Accela Rehab And Care Center At Somerton

Based on observation, interviews with resident and staff, review of clinical records and facility policy, it was determined that the facility failed to obtain physician orders to allow a resident to store a medication at bedside and further failed to ensure the medication was stored in a safe, secured location for one of 35 resident records reviewed (Resident R26). Findings include: Review of facility policy titled Self-Administration of Medications revised February 2021 states the facility will assess each resident's cognitive and physical abilities to determine whether self-administration of medication is safe and clinically appropriate for the resident. The same policy further states that self-administered medications are stored in a safe and secured place, which is not accessible by other residents. On March 13, 2025, at 9:15 a.m. the surveyor observed Resident R26's inhaler in an unsecured nightstand. Resident R26 indicated the resident had been keeping the inhaler in the resident's room, Because they (staff) can never find it. On March 13, 2025, at 3:15 p.m. the Director 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 observation, review of facility policies, clinical record review and interviews with staff, it was determined that the facility failed to maintain an effective infection control program related to proper disposal and storage of used and potentially contaminated suctioning devices and the use of a urinary catheter tubing and drainage bag in accordance with professional standards for one of two residents reviewed. (Residents R99 and R128). Findings include: Review of facility policy, Suctioning the Lower Airway (Endotracheal [ET] or Tracheostomy Tube) revised October 2010, revealed in section General Guidelines part 31, disconnect catheter from tubing. Wrap catheter around gloved hand. Pull the glove off and over the catheter. Discard in designated receptacle. Review of Resident R99's clinical record revealed that Resident R99 was admitted to the facility on [DATE] with diagnoses of but not limited to Traumatic Brain Injury and Acute Respiratory Failure. Review of Resident R99's clinical record 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 observation and resident and staff interview, it was determined that the facility failed to provide a sanitary and comfortable environment for 2 of 10 residents. (R130 and R160) Findings include: Review of R160's clinical record revealed the Resident was admitted to the facility on [DATE] with diagnoses of but not limited to Surgical Amputation (removal of a body appendage). Review of R160's MDS (Minimum Data Set) Section C- Cognitive Problems, dated February 3, 2025, revealed that the Resident has a BIMS (Brief interview for metal status) score of 15 (intact cognitive response). Observation of Resident R160's room on March 11, 2025 at 10:35 AM, revealed mouse droppings by baseboards of resident's room between head of resident's bed and night stand. Interview with Resident R160 on March 11, 2025 at 10:35 AM revealed that room cleanliness is an ongoing concern, room has not been cleaned properly since resident was admitted . Staff has been made aware of mouse droppings, however has not been cleaned up.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, observations, and staff and resident interviews it was determined that the facility failed to maintain an effective pest control program for one of five nursing units (2nd floor). Findings include: Review of facility policy Pest control revised May 2008, revealed policy statement of Our facility shall maintain an effective pest control program. Under section Policy Interpretation and Implementation, Part 1, This facility maintains an on-going pest control program to ensure that the building is kept free of insects and rodents. Review of R160's clinical record revealed the Resident was admitted to the facility on [DATE] with diagnoses of but not limited to Surgical Amputation (removal of a body appendage). Review of R160's MDS (Minimum Data Set) Section C- Cognitive Problems, dated February 3, 2025, revealed that the Resident has a BIMS (Brief interview for metal status) score of 15 (intact cognitive response). Observation of Resident R 160's room on March 11, 2025 at 10:35 AM,…

