Chapel Manor

Based on observation and staff interviews, it was determined that the facility failed to ensure that a resident was treated with respected during a group meeting for one of four residents reviewed (Resident 35). Findings include:On September 16, 2025, at 1:30 p.m., a resident council meeting was held with seven alert and oriented residents (R93, R78, R129, R35, R149, R52, and R13). At 1:57 p.m., during the meeting, Licensed Nurse Employee E8 entered and stated, Excuse me, I need to give Resident R35 medication. Employee E8 then proceeded to administer three pills in a medication cup along with a cup of water. The nurse left the room immediately after. Resident R35, appeared uncomfortable and unprepared to take his medication in front of peers.At 2:06 p.m., following the meeting, Resident R35 was interviewed privately regarding the incident. Resident R35 reported: It made me feel uncomfortable. I was surprised when the nurse came in to give me meds-it caught me off guard.At 2:30 p.m., a meeting was conducted with the Administrator, Employee E1 and Director of Nursing, Employee E2.…

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 facility documentation, review of clinical records, and staff interviews it was determined that the facility failed to conduct a complete and thorough investigation related to a resident fall for one of four residents reviewed (Resident R174). Findings Include: Review of facility policy Abuse Prohibition revised October 24, 2022, revealed the facility will implement an abuse prohibition program which would include investigation of incidents and accidents. Review of Resident R174's quarterly Minimum Data Set (MDS - federally mandated resident assessment and care screening) dated April 1, 2025, revealed the resident had a Brief Interview for Mental Status (BIMS -a structured interview to assess cognitive function and orientation) score of 14 (intact cognitive response). Further review of Resident R174's the MDS revealed the resident had diagnoses of muscle weakness, osteoarthritis (joint pain and stiffness), mild cognitive impairment, and polyneuropathy (condition characterized by damage to multiple peripheral nerves, leading to symptoms…

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

Based on clinical record review, and staff interview, it was determined that the facility failed to ensure that the residents and/or their representative received written notice notifying them of the transfer and the reason for the move in writing and in the language and manner they understand for two residents reviewed for hospitalizations (Resident R171 and R3). Findings include:Review of Resident R171's medical records revealed that on July 21, 2025, the resident was admitted to the hospital for tachycardia (irregular heartbeat). Continued review failed to reveal documentation of a written notification to the residents or resident's representative notifying them of the transfer and the reasons for the move in writing. Interview with the facility administrator on September 18, 2025, at 12:35 p.m. confirmed this finding. Review of Resident R3's clinical record revealed that Resident R3 was transferred to the hospital on February 17, 2025, for influenza. Continued review revealed that the resident was transferred to the hospital on April 18, 2025, for lower extremity weakness.…

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 and resident interviews it was determined that the facility failed to develop comprehensive care plan for three of 33 residents reviewed (Resident R26, R102, and R61).Findings Include:Review of facility policy Person-Centered Care Plan revised September 15, 2025, revealed the facility will develop and implement person-centered care plan for each resident with measurable objectives to meet a resident's medical, nursing, mental, and psychosocial needs. The care plan must be customized to each individual patient's preferences and needs.Review of Resident R26's comprehensive Minimum Data Set (MDS - federally mandated resident assessment and care screening) dated August 2, 2025, revealed a Brief Interview for Mental Status (BIMS - a structured interview to assess cognitive function and orientation) was not assessed because the resident is rarely/never understood. A staff assessment of mental status was conducted which 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 records review and staff interviews, it was determined that the facility failed to follow physician orders to place hearing aids in the residents ears each morning and remove them at bedtime for one of one resident reviewed for vision and hearing (Resident R7). Findings include:Review of physician orders dated September 7, 2025, revealed staff must place hearing aids in bilateral ears in the morning and remove at bedtime. Observations conducted on September 15, 2025, at 12:30 p.m., during screening, Resident R7 could not hear the surveyor and was observed without hearing aids. Observations on September 16, 2025, at 9:44 a.m. and 1:00 p.m., revealed resident R7 did not have the hearing aids in place. Observations on September 17, 2025, at 9:30 a.m. revealed the resident hearing aids on. Follow-up observations on September 17, 2025, at 2:20 p.m. again revealed the resident without hearing aids. Interview and observations conducted on September 17, 2025, at 2:30 p.m. with Nurse Manager, Employee E10, confirmed that Resident R7 did not have hearing aids in place.…

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

Based on review of facility documentation, review of clinical records, observations, and staff interviews it was determined that the facility failed to provide appropriate assistance/supervision for one of four residents reviewed for falls (Resident R174).Findings Include:Review of van driver, Employee E6, personnel file revealed the employee was hired as the facility van driver effective November 4, 2024. Review of van driver, Employee E6, job description for Positions that Involve Transporting Customers/Clients revealed the employee is responsible for assisting residents when boarding and disembarking the vehicle. The employee will operate the vehicle in a safe manner when transporting residents.Review of van driver, Employee E6, personnel file revealed a Vehicle Safety Competency dated November 15, 2024.Review of facility documentation Vehicle Safety Competency revised November 2018 revealed a competency checklist/instruction for operation of wheelchair van lift. Per the Vehicle Safety Competency the van should be placed in park with emergency brake on and wheelchair secured…

