Kadima Rehabilitation & Nursing At Campbelltown

Based on facility policy review, clinical record review, and observation, it was determined that the facility failed to follow policies and procedures to prevent the spread of infection for three of 19 sampled residents. (Residents 28, 38, 201) In addition, the facility failed to have a documented water management program for Legionella. Failure to have a water management program had the potential to affect 45 of 45 residents in the facility. Findings include: Review of the facility policy entitled, Enhanced Barrier Precautions, revealed that enhanced barrier precautions (EBP) were to be used with any resident with a wound or indwelling medical device during encounters when contact was expected, including during wound care and the care of feeding tubes. Precautions included the use of protective gowns and gloves during high-contact care activities. Observations made during all days of the survey revealed none of the residents with chronic wounds or indwelling medical devices had signs posted to indicate that personal protective equipment (PPE) was required and no PPE was observed 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 observation, it was determined that the facility failed to maintain an effective pest control program in the kitchen and on the nursing unit. Findings include: Observations in the kitchen on June 3, 2025, at 10:27 a.m. and 12:05 p.m., revealed flies in the dishwashing and food preparation areas. Observations on the nursing unit on June 3, 2025, from 10:28 a.m. through 12:40 p.m., revealed flies in resident rooms [ROOM NUMBER], at the nurses station, and in the resident shower room. Observations on the nursing unit on June 4, 2025, from 10:10 a.m. through 1:00 p.m., revealed flies in resident rooms [ROOM NUMBERS], and in the hallway by the food cart that was holding resident meal trays during the tray service. 28 Pa. Code 201.18(b)(3)(e)(2.1) Management

Based on facility policy review, resident group interviews, review of facility grievance forms, and staff interview, it was determined that the facility failed to act promptly upon resident grievances. Findings include: Review of a facility policy entitled, Grievance Policy, revealed that the reasonable timeframe the resident could expect a completed review of a grievance was within five days. The grievance official would issue written grievance decisions to the resident. The written grievance decision would include a statement as to whether the grievance was confirmed or not confirmed, any corrective action taken or to be taken by the facility as a result of the grievance, and the date the written decision was issued. During a confidential group interview conducted on June 4, 2025, at 1:30 p.m., six of 12 residents reported that the facility did not act promptly upon resident grievances. Review of resident grievance forms revealed that grievances were completed and submitted on the following dates: December 31, 2024, February 3, 2025 (three grievances for this date), March 26,…

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 notify the resident and the resident's representative of the bed hold and transfer, including the reasons for the move, and Ombudsman information, in writing upon transfer from the facility for seven of seven sampled residents who were transferred to the hospital. (Residents 21, 31, 36, 38, 39, 49, 201) Findings include: Clinical record review revealed that Resident 21 was transferred and admitted to the hospital on [DATE], after a change in condition. There was no documentation to support that the resident's representative was provided written information regarding a bed hold or the transfer to the hospital. Clinical record review revealed that Resident 31 was transferred and admitted to the hospital on [DATE], after a change in condition. There was no documentation to support that the resident's representative was provided written information regarding a bed hold or the transfer to the hospital. Clinical record…

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 policy review, clinical record review, and staff interview, it was determined that the facility failed to assess and document the status of wounds or provide physician ordered treatments to prevent new or worsened pressure ulcers for six of six sampled residents with wounds. (Residents 9, 24, 28, 36, 38, 201) Findings include: Review of the facility policy entitled, Skin and Wound Management Policy, last revised April 3, 2025, revealed that residents identified with skin impairments, their wound status would be assessed and documented in the electronic medical record, on the Wound Evaluation Flow Record by the Registered Nurse; for residents followed by contracted wound physician services or wound clinic physician, the facility would utilize the physician wound progress note to monitor wound status in addition to the in house Registered Nurse assessment. Clinical record review revealed that Resident 9 had diagnoses that included multiple sclerosis and adult failure to thrive. Review of wound consultation notes revealed that the resident had a stage four pressure…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy review, clinical record review, and staff interview, it was determined that the facility failed to adequately monitor and assess the nutritional status for seven of seven sampled residents at nutritional risk. (Residents 2, 9, 13, 18, 24, 28, and 38) Findings include: Review of the faiclity policy entitled, Nutrition Management, revealed that the facility would view bilateral edema and muscle wasting as potential indicators for malnutrition. The facility would also consider depression, dementia, and therapeutic and mechanically altered diets as potential risk factors for malnutrition. Clinical record review revealed that Resident 2 had diagnosis that included diabetes and feeding difficulties. Review of the Minimum Data Set assessment dated [DATE], revealed the resident had no cognitive impairment and required supervision or touching assistance with eating. Review of the current care plan revealed Resident 2 had a nutritional problem with an intervention to monitor and record weights. A…

