Fairview Rehab And Care Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, and interviews with staff and residents, it was determined that the facility did not ensure that medication was administered according to the physician's order for one of 32 residents reviewed (R65).During an interview on January 6, 2026, at 11:30 a.m., resident R65 stated that she had recently been on antibiotic drops for an ear infection, but that she had not received multiple doses. She stated that one of the nurses informed her that the drops could not be located, but the nurse had requested a pharmacy refill. The resident stated that no one ever came back and gave her the missing doses.Review of clinical documentation revealed that resident R65 was admitted to the facility on [DATE], with diagnoses including, but not limited to, asthma, hypertension, and arthritis. Revie of clinical documents revealed that the resident was prescribed Neomycin-polymyxin-HC otic solution 3.5-10,000-1.instill 3 drop[s] in right ear four times a day for Ear Infection for 10 days, indicating a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, facility policy and interviews with residents and staff, it was determined that the facility failed to ensure that the first floor nursing unit was adequately equipped with a functional resident call bell system for one out of the three units observed. (First Nursing Unit).Findings include:A review of the Facility Policy titled Call System, Residents last revised on September 2023revelaed Resident are provided with a means to call staff for assistance through a communication system that directly calls a staff member or a centralized workstation.On January 7, 2026, at 9:34 a.m., an interview was conducted with Resident R156, who reported that her call bell was not working. The surveyor tested the call bell and observed that no light was activated at her bedside or outside the room. The call bell for her roommate, Resident R25, was also tested and found not to be functioning. Nursing Assistant Employee E7 confirmed that these call bells were not working. Additional testing revealed that 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 observation, review of facility records, and interviews with staff and residents, it was determined that the facility did not maintain an adequate pest control program related to insects for three of three units reviewed (1st floor, 2nd floor, and 3rd floor). Findings Include: Review of clinical documentation revealed that resident R36 was admitted to the facility on [DATE], with diagnosis including, but not limited to, malignant neoplasm (cancer) of the rectum and colon, and hypertension. Review of his most recent comprehensive MDS (Minimum Data Set- a periodic assessment of resident needs) completed on September 25, 2025, revealed the resident to have a BIMS score (Brief Interview for Mental Status- an assessment of the resident's cognitive state) of 15 out of a possible 15, indicating that he was cognitively intact. During an interview with resident R36 on January 7, 2026, at 10:45 a.m., he revealed that he often saw roaches and other insects in his room and other areas of the building. He stated…

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.

Findings Include: A review of the Form Instructions Skilled Nursing Facility (SNF) Advanced Beneficiary Notice of Non-coverage (SNFABN) Form CMS-10055 revealed that examples of the common reasons why an extended care stay, or services may not be covered under Medicare might include the beneficiary no longer requires daily skilled care for a medical condition but wants to continue residing in the skilled nursing facility (SNF). The SNF enters a good faith estimate of the cost of the corresponding care that may not be covered by Medicare. In the blank that follows Beginning on ., the skilled nursing facility enters the date on which the beneficiary may be responsible for paying for care that Medicare is not expected to cover. The beneficiary selects an option box to indicate a desire to continue to receive the care or not to continue to receive the care and if there is a desire to have the bill submitted to Medicare for consideration. The beneficiary or their authorized representative must sign the signature box to acknowledge that they read and understood the notice. The SNF must…

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 interview with staff, it was determined that the facility failed to provide a copy of a resident's medical and financial records upon request by the resident one of one clinical record reviewed. (Resident R1)Findings include:A review of the clinical record revealed that Resident R1 had a care conference on June 2, 2025. During an interview with Resident R1 on August 28, 2025, at 10:38 a.m., it was confirmed that a request had been made for the full medical and financial records.On August 28, 2025, at 12:30 p.m., an interview with the Administrator, Employee E1 revealed that a meeting had been held a few weeks ago with Resident R1 and their family, during which Resident R1 requested a copy of their medical and financial records. These records were never provided to Resident R1. The Administrator confirmed that a full set of medical and financial records had not been given. It was further revealed that the medical record department is in the process of making a copy of the records to provide to Resident R1 as of today.A further interview with Employee E1 on August 28, 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 clinical records reviewed and staff interview, it was determined that the facility failed to ensure that a resident's urinary catheter's bag was maintained in sanitary condition for one of one resident reviewed. (Resident R1) Findings include:A review of the clinical record revealed that Resident R1 was admitted to the facility on [DATE], with diagnosis of pressure ulcer of sacral stage 4 (ulcer involving full thickness of skin loss), urinary tract infection, klebsiella pneumoniae (gram-negative bacterium commonly found in the intestine of humans which causes unitary [NAME] infections, pneumonia, bloodstream infections).A review of the physician orders dated May 8, 2025, revealed an order for a supra pubic urinary catheter 20 fr (french) 30 ml (milliliters) for obstructive and reflux uropathy (blockage of the urinary track).During an interview with Resident R1 on August 28, 2025, at 10:38 a.m., it was noted that the resident's urinary catheter's leg bag was lying on top of the sink in 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.