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 staff interviews 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 one of five residents reviewed (Resident R142).Findings Include: Review of facility policy Weights and Heights dated July 15, 2025, revealed the facility will ensure all patients maintain acceptable parameters of nutrition status. Review of Resident R142's quarterly Minimum Data Set (MDS - federally mandated resident assessment and care screening) dated July 21, 2025, revealed the resident was admitted to the facility on [DATE], had diagnoses of diabetes mellitus (metabolic disorder that results in elevated blood sugar levels), hypokalemia (low potassium blood levels) gastroesophageal reflux disease (GERD - when stomach acid flows back into the esophagus) and dysphagia (difficulty swallowing).Continued review of Resident R142's MDS revealed…

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

Based on observation, staff interviews, clinical record review, and review of facility policy, it was determined that the facility failed to ensure that a resident was provided with dialysis clamps for one of one resident reviewed receiving hemodialysis. (Residents 15).Findings include:Facility policy titled Dialysis: Hemodialysis (HD) - external catheter valuation and maintenance, last date revised December 16, 2024, stated under 2. Maintain two smooth edged clamps with the patient at all times. 2.1 Smooth edged clamps must be placed at the bedside at time of admission. 2.2 Smooth edged clamps are to be attend to the patient's clothing during transport to and from dialysis facility or for any appointment(s) outside the nursing center. 2.3 If patient is mobile throughout the Center, smooth edged clamps must be attached to the patient's clothing at all times.Review of Resident R15's clinical record indicated an admission date of June 15, 2025, with diagnosis of end stage renal disease, and anima in chronic kidney disease. Review of July 2025 physician orders revealed an order dated,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of clinical records, review of facility policy and interviews with staff and residents, it was determined that the facility failed to ensure complete documentation of Medication Administration Records for two of 10 residents records reviewed (Resident R1 and R4).Review of Facility policy titled Medication Administration: General Guidelines dated January 2025 revealed The individual who administers the medication dose, records the administration on the resident's MAR (Medication Administration Record) immediately following the medication being given. In no case should the individual who administered the medication report off-duty without first recording the administration of any medication. Further review of policy revealed When PRN medication are administered, the following documentation is provided: a. date and time of administration, dose, route of administration (if other than oral), and, if applicable, the injection site. b. complaints or symptoms for which the medication was given, c.…

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 interviews with residents and staff, observations of the laundry department and linen storage areas throughout the nursing units, it was determined that the facility failed to provide sufficient supplies of linen for the bathing and toileting care needs for 12 of 12 residents reviewed. (Residents R1, R2, R3, R4, R5, R6, R7, R8, R9, R10, R11 and R12). Findings include: Observations of the laundry department storage area with the director of laundry services, Employee E5, at 11:30 a.m., on June 4, 2025 revealed that there was no PAR (periodic automatic replacement) of wash clothes. Additional observations of the laundry inventory throughout the facility, revealed that there were no wash clothes in stock. Observations on the nursing units revealed that wash clothes were in low supply. There were not enough wash clothes for toileting care and bathing needs of the residents. Nursing staff, Employees: E6, E7, E8, E9, E10, E11 reported during interviews on June 4, 2025, that they frequently run out of wash clothes on a daily basis, over the past three months. The staff reported…

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 interviews with staff and residents and observations of the resident care equipment, it was determined that essential equipment for the mechanical preparation of ice throughout the facility was not being maintained in a safe operating condition. Findings include: Interview with the administrator, Employee E1, at 10:30 a.m., on June 4, 2025 revealed that the facility had two ice machines to service the nursing units and dietary department. The administrator also reported having to order bags of ice from an outside vender, because the the one ice machine that was in need of repairs could not keep up with the demand for ice form the nursing units for the residents. Interview with the maintenance director, Employee E4, at 11:00 a.m., on June 4, 2025 revealed that there was one ice machine that was inoperable at this time and the other ice machine was in need of repairs: (consistency of ice output, unit power issues and temperature issues), since May 20, 2025. Interviews on June 4, 2025, with alert and oriented residents: (R1,R2, R3, R4, R5, R6, R8, R9, R10, R11 and R12)…

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

Based on clinical record reviews, interviews with staff, reviews of hospital records and facility policies and procedures, it was determined that the facility failed to permit one of three residents reviewed to return to the facility after hospitalization. (Resident R1) Findings include: Review of the undated policy titled Bed-Hold revealed that when a resident/patient is transferred out of the service location to a hospital or on therapeutic leave, the designee will provide the resident and his/her representative, if applicable with the written Bed Hold Policy& Authorization form regardless or the payer. If the resident representative is not present to receive the notice upon transfer, the notice is delivered via e-mail, fax or hard copy via email. Review of the undated policy titled, Discharge and Transfer revealed that for unplanned acute care transfers for the patient must be permitted to return to the Center. For unplanned, acute transfers for the center to initiate discharge while the patient is in the hospital following transfer, the Center must have evidence that the…

