Care Pavilion Nursing And Rehabilitation Center

Based on review of facility documents and interview with staff, it was determined that the facility failed to ensure that residents were provided with education related to influenza vaccines prior to administering influenzas vaccines to residents for eight of eight residents reviewed. (Resident R8, R9, R14, R17, R20, R128, R260 and R284)Review of facility policy on Infection Prevention and Control Program revealed that under section Policy Statement: The infection prevention and control program is a facility wide effort involving all disciplines and individuals. Under section Policy Interpretation and Implementation. Coordination and oversight a. The infection prevention and control program is coordinated and overseen by an infection prevention specialist. #8. Immunization: a. Immunization is a form of primary prevention. b. Widespread use of influenza vaccine in the nursing facility is strongly encouraged Review of consents/declination forms for the influenza vaccines and review of clinical record for Resident R8, R9, R14, R17, R20, R128, R260 and R284, revealed no documented…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and interviews with residents and staff, it was determined that the facility failed to ensure a safe, functional, sanitary, and comfortable environment for residents, staff and the public for two of seven nursing units reviewed (3 [NAME] nursing unit, 3 East nursing unit.) and the boiler room. Findings include: Tour of the 3 East nursing unit on December 1, 2025, at 11:41 a.m. revealed the following: Resident room [ROOM NUMBER] the fan had fallen off of the wall, the dresser was missing a drawer, the bed remote had frayed wires, two holes in the floorboards were noted, a ceiling panel was loose and floor tiles were taped together.The dining room had five tables that were unsteady and wobbled when leaned on\.The cabinet in the dining room was covered in built-up debris and missing several handles. Tour of the 3 [NAME] nursing unit on December 1, 2025, at 11:02 a.m. revealed the following: Resident room [ROOM NUMBER] toilet was clogged, full of feces and unable to be flushed. Resident R45…

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, clinical record review and interviews with residents and staff, it was determined that the facility failed to assist residents to access Alcoholics Anonymous (AA)/ Narcotics Anonymous (NA) resources for one of 42 residents reviewed (Resident R63). Findings include:Interview on December 1, 2025, at 11:54 a.m. revealed that Resident R63 wanted to attend AA/NA meetings and that none were available at the facility. Review of Resident R63's care plan, dated June 12, 2025, revealed that the resident had or had the potential for ineffective coping related to history of substance use disorder (medical condition in which there is uncontrolled use of a substance despite harmful consequences). Interventions included encouraging support available and listed resources such as Alcoholics Anonymous. Review of the Facility Assessment, dated April 16, 2025, revealed that 55% of the facility population had a history of mental illness, including diagnosis of substance use disorder. Interview on December 4, 2024, the Director of Nursing (DON) confirmed 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 observation, review of clinical record, review of facility policy and interview with staff and residents, it was determined that the facility failed to ensure that postal mail was delivered in timely manner for one of 42 residents reviewed. (Resident R128)Review of facility's undated policy on Mail and Package Handling revealed that under section Policy Statement: It is the policy of Care Pavilion Rehabilitation & Nursing to ensure that all residents and facility mail and packages are handled in a secure and respectful manner and distributed timely. Section Procedure: #1. Mail Arriving in Envelopes: All incoming mail that arrives in envelopes, including USPS, UPS, FedEx, and other courier deliveries, must be directed to the Business Office immediately upon receipt. #3. Resident Mail Handling: Once resident mail arriving in envelopes is sorted, the Business Office will deliver it directly to the Recreation Department for distribution. The Recreation Department is responsible for organizing and ensuring…

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

Based on review of facility policies, personnel files and interviews with staff, it was determined that the facility failed to obtain criminal background checks as required for one of five personnel files reviewed for newly hired staff (Employee E19). Findings include: Review of facility policy Abuse dated June 1, 2025, revealed that the facility will screen employees prior to working with residents and that screening components include verification of references, certification and verification of license and criminal background check. Review of Employee E19's personnel file revealed that the employee was hired on October 1, 2025, as a nurse aide. Continued review revealed that a Pennsylvania Criminal Record Check was not completed until December 1, 2025, at 4:58 p.m., after the file was requested by state surveyors. Additionally, reference checks were not completed for the employee. Continued review of Employee E19's personnel file revealed that the employee had not resided in the state of Pennsylvania for at least two years and that the employee attested to having criminal charges…

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 notify the Office of the State Long-Term Care Ombudsman of facility initiated transfers and discharges as required for three of three months reviewed (August, September and October 2025). Findings include: During Entrance Conference with the Nursing Home Administrator on December 1, 2025, at 10:15 a.m. evidence of facility initiated transfer and discharge reports to the State Long-Term Care Ombudsman were requested. During an interview with Employee E15, Regional Director of Operations, on December 4, 2025, at 1:10 p.m. evidence of facility initiated transfer and discharge reports to the State Long-Term Care Ombudsman were requested again. Interview on December 4, 2025, at 1:20 p.m. the Nursing Home Administrator stated that the previous Director of Social Work left the facility in September 2025 and confirmed that the facility did not have evidence that notices were sent to the Office of the State Long-Term Care Ombudsman of facility initiated transfers and discharges…

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

Based on review of facility policies, clinical record review and interviews with staff, it was determined that the facility failed to ensure that the Minimum Data Set (MDS) accurately reflected the resident's diagnoses and medical conditions for two of 42 residents reviewed (Residents R81 and R296). Findings include: Review of facility policy MDS 3.0 Completion dated reviewed December 2025, revealed, Persons completing part of the assessment must attest to the accuracy of the section they completed by signature and indication of the relevant sections. Review of progress notes for Resident R81 from November 4 through 11, 2025, revealed that the resident received hospice services and wound treatments to (his/her) foot. Review of Resident R81's wound consultant note, dated October 31, 2025, revealed that the resident had arterial ulcers [wounds caused by inadequate blood flow] to (his/her) right great, second and third toes. Review of Resident R81's Significant Change MDS (Minimum Data Set - a mandatory periodic resident assessment tool), dated November 11, 2025, 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, review of facility policies and staff interview it was determined that the PASRR (Preadmission Screening and Resident Review) was not appropriately completed according to the resident assessment for three of four residents reviewed (Residents R13, R19 and R10). Findings include: The PASRR (Preadmission Screening Resident Review) was created in 1987 through language in the Omnibus Budget Reconciliation Act (OBRA) and it has three goals: to identify individuals with mental illness and/or intellectual disability, to ensure they are placed appropriately, whether in the community or in a nursing facility, and to ensure they receive the services they require for their mental illness or intellectual disability. The PASRR Level 1 must be completed on all persons who are considering admission to a Medicaid certified nursing facility. A Level II PASRR evaluation must be completed if the Level 1 PASRR determined that the person is a targeted person with mental illness or an intellectual…

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

Based on observations, review of facility policies, clinical record review and interviews with staff, it was determined that the facility failed to develop a baseline care plan within 48 hours of a resident's admission to the facility that included the minimum healthcare information necessary to properly care for a resident for one of 42 residents reviewed (Resident R375). Findings include: Review of facility policy, Baseline Care Plan, Comprehensive Care Plan and Ongoing Care Plan Updates dated October 1, 2024, revealed, The facility will develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meets professional standards of quality care. Observation on December 1, 2025, at 11:28 a.m. revealed that Resident R375 was resting in bed. The resident had a tracheostomy (a surgically created hole in your trachea that allows for breathing) that required respiratory care, including suctioning, oxygenation, assessment, care and maintenance. Continued observation on December 2, 2025,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, review of facility policies, clinical record reviews and interviews with staff, it was determined that the facility failed to update resident care plans related to hospice care, life code status, vascular wounds and tube feedings for two of 42 residents reviewed (Residents R81 and R336). Findings include: Review of facility policy, Baseline Care Plan, Comprehensive Care Plan and Ongoing Care Plan Updates dated October 1, 2024, revealed, Nursing staff will update the care plan related to physician's orders and/or changes in care needs. The nursing staff will initiate and/or update acute care plans for the resident as they are warranted. Observation on December 1, 2025, at 1:35 p.m. revealed Resident R81 was resting in bed. The resident's right foot was gangrenous (death of body tissue due to lack of blood flow). Review of progress notes for Resident R81 from August 15, 2025, through December 2, 2025, revealed that the resident received hospice services and wound treatments to his foot.…