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

Based on facility policy review, clinical record review, and staff interview, it was determined that the facility failed to ensure that staff provided services consistent with professional standards, including monitoring and ongoing communication, for two of two sampled residents receiving dialysis (process of removing excess toxins and water from the blood). (Residents 24, 28) Findings include: Review of the facility policy entitled, Hemodialysis Policy and Procedure, revealed a communication notebook with relevant information regarding the resident's medication, condition, and treatment would be shared between the facility and the dialysis provider. In addition, nursing staff would check the access site to ensure appropriate function, prevent infection, and prevent coagulation (blood clotting) at the site each shift. Clinical record review revealed that Resident 24 had a diagnosis of end stage renal disease which required dialysis. Review of the resident's dialysis communication forms revealed no evidence that staff had completed and obtained dialysis communication forms with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy review, clinical record review, and staff interview, it was determined that the facility failed to ensure that pharmacy recommendations were reviewed by the physician in a timely manner for four of five sampled residents. (Residents 14, 24, 44, 47) Findings include: Review of the facility policy entitled, Pharmacy Services, revealed that a licensed pharmacist would review the drug regimen of each resident at least once per month. The pharmacist would report any irregularities to the attending physician, the Director of Nursing, and the Medical Director. The reports would be acted upon, signed off, and addressed in the physician's progress note. Clinical record review revelaed that Resident 14 was admitted to the facility on [DATE], with diagnoses that inlcuded schizoaffective disorder, intermittent explosive disorder, major depressive disorder, and anxiety. Review of monthly drug regimen reviews revealed that the pharmacist made recommendations regarding Resident 14's medications 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 observation, review of facility documentation, resident interview, staff interview, and results of a test tray audit, it was determined that the facility failed to provide food that was palatable and at an appetizing temperature on the nursing unit. Findings include: Review of the facility's Meal Test Tray, form revealed that hot foods were to be above 135 degrees Fahrenheit (F) when served. In an interview on June 3, 2025, at 11:30 a.m., resident 28 stated that the food was often served cold. A test tray conducted on June 4, 2025, at 12:36 p.m., on the nursing unit, revealed mixed vegetables at a service temperature of 116.6 degrees F. The Director of dining stated that the hot foods should be served at a temperature of 135-140 degrees F. In an interview during the lunch meal on June 4, 2025, at 12:43 p.m., Resident 201 stated that the mixed vegetables were cold when served. 28 Pa. Code 201.14 Responsibility of licensee.

Based on facility policy review, clinical record review, observation and staff interview, it was determined the facility failed to assess a resident for a physical restraint and conduct an on-going assessment of a restraint for one of 19 sampled residents. (Resident 3) Findings include: Review of the facility policy entitled Physical Restraints, revealed that the need for restraints would be reevaluated monthly and that the interdisciplinary assessment team would develop a comprehensive care plan for the resident. Clinical record review revealed that Resident 3 had diagnoses that included severe intellectual disabilities, anxiety, and lack of coordination. Observations on June 3, 2025 from 11:28 a.m. through 1:30 p.m., June 4, 2025 from 9:00 a.m. through 1:00 p.m., and on June 5, 2025 from 9:37 a.m. through 12:30 p.m., revealed Resident 3 in her wheelchair with a seat belt intact. In an interview on June 5, 2025, at 11:31 a.m., Nurse Aide 1 stated Resident 3 could not self remove the seat belt. There was no documented evidence that the facility obtained a physician's order or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff interview, it was determined that the facility failed to complete an accurate Minimum Data Set (MDS) assessment for one of 19 sampled residents. (Resident 28) Findings include: Clinical record review revealed that Resident 28 had diagnoses that included end stage renal disease, diabetes, and dependence on renal dialysis. Review of Resident 28's clinical record revealed a physician's order dated December 19, 2023, for dialysis three time per week. Review of Resident 28's MDS dated [DATE], did not indicate that Resident 28 was dependent on renal dialysis. In an interview on June 5, 2025, at 9:57 a.m., the Administrator confirmed Resident 28's MDS was inaccurate. CFR 483.20(g) Accuracy of Assessments Previously cited 7/18/24

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff interview, it was determined that the facility failed to complete a Preadmission Screening to identify a mental disorder for one of 19 sampled residents. (Resident 14) Findings include: Clinical record review revealed that Resident 14 was admitted to the facility on [DATE], with diagnoses that included borderline personality disorder, schizoaffective disorder, intermittent explosive disorder, major depressive disorder, and generalized anxiety. There was a lack of evidence that the facility completed or obtained a Preadmission Screening for Resident 14. In an interview on June 6, 2025, at 11:37 a.m., the Administrator confirmed that there was a lack of evidence that the facility completed or obtained a Preadmission Screening for Resident 14.

Based on clinical record review and resident interview, it was determined that the facility failed to provide services to maintain adequate grooming and hygiene, and assistance with eating for one of 19 sampled residents. (Resident 9) Findings include: Clinical record review revealed that Resident 9 had diagnoses that included multiple sclerosis, muscle weakness, adult failure to thrive, and dysphagia. Review of the care plan revealed that staff were to check the resident's nail length, trim, and clean on bath day and as necessary, and report to the nurse with any changes. On June 3, 2025, at 1:44 p.m., the resident was observed in her room. Her nails were long, dirt was observed under the nails. She stated that she preferred her nails to be short, staff have not offered to provide nail care, and she has not refused. On June 5, 2025, at 11:53 a.m., the resident was observed in bed, her nails remained long. She stated that staff had not offered to provide nail care, and she would like her nails to be cut. Review of the care plan revealed that the resident required assistance from…

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 policy review, clinical record review, and staff interview, it was determined that the facility failed to ensure that adequate catheter care was provided for two of two sampled residents with an indwelling urinary catheter. (Residents 24 and 31) Findings include: Review of the facility policy entitled, Urinary Catheter Care, last revised January 31, 2013, revealed that staff would perform perineal care to the resident every eight hours to prevent skin rashes and breakdown, empty the collection bag at least every eight hours and as needed (PRN), cleanse the catheter from the insertion site to approximately four inches outward, and check the drainage tubing and bag to ensure that the catheter was draining properly and kept off of the floor. Clinical record review revealed that Resident 24 had diagnoses that included urogenital implants. The resident required the use of a urinary catheter. On May 1, 2025, a physician's order for foley catheter care every shift was discontinued. There was no new order for catheter care placed and the resident continued with a foley…