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

Based on the review of clinical records, facility policies, and interview with staff, it was determined that the facility failed to develop and implement an effective discharge planning process that focuses on the resident's discharge goals, the preparation of residents to be active partners and effectively transition them to post-discharge care, and the reduction of factors leading to preventable readmissions. Facility failed to update a resident's comprehensive care plan and discharge plan, as appropriate for one of three residents reviewed (Resident R1) Findings Include: Review of facility policy Discharge and Transfer: dated November 15, 2022 revealed that The Center must develop and implement an effective discharge planning process that focuses on the patient ' s/resident ' s (hereinafter patient) discharge goals, preparation of patients to be active partners and effectively transition them to post-discharge care, and the reduction of factors leading to preventable re-admissions. The Center ' s discharge planning process must be consistent with the patient ' s discharge rights.…

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

Based on review of facility provided documentation and interview with staff, it was determined that the facility did not provide requested evidence of yearly performance evaluations for three out of five nurse aides reviewed (Employee E20, E21, and E22) Findings include: On Wednesday, December 18th, 2024 at 9:58 AM, an email was sent to facility's director of nursing, employee E1 requesting evidence of yearly performance reviews for nurse aides. Another verbal request for yearly performance evaluations was made to E1 on Wednesday, December 18th, 2024 at 1:20 PM. Facility was unable to provide evidence for yearly performance evaluations for nurse aides - E20, E21, E22; findings confirmed with facility's administrator and director of nursing. 28 Pa Code 211.12(d)(1) Nursing services 28 Pa Code 211.12(d)(5) Nursing services

Based on observation, review of posted daily nurse staffing data, and staff interviews, it was determined that the facility did not ensure that nursing staffing information was posted on a prominent place readily accessible to residents on two out of two resident floors (First and Second floors) Findings include: Observations on Sunday, December 15, 2024 at 10:00 am revealed the facility did not post the nurse staffing data daily on the first and second floor that was readily accessible to residents in a clear and readable format. Further observations revealed that an assignment sheet was posted in facility's lobby area; which excluded facility name, total number and actual hours worked by registered nurses, licensed practical nurses and nurse aides and resident census. These findings were reviewed and confirmed with facility's administrator and supervisor, employee E5, on Wednesday, December 18th, 2024 at 2:00 PM. 28 Pa Code 201.14(a) Responsibility of licensee 28 Pa Code 211.12(d)(1) Nursing services

Based on observations, interviews with staff, and review of facility policy, 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 related to labeling and dating of food items and food wrapped or in covered containers Findings include: Review of facility policy titled Food Storage: Cold Foods Revised in September 2017. Revealed all food will be stored wrapped or in covered, labeled, and dated, and arranged in a manner to prevent cross contamination. A tour of the main kitchen was conducted with the supervisor cook, Employee E12, on December 15, 2024, at 9:33 a.m. revealed the following: Observation in the dry storage room revealed cans of food and fresh bread not having labeled and dated. Observation in the walk-in refrigerator revealed food not having plastic wrap or covered and labeled with a date on pizza that will be serving for dinner. Observation a pie dessert plated without covers or plastic wrap and labeled and dated on the cookie trays. Further observation…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, clinical record review and interview with staff, it was determined that the facility did not ensure the residents record was complete and accurate related to diagnosis and pharmacy review for two of 39 residents reviewed (Resident R98 and R 40). Findings include: Review of clinical documentation for resident R98 revealed that she was admitted to the facility on [DATE], and had diagnoses on record including, but not limited to, gastrostomy status (a surgical opening made through the abdominal wall and into the stomach, allowing for nutrition and medication to be administered through a tube), Alzheimer's disease, dysphagia, and gastric ulcer. Review of the resident's current and discontinued physician orders revealed no orders for enteral feeds or for care of a gastrostomy site. Observation of resident R98 on December 15, 2024, at 12:45 pm revealed the resident to be lying in bed, positioned on her left side, facing the door. There was no enteral feed equipment in the resident's room, and no…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and interviews with staff, it was determined that the facility failed to provide a safe, functional, sanitary and comfortable environment for residents, staff and the public, for four of four nursing units observed (A-Wing, B-Wing, C-Wing and D-Wing nursing units). Findings include: Observation on December 15, 2024, at 12:28 p.m. revealed that in room [ROOM NUMBER] on the D-Wing nursing unit, the wall trim behind the resident's bed was falling off from the wall. Continued observation on December 15, 2024, at 12:37 p.m. revealed that in room [ROOM NUMBER]A on the D-Wing nursing unit, the wallpaper behind the resident's bed was peeling away from the wall. Continued observation on December 15, 2024, at 1:20 p.m. revealed that in room [ROOM NUMBER]A on the C-Wing nursing unit, the wallpaper behind the resident's bed was peeling away from the wall. Interview with Employee E6, licensed nurse, confirmed that the wallpaper was peeling away in the residents' rooms. Observation on December 15, 2024,…