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 clinical record, interview with staff it was determined that the facility failed to ensure that residents are provided with services to maintain and prevent further deterioration of range of motion for two of 42 residents reviewed. (Resident R260 and Resident R16) Review of Resident 260's clinical record revealed that Resident R260 was admitted to the facility on [DATE], with diagnoses of hemiplegia/hemiparesis following unspecifies cerebrovascular accident. Review of Resident R260's MDS (minimum data set, a federally required resident assessment completed at a specific interval) dated September 26, 2025, revealed a BIMS (Brief Interview of Mental Status) score of 15 suggesting that Resident R260 was cognitively intact. Review of occupational therapy discharge note dated October 10, 2025, revealed that resident's last day of service was September 3, 2025 and recommended to continue to wear splint as established. Further review of the discharge note revealed that there were 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 reviews, review of facility documentation, and interviews with residents and staff, it was determined the facility failed to provide adequate supervision to Resident R284 with a diagnosis of alcohol dependency upon return from a leave of absence (Resident R284). The facility failed to ensure that a resident was properly secured during transportation to an outside appointment which resulted in the resident sliding out of the transportation van. (Resident R12) Findings include: Findings include:Review of facility policy title Substance Use Disorder (SUD) dated October 24, 2022, revealed under POLICY: To ensure the preservation of every resident's right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility. With this policy Focus Health Network affirms a commitment to maintain a drug-free environment for the health and safety of individuals in the facility but recognizes that residents with a history 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 observations, clinical record review, a review of facility policies and staff interviews, it was determined that the facility failed to provide adequate nutritional care related to enteral nutrition for two out of 35 sampled residents reviewed (Resident R336 and R86).The findings include: Review of the facility policy Enteral Feeding. Revised July 23, 2019, stated, The physician is responsible for ordering the traditional nutrient, volume, rate, time, flushes, and tube care for the enteral feeding in consultation with the dietician. The licensed nurse is responsible to assure patency of the feeding tube, administration of nutritional products and medications per physician orders, assessment of the tube and skin site, and documentation of the enteral feeding process. Review of Resident R336's clinical record revealed the resident was admitted to the facility on [DATE], for multiple conditions including dysphagia, oropharyngeal phase (difficulty initiating a swallow and can result in health complications,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, review of facility policies, clinical record review and interviews with staff, it was determined that the facility failed to provide adequate treatment, assessment and monitoring for the care and maintenance of midline catheter line in accordance with professional standards of practice for one of one residents reviewed for intravenous care (Resident R375). Findings include: Review of facility policy, IV Policy and Procedures dated May 4, 2020, revealed that intravenous catheters should be assessed frequently for complications, use aseptic/sterile technique during care of IV catheters, assess insertion site and dressing condition every shift, monitor infusions, measure external catheter length every seven days and assess catheter for patency. Observation on December 1, 2025, at 11:28 a.m. revealed that Resident R375 had a right upper extremity midline catheter (a thin soft tube inserted in a vein in the arm used to administer intravenous medications). Documentation on the midline catheter…

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 interviews, it was determined that the facility failed to ensure the proper functioning of an oxygen concentrator for one of one resident review receiving respiratory therapy. (Resident R357) Findings include:Observation of Resident R357 conducted on December 1, 2025, at 10:15 AM revealed that Resident R357 was in bed with nasal canula connected to an oxygen concentrator. Further, O2 concentrator was running at 2.5 liters/min.Further observation revealed that the oxygen concentrator indicator with an image of a wrench was lighted red. and the indicator with an image of an arrow pointing down next to a symbol O2 was lighted yellow. Follow-up observation with Employee E2, DON conducted on December 3, 2025, at 11:00AM, revealed that Resident R357 was on 2.5liters of O2 via oxygen concentrator further, an indicator with an image of a wrench was lighted red. and the indicator with an image of an arrow pointing down next to a symbol O2 was lighted yellow. Interview with DON Employee E2 conducted at the time of the observation confirmed that the oxygen…

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, review of personnel files and interviews with staff, it was determined that the facility failed to ensure that nursing staff have the appropriate competencies and skills sets necessary to care for residents' needs for three of three newly hired nursing staff reviewed (Employees E19, E27 and E28). Findings include: Review of Facility Assessment, dated April 16, 2025, revealed, Competencies are based on current standards of practice and may include knowledge and a test, knowledge and return demonstration, knowledge and observed ability, knowledge and observed behavior and annual performance evaluation. Competencies are based on the care and services needed by the resident population. Competencies are verified upon orientation, least annually and as needed. Review of personnel files revealed that Employee E19 was hired by the facility on October 1, 2025, as a nurse aide. Continued review of personnel files revealed that Employee E27 was hired by the facility on August 6, 2025, as a nurse aide. Continued review of personnel files 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.

Based on review of clinical records, observations and interviews with staff, it was determined that the facility failed to ensure an adequate supply of medications for one of 42 residents reviewed. (Resident R31) Findings include: Review of Resident R31's physician orders revealed an order for amlodipine besylate tablet 10 milligrams (mg), with instructions to administer one tablet by mouth once daily for hypertension and to hold the medication if systolic blood pressure is less than 110 mmHg. The medication order dated was August 4, 2020.Review of Resident R167's physician orders revealed an order for amlodipine besylate tablet 10 mg, with instructions to administer one tablet by mouth once daily for hypertension. The order dated was November 2, 2020.Observation on December 3, 2025, at 9:25 a.m., on the second-floor nursing unit revealed Licensed nurse, Employee E32 preparing medication administration. While preparing medications for Resident R31, it was identified that Resident R31 did not have the prescribed medication amlodipine available in the resident's medication supply.…

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 clinical records, staff and resident interviewed, it was determined that the facility failed to ensure that residents receive routine and emergency dental services for one of 42 residents reviewed. (Resident R128) Review of Resident R128's clinical record revealed that Resident R128 was admitted to the facility on [DATE], with diagnoses of but not limited to Schizoaffective Disorder, Type 2 Diabetes Miletus, Further, Resident R128's MDS (minimum data set, a federally required resident assessment completed at a specific interval) dated May 1, 2025 section C0500 BIMS (brief interview for mental status) score revealed that Resident R128's BIMS score was 14 suggesting that Resident R128 was cognitively intact. Review of Resident R128's MDS (minimum data set, a federally required resident assessment completed at a specific interval) dated May 1, 2025, section L0200 Dental, A. Broken or loosely fitting full or partial denture (chipped, cracked, uncleanable, or loose) was coded NO, B. No…

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

Based on observations and interviews with staff, it was determined that the facility did not ensure that that trash was properly disposed of in the receiving and dumpster area.Findings include: An initial tour of the Food Service Department was conducted on December 1, 2025, at 9:40 a.m. with Employee E8, Food Service Director, (FSD) which revealed a 50-gallon trash can in the corner near the door to the department that did not have a cover, and it was full of kitchen trash. Observation during a follow up visit to the kitchen on December 2, 2025, at 12:10 p.m. revealed the trash can in the corner near the door with no cover and filled with trash. A tour of the receiving area was conducted on December 3, 2025, at 12:05 p.m. with FSD and Maintenance Director (MD), Employee E12 which revealed the following: Observations in the receiving area revealed that the compacting dumpster was full and could not be used. Further observation in the parking lot revealed that staff were putting kitchen trash and housekeeping trash including dirty briefs in the open construction dumpster. 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.

Based on clinical record review and interviews with staff, it was determined that the facility failed to ensure a resident's hospice services were accurately reflected in the clinical record for one of two residents reviewed for hospice (Resident R81). Findings include: Review of progress notes for Resident R81 from August 15, 2025, through December 2, 2025, revealed that the resident received hospice services. Continued review of Resident R81's progress notes revealed that there were no notes regarding the resident's clinical condition or choice related to the election of hospice services. Review of physician orders revealed no physician orders for hospice care from September 5, 2025, until November 18, 2025. The above findings were reviewed with the Director of Nursing on December 5, 2025, at 10:25 a.m. 28 Pa Code 211.5(f)(i)(ii) Medical records

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of facility policies, observations, and staff interviews, it was determined that the facility failed to ensure proper infection control practices were followed during wound care for 1 of 2 residents observed for wound care (Resident R88). Review of facility policy titled Blood or Body Fluid Exposure dated July 2016 revealed that the policy requires that all blood and body fluids be treated as potentially infectious, and that staff wear appropriate protective equipment (gloves, gowns, masks, occlusive bandages) when performing tasks with potential exposure. Any employee exposure must be reported immediately to the Infection Preventionist (or designee), and appropriate cleaning, reporting, and counseling procedures must be followed. In this instance, performing wound care in a communal dining area without appropriate precautions failed to prevent potential transmission of infectious material, compromising both resident safety and staff protection. Review of facility policy titled Infection…