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 the review of facility assessment, facility staffing schedule, clinical records, and interviews with staff, it was determined that the facility failed to ensure sufficient nursing staff to provide nursing and related services, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility's resident population for three of four units reviewed. (Second floor, A unit and D unit). Findings Include: Review of facility assessment dated [DATE], revealed that Staffing plan: 3.2. Accela Rehab and Care at Somerton provides adequate daily staffing based on census, acuity and diagnosis of our resident population to ensure individualized patient-centered care needs are met. Individual staff assignment 3.3. Individual staff assignments are reviewed by the Director of Nursing/ designee and the nursing administrative team to ensure the coordination and continuity of care for residents are reflected in staff assignments. Assignments are based 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 observations, staff interviews, review of clinical records and facility documentation, it was determined that the facility failed to administer diabetic medications in accordance with professional standards of for five of five clinical records reviewed of residents who were order antidiabetic medication (Resident R1, R6, R9, R13 and R17). Findings Include: Review of facility policy Administering Medications, dated April 2019, revealed that Medications are administered in a safe and timely manner, and as prescribed. Medications are administered within one (1) hour of their prescribed time, unless otherwise specified (for example, before and after meal orders). Review of physician orders and medication administration record for Resident R1 for November 2024 revealed orders for the following medications: Glipizide 10 milligrams (mg) one time a day, 30 minutes before meals at 8:30 a. m. Metformin 500 mg two times a day, first dose at 9 a.m., administer with meals. The above medications were documented as administered at 12:04 p.m., medications. Licensed nurse, Employee E3…

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 the review of clinical records and interviews with staff, it was determined that the facility did not maintain accurate clinical records for two of five residents reviewed. (Resident R1 and Resident R5) Findings Include: Review of an undated facility document Medication Administration Policy revealed that Medications should be administered at the times that are order and signed out immediately when given. Observation of the facility second floor revealed that Licensed Nurse, Employee E3 was administering medications on November 5, 2024, at 10:57 a.m. She stated she was administering morning medications which mostly scheduled for 9:00 a.m. Licensed nurse, Employee E3, stated she had four more residents to finish. Licensed nurse, Employee E3 stated she had to finish 9 a.m. med pass for Resident R1, R2, R3 and R4. Licensed Nurse, Employee E3 stated she had 33 residents in her assignment to administer medication. Review of physician orders and medication administration record for Resident R1 for November 2024 revealed orders for the following medications: Divalproex 500 mg two…

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

Based on observations, review of facility documentation, and resident and staff interviews, it was determined that the facility failed to ensure that a safe, functional, and comfortable environment was maintained for two of ten residents observed. Findings: Observation conducted on September 30, 2024 at 9:40 a.m. revealed Resident R3's dresser located in the front right side of room had a top handle broken off shelf, the second draw shelf was broken and did not have a cover, which left Resident R3's clothes exposed. The shelf cover was leaning up against the wall near the window. An interview conducted on September 30, 2024 at 10:08 a.m. with Resident R4 revealed Resident R4's bed was not functioning properly. Resident R4 was unable to elevate the foot of his bed. Resident R4 stated he reported the bed not functioning properly to a nurse aide. Interview on September 30, 2024 at 11:15 a.m. with Employee E1, Nursing Home Administrator, confirmed Resident R3's shelf was broken and Resident R4's foot of bed did not elevate. 28 Pa. Code 202.28(b)(3) Management

Based on observations, review of resident records, and interviews with staff it was determined that the facility failed to maintain clinical records that were complete and accurately documented for one of nine residents reviewed. (Resident R1) Findings Include: Review of resident Minimum Data Set (MDS) revealed an admission date of August 18, 2022. The resident was admitted with a diagnosis of pulmonary embolism, seizures, tachycardia, chronic viral hepatitis, respiratory failure, hypocalcemia, depression, anxiety, hypertension, alcohol dependence with withdrawal, insomnia, bilateral primary osteoarthritis, adjustment disorder, and basal cell carcinoma of the skin. Review of Resident R1's record revealed the resident had a Level of Care determination on April 18, 2024 after an assessment was completed at the facility on March 25, 2024 and the determination was that the resident was Nursing Facility Ineligible. Review of Resident R1's all progress notes revealed at no time was this determination discussed with Resident R1. Interview with social services director Employee E3 on June…