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

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 corridors had firmly secured handrails on three of four nursing units observed (B-Wing, C-Wing and D-Wing nursing units). Findings include: Observations of the D-Wing nursing unit on December 15, 2024, at 12:42 p.m. revealed the following: The handrail between resident rooms [ROOM NUMBERS] was missing, with tape covering the broken brackets for the handrail; The handrail between resident room [ROOM NUMBER] and the fire door was missing, with tape covering the broken brackets for the handrail; The handrail next to the center stairwell door was broken; The handrail between the center stairwell door and the soiled linen room was missing. Observations of the C-Wing nursing unit on December 15, 2024, at 12:48 p.m. revealed the following: The end cover on the handrail next to the clean linen room was missing, exposing the rough and sharp edge of the plastic and metal; The handrail between resident room [ROOM…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, clinical record reviews and interviews with staff, it was determined that the facility failed to accurately complete MDS assessments for two of 39 residents reviewed (Residents R187 and R96). Findings include: Review of Resident R96's Quarterly MDS (Minimum Data Set - a mandatory periodic resident assessment tool) dated October 22, 2024, revealed that the resident was admitted to the facility on [DATE], with diagnoses including cerebrovascular disease (damage to the brain from interruption of its blood supply) and hemiplegia (paralysis). Continued review revealed that Resident R96 used physical restraints daily (physical restraints are any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body). Review of physician orders and care plans for Resident R96 revealed no indication that the resident used or required physical…

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

Based on observations, clinical record review, review of facility documents and staff interviews, it was determined that the facility failed to revise the care plan for Feeding-Related Care, for one of 36 residents reviewed (Resident R124). Findings include: Review of Resident R124's clinical record revealed that the Resident was admitted in the facility on April 07, 2021. R124's diagnoses included Dementia (Dementia is a set of symptoms that can be caused by a number of diseases which over time destroy nerve cells and damage the brain, typically leading to deterioration in cognitive function, the ability to process thought, beyond what might be expected from the usual consequences of biological aging), Severe Protein-Calorie Malnutrition (a condition that occurs when a person doesn't get enough protein, calories, and other nutrients from their food), Adult Failure to Thrive (a condition in older adults characterized by unexplained weight loss, poor nutrition, decreased appetite, inactivity, and often accompanied by declining physical and cognitive function), and Muscle Wasting 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 clinical record review, observations of residents and interviews with staff, it was determined that the facility failed to implement timely interventions for weight management of one of 36 residents reviewed (R181). Findings include: A review of the clinical record of Resident R181, revealed; admission in the facility on September 9, 2024. Diagnoses of R181 included Gastro-Esophageal Reflux Disease with Esophagitis,(Esophagitis is inflammation of the esophagus. The esophagus is the muscular tube that delivers food from your mouth to your stomach. Esophagitis can cause painful, difficult swallowing and chest pain ), and Abnormal Weight Loss. A review of the resident R181's weight record revealed the following recorded weights: 12/2/2024 07:33 113.4 Lbs Mechanical Lift 11/18/2024 21:07 114.2 Lbs Mechanical Lift 11/1/2024 08:34 113.8 Lbs Mechanical Lift 10/15/2024 13:26 115.2 Lbs Mechanical Lift 10/2/2024 09:56 116.4 Lbs Mechanical Lift 10/1/2024 10:50 115.2 Lbs Mechanical Lift 9/18/2024 13:33 126.4 Lbs Mechanical Lift 9/9/2024 21:03 135.1 Lbs Mechanical Lift Review of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, clinical record review, review of facility policy and staff interview, it was determined that the facility failed to provide appropriate respiratory care and services for one of 36 residents reviewed (R158). Findings include: Review of Resident R158's clinical record revealed; the resident was initially admitted to the facility on [DATE], and readmitted on [DATE]; diagnosed with Acute and Chronic Respiratory Failure with Hypoxia (a condition where the lungs are unable to adequately exchange oxygen, leading to low blood oxygen levels {hypoxia}, which can occur suddenly {acute} or develop over time {chronic}, causing significant breathing difficulties and potential complications depending on the severity and duration of the issue; essentially, it means the body isn't getting enough oxygen due to impaired lung function, either rapidly or gradually); Chronic Obstructive Pulmonary Disease (COPD- a common lung disease causing restricted airflow and breathing problems, in people with COPD, 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 observation, clinical record review, and interview with staff, it was determined that the facility did not ensure the physician notes were accurately completed related to resident assessment and gastrostomy status for one of 39 residents reviewed (Resident R98). Findings include: Review of clinical documentation for resident R98 revealed that she was admitted to the facility on [DATE], with diagnoses including, but not limited to, Alzheimer's disease, dysphagia, and gastric ulcer. Review of physician's notes revealed that on June 29, 2024, July 28, 2024, August 25, 2024, September 22, 2024, October 26, 2024, and November 24, 2024, the attending physician, employee E15, wrote monitor for chronic factors of gastrostomy (a surgical opening made through the abdominal wall and into the stomach, allowing for nutrition and medication to be administered through a tube; receiving nutrition in this was is called enteral feeding) feeding, and noted a diagnosis of gastrostomy status. Review of 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 review of clinical records, and staff interviews, it was determined that the facility failed to ensure that residents were free from unnecessary medications for one out of five residents sampled. (R 150). Findings include: Resident R150 was admitted to the facility on [DATE], Bipolar Disorder, (people with Bipolar Disorder often experience periods of extremely up, elated, irritable, or energized behavior; known as manic episodes; and very down, sad, indifferent, or hopeless periods; known as depressive episodes), Post-Traumatic Stress Disorder (a psychiatric disorder that may occur in people who have experienced or witnessed a traumatic event, series of events or set of circumstances; an individual may experience this as emotionally or physically harmful or life-threatening and may affect mental, physical, social, and/or spiritual well-being), Attention-Deficit Hyperactivity Disorder (ADHD) {Symptoms of ADHD include inattention [not being able to keep focus], hyperactivity (excess movement that is not…