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 as needed pain medication was administered per the physician's order and that nonpharmacological interventions were attempted prior to the administration of as needed pain medication for one of 19 sampled residents. (Resident 24) Findings inlcude: Clinical record review revealed that Resident 24 had diagnoses that included muscle weakness, low back pain, and neuropathy. Review of the care plan revealed that the resident was on pain medication therapy and that pain medication was to be administered as ordered. A physician's order dated May 5, 2025, directed staff to administer oxycodone (a narcotic pain medication) every four hours as needed for severe pain at pain levels seven through ten. Review of the Medication Administration Record (MAR) for May 2025, revealed that staff administered the oxycodone when the resident's pain was noted at a level less than seven on 24 occasions in May 2025. Review of a physician's order dated May 31, 2025, directed staff to administer…

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 clinical record review, it was determined that the facility failed to ensure that medications/biologicals were securely stored in a medication or treatment cart in on one of one nursing units. Findings include: Observations on June 3, 2025, at 12:19 p.m., in Resident 14's revealed a tube of medicated cream on the bed. Clinical record review revealed no assessments for medication self administration or bedside storage of medications. Observations on June 4, 2025, at 8:37 a.m., and on June 5, at 10:15 a.m. and 12:00 p.m., in Resident 43's room revealed two bottles of nasal medications on the bedside table. Clinical record review revealed no assessments for medication self administration or bedside storage of medications. CFR 438.45(H) Storage of Drugs and Biologicals Previously cited 7/18/24 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on clinical record review and resident interview, it was determined that the facility failed to treat a fungal infection timely for one of three sampled residents. (Resident 1) Findings include: Clinical record review revealed that Resident 1 had diagnoses that included heart failure and a history of cancer. According to the Minimum Data Set assessment, dated March 20, 2025, the resident was able to clearly communicate and understand others and had no memory impairments. On April 29, 2025, a nurse noted that the resident was examined by an ear, nose, and throat specialist. According to a nurse's note dated May 7, 2025 (a late entry), the specialist's office informed the facility that the resident had a fungal infection in her mouth and required antifungal lozenges (clotrimazole). There was no documented evidence that the resident received the medication until May 12, 2025. In an interview on May 27, 2025, at 12:00 p.m., Resident 1 stated that she had discomfort in her mouth and didn't receive the medicated lozenges until five days after they were ordered by the specialist. 28…

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 maintain medical records that were accurate for three of five sampled residents. (Residents 3, 4, and 5) Findings include: Clinical record review revealed that Resident 3 was admitted to the facility on [DATE], with diagnoses that included schizoaffective disorder, intermittent explosive disorder, anxiety, depressive disorder, and borderline personality disorder. Review of the care plan revealed that the resident had a problem with mood and the intervention was for staff to obtain behavioral health consultations (consults) as needed. On January 7, 2025, the resident's practitioner noted that she was feeling overwhelmed with placement in a new facility. The practitioner noted that the resident was referred for behavioral health services. On February 3, 2025, staff noted that the resident requested to speak to a mental health provider as she had been feeling manic and depressed. On February 4, 2025, 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, it was determined that the facility failed to provide a safe, clean, and comfortable environment on one of one nursing units. Findings include: On April 17, 2025, from 10:00 a.m. to 3:25 p.m., the following was observed: The right-side swinging glass door of the facility front door is did not open. In the dining room, the interior entrance door handle and windows were dirty with a white substance. There was garbage on the floor under the dining room exterior windows. There was a reddish stain on the door frame of the linen closet across from the nurse station. In the hallway, there was damage on the wall's wallboard and wallpaper at rooms 1, 3, 8, 24, 27, and 30. In room [ROOM NUMBER], the floor was sticky with a black residue between the door and A bed. There was a urine smell. In room [ROOM NUMBER], the floor was sticky with a black residue between the door and the bed. In room [ROOM NUMBER], there was a damaged spot on the wall behind the A bed. In room [ROOM NUMBER], the floor was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy review, facility documentation, clinical record review, resident interview, and staff interview, it was determined that the facility failed to immediately report an allegation of abuse or injury of unknown origin to the Administrator/Abuse Prevention Coordinator of the facility and the State Survey Agency for one of six sampled residents. (Resident 6) Findings include: Review of the facility policy, Abuse Reporting and Investigation, last reviewed November 9, 2024, revealed that all suspected or alleged incidents of abuse, neglect, or exploitation would be reported to the Administrator immediately. The State Agency would be notified of the alleged or actual event of abuse within two hours. Clinical record review revealed that Resident 6 had diagnoses that included Parkinsonism. The Minimum Data Set assessment dated [DATE], indicated that the resident was not cognitively impaired and needed substantial/maximal staff assistance with showering or bathing. Resident 6 stated in an interview…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy review, clinical record review, review of facility documentation, resident interview, and staff interview, it was determined that the facility failed to thoroughly investigate an allegation of abuse for one of six sampled residents. (Resident 6) Findings include: Review of the facility policy, Abuse Reporting and Investigation, last reviewed November 9, 2024, revealed that all suspected or alleged incidents of abuse, neglect, or exploitation would be investigated. Clinical record review revealed that Resident 6 had diagnoses that included Parkinsonism. The Minimum Data Set assessment dated [DATE], indicated that the resident was not cognitively impaired and needed substantial/maximal staff assistance with showering or bathing. In an interview on April 17, 2025, at 11:10 a.m Resident 6 reported that on March 28, 2025, two aides treated her in an abusive and humiliating manner during her shower by forcefully removing her clothing, shoving her under first cold, then hot water, and roughly…