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 interview with staff, it was determined that the facility did not ensure that essential equipment was in a safe and functioning manner related to the dish machine sanitizer pump not operating and keeping the machine out of service for two days causing the facility to serve meals on disposable paperware. Findings include: Observations during the initial tour of the kitchen on December 1, 2025, at 9:40 a.m. with Employee E8, Food Service Director (FSD), which revealed that the dish machine final rinse gage was reading 120 degrees. The FSD indicated that the dish machine was a chemical sanitizing low temperature machine. Testing of chemical sanitizing dish machine revealed that no sanitizer was present in the final rinse confirming that the machine was not sanitizing the dishes that were being run through. The FSD could not get the machine to pump the sanitizing chemical into the rinse water and the machine. The FSD attempted to reach the rep from the chemical company to have them check the machine, but they could not come out the same day. The facility…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and interviews with staff, it was determined that the facility failed to ensure that handrails were safe and properly secured for one of seven nursing units reviewed (3 [NAME] nursing unit). Findings include: Tour of the 3 [NAME] nursing unit on December 2, 2025, at 9:32 a.m. revealed the following:The railings by the elevator across from room [ROOM NUMBER] were missing endcaps; The railing by the clean linen room was missing endcaps;The railing by the dining room across from room [ROOM NUMBER] was missing endcaps.Endcaps or finishings on handrails are required for safety and to prevent snagging. The above findings were reviewed with Employee E12, Maintenance Director, on December 4, 2025, at 9:23 a.m. Observation on December 4, 2025, at 9:42 a.m. revealed that the handrail by the elevator in the lobby area was falling off from the wall. The Nursing Home Administrator confirmed the finding at the time of the observation. 28 Pa Code 205.9(a) Corridors

Based on review of facility documentation, review of personnel files and interviews with staff, it was determined that the facility failed to develop, implement, and maintain an effective training program for five of five newly hired staff (Employees E19, E27, E28, E29 and E30). Findings include: Review of Facility Assessment, dated April 16, 2025, revealed, The staff training and education program is designed to ensure knowledge competency for all staff. Continued review revealed, Every staff member has knowledge competency in: abuse, neglect, exploitation and misappropriation; resident rights; identification of condition change; Behavior management, Identification of changes in condition, Substance Use Disorders and Trauma Informed Care and resident preferences. Additional knowledge competencies for all staff include dementia management, infection transmission and prevention, immunization, QAPI, and OSHA hazard communication. Hand hygiene return demonstration competencies and observed knowledge competencies for emergency response are also required. Review of personnel files…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based upon observation, interviews with residents and staff, review of resident records, facility documentation and policies, and in accordance with accepted professional standards and practices, it was determined the facility failed to maintain medical records on each resident that were complete and accurately documented for one of 13 resident records reviewed (Resident R6).Findings include:Review of the facility policy titled, Charting and Documentation revised July 2017, states all services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate. Review of facility policy titled, Prevention of Pressure Ulcers…

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, observations, and staff interviews, it was determined that the facility failed to develop a comprehensive person-centered care plan for one of 7 Residents reviewed (R2).Findings include:Review of clinical records indicated that Resident R2 was admitted in the facility on August 4, 2025. with the diagnoses of Homelessness, Anxiety Disorder (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), and Psychoactive Substance Abuse (the harmful or hazardous use of substances that alter brain function, affecting mood, perception, cognition, and behavior). Review of information submitted to the State Survey Agency revealed that on August 29, 2025, at approximately 5:25 p.m., a staff member, receptionist, Employee E4, who was outside of the facility on her way back from her break and observed Resident R2, on the sidewalk at the corner of the facility. Employee E4 immediately returned the resident to the facility and notified the 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility documentation, observations and interviews with residents and staff, it was determined that the facility failed to maintain an effective pest control program. Findings include: Observation on all six nursing units in the building on June 26, 2025, accompanied with Maintenance Director, Employee E2 on June 26, 2025, at 9:30 a.m., revealed large quantity of mouse droppings in the following resident rooms: 151,152, 157,162, 252, 211, 215, 221, 307, 317, 320, 321, 322, 328, 408, 410, 413, and 418. Interview with Resident R2 on June 26, 2025, at 9:35 a.m. revealed that this resident saw a mouse in his room a while ago, does not remember when. Interview with Resident R3 on June 26, 2025, at 9:50 a.m. revealed that this resident has seen mice. Interview with Housekeeping Director, Employee E 3 in room [ROOM NUMBER], on June 26, 2025, at 9:50 a.m. revealed that all rooms are cleaned daily. This employee confirmed that the room [ROOM NUMBER] observed together has not been cleaned yet at this…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interview with staff and resident it was determined that facility did not ensure to assure resident safety and maintain the highest practicable physical, mental, and psychosocial well-being for one of six residents reviewed (Resident R1) Findings include: Review of facility policy 'Administering Medications, reviewed December 11, 2024, indicates that the individual administering the medications must sign it out as being administered (or held/refused) per protocol in the electronic health record, and if a drug is withheld, refused or given at a time other than the scheduled time, the individual administering the medications shall document in the electronic health record per protocol. The resident's responsible party, if applicable, and Attending Physician will be made aware. Interview with Resident R1 on Wednesday, June 11, 2025 , 11:00 am, on third floor unit in room [ROOM NUMBER]-A, revealed that resident was not ready to take his morning medications earlier; observed medications cup 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.

Based on review of clinical record and interview with staff, it was determined that facility did not ensure that residents received treatment and care in accordance with professional standards practice related to physician orders for blood sugar levels for one of three residents reviewed (Resident R3) Findings include: Review of facility's policy 'Insulin Administration,' revised April 1, 2022, indicates that blood glucose is to be checked per physician's order or facility protocol. Review of facility policy 'Administering Medications,' reviewed December 11, 2024, indicates that the following information must be checked/verified for each resident prior to administering medications: blood sugar, if necessary, per physician order. Review of Resident R3's clinical record revealed that resident had the diagnoses of end stage renal disease, type 2 diabetes mellitus (failure of the body to produce insulin), mild protein-calorie malnutrition, and dependance on renal dialysis. Review of Resident R3's May 2025 physician order for Novolog (insulin Aspart) to be injected per sliding scale…

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 reviews of clinical records, interviews with staff, reviews of the facility assessment and policies and procedures reviews, it was determined that the facility failed to established criteria or a screening process for the safe escort to ensure the safety of residents for an approved leave of absence for one of nine residents reviewed. (Resident R8) Findings include: A review of the facility policy titled leave of absence dated February 24, 2025 indicated that the purpose of this policy was to ensure the health, safety and quality of life for all of the residents. The policy indicated that residents requesting either an independent and escorted leaves of absence from the facility must receive an order from their physician that indicates a leave of absence will be safe for there resident prior to leave being granted. The physician my deem an independent leave of absence to be unsafe, but may consider and approve an escorted leave of absence if they feel that escorted leaves of absence are in the best…

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, interview with residents and staff, it was determined facility did not implement infection prevention and control program for one of three residents reviewed (Resident R1) Findings include: Review of facility policy 'Isolation Steps: Categories of Transmission Based Precautions,' updated July 12, 2022, indicates that Enhanced Barrier Precautions expand the use of personal protective equipment (PPE) beyond situations in which exposure to blood and body fluids is anticipated and refer to the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of multidrug-resistant organisms (MDRO) to staff hands and clothing. Further review of policy indicates that all residents with the following condition should use EBP's: open wounds and/or indwelling medical devices (e.g., central line, urinary catheter, feeding tube, tracheostomy) regardless of MDRO colonization status who reside on a unit or wing where a resident known to be infected or colonized with a novel or targeted MDRO resides. Review of Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based upon interviews with resident, resident's family, and staff, review of resident records and facility policy it was determined that the facility neglected to give timely incontinence care to one of four residents reviewed (Resident R1). Findings include: Review of the facility policy for Abuse states, Abuse and neglect exist I many forms and to varying degrees. The policy further states that, Neglect occurs when the facility is aware of or should have been aware of goods and service that a resident requires but the facility failed to provide them to the resident(s) that resulted in or may result in physical harm, pain, mental anguish or emotional distress. Resident R1 was admitted to the facility on [DATE], with history of cerebral infarction (stroke) with left side weakness, and aphasic (non-verbal). Review of Resident R1 functional abilities dated April 16, 2025, assessed the resident as dependent upon staff for all self-care, that included eating, hygiene, toileting, bathing,and dressing, bed mobility…