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

Based on observations and interviews with staff, it was determined that the facility did not ensure that food was stored, prepared, distributed and served in accordance with professional standards for food service safety. Findings include: A tour of the Food Service Department was conducted on April 30, 2024, at 10:00 a.m. with Employee E4, Food Service Director (FSD), revealed the following concerns: Observations in the dry storage area revealed a jug of honey which was very dark and crystalized with a receiving date of 2/2022. Observations in the walk-in cooler revealed a dusty and dirty floor littered with debris, the shelving and dunnage racks were dusty and dirty, and the walls and ceiling has dark spots. Observations in the kitchen revealed an AC unit blowing air through vents covered with dark blackish dust and grime into the kitchen. Observations of the cooking equipment including tilt skillet with a heavy buildup of dark substance on the bottom exterior, and two stack convection ovens which had a buildup of black, burned on grease and food spatters on the interior 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 a review of clinical records, facility documentation, and staff interviews, it was determined the facility failed to implement a complete drug regimen review process for three of 36 residents reviewed (Resident R54, R26, R61) Findings Include: Review of the Pharmacy Services - Role of the Consultant Pharmacist Policy dated April 2019, revealed, the consultant pharmacist will provide specific activities related to medication regimen review including a documented review of the medication regimen of each resident at least monthly, appropriate communication of information to prescribers and facility leadership about potential or actual problems related to any aspect of medications and pharmacy services, including medication irregularities and pertinent resident-specific documentation in the medical record. Review of Resident R54's clinical record revealed that the resident was admitted on [DATE], with diagnoses including depression and anxiety. Further review of Resident R63's 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 observations and resident interviews, it was determined that the facility failed to maintain the facility in a clean, comfortable, and homelike condition for 2 of 5 nursing units (1st and 2nd floor). Findings include: Observations during the initial tour of the facility on April 30, 2024, revealed the following concerns: Observations on April 30, 2024, at 9:03 a.m. revealed several wet spills in the hallway entering the second floor off of the elevator. Observations on April 30, 2024, at 10:25 a.m., in room [ROOM NUMBER], revealed that the HVAC unit below the window was missing the cover for the vent and there were sharp metal inside, and the unit was very dusty and dirty inside the unit. Interview with Resident R108 revealed that the HVAC unit had been like this for some time. Observation on April 30, 2024 at 10:50 a.m. in Resident R2's room revealed the headboard was broken. Behind the head of the bed the paint on the wall was scraped off. Observation on April 30, 2024 at 10: 53 a.m. of room [ROOM…

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

Based on review of facility provided documentation and interview with staff, it was determined that the facility failed to conduct a complete and thorough investigation related to missing narcotics for three residents reviewed (Residents R163, R500, R501) Findings include: Review of facility's policy 'Accidents and Incidents - Investigating and Reporting,' indicates The following data, as applicable, shall be included on the Report of Incident/Accident form: a. The date and time the accident or incident took place; c. The circumstances surrounding the accident or incident; e. The name(s) of witnesses and their accounts of the accidents of the accident or incident. Review of facility reported incident, dated January 13, 2024, revealed the following statement by Licensed nurse, Employee, E23, dated January 13, 2024, evening shift (3-11pm) involving Residents R163, R500, R501 I [Employee E23] was counting the narc draw around 3:05 pm, I realized that there was multiple patients drugs missing. I worked the previous night and from then to now the count was off. 1st - R163 oxycodone 5mg…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of clinical records, review of facility provided documentation and interview with staff, it was determined that the facility did not develop and implement a comprehensive person-centered care plan related to urinary tract infection for one of 35 residents reviewed. (Resident R47) Findings include: Review of facility's policy 'Care Plans, Comprehensive Person-Centered,' indicates that the comprehensive, person-centered care plan: e. reflects currently recognized standards of practice for problem areas and conditions. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions' change. Review of Resident R47's clinical records revealed that the resident was hospitalized on [DATE], with due to an urinary track infection. Further review of of R47's clinical records revealed past medical history of urinary tract infection, and benign prostatic hyperplasia with lower urinary tract symptoms. Review of R47's current care plan 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.