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, resident interview, and staff interview, it was determined that the facility failed to provide behavioral health services for one of three sampled residents with mood and behavior concerns. (Resident 6) Findings include: Clinical record review revealed that Resident 6 had diagnoses that included schizoaffective disorder, borderline personality disorder, intermittent explosive disorder, and anxiety disorder. Review of the care plan dated January 21, 2025, revealed the resident had a history of mood problems and used anti-anxiety and anti-depressant medications. The interventions included notification of the resident's physician of mood changes and behavioral problems and referral to behavioral health services as needed. On March 25, 2025, the psychiatric nurse practitioner recommended referral to outpatient mental health therapy for increased anxiety. On April 3, 2025, notes indicated the resident had requested referral to outpatient therapy for increased anxiety. There was no evidence that staff notified the resident's physician of the alteration 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 policy review and staff interview, it was determined that the facility did not have a credentialed Infection Preventionist (IP). Findings include: Review of the facility policy entitled, Infection Control, last reviewed August 21, 2023, revealed that the facility staff was to report all infections to the IP, who would then conduct routine surveillance. In an interview on December 17, 2024, at 11:00 a.m., the Administrator stated that the facility did not have staff that was a credentialed Infection Preventionist. CFR 483.80 (b) Infection Preventionist Previously cited 7/18/24 28 Pa. Code 211.10(d) Resident care policies. 28 Pa. Code 211.12 (d)(1)(3)(5) Nursing services

Based on staff interview, it was determined that the facility failed to employ a full-time qualified dietary services manager in the absence of a full-time qualified dietitian. Findings include: In an interview conducted on December 17, 2024, at 11:00 a.m., the Administrator stated that there was not a full-time dietitian employed onsite at the facility and that the facility did not employ a qualified certified dietary manager in the absence of a full-time dietitian. 28 Pa. Code 201.18(b)(3) Management.

Based on clinical record review it was determined that the facility failed to ensure that a physcian ordered medication was available from the pharmacy for one of six sampled residents. (Resident 1) Findings include: Clinical record review revealed that Resident 1 had diagnoses that included an open wound of the left lower leg and lymphedema. Review of nursing documentation dated December 4, 2024, revealed that the resident was alert and oriented and able to make her needs known. On December 12, 2024, a physican ordered for staff to administer a narcotic medication, Oxycontin, every 12 hours for pain. Review of the medication administration record for December 2024, revealed that the medication was not administered on December, 14, 15, and 16 for a total of six doses. Further review of nursing documentation revealed that the medication had not been administered due to the medication being unavailable from the pharmacy. 28 Pa Code 211.12(d)(5) Nursing services.

Based on a review of the facility's meal schedule, observation, and resident and staff interview, it was determined that the facility failed to ensure that meals were served at regularly scheduled times in accordance with resident preferences on the nursing unit. Findings include: Review of the facility's meal schedule revealed that the scheduled mealtime for the back hall of the nursing unit was 12:15 p.m., and mealtime for the front hall was 12:30 p.m. During interviews on December 13, 2024, from 9:57 a.m. through 11:31 a.m., Residents 1, 2, 3, 4, 5, and 6, stated that they usually received their meals late. Observation of the back hall on December 13, 2024, revealed that Residents 4 and 5 received their lunch trays between 12:45 and 12:59 p.m., over 30 minutes past the scheduled mealtime. Observation of the front hall on December 13, 2024, revealed that Residents 1, 2, 3, and 6, received their lunch trays between 1:14 p.m. and 1:30 p.m., over 44 minutes past the scheduled mealtime. In an interview on December 13, 2024, at 1:26 p.m., the Administrator confirmed that meals were…

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, review of the facility shower schedule, and staff and resident interview, it was determined that the facility failed to provide services that enhanced each resident's quality of life by offering showers as scheduled for four of seven sampled residents. (Residents 1, 2, 3, 4) Findings include: Clinical record review revealed that Resident 1 had diagnoses that included difficulty walking and muscle weakness. Review of the care plan revealed that the resident required assistance from staff for activities of daily living (ADLs). Review of the facility shower schedule revealed that the resident was to be offered a shower weekly on Thursdays. In an interview on November 25, 2024, at 11:30 a.m., the resident stated that staff had not offered to provide a shower weekly per her preference. There was no documentation to support that Resident 1 received any showers in November 2024. There were no documented refusals. Clinical record review revealed that Resident 2 had diagnoses that included muscle weakness and anxiety. Review of the care plan 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 clinical record review and staff interview, it was determined that the facility failed to ensure physician's orders were implemented for two of seven sampled residents. (Residents 3, 4) Findings include: Clinical record review revealed that Resident 3 had diagnoses that included protein calorie malnutrition, anemia, and muscle weakness. Review of a wound care consultation dated November 19, 2024, revealed that the resident had a stage three pressure ulcer to her sacrum. A physician's order dated September 26, 2024, directed staff to cleanse the sacral wound with normal saline solution (NSS), apply calcium alginate, and cover with a foam dressing once daily on day shift. Review of the November 2024 treatment administration record (TAR) revealed no evidence that staff provided the treatment as ordered on six of 24 days. Clinical record review revealed that Resident 4 had diagnoses that included muscle weakness, chronic kidney disease, and required hemodialysis. Review of a wound care consultation dated November 19, 2024, revealed that the resident had a non-pressure wound to…