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 interviews with staff review of resident records and facility policy and procedure, it was determined that the facility failed to notify state agencies as required for two of four resident records reviewed (Residenr R1 and R2). Findings include: Review of facility policy for Abuse, states, Abuse and neglect exist I many forms and to varying degrees. Neglect occurs when the facility is aware of or should have been aware of goods and service that a resident requires but the facility failed to provide them to the resident(s) that resulted in or may result in physical harm, pain, mental anguish or emotional distress. The same policy states that initial reporting of incidents and or allegations will immediately be reported to the state agency including a follow-up investigation report within five working says. Resident R1 was admitted to the facility on [DATE], with history of cerebral infarction (stroke) with left side weakness, incontinent of bowel and bladder and depended upon staff for all 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 observations, interviews with staff and resident family and review of facility policy, it was determined that the facility failed to ensure that call bells were within reach for one of four residents reviewed (Resident R1 ). Findings include: Review of the facility's policy for call bells dated April 1, 2022, states, The residents are to have access to call bells at all times and ensure the call bell is within reach before leaving the resident room. Resident R1 was admitted to the facility on [DATE], with history of cerebral infarction (stroke) and left side weakness, and was aphasic (non-verbal). Review of Resident R1 functional abilities dated April 16, 2025, assessed the resident as dependent on staff to provide all self-care needs, including eating, toileting bathing, dressing, bed mobility, and transfers from bed to chair and/or chair to bed. Interview with Resident R1's family on April 24, 2025, at 12:30 p.m. stated, Resident R1 was non-verbal and could not use the right side because it 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.

Based on observations, resident and staff interviews, it was determined that the facility failed to provide food and drink that were served at palatable temperatures for one out of the five residents reviewed. (Resident R1) Findings include: Review of facility policy titled, Accurate and Quality of Tray Line Service, dated January 17, 2019, revealed, Hot food will be kept hot ( > 135° F) and cold foods will be kept cold (<41 ° F). Interview with Resident R1 on April 10, 2025, at 10:54 a.m. revealed food is cold, drink is too warm. Observations during a test tray conducted with the Food Service Director, Employee E8, on April 10, 2025, at 11:37 p.m. revealed Corned Beef 120 degrees Fahrenheit (F); New Potatoes registered 125 degrees F; and cold Lemon Meringue Pie registered 80 degrees F, Cranberry juice registered 62 degrees. Follow-up interview with the FSD, at 11:45 a.m. revealed that thot foods should be at at least 135 degrees F and confirmed that these food items were outside the acceptable temperature range and therefore not palatable. 28 Pa. Code 201.14(a) Responsibility of…

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

Based on observations, resident and staff interview and review of facility policy, it was determined facility failed to maintain standards of an infection control practices by reusing resident's bedpan for three out of five residents reviewed. (R1, R2, R3). Findings include: Review of the facility policy titled Non-critical Resident Care Equipment -Cleaning, dated April 1, 2022, revealed Reusable resident care equipment/instruments/devices will be maintained and decontaminated according to manufacturer's instructions to prevent resident-to-resident transmission of infections (cross contamination). It further under Responsibility states The responsibility for cleaning non-critical resident care equipment is divided between housekeeping and clinical staff. The housekeeping items are addressed in a department specific policy. Interview with Resident R1 on April 10, 2025, at 10:42 a.m. revealed they reuse my bedpan with my roommate and it's unsanitary. An observation revealed one bedpan located in the Resident's R1 and R2 restroom laying on the top of the toilet not being labeled and…

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

Based on observations and interviews with staff, it was determined that the facility failed to provide an environment that promotes the maintenance and enhancement of each resident's dignity for one of four nursing units (4th floor nursing units). Findings include: Observations during the initial tour on April 1, 2025, at 12:30 p.m. revealed that the staff served resident meals with plastic utensils. Interview with Resident R1 on April 1, 2025, at 11:30 a.m. stated facility served food with plastic utensils. Observations during the initial tour on April 1, 2025, at 12:30 p.m. revealed that Resident R1 was eating with plastic Interview with Nurse Aide, Employee E3, on April 1, 2025, at 12:35 p.m. stated facility served all residents for breakfast with plastic utensils. She said she did not know reason for it. Interview with Dietary Staff, Employee E4, on April 1, 2025, at 12:45 p.m. stated facility served all residents for breakfast with plastic utensils. Employee E4 stated facility was out of regular utensils and did not have enough utensils to serve all residents. 28 Pa. Code…

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

Based on observations, resident and staff interviews, it was determined that facility failed maintain a safe, clean comfortable and home like environment for residents of one of four nursing units. (third floor) Findings Include: Observation of Resident R3 on April 1, 2025, at 11:30 AM revealed that there were two urinals filled with urine sitting on resident's bedside table and dresser. Interview with Resident R3 on April 1, 2025, at 11:30 AM stated one urinal was filled last night before he went to sleep but staff did not empty it on 3-11 p.m. shift or overnight shift. Resident also stated the morning staff did not empty the urinal even though the staff was inside the room multiple times. Interview with Employee E5 on April 1, 2025, at 12 noon stated staff should have emptied Resident R3's urinal. Employee stated that she talked to the assigned nurse aide, but she did not give a reason for not emptying urinal. Employee E5 asked the assigned nurse aide to empty the urinal. Observation of Resident R4 on April 1, 2025, at 11:40 AM revealed that there was one urinal filled with urine…

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

Based on observations of the food and nutrition services department, reviews of the pest control operator's reports, interviews with staff, reviews of policies and procedures and reviews of the city department of health inspection report, it was determined that the dietary services was not maintained in accordance with standards for food service safety . Findings include: A review of the policy titled Sanitation of Dining and food service areas dated January 17, 2019 revealed that it was the responsibility of the food service staff to maintain the sanitation of the main kitchen through cleaning. It was the responsibility of the food service director to over see the cleaning and sanitation throughout the dietary department. The cleaning schedule indicated that the dietary and housekeeping staff were responsible for the routine cleaning of the ceiling area of the main kitchen. Observations of the entire ceiling area throughout the main kitchen revealed porous, bulging tiles that were water damaged. Interview with the Director of Dietary Services, Employee E7 and the Maintenance…

