outside the facility…

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 personnel files, as well as staff interviews, it was determined that the facility failed to verify registry verification prior to allowing individuals to work as a nurse aide for one of three newly hired nurse aides reviewed (Nurse Aide 3). Findings include: The personnel file for Nurse Aide 3 revealed that she was hired by the facility on July 10, 2024. However, there was no documented evidence that the facility verified the nurse aide's standing with the state nurse aide registry until October 2, 2024. Interview with the Human Resources Director October 2, 2024, at 2:20 p.m. confirmed that Nurse Aide 3 did not have a nurse aide registry check completed prior to her start date and that she should have. 28 Pa. Code 201.29 Personnel Policies and Procedures.

Based on clinical record reviews and staff interviews, it was determined that the facility failed to provide appropriate treatment and services for one of 38 residents reviewed (Resident 40) who had dementia. Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 40, dated July 16, 2024, revealed that the resident was understood, could understand others, had no behaviors, and had diagnosis that included cerebrovascular accident/stroke and anxiety. A care plan for the resident, dated June 17, 2022, revealed that the resident has behaviors including screaming, yelling, refusal of care, throwing items, and being demanding of staff. Observations of Resident 40 on September 30, 2024, at 11:48 a.m. during and after incontinence care provided by Nurse Aides 4 and 5 revealed that she saw snakes on her comforter and dinosaurs outside of her window. Both Nurse Aides 4 and 5 assured the resident that the snakes were not harmful and would be helpful during care and this was a good day for Resident 40 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 facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to maintain accountability for controlled medications (drugs with the potential to be abused) for one of 38 residents reviewed (Resident 12). Findings include: The facility's policy for storage of controlled medications, dated March 15, 2024, revealed that when administering a controlled medication, the controlled drug record form must be signed when the medication is removed from the narcotic box, and the Medication Administration Record (MAR) must be signed after the medication is administered. Both documents must be signed. A significant change Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 12, dated July 26, 2024, revealed that the resident was understood and able to understand, was moderately cognitively impaired, had pain management, had a Stage IV pressure ulcer (wound caused by pressure with bone or tendon exposure), was receiving an opioid (controlled drug), and received hospice care (end 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 a review of facility policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to store medications properly for one of 38 residents (Resident 53) and failed to label multi-dose insulin pens with the date they were opened in one of one medication cart observed (300 Long). Findings include: The facility's policy regarding medication labeling and storage, dated March 15, 2024, revealed that multi-dose medications that have been opened or accessed are to be dated and discarded within 28 days unless the manufacturer specifies a shorter or longer date for the open medication. In addition staff are to prepare and observe the resident taking their medications. A diagnosis record for Resident 53 revealed diagnoses that included cancer of the prostate, high blood pressure, and heart disease. Observations on September 30, 2024, at 11:15 a.m. revealed that the resident was sleeping in his bed and he had a medicine cup full of pills on his bedside table. The medications included one large, white, round tablet; one small,…

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

Based on review of the facility's plans of correction and the results of the current survey, it was determined that the facility's Quality Assurance Performance Improvement (QAPI) committee failed to correct quality deficiencies and ensure that plans to improve the delivery of care and services effectively addressed recurring deficiencies. Findings include: The facility's deficiencies and plans of corrections for State Survey and Certification (Department of Health) surveys ending November 30, 2023; January 29, 2024; April 30, 2024; and July 10, 2024, revealed that the facility developed plans of correction that included quality assurance systems to ensure that the facility maintained compliance with cited nursing home regulations. The results of the current survey, ending October 3, 2024, identified repeated deficiencies related to failure to prove a safe, clean, homelike environment; failure to develop and implement abuse and neglect policies; failure to develop resident care plans; failure to be free from accident hazards; failure to maintain a complete and accurate account of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policies, clinical records, and investigation documents, as well as staff and resident interviews, it was determined that the facility failed to ensure that residents were free from abuse and neglect for one of five residents reviewed (Resident 4). Findings include: The facility's abuse policy, dated March 15, 2024, indicated that residents have the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraint not required to treat resident's symptoms. Failure to report abuse, neglect, exploitation may result in civil monetary penalties. Administration will investigate and report any allegation of abuse within the timeframes as required by federal requirements. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs), dated, April…

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 policies, clinical records, and investigation documents, as well as staff and resident interviews, it was determined that the facility failed to ensure that staff implemented care-planned interventions for one of five residents reviewed, resulting in injury (Resident 4). The facility's comprehensive care plan policy, dated March 15, 2024, indicated that the facility is to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs), dated, April 11, 2024, revealed that Resident 4 was cognitively intact, was clearly understood and able to clearly understand, required assistance with care needs, had weakness to one side, and had no fall history. A care plan related to care needs for Resident 4, dated February 9, 2024,…