Based on observation, and interviews with staff, it was determined that the facility failed to maintain an environment free from hazards related to cleaning supplies left in the one resident's room in one of five units (A unit) Findings include: On April 30, 2024, at 10:01 a.m. observations were made of the A wing, room A1. Resident R5 had cleaning supplies (Comet) left on the floor visible to everyone that was pass by that room. On May 1, 2024, at 1:10 p.m. observation was made of the A wing, room A1. Cleaning supplies were still in the resident's room. Interview with the Director of Nursing, on May 1, 2024, at 1:15 p.m. revealed that residents were not to have cleaning supplies in resident's rooms. 28 Pa. Code 201.14 (a) Responsibility of license 28 Pa. Code 201.18 (b)(1)(3) Management

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, review of clinical record, review of facility policy and staff interview, it was determined that the facility failed to ensure proper care of a urinary catheter bag and that a physician order was obtained to perform self catherization flushes for one of one residents review with a urinary catheter.(Resident R9) Findings include: Review of facility policy on Catheter Care, Urinary dated in September 2014, revealed that under section infection control: Be sure the catheter tubing and drainage bag are kept off the floor. Review Resident R9's clinical record revealed that the resident was admitted on [DATE], with diagnosis of spinal stenosis, lumbosacral, neurogenic bladder dysfunction, urinary tract infection, Observation of Resident's R9 on April 30, 2024, at 11:32 a.m. revealed that the resident was in bed and the urinary catheter bag was laying directly on the floor. Observation in Resident's R9 on May 1, 2024, at 10:15 a.m., revealed that Resident R9 was in bed and the urinary catheter bag…

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 policy, review of clinical records, and staff interview, it was determined that the facility failed to implement a system of records of receipt and disposition of all controlled drugs between shifts to enable an accurate reconciliation and accountability for one of four medication carts observed (unit Second Floor A). Findings include: Review of facility policy on Controlled Substances reveal that under section Policy Statement: The facility complies with all laws, regulations and other requirements related to handling, storage, disposal, and documentation of controlled medications. Under section Policy Interpretation and Implementation: #1 Only authorized licensed nursing and or pharmacy personnel have access to controlled drugs maintained on premises. #8 Controlled substances are reconciled upon receipt, administration, disposition, and at the end of each shift. #12 At the end of each shift: #a Controlled medications are counted at the end of each shift. The nurse coming on duty and the nurse going off duty determined the count together. #b…

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, observation and staff interview, it was determined that the facility failed to ensure that all drugs and biologicals are stored and labeled in accordance with professional standards for one of two medication rooms observed. (First floor Unit A) Findings include: Review of facility policy related to labeling of medication containers reveal that under section policy statement all medications maintained in the facility are properly labeled in accordance with the current state and federal guidelines and regulations. Observation of the Medication Room on First floor Unit A conducted on May 1, 2024, at 08:50 a.m. with Unit Manager, Employee E19, revealed that there were two refrigerators in the medication room stacked up together (top refrigerator and bottom refrigerator). Observation of the top refrigerator revealed an opened, unlabeled bottle of the probiotic Acidophilus. Further observation revealed that the opened bottle of Acidophilus did not have the date it was opened affixed to it. Interview with Licensed nurse, Employee E19 conducted at 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 observations and interviews with staff, it was determined that the facility did not ensure that that trash and recyclables were properly disposed of in the receiving and dumpster area. Findings include: A tour of the Food Service Department was conducted on April 30, 2024, at 10:00 a.m. with Employee E4, Food Service Director (FSD), revealed the following concerns: Observations in the receiving area revealed cardboard, bread racks/dolly, milk crates, paper and other trash scattered around the generator and staff smoking area. The recycling dumpster was overflowing with the lid open, and a mound of cardboard boxes piled in front of the dumpster. There were four old mattresses leaning against a metal shed. Interview with the FSD on April 30, 2024, at 10:15 a.m. confirmed the above findings. 28 PA Code: 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(3) Management