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, review of clinical records, observations and staff interviews, it was determined that the facility failed to implement pressure ulcer prevention interventions for three of six residents reviewed for pressure ulcers (Resident R122, Resident R231 and R153). Findings Include: Review of the facility's policy titled, Prevention of Pressure Ulcers states to identify residents at risk for pressure ulcers, common sites of pressure ulcers include back of head, around ears, and heels of feet. Reduce or remove underlying risk factors and monitor the impact of the interventions and to modify the interventions as appropriate. Review of Resident R122's clinical record revealed a physician order dated September 17, 2022, to put on heel protectors to bilateral heels while Resident R122 was in bed for the prevention of skin breakdown. Review of Resident R122's quarterly Minimum Data Set (MDS - federally mandated resident assessment and care screening) dated January 15, 2025, revealed 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 staff interviews and review of resident's records and facility policy, it was determined that the facility did not ensure that a resident had reasonable access to their personal funds for one of 36 resident records reviewed (Resident 91). Findings include: Review of the facility's policy titled, Resident Trust Policy revised July 2023 indicated the facility ensures that the residents has the right to have access to their personal funds. Resident R91 was admitted to the facility on [DATE] diagnosed with epilepsy (brain condition that causes recurring seizures), Parkinson's Disease (progressive disease of the central nervous system), cataract (clouding of the lens of the eye), severe stage of primary open-angle glaucoma (increase eye pressure resulting in the inability of fluid to drain [NAME] the inner eye), bilateral and had severe cognitive impairment and required a responsible party (RP) to take care of his affairs. Interview with the RP on February 11, 2025, at 12:00 p.m. indicated no one from 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 review of clinical records and interviews with staff and facility policy, it was determined the facility did not ensure a resident's code status was updated to reflect the residents wishes for one of 36 resident records reviewed (Resident R101). Findings include: Review of facility policy titled, Advanced Care Planning states, it is the policy of the facility to support the rights of residents in making decisions regarding their care and treatment. Resident R101 was admitted to the facility on [DATE] with the diagnosed with epilepsy (brain condition that causes recurring seizures), anxiety disorder, hemiplegia (weakness of one side of the body) following cerebral infarction and major depressive disorder and was placed on hospice October 31, 2024. Review of Resident R101 hospice communication book and resident care plan revealed the resident's Physician Orders for Life-Sustaining Treatment and Medical Orders for Life-Sustaining Treatment ( POLST- are medical orders that specify a person's wishes for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and resident interviews, it was determined that the facility failed to maintain the facility in clean and homelike environment for two of six nursing units toured (3 west and 3 east). Findings Include: Interview on February 11, 2025, at 1:15 p.m. with Resident R502 revealed about two weeks ago there was allegedly a leak from the unit above and water was pouring from the ceiling. Observations on February 11, 2025, at 1:15 p.m. in room [ROOM NUMBER] confirmed the ceiling tiles above the sink in the room and in bathroom had water damage and had a brown/yellow discoloration. Observations on February 12, 2025, at 11:55 a.m. on the 3 east nursing unit revealed in the soiled linen closet there was multiple bags of soiled linen and trash on the floor of the closet. Observations on February 12, 2025, at 12:00 p.m. in room [ROOM NUMBER] revealed there was leftover food wrapped in foil on the night stand next to the B-Bed. Observations on February 12, 2025, at 12:23 p.m. in room [ROOM NUMBER] 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 review of clinical records, and interviews with staff and facility policy, it was determined that the facility failed to provide vision and audiology services in a timely manner for one out of 36 residents reviewed (Resident R91). Findings include: Resident R91 was admitted to the facility on [DATE] diagnosed with epilepsy (brain condition that causes recurring seizures), Parkinson's Disease (progressive disease of the central nervous system), cataract (clouding of the lens of the eye), severe stage of primary open-angle glaucoma (increase eye pressure resulting in the inability of fluid to drain [NAME] the inner eye), bilateral and had severe cognitive impairment. Interview with Resident R91's family member on February 11, 2025 at 12:00 p.m. indicated they have been asking to see a doctor about his glaucoma and cataracts . The family stated the resident told them he only sees shadows. Also during the interview, the family indicated the resident was hard of hearing and asked the facility to see 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, review of clinical records, and staff interview, it was determined that the facility failed to ensure residents with limited range of motion received treatment and services to maintain or improve range of motion/mobility for one of one resident reviewed with limited range of motion (Resident R231). Findings Include: Review of Resident R231's quarterly Minimum Data Set (MDS - federally mandated resident assessment and care screening) dated November 23, 2024, revealed the resident had severe cognitive impairment and had diagnoses of hemiplegia (one sided paralysis or weakness of the face, arm, or leg) affecting left nondominant side, muscle wasting, and other muscle spasm. Review of Resident R231's comprehensive care plan dated June 1, 2022, revealed the resident had an activities of daily living self-care performance deficit related to non-verbal, non-oriented, weakness to right upper arm, and lower legs. Continued review of Resident R231's comprehensive care plan dated April 4, 2023, revealed the resident had limited physical mobility related to contractures…

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, interviews with staff and review of facility documentation and policy, it was determined the facility failed to ensure residents received adequate supervision to maintain residents' safety for 3 of 36 resident records reviewed (Residents R93, 253, and 224 ) Findings include: Review of the facility's policy titled Accidents stated its purpose is provide an environment that is free from controllable accident hazards and provision of supervision needed to prevent avoidable accidents. Review of Resident R93's clinical record revealed that the resident was admitted to the facility on [DATE] with the diagnoses of dementia (progressive degenrative disease of the brain) unspecified severity with agitation, alcohol dependence with alcohol-induced persisting dementia, and anxiety disorder. Review of Resident R93 initially cared planned in May 2020 revealed that a care plan was developed for aggression and verbal abuse related to the resident's diagnosis of dementia, poor impulse…

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 select facility policies and procedures, clinical record review, and staff interview, it was determined that the facility failed to implement treatment and services for incontinence management for two of five residents reviewed with incontinence (Resident R80, and R256). Findings include: Review of physician order for Resident R80, dated April 4, 2024, indicated an order for Supra Pubic Urinary Catheter with size 16FR/30 cc balloon. On February 18, 2025, at 11:49 a.m., it was observed that Resident R80 had a Supra Pubic Urinary Catheter of 16FR/10ML, instead of 16FR/30 cc balloon. At the time of the finding, confirmed the same with the Unit Manager, a Licensed Nurse, Employee E28. Review of physician order for Resident R256, dated October 14, 2024, indicated an order for Supra Pubic urinary Catheter with size 14FR/10 cc balloon. On February 18, 2025, at 10:55 a.m., it was observed that Resident R256 had a Supra Pubic Urinary Catheter of 14FR/30 cc, instead of 14FR/10 cc Balloon. At the time of the finding, confirmed the same with a Licensed Nurse, Employee E29. 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 review of facility policy, observations, review of clinical record, and resident interview, it was determined that the facility failed to monitor and modify interventions consistent with the resident's assessed needs to maintain acceptable parameters of nutritional status for two of four residents reviewed for nutrition (Resident R251 and R214). Findings Include: Review of facility policy Weight Assessment and Intervention dated February 15, 2022, revealed the nursing staff and Registered Dietitian will work to prevent, monitor, and intervene for undesirable weight loss of the residents. Any weight change of greater than or less than 5 pounds within 30 days will be retaken for confirmation. Significant Weight Changes are defined as: a. more or less than 5% within 30 days; and b. more or less than 10% within 6 months. Review of Resident R251's quarterly Minimum Data Set (MDS - federally mandated resident assessment and care screening) dated January 24, 2025, revealed the resident had severe cognitive…

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 record and interviews with staff, it was determined that the facility failed to follow physician orders regarding tube feeding for one resident out of six residents' with tube feedings reviewed. (Resident R96). Findings include: Review of Resident R96's clinical record revealed the resident was admitted to the facility on [DATE]. Resident R96 had diagnoses of Adult Failure to Thrive, (Adult failure to thrive is a decline seen in older adults - typically those with multiple chronic medical conditions - resulting in poor nutrition, weight loss, inactivity, depression and decreasing functional ability), and Gastrostomy (a surgical procedure that creates an opening (stoma) in the stomach through the abdominal wall. This opening allows a tube (gastrostomy tube) to be inserted directly into the stomach for feeding, medication administration, or gastric decompression). Review of Resident R96's physician orders revealed an order dated January 22, 2025, to administer Jevity 1.2 Cal Enteral…

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, interview review of clinical records it was determined that the facility failed to provide oxygen therapy consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences for one of 36 resident records reviewed (Resident R153) Findings include: Resident R153 was admitted to the facility diagnosed with chronic obstructive pulmonary disease (a lung disease that makes it difficult to breathe) and was ordered 3 liters of continuous supplemental oxygen with instruction to change the tubing every Wednesday and initial and date the new tubing. Observation and interview with the resident's nurse, Licensed nurse, Employee E18 confirmed on February 11, 2025, at 11:30a.m. that the tubing was not dated to indicate when it was last changed, and the oxygen was set at 4.5 liters not 3 liters per the physician's orders. 28 Pa. Code 211.10(c) Resident care policies 28 Pa. Code 211.12(d)(1) Nursing services

Based on staff interviews and the review of clinical records, it was determined that the facility failed to maintain complete and accurate records related to dialysis communication for one of four dialysis residents reviewed (Resident R64). Findings include: Review of Resident 648's physician order, dated November 15, 2024, revealed Resident R64 receives Hemo dialysis treatment on Mondays, Wednesdays, and Fridays. Review of Resident R64 's Hemodialysis Communication Record revealed that on November 22, 2024; November 27, 2024; December 2, 2024; December 6, 2024; December 13, 2024; December 20, 2024; December 25, 2024; January 13, 2025; January 15, 2025; January 17, 2025; January 20, 2025; January 22, 2025; January 25, 2025; January 27, 2025; January 29, 2025; January 31, 2025; February 5, 2025; February 7, 2025; February 10, 2025; and February 12, 2025, it was lacking information on bruit (A dialysis bruit is a whooshing sound heard over a dialysis fistula or graft that indicates how well the access is working), thrill (A dialysis thrill is a vibration felt over a fistula or graft…

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, review of clinical records, and resident and staff interviews, it was determined that the facility failed to provide pharmaceutical services to meet the needs of each resident for one 36 residents reviewed (Resident R502). Findings Include: Review of facility policy Administering Medications revised April 17, 2024, revealed medications should be administered in a safe and timely manner, and as prescribed. Continued review of facility policy revealed that if a medication is not available the nurse will identify reason for the unavailable medication and subsequently reach out to the pharmacy as applicable, to determine when medication will be available. If the mediation is not available in the emergency supply the nurse should contact the physician for further instructions. Review of Resident R502's clinical record revealed the resident was newly admitted to the facility on [DATE], and was identified as alert and oriented (AAOX3- aware of who they are, where they are, and what…