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

Based on a review of documentation, policy review, and staff interview, it was determined that the facility failed to ensure that all required staff persons were in attendance at quarterly Quality Assurance and Performance Improvement (QAPI) Committee meetings for four of four quarters reviewed. In addition, the facility failed to ensure that QAPI meetings were held on a quarterly basis for three of four quarters between June 2023 through June 2024. Findings include: A review of Quality Assurance and Performance Improvement (QAPI) Committee meeting sign-in sheets for the period of July 2023 through June 2024, revealed no documentation of meetings was available for the third quarter 2023, July - September, 2023; first quarter 2024, January - March, 2024; and second quarter 2024, April - June, 2024. The Infection Preventionist was not present for the fourth quarter 2023, October - December, 2023, meeting held on January 18, 2024. In an interview on July 18, 2024, at 11:24 a.m., the interim Administrator confirmed there has been only one QAPI meeting since the last survey in 2023 and…

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

Based on policy review and staff interview, it was determined that the facility did not have a credentialed Infection Preventionist (IP). Findings include: Review of the facility policy entitled, Infection Control, last reviewed August 21, 2023, revealed that the facility staff was to report all infections to the IP, who would then conduct routine surveillance. In an interview on July 18, 2024, at 9:30 a.m., the Director of Nursing stated that the facility had no staff that were credentialed infection preventionists. 28 Pa. Code 211.10(d) Resident care policies. 28 Pa. Code 211.12 (d)(1)(3)(5) Nursing services.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, it was determined that the facility failed to provide a clean, homelike, and comfortable environment on one of one nursing units. (Skilled Nursing Unit) Findings include: During a tour of the Skilled Nursing Unit on July 16, 2024, between 10:45 a.m. and 1:20 p.m., and again on July 18, 2024, between 10:25 a.m. and 10:50a.m., the following were observed: In the shared bathroom between rooms [ROOM NUMBERS], there was peeling paint on the walls behind and beside the sink. Outside of room [ROOM NUMBER], there was peeling paint on both sides of the doorway. In room [ROOM NUMBER], a black substance covered the floor from the entrance and extended under A bed. The curtain for bed A had a large stain on it. At the nursing station entrance there was a hard piece of wall molding that was peeling off the wall and sticking out into the hallway. In the bathroom across the hallway from the nurses' station, a black substance was noted around the perimeter of the room on the grout lines and tiles adjacent…

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 Resident Assessment Instrument (RAI) User's Manual, clinical record review and staff interview, it was determined that the facility failed to document why information was not coded and failed to complete an accurate Minimum Data Set (MDS) assessment for two of 15 sampled residents. (Residents 17, 24) Findings include: Review of the Long-Term Care Facility RAI User's Manual dated October 2023, which provided instructions and guidelines for completing MDS assessments (federally mandated assessment tool that evaluates a resident's functional capabilities and helps nursing home staff identify health problems), revealed for section K that if a resident cannot be weighed, the standard no information code should be used and then the reason should be documented on the resident's clinical record. Clinical record review revealed that Resident 17's section K in the MDS assessment dated [DATE], had the no information code entered for height and weight. Review of the clinical record revealed 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff interview, it was determined that the facility failed to develop a comprehensive care plan to meet each resident's needs identified in the comprehensive assessment for two of 15 sampled residents. (Residents 17, 46) Findings include: Clinical record review revealed Resident 17 was admitted to the facility on [DATE], and had diagnoses that included end stage renal disease. The Minimum Date Sat (MDS) Care Area Assessment (CAA) summary dated November 3, 2023, noted that the resident's nutritional status was to be addressed in the care plan. There was no documented evidence that interventions to address Resident 17's nutritional status were included in the current care plan. Clinical record review revealed Resident 46 was admitted to the facility on [DATE], and had diagnoses that included psychological problems, an enlarged prostate and difficulty walking. The MDS CAA summary dated March 20, 2024, noted that the resident's occasional incontinence was to be addressed in the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff interview, it was determined that the facility failed to schedule a follow-up doctor's appointment for one of 15 sampled residents. (Resident 2) Findings include: Clinical record review revealed that Resident 2 was admitted to the facility on [DATE], following a hospitalization with diagnoses that included a urinary tract infection and diabetes. Resident 2's discharge instructions from the hospital noted the presence of a salivary gland tumor and recommended the resident follow-up with an oncologist. A nurse practitioner's admission note, dated March 4, 2024, noted that Resident 2 had a salivary gland tumor that was most likely cancerous and oncology follow-up was scheduled. Subsequent progress notes by the physician between March 4 and May 20, 2024, continued to note the same information regarding the tumor. There was lack of evidence to support the resident had been evaluated by an oncologist or that an appointment was scheduled. In an interview on July 18, 2024, at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy review, clinical record review, and staff interview, it was determined that the facility failed to assess significant weight changes in accordance with facility policy for two of 15 sampled residents. (Residents 2, 24) Findings include: According to the facility policy entitled, Nutrition Management and Weight Policy, last reviewed [DATE], facility staff was to monitor resident weights and report any significant changes (5 percent in a month, 7.5 percent in 3 months, or 10 percent in 6 months) to the dietitian. The dietitian and the interdisciplinary team were to evaluate the weight changes and discuss them at a nutrition meeting. These meeting were to be held at least quarterly. Clinical record review revealed that Resident 2 had diagnoses that included diabetes and heart disease. According to the Minimum Data Set (MDS) assessment, dated [DATE], the resident was cognitively impaired, required assistance from staff for eating, and had significant weight loss. The Care Area Assessment,…

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 policy review, staff interview, and clinical record review, it was determined that the facility failed to provide services consistent with professional standards of practice and the facility failed to develop and implement a care plan for one of three sampled residents receiving dialysis (process of removing excess toxins and water from the blood). (Resident 17) Findings include: A review of the facility policy entitled, Hemodialysis, last reviewed August 21, 2023, revealed that all residents receiving hemodialysis would have their access site (a way to reach the blood for hemodialysis) assessed every shift. The nurse was to check the access site for bleeding, signs of infection, and bruit and thrill (sight and sound of blood flow at the site). In an interview on July 17, 2024, at 1:30 p.m., the Director of Nursing stated this access site monitoring by nursing should be documented on the Treatment Administration Record (TAR) every shift, that there should be physician's orders for hemodialysis, and that…