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

Based on observations and staff interviews, it was determined that the facility failed to ensure that residents had a clean and homelike environment by failing to ensure that three medication carts and two mechanical lift machines were free of dirt and debris. Findings include: Observations on January 29, 2024, at 10:00 a.m. revealed that there was one stand-up lift machine parked in the hall that had a large accumulation of dirt, dust, debris, and food on the base of the machine. Observations of the full-body lift in the shower room at that time revealed that there was an accumulation of dirt, dust, and debris on the base of the lift. Interview with Nurse Aide 1 on January 29, 2024, at 10:11 a.m. revealed that she was not sure who was supposed to clean the mechanical lift machines. She stated she just uses them and did not notice the dirt or debris on the bases. Observations on January 29, 2024, at 10:18 a.m. revealed that one medication cart on the 300 hall had a large accumulation of hair, dirt, and debris on both of the rear casters. Interview with Licensed Practical Nurse 2 on…

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

Based on clinical record reviews and staff interviews, it was determined that the facility failed to ensure that physician's orders regarding medication administration were followed for one of 39 residents reviewed (Resident 46). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 46, dated October 10, 2023, revealed that the resident was cognitively intact, required extensive assistance with daily care needs, had diagnoses that included kidney failure, and required dialysis (process of removing excess water, solutes, and toxins from the blood in people whose kidneys can no longer perform these functions naturally). Physician's orders for Resident 46, dated July 5, 2023, included an order for the resident to receive a 5 milligram (mg) tablet of Buspirone (anti-psychotic) three times per day every Monday, Wednesday, and Friday; an order dated July 5, 2023, for the resident to recive 0.4-0.3 percent Lubricant eye drops, one drop in both eyes four times a day every Monday, Wednesday, and Friday;…

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

Based on review of facility policy, clinical records, as well as staff interviews, it was determined that the facility failed to ensure that pressure ulcers were monitored and treated for two of 39 residents reviewed (Residents 34, 52). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 52, dated September 7, 2023, revealed that the resident was cognitively intact, required extensive assistance with daily care needs, and had pressure ulcers. A nursing note for Resident 52, dated June 5, 2023, revealed that the registered nurse assessed the resident and found her to have an open area on her right buttock and that she was receiving treatment for the area. A Certified Registered Nurse Practioner (CRNP - an advanced practice registered nurse that can work independent of a physician) wound nurse note for Resident 52, dated June 13, 2023 revealed that she assessed the resident that morning and found a new open area on the resident's right buttock and that she ordered a wound treatment for the area.…

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 manufacturer's instructions, facility policies, and residents' clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that residents were free from significant medication errors, by failing to ensure that insulin was administered as ordered by the physician for two of 39 residents reviewed (Residents 46, 55). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 46, dated October 10, 2023, revealed that the resident was cognitively intact, required extensive assistance with daily care needs, had diagnoses that included kidney failure, and required dialysis (process of removing excess water, solutes, and toxins from the blood in people whose kidneys can no longer perform these functions naturally). Physician's orders for Resident 46, dated August 1, 2023, included an order for the resident to receive 14 units of Novolog Insulin at 12:00 p.m. everyday. A review of Resident 46's Medication Administration Record (MAR),…

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 policies, as well as observations and staff interviews, it was determined that the facility failed to store and prepare food under sanitary conditions in the kitchen and in one of two resident pantries. Findings include: The facility's policy regarding dating and labeling food, dated February 12, 2023, indicated that all food that requires time and temperature control should be labeled with the name, the date the food was made, and the use by date. The guidelines established by the United States Department of Agriculture (USDA) for determining the length of time that the shelf-stable item can be maintained in dry storage would be used. The marking system shall consist of a color-coded label, the day/date of opening, and the day/date the item must be consumed or discarded. The facility's policy regarding storage of food brought in by family or visitors, dated February 12, 2023, indicated that the facility may refrigerate labeled and dated prepared items in the nourishment refrigerator. Observations in the kitchen's dry storage on November 27, 2023, at 10:12 a.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 review of facility policy, observations, clinical record reviews, and staff interviews, it was determined that the facility failed to enhance each resident's dignity by failing to provide privacy during wound care for one of 39 residents reviewed (Resident 55). Findings include: Facility policy regarding resident privacy, dated February 16, 2023, indicated that staff would provide care and treatment in such a way to maintain dignity and privacy. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 55, dated September 5, 2023, indicated that the resident was alert and oriented, cognitively intact, required substantial assistance, and had unstageable pressure ulcers (wounds caused by pressure). Observations of wound care on November 11, 2023, at 3:35 p.m. revealed that Licenced Practical Nurse (LPN) 1 changed Resident 55's dressing on the left lower leg. LPN 1 did not close the door or arrange the curtain to provide privacy. Resident 55's roommate was in the other bed and there was another resident in the…