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 to Transmission Based Precautions for one of 36 residents reviewed (Resident R49). Findings include: Review of facility policy, Infection Control Policies and Procedures, Enhanced Barrier Precautions revised in December 2024, revealed that Enhanced Barrier Precautions are infection control Intervention designed to reduce the transmission of novel or Multi-Drug Resistant Organisms. The policy stated to employ targeted personal protective equipment (PPE) use during high contact patient/resident activities. It also specified that Multi-Drug Resistant Organisms (MDROs) are bacteria and other microorganisms that have developed resistance to one or more classes of antimicrobial drugs. The policy continued that ESBL-producing Enterobacterales are included in MDROs. (An ESBL infection is caused by bacteria that produce extended-spectrum beta-lactamase…

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 call bell systems functioned properly for one of four nursing units observed (C-Wing nursing unit). Findings include: Observation on December 15, 2024, at 1:17 p.m. revealed that the call bell system was activated on the C-Wing nursing unit. The beeping of the alarm could be heard, however, no lights above any of the residents' rooms were illuminated. Observation of the call bell control panel at the C-Wing nurses station revealed that no lights were illuminated that would indicate which room activated their call bell. Employee E6, licensed nurse, stated that she could hear the call bell, however, she was unable to determine which room had activated their call bell. Employee E6, licensed nurse, walked up and down the halls looking for any indications of call bell activation, but was unable to see any. Employee E6, licensed nurse, then proceeded to go room by room on the C-wing nursing unit in attempts to…

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

Based on review of a meal tray test results, review of facility policy and interviews with resident and staff, it was determined that the facility failed to serve foods that were palatable and at proper temperatures for one of eight nursing floors reviewed. (Unit D) Findings include: Review facility document date revised on September 2017 Food Preparation revealed that all food will be held at appropriate temperatures, greater than 135-degree Fahrenheit or as state regulation requires) for hot holding, and less than 41-degree Fahrenheit for cold food holding. Interview with Resident R1 on October 3, 2024, at 10:00 a.m. the resident stated that the hot food is cold always when brought to his room. The food taste bad most of the times and it's hard to eat it. Interview with Resident R2 on October 3, 2024, at 10:00 a.m. the resident stated that the hot food was not served hot bad quality that he got sick from it. He stated he reported this to staff but did not change anything. A test tray on the Unit D nursing unit was performed on October 3, 2024, at 12:45 a.m. with the Dietary staff,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interviews with staff, it was determined that the facility failed to equip corridors with safe handrails on each side, for one of four nursing units observed (Second floor nursing D unit). Findings include: Observation of the Second Floor Nursing Unit D on October 3, 2024, at 11:45 p.m. revealed the following: The handrail by room [ROOM NUMBER]-unit D was broken and hanging off. The handrail by room rooms 215-unit D was missing. Interview on October 3, 2024, at approximately 11:48 a.m. with second floor unit manger licensed practical nurse, Employee E4, revealed that the handrails were not secured. Interview on October 3, 2024, at 1:45 p.m. the Nursing Home Administrator reported that facility will be sending the working order for handrails. 28 Pa Code 201.14(a) Responsibility of licensee