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

Based on clinical record review and staff interview, it was determined that the facility failed to ensure the physician acknowledged the pharmacist's recommendations for one of 15 sampled residents. (Resident 17) Findings include: Clinical record review revealed that Resident 17 had diagnoses that included reflux disease, constipation, and chronic respiratory failure. On March 16, 2024, the consultant pharmacist made recommendations regarding Resident 17's medication regimen that included adding the amount of liquid to add to the Miralax dose, changing the timing of the dose of pantoprazole, and adding the instruction to rinse out mouth after use of albuterol. On May 15, 2024, the consultant pharmacist made a recommendation regarding Resident 17's medication regimen to include a risk versus benefit analysis if the resident was to continue on Montelukast. There was no documented evidence that the attending physician had acknowledged or acted upon the recommendations. In an interview on July 18, 2024, at 12:50 p.m., the interim Nursing Home Administrator confirmed that the medication…

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 policy review, observation, and staff interview, it was determined that the facility failed to ensure that medications were securely stored in a medication storage room on one of one nursing units. (Skilled Nursing unit) Findings include: Review of the facility policy entitled, Medication Storage in the Facility, Storage of Medication, last reviewed August 21, 2023, revealed that drugs and biologicals were to be stored in locked compartments and only persons authorized to administer medications were to have access to locked medications. Controlled substances were to be stored separately from other medications in a designated locked drawer or compartment. Observation of the medication room on the Skilled Nursing unit on July 18, 2024, at 10:49 a.m., revealed that a controlled substance was stored in a locked box inside an unlocked refrigerator and the box was not permanently affixed to the refrigerator wall. The portable medication box contained one bottle with 30 milliliters of Ativan, which is a controlled substance. In an interview on July 18, 2024, at 11:21…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy review, clinical record review, and staff interview, it was determined that the facility failed to offer pneumococcal disease vaccines in accordance with facility policy to two of five residents whose vaccines were reviewed. (Residents 26, 34) Findings include: Review of the facility policy entitled, Infection Control, last reviewed August 21, 2023, revealed that upon admission, the facility would assess each resident to determine if they had been previously vaccinated for pneumococcal disease and offer the vaccine if the resident had not received it. Clinical record review revealed that Resident 26 was admitted to the facility on [DATE]. There was no documented evidence that the facility offered a pneumococcal disease vaccine or determined if the resident had received it prior to admission. Clinical record review revealed that Resident 34 was admitted to the facility on [DATE]. There was no documented evidence that the facility offered a pneumococcal disease vaccine or determined if the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and resident interview, it was determined that the facility failed to provide services to enhance each resident's quality of life by offering showers as scheduled to three of six sampled residents. (Residents 1, 2, 3) Findings include: Clinical record review revealed that Resident 1 had diagnoses that included congestive heart failure and diabetes mellitus. The Minimum Data Set (MDS) assessment dated [DATE], indicated that the resident was oriented and was dependent on staff assistance for bathing. The resident was to receive a shower once per week on Friday evenings. During an interview on May 2, 2024, at 11:00 a.m., the resident reported that she preferred to take a shower and was not offered the opportunity to do so. Review of documentation in the clinical record revealed that the resident was not offered a shower four of four scheduled times in the past 30 days. Clinical record review revealed that Resident 2 had diagnoses that included diabetes mellitus and depression. 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 staff interview, it was determined that the facility failed to employ a full-time qualified dietary services manager in the absence of a full-time qualified dietitian. Findings include: During an interview on May 2, 2024, at 10:00 a.m., the Director of Nursing, stated that the facility did not employ a certified dietary manager (CDM). In an interview on May 2, 2024, at 10:11 a.m. Employee 1 stated that there was not a full time registered dietitian at the facility. In an interview on May 2, 2024, at 12:20 p.m. Employee 2 and Employee 3 stated that they were the only staff in the kitchen and neither were a CDM or registered dietitian. There was no evidence that the facility employed a certified dietary manager in the absence of a full time qualified dietitian. CFR. 483.60(a)(1) Staffing. Previously cited 6/28/23 28 Pa. Code 211.6(c) Dietary services. 28 Pa Code 201.18(e)(1)(6) Management.

Based on resident interviews, review of facility documentation, observation, and results of a test tray evaluation, it was determined that the facility failed to provide food that was palatable and at acceptable temperatures on the nursing unit. Findings include: In interviews on May 2, 2024, at 11:00 a.m. through 1:00 p.m., Residents 1, 2, 3, and 4 stated that food was often served cold. Review of the facility's Meal Test Tray, form revealed that the temperature for the hot entree, starch, and vegetable should be greater than 135 degrees Fahrenheit when served. A test tray conducted on May 2, 2024, at 1:10 p.m., on the nursing unit, revealed macaroni and cheese at a service temperature of 121.6 degrees Fahrenheit, and stewed tomatoes at a service temperature of 114.2 degrees Fahrenheit. 28 Pa. Code 201.29(j) Resident rights.