Based on observation, review of facility documents, staff interview and review of facility policy, it was determined that the facility failed to ensure that proper infection control practices were followed according to professional standards related to enhance barrier precaution during wound care for one of 35 residents reviewed. (Resident R103) Findings include: Review of facility policy title Isolation-Categories of Transmission-Based Precautions revealed that under Policy Statement: Transmission based precautions are initiated when the resident developed signs and symptoms of transmissible infection, arrives for admission with symptoms of infection or has a laboratory confirmed infection and is at risk of transmitting the infection to other residents. Under section Policy, Interpretation and Implementation #2, Transmission based precautions or additional measures that protect staff, visitors, and other residents from becoming infected. These measures are determined by the specific pathogens and how it is spread from person to person. The three types of transmission because based…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations of the physical environment, review of pest control logs, review of pest control reports, and interviews with residents and staff, it was determined that the facility failed to maintain an effective pest control program. Findings Include: Review of the facilities pest control policy Titled, Pest Control dated May 2008 states, Policy Statement, Our facility shall maintain an effective pest control program. The Policy Interpretation and Implementation states, 1. This facility maintains an on-going pest control program to ensure that the building is kept free of insects and rodents. 2. Pest control services are provided by __(left blank)___. 3. Windows are screened at all times. 4. Only approved FDA and EPA insecticides and rodenticides are permitted in the facility and all such supplies are stored in areas away from food storage areas. 5. Garbage and trash are not permitted to accumulate and are removed from the facility daily. 6. Maintenance services assist, when appropriate and necessary,…

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

Based on observation, review of clinical record, review of facility policy and staff and resident interviews, it was determined that the facility failed to ensure that nursing services met professional standards of quality according to the Pennsylvania Code Title 49, Professional and Vocational Standards, by failing to ensure to ensure that MAR (medication administration record) documentation during medication administration was conducted according to professional standards for six of seven residents observed. (Residents R33, R38, R104, R139, R165 and R180) Findings include: According to the Pennsylvania Code Title 49, Professional and Vocational Standards Department of State, Chapter 21 State Board of Nursing, Chapter 21.145 Functions of the LPN (Licensed Practical Nurse) requires the following: (a) The LPN is prepared to function as a member of the health care team by exercising sound nursing judgement based on preparations, knowledge, skills, understandings, and past experiences in nursing situations. The LPN participates in the planning, implementation, and evaluation of 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 clinical record reviews, interviews with staff and reviews of policies, procedures and the respiratory service agreement, it was determined that the facility failed to ensure that routine assessments and monitoring by the respiratory care service and licensed respiratory therapist were completed and availavable for review, for two of three residents with tracheostomy care needs. (Residents R1 and R2) Findings include: A review of the facility policy titled Tracheostomy Care dated August, 2013, revealed that it was the responsibility of only trained and licensed staff to provide tracheostomy care for each resident. The licensed staff were responsible for changing all tubing weekly and as needed. The licensed staff were responsible for changing the inner cannula weekly. The licensed staff were responsible for tracheostomy care every day every shift; which included suctioning the resident every shift and as needed. A review of the facility's respiratory service contract that began on October 1, 2021 revealed that a licensed respiratory therapist was responsible for respiratory…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, clinical record reviews and interviews with residents and staff, it was determined that the facility failed to develop comprehensive person centered care plans related to activities of daily living and activities programs for four of six residents reviewed (Residents R1, R2, R3 and R4). Finding include: Observation, on October 2, 2023, at 9:14 a.m. Resident R1 had a grown-out facial beard and long, overgrown fingernails. Interview, at the time of the observation, Resident R1 stated that he prefers to be clean shaven and that he has only been shaved once since his admission to the facility. Continued interview, Resident R1 stated that he needs his nails trimmed and that they also have only been trimmed once since has admission. Further interview, Resident R1 stated that he would like to get out of bed and attend activities programs but that staff never offer or provide him with assistance for either of those things. Continued observation, on October 2, 2023, at 9:40 a.m. Residents R2 and R4…