Based on the review of clinical records, interview with staff and resident, it was determined that the facility failed to provide care and services as ordered by the physician for one of three residents reviewed (Resident R2). Findings Include: During interview with Resident R2 on August 12, 2024, at 10:00 a.m. the resident stated that he should be getting ACE wraps to his lower extremity for swelling. Resident stated he was seen by the physician and recommended he wear compression stockings for lower extremity. Resident stated compression stocking was uncomfortable for him so the physician stated he should wear ACE wraps. Resident stated staff did not assist him for putting the ACE wraps on. Observation of the Resident R2 on August 12, 2024, at 10:00 a.m. revealed that the resident was not wearing ACE wraps or compression stockings to the lower extremity. Observation of the resident's room revealed that there was ACE wraps in his bed side drawer. However, there was no compression stocking available in his room. Review of physician's orders for Resident R2 revealed that an order 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 review of a meal tray test results, review of facility policy and interviews with resident and staff, it was determined that the facility failed to serve foods that were palatable and at proper temperatures for one of eight nursing floors reviewed. (Unit A) Findings include: Review of an undated facility document Resident Tray Assessment Report, revealed that the standard temperature for food items as below: Soup and Hot beverages- greater than or equal to 150-degree Fahrenheit- 3 points; 145-149 degree Fahrenheit -2 points, 140-144 degree Fahrenheit-1 point less than 140 degree Fahrenheit -0 points. Hot Entrees, starch and vegetables- greater than or equal to 130-degree Fahrenheit 3 points; 125-129 degree Fahrenheit -2 points, 120-124 degree Fahrenheit -1 point less than 120 degree Fahrenheit -0 points. All cold food- less than 45 Fahrenheit -3 points, 48-50 degree Fahrenheit -2 points, 51-54 degree Fahrenheit -1 point, greater than 55 degree Fahrenheit- 0 points. Qualitative Assessment: Correct 1 point, Unacceptable -0 point. Fully acceptable-2 point, Need improvement- 1…

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 resident and staff interview, it was determined that the facility failed to schedule an appointment for outside services in a timely manner for one of 3 residents reviewed (Resident R3). Findings include: During an interview on August 12, 2024, at 10:30 a.m. Resident R3 stated he needed to see an outside provider for his shoulder pain. He stated he was suffering from excruciating pain to the shoulder which he rated at 10/10. He stated he was regularly receiving cortisone shots from an outside provider prior to his admission. Since his admission, he was not seen by an outside provider for an appointment. Resident stated he understand the provider he used to go was far from the facility, however he wanted to see any provider that can treat his shoulder pain and give injection which was effective for him in the community. Resident R3's clinical record revealed an admission date of February 14, 2024, with diagnoses that included muscle weakness, osteoarthritis, pain right upper arm and pain and left upper arm. Review of hospital record for Resident R3…

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 policy and procedures, observations, and resident and staff interviews, it was determined that the facility failed to ensure that residents could make choices about aspects of their lives that were significant to them, such as smoking and outdoor fresh air times were provided and or honored consistent with interests of the residents for four of six residents reviewed (Resident R1, R2, R3 and R4). Findings include: Review of facility policy Resident Rights Under Federal Law revealed that On admission each residents will be informed orally and in writing of his/her Resident Rights. Purpose: -To incorporate the residents goals, preference, and choices into care -To promote rights of the residents. Self Determination. The resident has the right to and the facility must promote and facilitate resident self-determination through support of resident choice, including but not limited to: 6.1. The resident has a right to choose activities, schedules (including sleeping and waking times), health care and providers of health care services consistent 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 observation, review of facility documentation, interview with staff and residents, it was revealed that the facility failed to ensure a safe, clean and homelike environment for resident for one of four nursing units reviewed, A nursing unit. Findings Include: During an initial tour of the facility on June 12, 2024, Resident R5, requested surveyor to come to his friend's room, A 115 to look at his bathroom. Observation inside resident's bathroom revealed that the ceiling tiles were removed and there was a hole to the ceiling, some of the ceiling tiles had brown colored discoloration. Interview with Resident R5, on June 12, 2024, at 10:00 stated his friend's bathroom had a leak from bathroom from the above floor, it was leaking for almost a month. Facility did not fix it, there was dirty water from the above floor toilet. Further observation of the resident's room A115 with Maintenance Director revealed that the ceiling tiles were closed, but there was still brown colored discoloration on the ceiling tiles. Maintenance Director stated the toilet on the second floor was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on the review of clinical records, facility policies, and interview with staff, it was determined that the facility failed to develop and implement an effective discharge planning process that focuses on the resident's discharge goals, the preparation of residents to be active partners and effectively transition them to post-discharge care, and the reduction of factors leading to preventable readmissions. Facility failed to update a resident's comprehensive care plan and discharge plan, as appropriate, in response to information received from referrals to local contact agencies or other appropriate entities for one of one residents reviewed for discharge planning process. (Resident R5) Findings Include: Review of facility policy Discharge Planning Process: dated November 15, 2022 revealed that The Center must develop and implement an effective discharge planning process that focuses on the patient ' s/resident ' s (hereinafter patient) discharge goals, preparation of patients to be active partners 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 the review of clinical records, interview with resident and staff, it was determined that the facility failed to administer the medications as ordered by the physician for One of One resident reviewed. (Resident R1). Findings Include: Review of facility policy General Dose Preparation and Medication Administration, revealed that Prior to administration of medication, Facility staff should take all measures required by Facility policy and Applicable Law, including, but not limited to the following: 4.1 Facility staff should: 4.1.1 Verify each time a medication is administered that it is the correct medication, at the correct dose, at the correct route, at the correct rate, at the correct time, for the correct resident, as set forth in facility's medication administration schedule. During medication administration, Facility staff should take all measures required by Facility policy and Applicable Law, including, but not limited to the following: Administer medications within timeframes specified by Facility policy or manufacturer's information. Interview with Resident R1 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 review of clinical records and facility provided documentation, and interview with staff, it was determined that the facility failed to provide the required advanced notice, through a Notice of Medicare Non-Coverage (CMS 10123), regarding termination of Medicare services for one of four residents reviewed. (Resident R2) Findings Include: Review of Resident R2's clinical record revealed the resident was given two Notices of Medicare Coverage (NOMNC) cms-10123 during the month of May. Continued review of the resident's clinical record revealed the resident was given a Notice of Medicare Non-Coverage (NOMNC) cms-10123 on May 13, 2024 at 8:30 a.m. with a last day of coverage listed as the same day May 13, 2024. Resident R2 and his representative did not receive appropriate notice to appeal the denial on Medicare services. On May 31, 2024 at 1:15 p.m. the MDS Coordinator, Employee E5 confirmed the notice was not given timely. Employe E5 stated that managed care Notice of Medicare Coverage (NOMNC) occurs by outside company. The company sent the Notice of Medicare Coverage (NOMNC)…