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

Based on observations of the food service, reviews of policies and procedures and interviews with residents and staff, it was determined that the facility did not ensure food was palatable, attractive and prepared and served in portion sizes to meet each residents' needs. (Residents: R 278, R 267, R50, R 241, R10, R175, R 299, R 279, R5, R16, and R11). Findings include: A review of the policy titled test tray evaluation dated January 17, 2019, revealed that test tray evaluations and monitoring were the responsibility of the food and nutriton services department. The policy indicated that the food and nutrition services department was to use the meal tray evaluation system to objectively evaluate the quality of the foods being served to the residents. A review of the policy titled altered portions dated January 17, 2019, revealed that it was the responsibility of the registered dietitian to ensure that all residents food preferences were being honored to promote meal satisfaction. The policy indicated that double portion sizes of foods at meals would be ordered by the physician.…

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 documentation, review of clinical records, and interviews with staff, it was determined that the Nursing Home Administrator and the Director of Nursing failed to effectively manage the facility resulting in an Immediate Jeopardy situation with a resident who had a history of sexually inappropriate behaviors engaging in unwanted/non-consensual sexual contact with a resident who had severe cognitive impairment. Findings Include: Review of the job description of the Nursing Home Administrator (NHA) revealed that, the employee assumes full-time administrative authority, responsibility and accountability for the operations of the nursing facility. The employee manages facility employees in the provision of care and services rendered in accordance with professional standards, and in compliance with state and federal laws and regulations. The employee implements operational and financial objectives of management and allocates resources in an efficient and economical manner to attain 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.

Based on observations, review of facility policies, review of facility documentation, clinical record review and interviews with staff, it was determined that the facility failed to maintain an effective infection control program related with Enhanced Barrier Precautions for one of two residents reviewed (Residentb R96). Findings include: Review of literature revealed that Enhanced Barrier Precautions are infection control Intervention designed to reduce the transmission of novel or Multi-Drug-Resistant Organisms. Enhanced Barrier Precautions require to employ the use of targeted personal protective equipment (PPE) during high contact patient/resident activities. On February 18, 2025, at 11:28 a.m. review of physician order for Resident R96 revealed an order dated February 12, 2025, for Enhanced Barrier Precautions: Gown and Gloves during high contact care/activities with resident, every shift for prophylaxis secondary to peg tube, and chronic wound. Observation on February 18, 2025, at 11:39 a.m. revealed that a Licensed nurse, Employee E28, was cleaning the peg tube site of…

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

Based on observations, resident and staff interviews, and a review of facility documentation, it was determined that the facility failed to provide food and drink that was palatable and served at palatable temperatures for five of ten residents reviewed (Residents R2, R8, R9, R10 and R11). Findings include: A review of Test Tray Evaluation Form, revealed that the standard temperature for hot foods, including entrée and starch, on tray line was over 135 degrees and cold food, including milk and juice, was under 50 degrees. Interview with Resident R8 on December 16, 2024, at 10:55 a.m. revealed that the food is not always warm enough. Interview with Resident R9 on December 16, 2024, at 11:00 a.m. revealed that the food is often cold, that they do not bring her coffee and she prefers oatmeal as the cream of wheat makes her sick. Interview with Resident R10 on December 16, 2024, at 11:03 a.m. revealed that the food does not taste good, and it is not always hot enough. Interview with Resident R11 on December 16, 2024, at 11:07 a.m. revealed that the food is not always warm, and that they…

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, interviews, and a review of facility policies and documentation, it was determined that the facility was not maintaining an effective pest control program for six of ten residents interviewed (Residents R2, R3, R4, R5, R8 and R10). Findings include: A review of facility Pest Control policy revised September 27, 2024, states that the facility maintains an ongoing pest control program to ensure the building is kept free of insects and rodents. Interview with Resident R4 on December 16, 2024, at 10:44 a.m. revealed that she has seen mice in her room. Interview with Resident R5 on December 16, 2024, at 10:48 a.m. revealed that there is a problem with mice, and that he see's mouse poop all over the facility. He said that the exterminator was in his room last week and said that they would be gone in three days, but he still sees and hears them. He thinks the mice chewed the pillows on the bed next to his. Resident R5 said that a while ago he got a small mouse stuck between his meal plate and the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of facility policies, facility documentation, review of clinical records and interviews with residents and staff, it was determined that the facility failed to conduct a thorough investigation related to an allegation of verbal and physical abuse for one of two residents (Resident R1). Findings include: Review of Resident R1's clinical record revealed that Resident R1 was admitted to the facility on [DATE], with diagnoses of Unspecified Intellectual Disability, Post Traumatic Stress Disorder (PTSD), Transsexualism, and Anxiety Disorder. Review of Resident R1's Quarterly MDS (minimum data set, a federally required resident assessment completed at a specific interval) assessment dated [DATE] Section C0500 BIMS (brief interview of mental status) score revealed that Resident R1 scored 15, suggesting that Resident R1 was cognitively intact. Review of resident's care plan revealed that a care plan was developed on November 6, 2024 for the resident having the potential to be physically aggressive…

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 reviews and interviews with residents and staff, it was determined that the facility failed to ensure that a resident received appropriate care to a surgical wound, for one of seven residents reviewed (Resident R2). Findings include: Interview on October 22, 2024, at 10:25 a.m. Resident R2 stated that she had a wound vac (device that decreases air pressure on a wound, helping the wound to heal more quickly) upon her admission to the facility to her surgical wound and that she did not receive any wound care or dressing changes to the wound vac device for a week. Review of Resident R2's admission MDS (Minimum Data Set - a mandatory periodic resident assessment tool), dated October 2, 2024, revealed that the resident was admitted to the facility on [DATE], with diagnoses including cellulitis (bacterial skin infection) of the right axilla (armpit). Continued review revealed that the resident had a surgical wound. Review of Resident R2's care plan, dated initiated October 2, 2024, 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 reviews of policies and procedures, observation of mechanical and electrical equipment and interviews with staff, it was determined that the facility was not adequately equipped to allow residents to call for staff assistance through a communication system directly to a centralized staff work area on one of four nursing units. (Four [NAME] nursing unit) Findings include: A review of the policy and procedure titled call bells, dated April 1, 2022 revealed that it was the responsibility of the facility to ensure that each resident had access to a call bell at all times; while in their rooms, bathing areas and toilet areas. The facility was also responsible for providing a variety of call bells to each resident so that each resident could communicate their needs to the staff directly to a centralized staff work area. Observations of the Fourth floor nursing unit revealed that residents when in their rooms, toilet and bathing areas did not have a means of directly contacting caregivers through the resident call system at the centralized nurses station. Observations of the call…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, interviews with staff and reviews of policies and procedures, it was determined that the facility failed to develop and implement a comprehensive person center care plan for respiratory care for one of ten residents reviewed. (Resident R1) Findings include: Review of the policy and procedure titled Baseline care plan, comprehensive care plan and ongoing care plan updated dated April 1, 2022, revealed that a comprehensive care plan was to be developed and implemented by the interdisciplinary care team for each resident. The care plan was required to include measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs. The policy indicated that the services provided by the interdisciplinary care team were required to meet professional standards of quality and provided by qualified persons. Review of Resident R1's comprehensive assessment (MDS-an assessment of care needs) dated September 17, 2024, indicated that this resident was admitted…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, and resident and staff interviews, it was determined that the facility failed to maintain a safe, clean, homelike environment on three of five nursing units (A, B, E Nursing Units). Findings include: An initial tour of the facility on August 21, 2024, 11:00 a.m. revealed the following observations. Observation of facility room [ROOM NUMBER] revealed there were broken air conditioning unit with open covers. During the observation Resident R1 stated that the air conditioning unit had been in the same condition for a while at least from June or July of 2024. Observation of room [ROOM NUMBER] revealed that base board molding under the air condition unit was missing. Interview with Employee E4, Nurse aide stated room [ROOM NUMBER] had water leak from air-condition unit which created flood in the room. Employee stated the air condition unit work more when it was warm outside and caused water leak in the room. During the observation air condition unit was not on and no water was seen on the…