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, clinical record reviews and interviews with residents and staff, it was determined that the facility failed to provide assistance with activities of daily living, including shaving and nail care, for 3 of 6 residents reviewed (Residents R1, R2 and R4). Findings include: Observation, on October 2, 2023, at 9:14 a.m. Resident R1 had a grown-out facial beard and long, overgrown fingernails. Interview, at the time of the observation, Resident R1 stated that he prefers to be clean shaven and that he has only been shaved once since his admission to the facility. Continued interview, Resident R1 stated that he needs his nails trimmed and that they also have only been trimmed once since has admission. Continued observation, on October 2, 2023, at 9:40 a.m. Residents R2 and R4 were sitting in their wheelchairs in their room. Resident R2 had a grown-out facial beard. Resident R4 had a stubble beard. Both Residents R2 and R4 reported that they received a shower this morning, but that they were not shaved or offered any assistance with shaving. In addition, both Residents…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, review of facility and staff interviews, it was determined the facility failed to maintain a safe, clean, and comfortable homelike environment for two of 4 nursing units (A and D nursing units). Findings Include: Review of facility's 'Homelike Environment' policy, revised on February 2021, states the following: The facility staff and management maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include: a. clean, sanitary and orderly environment, e. clean bed and bath linens that are in good condition, f. pleasant and neutral scents, g. plants and flowers where appropriate, h. comfortable and safe temperatures (71F - 81F). Observations on June 27, 2023, at 10:33 am, on unit D, room [ROOM NUMBER]-C, revealed excess trash on floor, used dirty towels on floor, bed remote control on floor. Additional observations on unit D revealed excess trash and dirt on floor in room [ROOM NUMBER]-C; temperature of 65…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, review of clinical records, and staff, resident, and family interviews, it was determined that the facility failed to ensure a baseline care plan was developed related to communication needs and transmission based precautions for one of five new admissions reviewed (Resident R309). Findings Include: Review of Resident R309's clinical record revealed the resident was admitted to the facility June 22, 2023. Review of Resident R309's nursing admission assessment dated [DATE], revealed the resident had aphasia (communication deficit disorder) and was difficult to understand. Review of Resident R309's speech therapy evaluation and plan of treatment for certification period June 27, 2023, through July 26, 2023, revealed the speech therapist was unable to determine cognitive status secondary to severe language impairment. Further review of the evaluation revealed Resident R309's primary language was Ukrainian. Resident R309 had no attempts to verbally communicate, and instead resident would point…

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, clinical records, and staff interviews, it was determined that the facility failed to ensure that a comprehensive resident care plan was developed and implemented related to oxygen therapy, Activities of Daily Living, and tracheostomy for three of five residents reviewed (Resident R30, R310 and R362). Findings include: Review of facility policy Care Plans, Comprehensive Person Centered last reviewed June 1, 2023, indicated that the A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Review of the clinical record revealed that Resident R30 was admitted to the facility on [DATE], with diagnosis of asthma ( a condition in which the airways narrow and swell and may produce extra mucus. This can make breathing difficult) severe persistent asthma with acute exacerbation, personal history of transient ischemic attach(TIA).…

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 record, observation and review of facilty policy, it was determined that the facilty failed to ensure that personal hygiene was timely provided to one of seven residents reviewed. (Resident R7) Findings include: Review of facility's 'Dignity' policy, revised on February 2021, 12. Demeaning practices and standards of care that compromise dignity are prohibited. Staff are expected to promote dignity and assist residents, for example: a. Promptly responding to a resident's request for toileting assistance; and b. Allowing residents unrestricted access to common areas open to the public, unless this poses a safety risk for the resident. 7. Staff are expected to knock and request permission before entering residents' rooms. 13. Staff are expected to treat cognitively impaired residents with dignity and sensitivity; for example: a. addressing the underlying motives or root causes for behavior. Observation on June 27, 2023 at 10:57 p.m. revealed Resident R7 laying in bed with soiled briefs, on soiled mattress. Resident R7's gown and bed linens were on floor next…