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

Based on review of policies and personnel files, as well as staff interviews, it was determined that the facility failed to complete work-related reference checks upon hire for five of five staff reviewed (Nurse Aide 11 and 12, Licensed Practical Nurse (LPN) 13, Registered Nurse (RN) 14, and Dietary Aide 15). Findings include: The facility's policy regarding abuse and screening potential employees, dated February 16, 2023, revealed that the purpose of the policy was to ensure that the facility will screen employees for a history of abuse, neglect or mistreating residents by attempting to obtain information from previous employers and /or current employers. The purpose is to ensure that the facility is doing all that is within its control to prevent occurrences. The personnel file for Nurse Aide 11 revealed that she was hired on October 23, 2023. As of November 30, 2023, there was no documented evidence that the work-related reference checks were completed. The personnel file for Nurse Aide 12 revealed that she was hired on August 15, 2023. As of November 30, 2023, there was no…

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

Based on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to develop and implement comprehensive care plans that included specific and individualized interventions to address specific care needs for two of 39 residents reviewed (Residents 3, 34). Findings include: The facility's policy regarding care plans, dated February 16, 2023, indicated that individualized, comprehensive, person-centered care plans would be developed and implemented based on the resident's rights, including measurable objectives and timeframes to meet a resident's medical, nursing, mental, and psychosocial needs identified in the resident's comprehensive assessment. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's care needs and abilities) for Resident 3, dated September 3, 2023, indicated that the resident was cognitively impaired, required extensive assistance with personal care needs, and had diagnoses that included dementia. Nurse's notes for Resident 3, dated February 23, 2023, revealed that the…

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

Based on review of the Pennsylvania Nursing Practice Act, clinical records, and the facility's investigative documents, as well as staff interviews, it was determined that the facility failed to ensure that a professional (registered) nurse completed a timely assessment when changes in condition occurred for one of 39 residents reviewed (Resident 95). Findings include: The Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.11 (a)(1)(2)(4) indicated that the registered nurse was to collect complete and 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. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 95, dated August 21, 2023, revealed that the resident was cognitively intact and required extensive assistance from staff for daily care. A diagnosis list for the…

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

Based on a review of facility policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that residents were transported in a safe manner for one of 39 residents reviewed (Resident 67). Findings include: The facility's policy regarding leg rests, dated February 16, 2023, revealed that for residents who self propel, the use of leg rests would be limited to when being transported by staff. An annual Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 67, dated November 2, 2023, revealed that the resident had moderately cognitive impairment, was sometimes understood, and could sometimes understand. A care plan for the resident, dated November 7, 2019, revealed that the resident had a self-care deficit related to arthritis and deconditioning, was not ambulatory, and had a broda chair with foam cushions and bilateral leg rests. Observations on November 27, 2023, at 12:13 p.m. revealed that Nurse Aide 2 pushed Resident 67 in a broda chair without foot rests…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policies, clinical record reviews, and staff interviews, it was determined that the facility failed to change an intravenous line dressing and caps (caps that disinfect IV ports) as ordered by the physician for one of 39 residents reviewed (Resident 109). Findings include: The facility's policy, dated February 16, 2023, indicated that central line (a tube placed in the neck, chest or arm to deliver medications) dressing changes are performed at established intervals to minimize site complications, and immediately when the integrity of the dressing is compromised. An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 109, dated October 17, 2023, indicated that the resident was alert and oriented, had diagnoses that included septicemia (a serious infection in the bloodstream), and received intravenous medications (IV therapy - medications administered directly into a vein). Physician's orders, dated October 22, 2023, indicated…

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 reviews, as well as observations and staff interviews, it was determined that the facility failed to ensure that a dialysis emergency kit containing appropriate equipment in order to stop bleeding was at the resident's bedside per physician's orders and care plans for one of 39 residents reviewed (Resident 72). Findings include: The facility's policy regarding dialysis care, dated February 16, 2023, indicated that the facility would ensure that residents undergoing dialysis treatments were assessed and safe, and that the facility, in collaboration with the dialysis unit, would meet the needs of the resident. An annual Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 72, dated November 9, 2023, indicated that the resident was cognitively intact and required hemodialysis (a process of cleaning the blood of toxins and returning it into the body). A care plan for the resident, dated March 17, 2023, revealed that the resident had dialysis related to end-stage renal disease and required an emergency…

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 facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to maintain accountability for controlled medications (drugs with the potential to be abused) for one of 39 residents reviewed (Resident 50). Findings include: The facility's policy for medication administration, dated February 16, 2023, revealed that the nurse responsible for administering the medication was responsible for charting the drug. The medication shall be charted as soon after the medication administration as possible. Each dose of a medication shall be initialed on the Medication Administration Record (MAR). An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 50, dated October 2, 2023, revealed that the resident was understood and able to understand, had a diagnosis of Chronic Obstructive Pulmonary Disease (COPD - a group of diseases that cause airflow blockage and breathing-related problems), depression, chronic pain syndrome, and anxiety. Physician's orders for Resident 50,…