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

Based on a review of clinical records and the Resident Assessment Instrument and staff interviews, it was determined that the facility failed to conduct a significant change Minimum Data Set Assessments (MDS - a federally mandated standardized assessment process conducted at specific intervals to plan resident care) for one of three residents reviewed (Resident R4). Findings include: According to the RAI User's Manual dated October 2024, A significant change is a major decline or improvement in a resident's status that: 1. Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions, the decline is not considered self-limiting; 2. Impacts more than one area of the resident's health status; and 3. Requires interdisciplinary review and/or revision of the care plan. o Decline in two or more of the following: - Resident's decision-making ability has changed; - Presence of a resident mood item not previously reported by the resident or staff and/or an increase in the symptom frequency (PHQ-2 to 9©), e.g., increase 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 the review of clinical records, review of facility policy, staff interviews, it was determined that the facility failed to maintain appropriate nutritional parameters for one of four residents reviewed. (Resident R4). Findings include: Review of facility policy Weights Assessment and Interventions dated February 15, 2022, revealed Any weight change of greater than 5 pounds within 30 days will be retaken for confirmation. Dietician will also review monthly weights by the 10th of the month to follow individual weight trends over time. Negative trends will be assessed by the dietician weather or not the definition of Significant weight change is met. Review of weight data for Resident R4 revealed that the resident weighed 138.6 on June 11, 2024, and 124.6 on July 19, 2024 which was 14-pound weight loss over 30 days/ a month. Review of dietary weight note for Resident R4 dated July 22, 2024, revealed that the resident had a significant weight loss on July 19, 2024. Resident lost 10.1% body weight in 1 month and 11.3% in 6 months. Further review of the progress note 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 clinical record review, facility policy and interviews with staff, it was determined that the facility did not ensure that a physician assessment was completed related to unplanned weight loss for one of 4 residents with weight loss reviewed (Resident R4). Findings include: Review of facility policy Weights Assessment and Interventions dated February 15, 2022, revealed Any weight change of greater than 5 pounds within 30 days will be retaken for confirmation. Dietician will also review monthly weights by the 10th of the month to follow individual weight trends over time. Negative trends will be assessed by the dietician weather or not the definition of Significant weight change is met. If a weight loss meets the definition of significant, the dietician should discuss with the interdisciplinary team and make recommendation. Review of weight data for Resident R4 revealed that the resident weighed 138.6 on June 11, 2024, and 124.6 on July 19, 2024. Which was 14-pound weight loss over 30 days/ a month. Review of dietary weight note for Resident R4 dated July 22, 2024, 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 observations and interviews with resident and staff, it was determined that the facility failed to ensure a safe and functional environment for one of four floors (Third floor). Finding Include: Observation of facility Third floor west nursing unit on August 21, 2024, at 12:00 p.m. revealed that next to room [ROOM NUMBER] there were two large trash containers without lids on the hallway. There was water in both containers. There were also sheets on the floor. However, the floor appeared dry during the observation. There was no rain at the time of the observation. Interview with Nurse Aide, Employee E8, stated there was leak from the ceiling and the containers and sheets were placed there to collect the water. Employee E8 stated the leak was going on for months. Interview with Resident R3 on August 21, 2024, at 12:30 p.m. stated he was a resident at the facility for years and the water leak has been going on for almost least a year. Resident stated sometimes the leak was so bad that it created wet floors…

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, facility policy review, clinical record review and interviews with staff, it was determined that the facility did not ensure that the resident environment remained as free of accident hazards related to access to smoking materials for two of 35 residents reviewed (Residents R12, and R222), and during three out of three smoking breaks observed. Findings include: Review of facility policy Smoking Safety Policy, most recently revised March 2024, revealed that during designated smoking times, staff will be present. The staff member will be responsible for .Handling smoking paraphernalia . [and to] Return smoking paraphernalia to designated areas. Further review revealed that smoking and lighting materials will be kept in a designated area and not in the resident's possession. Continued review revealed that [policy] violations could include but not limited to . Maintaining supplies/ lighting materials that should be locked up. Review of clinical documentation for Resident R12 revealed that he…

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: An initial tour of the Food Service Department (FSD) was conducted on May 28, 2024, at 10:45 a.m. with Employee E4, Food Service Director, which revealed the following: Observations in the receiving area revealed both garage doors were wide open, and the inner door was not functioning. Cardboard boxes stacked on top of the trash compactor. Observation in the walk-in cooler revealed a buildup of greyish substance growing on the ceiling, Observations of the convection ovens revealed a buildup of dust and grime on the top and exterior of the ovens. Observation in the dish room revealed a white fan with a heavy buildup of black dust and dirt on the fan blades and grills and the fan blowing toward the clean dishes. Interview with FSD on May 28, 2024, at 10:45 a.m., confirmed the above findings. 28 Pa. Code: 201.14(a) Responsibility of licensee. 28 Pa.…

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's policies, interview with staff and resident, it was determined that the facility did not ensure that residents were treated with dignity and respect for three of 35 residents reviewed (Residents R27, R125, R129) Findings include: Review of facility provided documentation of job description for nurse aides indicates that nursing staff are to provide care in a manner that protects and promotes resident rights, dignity, self-determination and active participation. Offers and respects resident choices in matters of daily routine .handles all resident property with respect. Review of facility provided 'nurse aide clinical skill competency,' completed for nurse aides, Employees E11 and E10 on May 15, 2024 and May 2, 2024 indicated that nursing staff are to demonstrate respecting resident privacy and dignity by knocking on doors before entering resident rooms and bathrooms. Observations on May 28, 2024 at 11:51 a.m. revealed a nurse aide, Employee E11 was in Resident R129'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.

Based on the review of clinical records and interview with staff, it was determined that the facility failed to notify the resident and the resident's representative(s) of the transfer to the hospital and the reasons for the transfer in a timely manner for two of 35 residents reviewed (Residents R202 and R286). Findings include: A review of Resident R286 's clinical record revealed that the resident was transferred to the hospital on March 13, 2023. Further review of Resident R286's clinical record failed to reveal documentation of a written hospital transfer notice provided by the facility to the Office of the State Long-Term Ombudsman and representative. A review of Resident R202's clinical record revealed that the resident was transferred to the hospital on January 22, 2024. Further review of Resident R202's clinical record failed to reveal documentation of a written hospital transfer notice provided by the facility to the Office of the State Long-Term Ombudsman and representative. Interview with the facility Administrator, Employee E1, and Director of Nursing Employee, E2, on…

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

Based on clinical record review and interviews with staff, it was determined that the facility failed to accurately complete a resident assessment for one of 35 residents reviewed (Resident R242). Findings include: A review of Resident R242's quarterly Minimum Data Set (MDS- assessment of resident needs) dated March 1, 2024, revealed that the resident was on dialysis. Review of Resident R242 entire clinical record revealed no evidence that the resident was receiving dialysis services. An interview with the Registered Nurse Assessment Coordinator, Employee E5, conducted on May 31, 2024, at 10:38 a.m. confirmed that Resident 242's MDS was coded inaccurately. 28 Pa. Code 201.14(a) Responsibility of licensee 2 Pa. Code 211.5(f) Medical records

Based on observation of the facility's physical environment and interviews with staff, it was determined that the facility failed to ensure that a supply of potable (safe for drinking) water on hand at the facility in the event that there was a loss of normal water supply. Findings include: A review of the undated facility policy, Emergency Preparedness Program, revealed that, in the event of an emergency, which prohibits the use of internal water sources, alternate potable water sources are available. Bottled water is available in the employee lounge and the main kitchen. The facility is storing one gallon per day for three days plus an additional 100 gallons for staff and volunteers. Observation of the facility storage are in the basement on May 28, 2024, at 11:05 a.m. revealed that there was only 300 gallons of potable water being stored as part of the facility's emergency preparedness. Interview with the Food Service Director on May 28, 2024, at 11:05 a.m. confirmed that the facility had a census of 288 residents and that they did not have a three-day supply of water on site for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, review of facility policy, resident and staff interviews, and review of facility documentation, it was determined that the facility failed to provide an environment that was free of accidents hazards to three of eleven residents observed. (Residents R3, R8, R9). Findings Include: Interview with Director of Maintenance Employee E9 on March 26, 2024 at 10:30 a.m. revealed they did recently have an issue with one window fully opening. The Director of Maintenance Employee E9 stated that it was brought to his attention by a staff member that room [ROOM NUMBER] had a window that was opening all the way. The Director of Maintenance Employee E9 stated that they immediately did a whole house audit and found that one window in room [ROOM NUMBER] did fully open. The Director of Maintenance Employee E9 stated that it was fixed. On March 26, 2024 at 1:00 p.m. the surveyor entered the hallway on the second floor to go to room [ROOM NUMBER] to check to ensure the window was not fully opening. As 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 observations, review of facility documentation, interviews with residents and staff, it was determined that the facility has failed to maintain an effective pest control program in the kitchen and two of three nursing units (2nd and 3rd floor). Findings Include: Tour of the main kitchen on March 26, 2024 at 9:02 a.m. was conducted with Regional Director of Dining, Employee E4 and Assistant Director of Dining Employee E5. A tour was taken of the entire kitchen included the loading dock area. Regional Director of Dining stated that there was a crack in the old trash compactor, and they just received a new one. Around the trash compactor was several small pieces of paper trash. The surveyor asked The Regional Director of Dining Employee E4 if he has had any trouble with mice recently and he stated yes. Employee E4 confirmed on March 26, 2024 at 9:20 a.m. that he had seen a picture of a mouse on top of the chicken in the walk in refrigerator. Employee E4 stated that last Thursday (March 21, 2024) he came 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews with facility staff and residents and review of facility documents, it was determined that the facility failed to report an incident of alleged verbal abuse to the Department of Health as required for one of five resident reviewed (Resident R2). Findings include: Review of facility document titled Formal Investigation Report and dated January 14, 2024, revealed a witness statement by Resident R2 alleging verbal abuse by a staff member. Resident R2 alleged that on January 14, 2024, during the 3 p.m. to 11 p.m. shift, she overheard a nursing assistant providing care to her roommate refer to her (resident R2) as a junkie and a whore. Review of Resident R2 revealed that the resident was admitted to the facility on [DATE], with the diagnoses of adult failure to thrive (a state of decline caused by multiple chronic concurrent diseases), diabetes (a disorder of the body's metabolism caused by insufficient insulin production), anemia (a condition in which the body does not have enough healthy red…