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, clinical record review and staff interview, it was determined that the facility failed to ensure the application of a hand splint for one of one resident reviewed who was ordered for a hand splint (Resident R89). Findings include: Review of Resident R89's June 2023 physician orders revealed an order obtained June 23, 2023; Apply Right hand resting splint for up to 4 hours daily as tolerated. Check skin prior to application and after removal of splint. Observations of Resident R89, on June 29, 2023, at 12:26 p.m., revealed that there was no right-hand splint applied. Interview conducted with Resident R89 at the time of the observation confirmed that no right-hand resting splint had been applied. Interview with Licensed Nurse, Employee E9, at the time of the observation, revealed that Resident R89 had no right-hand resting splint applied as ordered by the physician. 28 Pa. Code 211.10(c) Resident care policies 28 Pa. Code 211.12(d)(1)(3) Nursing services

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, review of clinical records, observations, and staff interviews, it was determined that the facility failed to provide enteral feeding in accordance with resident needs and physician orders for one of two residents reviewed with tube-feedings (Resident R309). Findings Include: Review of facility policy Enteral Tube Feeding via Continuous Pump revealed staff should verify that there is a physician's order for this procedure and review the resident's care plan and provide for any special needs of the resident. Review of Resident R309's clinical record revealed the resident was admitted to the facility on [DATE], and had a diagnosis of gastrostomy status (surgical procedure for inserting a tube into the stomach through the abdomen used for delivering nutrition formula). Review of Resident R309's care plan dated June 23, 2023, revealed the resident was at nutritional risk related to dysphagia (swallowing difficulties), and NPO (nothing by mouth) status requiring enteral feeding…

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, clinical record review, review of facility policy and staff interview, it was determined that the facility failed to provide appropriate respiratory care and services for one of 33 residents reviewed (Residents R30). Findings include: Review of the facility policy entitled Oxygen Administration, last revised on October, 2010, revealed that The purpose of this procedure is to provide guidelines for safe oxygen administration further under Preparation suggests 1. Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration. 2. Review the resident's care plan to assess for any special needs of the resident. 3. Assemble the equipment and supplies as needed. Review of the clinical record revealed that Resident R30 was admitted to the facility on [DATE], with diagnosis of asthma, severe persistent asthma with acute exacerbation, personal history of transient ischemic attach (TIA). Review of Resident R30's Minimum Data…

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, interviews with staff and review of facility policies and procedures, it was determined that the facility did not ensure that narcotic medication was disposed of in accordance with federal, state, and local regulations and did not ensure physician ordered medications were obtained from the pharmacy in a timely manner (Resident R309). Findings include: Review of facility policy, Discarding and Destroying Medications, revised April 2019, revealed: Medications will be disposed of in accordance with federal, state and local regulations governing management of non-hazardous pharmaceutical, hazardous waste and controlled substances. 7. For unused, non-hazardous controlled substances that are not disposed of by an authorized collector, the EPA (Environmental Protection Agency) recommends destruction and disposal of the substance with other solid waste following the steps below: a. take the medication out of the original container. b. mix medication, either liquid or solid with an underirable substance, such as sand, coffee grounds, or other absorbent materials. Place…