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

Based on review of facility policies and medication package inserts, as well as observations and staff interviews, it was determined that the facility failed to label medication with the date it was opened in one of two medication rooms reviewed (300 hall), and failed to ensure that controlled medications were stored in a separately-locked, permanently-affixed compartment in two of two medication refrigerators reviewed (200 and 300 Hall). Findings include: The facility's policies regarding medication administration and medication storage, dated February 16, 2023, revealed that once opened, a multi-dose vial was to have the date it was opened recorded on the container, and that controlled medications were stored in a separately-locked, permanently-affixed compartment in the medication refrigerator. Observations in the 300 hall medication room refrigerator on November 30, 2023, at 8:10 a.m. revealed that an opened vial of Tubersol (a medication used to test for tuberculosis - a bacterial infection) was not labeled with the date it was opened. Further observations revealed that the…

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

Based on review of clinical records and observations, as well as resident and staff interviews, it was determined that the facility failed to honor food preference for one of 39 residents reviewed (Resident 50). Findings include: A policy for resident food preferences, dated February 16, 2023, revealed that upon admission (or within twenty-four hours after admission), the dietitian or nursing staff will identify a resident's food preferences. Nursing staff will document the preferences in the care plan. An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 50, dated October 2, 2023, revealed that the resident was understood, could usually understand, and required supervision from staff for eating. Observations during the lunch meal on November 27, 2023, at 12:24 p.m. revealed that Resident 50 received her tray in her room. The meal slip for Resident 50 indicated that she was to have mashed potatoes and gravy with every lunch meal. The lunch tray for Resident 50 did not have mashed potatoes and gravy on it upon…

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 staff interviews, it was determined that the facility failed to maintain clinical records that were complete and accurately documented for two of 39 residents reviewed (Residents 1, 95). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated September 14, 2023, revealed that the resident had diagnoses that included chronic ischemic heart disease and cerebral palsy, required extensive assistance for care, was independent with locomotion, and required oxygen at bedtime. A care plan for the resident indicated that he had recovered from COVID pneumonia, had chronic bronchitis and asthma with intermittent shortness of breath, and used nebulizer treatments as needed. Physician's orders for Resident 1, dated March 29, 2022, included an order to change the nebulizer mask and tubing weekly on Thursday night shift and place in a dated plastic bag when not in use. Observations in Resident 1's room on November 28, 2023, at 1:47 p.m. revealed a date on the…

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

Based on review of the facility's plans of correction and the results of the current survey, it was determined that the facility's Quality Assurance Performance Improvement (QAPI) committee failed to correct quality deficiencies and ensure that plans to improve the delivery of care and services effectively addressed recurring deficiencies. Findings include: The facility's deficiencies and plans of corrections for State Survey and Certification (Department of Health) survey ending January 11, 2023, revealed that the facility developed plans of correction that included quality assurance systems to ensure that the facility maintained compliance with cited nursing home regulations. The results of the current survey, ending November 30, 2023, identified repeated deficiencies related to failure to comply with abuse policies, failure to develop resident care plans, failure to meet professional standards of care, failure to provide quality care, failure to provide an environment free of accidents or hazards, failure to keep complete and accurate medical records, and failure to follow…

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 policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that proper hand washing/hand hygiene was completed during wound care for two of 39 residents reviewed (Residents 39, 55). Findings include: The facility's policy regarding wound care and hand washing/hand hygiene, dated February 16, 2023, revealed that staff were to provide wound care in a manner to decrease potential for infection and/or cross-contamination. In addition, gloves should be removed and hand hygiene done prior to moving from a dirty to clean task. A comprehensive Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 39, dated November 2, 2023, indicated that the resident was severely cognitively impaired, required extensive assistance from staff for care tasks, had diagnoses that included diabetes and peripheral vascular disease (a circulation disorder in the blood vessels), and had a Stage 3 pressure ulcer (skin breakdown from pressure that exposes fat under the…

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

Based on review of policies and clinical records, as well as observations and resident and staff interviews, it was determined that the facility failed to ensure that the call bell system was adequately equipped to allow residents to call for staff assistance, by failing to ensure that the resident's call bell was in working order for one of 39 residents reviewed (Resident 64). Findings include: The facility's policy regarding call lights: accessibility and timely response, dated February 16, 2023, revealed that the facility is to be adequately equipped with a call light at each resident's bedside, toilet, and bathing facility to allow residents to call for assistance. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 64, dated August 15, 2023, indicated that the resident was confused and that she was independent for her daily care needs. The resident's care plan, dated October 24, 2021, indicated that she was at risk for falls, her call light was to be within reach, and that staff were to respond promptly.…

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.