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 review of facility documentation, it was determined that the facility failed to provide assistive devices necessary to prevent falls for one of 36 residents reviewed for accidents. (Resident R286). Findings include: Review of the January 2024 physician orders for Resident R286 included the following diagnosis: cerebral infarction (a stroke); diabetes (a condition that happens when an individual's blood sugar is too high); chronic obstructive pulmonary disease (COPD- a chronic inflammatory lung disease that causes obstructed airflow from the lungs); dysphagia (difficulty swallowing) and a history of falling. Review of the resident's December 14, 2023 Quarterly Minimum Data Set Assessment indicated that the resident was cognitively impaired. Review of the resident's person-centered plan of care revealed a care plan dated April; 28, 2023 that stated Resident R286 uses floor mats. The goal in the care plan indicated that the resident will not be injured if he falls out of bed and the interventions included placing…

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 record review and interview with staff. It was determined that the facility did not ensure that a physician's order for a STAT (immediately or without delay) CT (Computed Tomography scan is a diagnostic imaging procedure that uses a combination X-rays and computer technology to produce images of the inside of the body) for one of one resident reviewed. Findings include: Review of Resident R1's clinical record revealed that Resident R1 was initially admitted to the facility on [DATE], with a most recent readmission to the facility on [DATE]. Further review of Resident R1's clinical record revealed that Resident R1's diagnoses included Chronic Kidney Disease, End Stage Renal Disease, Dependence on Renal Dialysis, Weakness. Review of Resident R1's Significant Change MDS (minimum data set- a federally required resident assessment completed at a specific interval) dated [DATE], section C0500, BIMS (brief interview for mental status) Summary Score revealed that Resident R1 scored 8 suggesting that Resident R…

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 and procedure review, interviews with staff and review of the reportable event submitted to the State survey agency, it was determined that the facility failed to report immediately, an allegation of sexual abuse, in response to an allegation made by a resident and failed to report the results of the investigation in accordance with State laws within five working days of the incident for one of 18 residents reviewed. Findings include: A review of the policy titled Abuse dated October 24, 2022, revealed that it was the responsibility of the facility to ensure that each resident was free from abuse. The policy indicated that abuse included: neglect, verbal, sexual, physical, mental abuse, corporal punishment or involuntary seclusion. The policy also indicated that no abuse would be tolerated and that residents and staff would be monitored and protected from abuse. The policy indicated that sexual abuse was defined as non-consensual contact of any type with a resident. The procedures for investigation of possible sexual abuse were that the investigation was to occur…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, reviews of clinical records, review of policies and procedures, review of facility documentation and interviews with staff and residents, it was determined that the facility failed to conduct a completed and thorough investigation into an allegation of possible sexual abuse for one of 18 residents reviewed. (Resident R1) Findings include: A review of the policy titled Abuse dated October 24, 2022, revealed that it was the responsibility of the facility to ensure that each resident was free from abuse. The policy indicated that abuse included: neglect, verbal, sexual, physical, mental abuse, corporal punishment or involuntary seclusion. The policy also indicated that no abuse would be tolerated and that residents and staff would be monitored and protected from abuse. The policy indicated that sexual abuse was defined as non-consensual contact of any type with a resident. The procedures for investigation of possible sexual abuse were that the investigation was to occur immediately. 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 review of facility polices, clinical record reviews and interviews with staff, it was determined that the facility failed to provide a resident's representative with the right to participate in the care planning process for one of 19 residents reviewed (Resident R13). Findings include: Review of facility policy titled, Care Plan Meeting dated October 24, 2022, revealed, The facility will ensure that the residents, families, or representatives understand the comprehensive care planning process which includes the care planning meetings. The facility will designate a member of the team to communicate with the residents, families or representatives regarding the day and tine of the scheduled care plan meeting. Review of Resident R13's admission MDS (Minimum Data Set - a mandatory periodic resident assessment tool), dated July 3, 2023. Revealed that the resident was admitted to the facility on [DATE], with Diabetes (disease in which the body's ability to produce or respond to the hormone insulin is…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of clinical records, facility documentation and interviews with staff, it was determined that the Nursing Home Administrator and the Director of Nursing failed to effectively manage the facility related to a resident eloping from the facility for one of eight clinical records reviewed (Resident R1). This failure placed Resident R1 at high risk for injury and was identified as an Immediate Jeopardy situation. Findings include: Review of the job description for the Nursing Home Administrator (NHA) revealed NHA assumes full-time administrative authority, responsibility and accountability for the operations and for the financial responsibility of the nursing facility. Manages facility employees in the provision of care and services rendered in accord with professional standards, and in compliance with state and federal laws and regulations. Review of job description for the Director of Nursing (DON) revealed The Director of Nursing Services assumes full time administrative and clinical authority,…

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 interviews, it was determined that the facility failed to ensure a safe, clean, comfortable, and homelike environment for residents on 3 of 4 nursing units (1st floor, 2nd floor and 3rd floor nursing units). Findings include: Observation conducted of room [ROOM NUMBER] on the 1st floor, on [DATE], at 11:12 a.m. revealed that there were 4 strawberries lying on a napkin with 4 flying bugs flying around them and on them at various periods of time during the observation. Resident R1 reported that they were his strawberries and that he planned to eat them. Employee E5 (licensed nurse) came to the resident's room to administer his medication, saw the flying bugs and strawberries, and moved the medications over to another area in the resident's room so that she could administer them. During another observation in Resident R2's room on [DATE], at 12:04 p.m. 1 strawberry was observed on the resident's bedside table with 3 flying bugs observed flying around it and on it during various times 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 observations, review of facility policy, review of clinical records, and staff interviews, it was determined that the facility failed to ensure dependent residents received the necessary services to maintain good grooming and personal hygiene for 1 out of 3 residents reviewed (Resident R13). Findings include: Review of the facility policy, Activities of Daily Living, dated April 1, 2022, indicted that the facility will ensure that a resident is given the appropriate treatment and services to maintain or improve his or her ability to carry out the activities of daily living. The policy also indicated that the facility would provide care and services for the following activities of daily living which included bathing, dressing, grooming, and oral care, in addition to toileting and eating. Continued review of the policy indicated that a resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal an oral hygiene.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interviews, review of facility policy and review of the clinical record, it was determined that the failed to provide routine and emergency drugs and biologicals to meet the needs of its residents in a timely manner for 1 out of 3 residents reviewed (Resident R13) Findings include: Review of the facility policy, Pharmacy Services, dated October 4, 2022, indicated that it is the policy of the facility to provide Pharmacy Services in accordance to State and Federal regulation. Continued review of the policy indicated that the pharmaceutical services including procedures that assure the accurate, acquiring, receiving, dispensing and administration of all drugs and biologicals to meet the needs of each resident. Review of the physician orders for Resident R13 indicated that the resident was admitted into the facility on August 1, 2023 from the hospital with the following diagnosis: malnutrition (an imbalance between the nutrients that an individual's body needs to function, and the nutrients 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.