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

Based on review of facility policy, observations, review of clinical record, and interviews with residents and staff, it was determined the facility failed to ensure the environment was free of potential accidents and hazards related to medication administration for one of seven residents reviewed. (Resident R1) Findings Include: Review of the facility policy titled, General Dose Preparation and Medication Administration with a revision date on January 1, 2022 states under dose preparation 3.10 Facility staff should not leave medications or chemicals unattended. Under medication administration, 5.10 Observe the resident's consumption of the medication(s). Review of Resident R1's clinical record revealed the resident was admitted to the facility March 20, 2024 with diagnoses of Chronic Congestive Heart Failure, Acute and Chronic Respiratory Failure with Hypoxia, Asthma , Hypertension, Muscle Weakness, Anxiety and Spinal Stenosis. While taking a tour of the of the first-floor unit on May 31, 2024 the surveyor entered Resident R1's room. The resident had her daughter in with her at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility documents, clinical record reviews, and interviews with facility staff, it was determined that the facility failed to ensure the timely delivery of cancer medication from pharmacy for one of six resident records reviewed. (Resident R3) Findings include: Review of Resident R3's clinical record revealed that the resident was admitted to the facility on [DATE]. The admitting diagnoses included chronic obstructive pulmonary disease (COPD-progressive lung disease characterized by symptoms such as shortness of breath, coughing, and sputum production), hypertension (high blood pressure), diabetes (a disease in which the body does not produce enough insulin resulting in high blood sugar levels), malignant neoplasm of the prostate (cancer of the prostate gland), anemia (reduced ability of the blood to carry oxygen) and urinary tract infection. Additional review of the clinical record revealed that a physician order was obtained on April 6, 2024 for Abiraterone Acetate (Zytiga) 250 milligrams…

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

Based on staff interviews, and the review of clinical records, it was determined that the facility failed to ensure that residents were informed of the discontinuation of a medication for one out of four residents reviewed (Resident R3). Findings include: Review of the April 2024 physician orders for Resident R3 included the following diagnosis: anxiety (a feeling of worry, nervousness, or unease, typically about an imminent event or something with an uncertain outcome); bipolar (a mental illness that causes mood episodes that range from extremely high to extremely low); heart failure (a long-term condition that affects your heart's ability to pump blood well); chronic kidney disease (a gradual loss of kidney function occurs over a period of time); asthma (a chronic lung disease); and cerebral infarction (a stroke). Review of the Resident R3's March 2024 physician orders included a physician's order dated March 7, 2024 for the resident to be administered 1-0.5 milligram tablet of the medication, Lorazepam (brand name, Ativan), by mouth every 8 hours for the treatment of anxiety and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and the review of clinical records, it was determined that the facility failed to ensure that behavioral health care services were attained for two out of four residents reviewed (Resident R1 and Resident R2). Findings include: Review of the April 2024 physician orders for Resident R1 indicated that the resident was admitted on [DATE] from the hospital after receiving treatment for injuries that he sustained after falling out of a 2nd floor window at his home. The resident's admission diagnosis included the following: aphasia (a comprehension and communication, reading, speaking, or writing disorder resulting from damage or injury to the specific area in the brain); difficulty in walking, intellectual disabilities, hearing loss, in addition a dislocated left elbow and a left wrist fracture that he sustained after a fall while at home. Review of the resident's admission Minimum Data Set Assessment (MDS-a periodic assessment of a resident's needs) dated March 28, 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 resident and staff interviews, and review of clinical records, it was determined that the facility failed to ensure the timely delivery of an anti-anxiety medication for one out of four residents reviewed (Resident R3). Findings include: Review of Resident R3's April 2024 physician orders revealed the diagnoses of anxiety (a feeling of worry, nervousness, or unease, typically about an imminent event or something with an uncertain outcome); and bipolar (a mental illness that causes mood episodes that range from extremely high to extremely low); Continued review of April 2024 physician orders indicated an ordered with a start date of April 2, 2024 at 6:00 p.m. for the resident to be administered 1-0.5 milligram tablet of the medication Ativan, by mouth every 8 hours for the treatment of anxiety. The times of administration that were listed in the physician's order were: 12:00 a.m., 6:00 a.m., 12:00 p.m. and 6:00 p.m. Review of nursing notes dated April 2, 2024; April 3, 2024 and and April 4, 2024, indicated that although the medication was re-ordered by the physician for the…