Based on observation, and resident and staff interview, it was determined that the facility failed to ensure that meals were served at regularly scheduled times in accordance with the resident needs on the nursing unit. Findings include: In an interview on May 2, 2024, Employee 2 stated that meal delivery times on the nursing unit were 12:15 p.m for the first cart and 12:30 p.m. for the second cart. On May 2, 2024, from 11:00 a.m., through 12:05 p.m., Residents 1, 2, 3, and 4 stated that their meals usually arrived late. Observation on the nursing unit, on May 2, 2024, revealed Residents 1, 2, 3, and 4 received their lunch trays at 12:50 p.m. through 1:20 p.m., over 35 minutes past their scheduled meal time. CFR 483.60(f)(1) Frequency of meals. Previously cited 1/14/24

Based on observation it was determined that the facility failed to store food under sanitary conditions in the kitchen. Findings include: Observation of the kitchen during a tour on January 13, 2023, at 10:40 a.m. revealed a case of milk with a sell by date of January 5, 2024, and a gallon of milk with a sell by date of December 30, 2023, in the walk-in refrigerator. The floor of the walk-in refrigerator had various food debris and trash on the floor. In the dry storage area there was food debris and trash on the floor. CFR 483.60 Food Procurement Store/Prepare/Serve-Sanitary. Previously cited 8/30/23 28 Pa. Code 201.18(b)(3) Management. 28 Pa. Code 207.2(A) Administrator's responsibility.

Based on a review of the facility's meal schedule, observation, and resident and staff interview, it was determined that the facility failed to ensure that meals were served at regularly scheduled times in accordance with the resident needs on the nursing unit. Findings include: Review of the facility's meal schedule revealed that the scheduled times for lunch delivery on the nursing unit was 11:15 a.m. and 11:30 a.m. In an interview on January 13, 2024, Employee 1 stated that meal delivery times on the nursing unit was 11:15 a.m for the first cart and 11:30 a.m. for the second cart. On January 13, 2024, from 10:55 a.m., through 12:30 p.m., Residents 1,3, 5, 6, 7, and 8 stated that their meals usually arrived late. Observation on the nursing unit, on January 13, 2024, revealed Residents 1, 3, 5, 6, 7, and 8 received their lunch trays at 12:30 p.m. through 1:10 p.m., over an hour past the scheduled meal delivery times.

Based on a review of facility policy, review of facility documentation, and staff interview, it was determined that the facility failed to perform infection surveillance in accordance with facility policy. In addition, the facility also failed to develop an antibiotic stewardship program that included antibiotic use protocols. Findings include: Review of the facility policy entitled, Infection Control Surveillance, last reviewed August 21, 2023, revealed that the infection control nurse or designee would systematically collect data related to infections. That data would be collected throughout the month and utilized for compiling the monthly infection control report. Review of the facility policy entitled, Prevention, Control and Antibiotic Stewardship, last reviewed August 21, 2023, revealed that the program aimed to improve antibiotic use and frequency with a commitment to quality improvement. During the review of the facility infection control program on August 30, 2023, there was no documented evidence of any infection surveillance or antibiotic stewardship program prior to 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.

Based on a review of facility policy, review of personnel files, and staff interview, it was determined that the facility failed to document completion of orientation and abuse prevention training for three of five new employees (E2, E4, E5). Findings include: A review of the facility policy entitled Abuse Protection, last reviewed August 21, 2023, revealed that the facility mandated that new hires complete a training/orientation program. Training was to be provided at time of hire, annually and as needed. Employee E2 had been working as a dietary aide since May 3, 2023. Review of E2's employee file revealed there was no evidence of an orientation or completion of abuse prevention training. Employee E4 had been working as a registered nurse since July 26, 2023. Review of E4's employee file revealed there was no evidence of an orientation or completion of abuse prevention training. Employee E5 had been working as a nurse aide since July 26, 2023. Review of E5's employee file revealed there was no evidence of an orientation or completion of abuse prevention training. In an interview…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, policy review, observation, resident interview, and staff interview, it was determined that the facility failed to provide adequate supervision for one resident who wandered (Resident 40) and failed to reassess, implement, and/or monitor safety measures related to smoking, elopment, falls, and injuries (skin tears) for four of 21 sampled residents. (Residents 3, 6, 13, 51) Findings include: Clinical record review revealed Resident 40 had diagnoses that included Alzheimer's disease and psychosis. Review of the Minimum Data Set (MDS) assessment dated [DATE], revealed that Resident 40 had cognitive impairment, needed extensive assistance from staff for transfers, and needed staff supervision with walking. Review of the current care plan revealed the resident had a behavior problem due to wandering and entering other residents rooms and had interventions to distract him with diversions, activities, food, conversation, television or books. The care plan also revealed that Resident 40…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy review, clinical record review, and staff interview, it was determined that the facility failed to adequately monitor and assess significant weight changes for three of 21 sampled residents. (Residents 3, 6, 50) Findings include: Review of the facility policy entitled, Resident Weights, last reviewed August 21, 2023, revealed that the re-weights would be obtained within 72 hours if a weight change was greater than three percent and that the licensed nurse would notify the interdisciplinary team for further assessment if the weight change was significant. Clinical record review revealed that Resident 3 was admitted to the facility on [DATE], with diagnoses that included diabetes mellitus, dementia, and dysphagia (difficulty swallowing). Review of the Minimum Data Set (MDS) assessment dated [DATE], revealed the resident had cognitive impairment and required supervision with eating. Review of the current care plan revealed that Resident 3 was at nutritional risk due to her cognitive status…

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 provide a clean, safe, and home-like environment in a resident's room for one of 21 sampled residents reviewed. (Resident 31) Findings include: Observation of Resident 31's room on August 27, 2023, at 11:53 a.m., August 28, 2023, at 1:01 p.m., and August 29, 2023, at 9:35 a.m., revealed a broken electrical outlet cover and holes in the wall between the door and the corner. There were scratches in the paint on the walls and exposed wallboard beneath. The bottom dresser drawer handle was broken. The floor was sticky. In an interview on August 30, 2023, at 11:00 a.m., the Administrator confirmed that the walls required repair and the floor needed to be cleaned. 28 Pa. Code 201.18(e)(2.1) Management