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, review of clinical records, and staff interview, it was determined that the facility failed to ensure one resident was free from significant medication error for one of five new admissions reviewed (Resident R309). Findings Include: Review of facility policy Adverse Consequences and Medication Errors revealed a medication error is defined as the preparation or administration of drugs which is not in accordance with physician's orders. Example of medication error includes omission - a drug is ordered but not administered. The attending physician should be notified promptly of any significant error. Further review of facility policy revealed the following information should be documented on in an incident report and in the resident's clinical record: 1. Factual description of the error, 2. Name of physician and time notified, 3. Physician's subsequent orders, 4. Resident's condition for 24 to 72 hours or as directed. Review of Resident R309's clinical record revealed the resident was transferred from another skilled nursing facility on June 22,…

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 laboratory studies were obtained as ordered by the physician for one of 33 residents reviewed (Resident R37). Findings include: Review of Resident R37 physician's orders dated June 12, 2023, included an order to obtain CBC (Complete Blood Count, CMP (Complete Metabolic Panel) in the morning every Tue (Tuesday) for IV (Intravenous) ABT (antibiotic) Labs. Review of Resident 37's clinical record revealed that there was no CBC, CMP that was completed the week of June 18, 2023 thru June 24, 2023. On June 27, 2023, at 11:32 a.m. Resident R37 was interview and reported that she was supposed to have weekly labs done and only had two labs completed for her entire stay. Resident R37 had not refused any lab while residing at the facility. Interview with Nurse Partitioner, Employee E24 on June 27, 2023, at 12:37 p.m. who confirmed that Resident R37 had CBC, CMP labs orders on weekly basis and there were no labs completed for the week of June 18, 2023 thru June 24, 2023. On June 29,…

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

Based on review of clinical records, observations, and staff interviews, it was determined that the facility failed to maintain clinical records that were complete and accurately documented for one of seven residents with hospice care reviewed (Resident R259). Findings include: Review of Resident R259's clinical record revealed diagnoses including Pneumonia (an infection of one or both lungs caused by bacteria, viruses, or fungi), Unspecified Protein Calorie Malnutrition (Protein Calorie Malnutrition happens when an individual not consuming enough protein and calories), Muscle Weakness (Generalized), and Chronic Obstructive Pulmonary Disease (A group of lung diseases that block airflow and make it difficult to breathe). On June 29, 2023, at 1:28 p.m., review of clinical records of Resident R259 revealed that the resident did receive hospice services. Review of Resident R259's June 2023 physician orders revealed no physician order for hospice services. On June 29, 2023, at 1:37 p.m., an interview with Registered Nurse, Employee E10, confirmed that there was no physician order for…

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

Based on review of facility documentation and interviews with staff, it was determined that the facility failed to implement a system for the identification of and control measures for Legionella (bacteria that causes disease found in contaminated water) as required. Findings include: Review of Centers for Disease Control and Prevention (CDC) guidelines for Water Management in Healthcare Facilities revealed Legionella water management programs identify hazardous conditions and include taking steps to minimize the growth and spread of Legionella in building water systems. Having a water management program is now an industry standard for large buildings in the United States. Review of facility's policy titled 'Legionella Water Management Program,' revised on July 2017: The water management program includes the following elements: A detailed description and diagram of the water system in the facility, including the following: receiving, cold water distribution, heating, hot water distribution and waste. The identification of areas in the water system that could encourage the growth 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 observations and staff interview, it was determined that the facility failed to maintain an effective pest control program for one of four nursing units (A Wing). Findings Include: Review of Resident R309's clinical record revealed the resident was admitted to the facility on [DATE], and had a diagnosis of tracheostomy status (plastic tube placed through a small surgical opening through the front of the neck into the windpipe allowing air to flow in and out). Observations on June 28, 2023, at 11:50 a.m. confirmed Resident R309 had a tracheostomy. Observations on June 28, 2023, at 11:50 a.m. revealed small gnats in the residents bathroom and a fruit fly hovering around the resident's head. Interview on June 28, 2023, at 11:56 a.m. with nurse aide, Employee E8, confirmed the presence of flies in the room and reported there's flies in every room. Flies were also observed hovering at the nurses station adjacent to Resident R309 's room during interview with nurse aide, Employee E8. Observations on June 29,…

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.