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

Based on review of facility documentation, ombudsman communications, clinical records and interview with resident, ombudsman and staff, it was determined that the facility failed to put forth sufficient efforts to promptly resolve resident complaints/grievances reported by ombudsman for one of three residents reviewed. (Resident R1) Findings include: Interview with Resident R1 on March 26, 2024, at 10:30 a.m. stated facility stole his wheelchair while he was sleeping. He stated facility did not provide him a wheelchair after removing his motorized wheelchair. He also stated he could not move around, and he could not go to the bathroom with manual wheelchair which caused him to have urine infection. He stated his urine was cloudy. Review of an ombudsman email communication sent to the administrator dated March 20, 2024, at 1:45 p.m. indicated I'm here speaking to [Resident R1] and he is stating his motorized wheelchair was removed from his room while he was sleeping. [ResidentR1]was not given a reason for the removal of his chair. Can you please tell me why the chair was taken? Also,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on the review of facility policy, clinical records, interviews with resident and staff, it was determined that the facility failed to provide care and services as outlines by the comprehensive care plan met the professional standards of quality related to the appropriate use of electric wheelchair by Resident R1 who had a history of dangerously using electric wheelchair and placing staff and residents at risk for injuries for one of three residents reviewed. (Resident R1) Findings Include: Review of facility policy, Motorized Mobility Devices: use, dated August 7, 2023, revealed that, In accordance with the Americans with Disabilities Act, Title II, Part 35, Nondiscrimination on the Basis of Disability in State and Local Government Services, Use of other power-driven mobility devices: A public entity shall make reasonable modifications in its policies, practices, or procedures to permit the use of other power-driven mobility devices by individuals with mobility disabilities, unless the public entity can…

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 and resident interviews, it was determined that the facility failed to maintain resident dignity for two of five residents reviewed (Resident R2 and R4). Findings Include: Review of facility policy Resident Rights, effective November 2016, revealed the resident has a right to a dignified existence inside the facility. Further review of facility policy revealed the facility must treat each resident with respect and dignity, and care for each resident in a manner, and in an environment, that promotes maintenance, or enhancement, of quality of life, recognizing each resident's individuality. Review of Resident R2's quarterly Minimum Data Set (MDS - federally mandated resident assessment and care screening) dated November 4, 2023, revealed the resident was cognitively intact and was dependent on staff for upper and lower body dressing. Review of Resident R4's comprehensive MDS dated [DATE], revealed the resident was cognitively…

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 staff and resident interviews, it was determined that the facility failed to ensure that each resident was involved in developing the care plan and making decisions about his or her care for two of five records reviewed (Resident R1 and R3). Findings Include: Review of facility policy Person-Centered Care Plan, revised October 24, 2022, revealed person-centered care means to focus on the resident as the point of control and support the resident in making their own choices and having control over their daily life. The policy states that the resident has the right to participate in the development and implementation of the person-centered care plan. Further review of facility policy revealed that a person-centered care plan must be developed for each resident and, in consultation with the patient, must include preference and potential for future discharge. The facility has the responsibility to assist residents to participate by facilitating 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 observation of the storage room located on the basement level of the facility and review of facility documents, it was determined that the facility failed to maintain an effective pest control program. Findings include: On January 18, 2024, at 11:00 a.m. an inspection was conducted of the storage room located on the basement level of the facility. The surveyor was accompanied by the maintenance supervisor (employee E3). During the tour mouse droppings were observed in various areas of the storage room. The observations were confirmed by employee E3. Review of the pest control logs dated January 12, 2024, revealed that a service call was made to the facility by the contracted pest control service. There was no documentation in the pest control log that the storage room was inspected or treated for rodent activity Review of the pest control logs dated December 22, 2023, revealed that a service call was made to the facility by the contracted pest control service. There was no documentation in the pest control log that the storage room was inspected or treated for rodent…

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.