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, observation, and staff interview, it was determined that the facility failed to complete assessments to accurately reflect the resident's status for three of 21 sampled residents. (Residents 15, 21, 27) Findings include: Clinical record review revealed that Resident 15 had diagnoses that included multiple sclerosis and neuromuscular dysfunction of bladder. The Minimum Data Set (MDS) assessment dated [DATE], indicated that the resident had an indwelling catheter. Review of the nursing notes revealed that on April 9, 2023, Resident 15's catheter was removed and a Bladder Assessment completed on April 10, 2023, revealed that she had functional incontinence of her bladder. Resident 15 was observed from August 27, through 30, 2023, and she did not have an indwelling catheter. In an interview on August 30, 2023, at 10:44 a.m. the Director of Nursing confirmed that Resident 15's catheter was removed and not in place at the time of the MDS assessment. Clinical record review revealed that…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff interview, it was determined that the facility failed to develop a comprehensive care plan to meet each resident's needs identified in the comprehensive assessment for one of 21 sampled residents. (Resident 2) Findings include: Clinical record review revealed that Resident 2 was admitted to the facility on [DATE], and had diagnoses that included anxiety, depression, and hypertension. The Minimum Data Set (MDS) Care Area Assessment (CAA) worksheet dated May 20, 2023, noted that the resident's cognitive impairment, psychotropic drug use, urinary incontinence, and potential for rehabilitation of activities of daily living were to be addressed in the care plan. There was no evidence that interventions to address the above areas were included in the current care plan. In an interview on August 30, 2023, at 10:46 a.m., the Nursing Home Administrator confirmed there was no documented evidence that the above mentioned areas were addressed in Resident 2's current care plan. CFR.…

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, observation, and staff interview, it was determined that the facility failed to provide nail care to maintain good foot health for one of 21 sampled residents. (Resident 40) Findings include: Clinical record review revealed that Resident 40 was admitted to the facility on [DATE], and had diagnoses that included Alzheimer's disease and depression. The Minimum Data Set assessment dated [DATE], indicated that the resident required extensive staff assistance for care and was totally dependent on staff for bathing. Observation on August 28, 2023, at 12:00 p.m. revealed that the resident's toenails were long and in need of nail care. Observation on August 30, 2023, at 11:10 a.m. with the Director of Nursing revealed that the resident's toes nails were long and in need of care. During an interview on August 30, 2023, at 11:15 a.m. the Director of Nursing stated that staff were to check residents' toenails and if care was needed, they were to report it so that the podiatrist could be…

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

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 to increase or prevent a reduction in range of motion and/or to improve or maintain mobility for two of 21 sampled residents. (Residents 15, 21) Findings include: Clinical record review revealed that Resident 15 had diagnoses that included multiple sclerosis. The Minimum Data Set (MDS) assessment dated [DATE], indicated that the resident had limitation in range of motion of both legs. Review of an occupational therapy Discharge summary dated [DATE], revealed that the resident was to be discharged to a restorative nursing program to maintain her current level of performance and prevent a decline. Review of the current care plan revealed that Resident 15 was on a restorative nursing program for passive range of motion for both of her legs and staff were to complete the exercises daily. Review of restorative nursing documentation July 31, 2023, through August 29, 2023, revealed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy review, clinical record review, and staff interview, it was determined that the facility failed to accurately assess bladder continence to provide services to restore or maintain continence to the extent possible for one of 21 sampled residents. (Resident 2) Findings include: Review of the facility policy entitled, Incontinence Management Protocol, last review August 21, 2023, revealed that based on the resident's comprehensive assessment, the facility was to ensure that a resident who was incontinent would be evaluated for appropriate interventions to regain or maintain their ability to control bowel and bladder function and that a resident who was incontinent of bladder received appropriate treatment and services to promote continence. Clinical record review revealed that Resident 2 was admitted to the facility on [DATE], and had diagnoses that included anxiety and depression. The Minimum Data Set assessment, dated May 20, 2023, indicated that the resident required supervision from…

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, observation, and resident interview, it was determined that the facility failed to provide adaptive equipment to assist with eating meals for one of 21 sampled residents. (Resident 15) Findings include: Clinical record review revealed that Resident 15 had diagnoses that included multiple sclerosis and dysphagia. On January 28, 2022, the physician ordered for staff to provide Resident 15 with red foam (padded handle) utensils and a plate guard with all meals. The care plan indicated that the resident was to receive red foam utensils and a plate guard at all meals to assist with eating. Observation on August 27, 2023, at 12:40 p.m., revealed that the resident was in the dining room for lunch. She did not have a plate guard or red foam utensils on her meal tray. Observation on August 28, 2023, at 12:45 p.m., revealed that the resident did not receive a plate guard with her lunch meal. In an interview at that time, Resident 15 stated that the red foam utensils and plate guard made it easier for her to eat her meals. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing…

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, it was determined that the facility failed to store food in a sanitary manner on the nursing unit. Findings include: Observation of the resident refrigerator at the nurse's station on August 28, 2023, at 12:00 p.m. revealed that there was a container of yogurt with a use by date of July 27, 2023, and a container of milk with a use by date of August 26, 2023. The refrigerator shelves had multiple brown stains and puddles of water on them. CFR. 483.60(i)(2) Food Storage. Previously cited 9/1/22