Based on observations and interviews with residents and staff, it was determined that the facility failed to ensure that the facility was adequately equipped resident call system for the second floor nursing unit, 7 out of 7 residents reviewed (Resident R1, R2, R3, R4, R5, R6 and R7).Findings include:Review of information submitted to the State Survey Agency on August 4, 2025 indicated that the resident call system at the facility was not working properly, and that some residents had to yell for help. The information submitted also indicated that the facility provided hand-held silver bells for residents to use to shake when they need help, and that such bells cannot be heard from a distance. During interview with Resident R1 and Resident R2's room on August 21, 2025 at 10:20 A.M. both residents reported that their call bells have not worked for quite some time. Resident R1 and Resident R2 reported that they have to yell for help because staff cannot hear them when they ring the silver handheld bells. Resident R1's call bell was not observed in her room during the above referenced…

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

Based on the review of clinical records and interviews with staff it was determined that the facility failed to ensure a complete and thorough investigation was conducted into a resident's allegation of a fall for 1 out of 2 residents reviewed (Resident R1)Findings include:Review of the August 2025 physician orders for the resident included diagnosis that included hypertension (high blood pressure); cerebral infarction (a stroke); arthritis; history of falling; diabetes (a group of common endocrine diseases characterized by sustained high blood sugar levels); schizophrenia ( a mental disorder characterized variously by hearing voices, having false beliefs that conflict with reality , disorganized thinking or behavior, and flat or inappropriate affect) and substance abuse. Review of a nursing note dated April 5, 2025 at 3:05 p.m. indicated Resident reports falling last week, she states she dose[sic] not remember the day but it was approximately Tuesday at 5am when she fell. She reports slipping on water at left bed side while attempting to walk to wheelchair, hitting her head when…

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, it was determined that the facility failed to ensure that a person-centered plan of care was developed for a resident with a history of substance abuse for 1 out of 2 residents reviewed (Resident R1).Findings include:Review of Resident R1 August 2025 physician orders revealed the diagnoses of hypertension (high blood pressure); cerebral infarction (a stroke); arthritis; history of falling; diabetes (a group of common endocrine diseases characterized by sustained high blood sugar levels); schizophrenia ( a mental disorder characterized variously by hearing voices, having false beliefs that conflict with reality, disorganized thinking or behavior, and flat or inappropriate affect) and substance abuse. Review of the resident's person-centered plan of care included a plan of care dated July 18, 2023, stating that the resident admitted to smoking drugs in her room. Interventions included the use of a smoke detector in the resident's room, restricting the resident's leave of absence visits on a temporary basis, and supervised visitation. Review 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 staff interviews, review of facility policy and the review of facility documentation, it was determined that the facility failed to ensure that one resident had a physician's order for a leave of absence from the facility for 1 out of 2 residents reviewed (Resident R1).Findings include: Review of the facility policy, Signing Resident' s Out-LOA (Leave of Absence), with a revision date for August 2006 indicated that each resident leaving the premises (excluding transfers and discharges) must be signed out. Review of Resident R1's August 2025 physician orders included the diagnoses of hypertension (high blood pressure); cerebral infarction (a stroke); arthritis; history of falling; diabetes (a group of common endocrine diseases characterized by sustained high blood sugar levels); schizophrenia (a mental disorder characterized variously by hearing voices, having false beliefs that conflict with reality , disorganized thinking or behavior, and flat or inappropriate affect, and other psychoactive), and substance abuse. Review of nursing note dated March 6, 2025 at 9:30 a.m.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, review of clinical records, review of facility documentation, and staff interviews, it was determined that the facility failed to notify the physician of a significant change in the resident's condition for one of three residents reviewed (Resident R1). Findings Include: Review of facility policy Change in a Resident's Condition or Status revised February 2021 revealed the nurse will notify the resident's attending physician, or physician on call, when there has been a significant change in the resident's physical/emotional/mental condition. Per the facility policy, a significant change of condition is a major decline, or improvement, in the resident's status that will not normally resolve itself without intervention. Review of Resident R1's quarterly Minimum Data Set (MDS - federally mandated resident assessment and care screening) dated July 3, 2025, revealed the resident was readmitted to the facility on [DATE], status post hospitalization. Continued review of Resident R1'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 interview it was determined that the facility failed to maintain complete and accurate clinical record documentation for two of three residents reviewed (Resident R1 and R2).Findings Include: Review of Resident R1's clinical record revealed a physician order dated July 2, 2025, for daily respiratory assessment every day shift, which included documentation of lung sounds, pulse and O2 saturation (measures the amount of oxygen in the blood).Continued review of Resident R1's clinical record revealed a nursing note dated July 4, 2025, at 10:20 a.m. by Licensed Nurse, Employee E3, that indicated upon attempt to administer medication, resident appears to be lethargic with very little verbal response. VS [vital signs] WNL [within normal limits] at this time.Review of Resident R1's entire clinical record revealed no documented evidence Licensed Nurse, Employee E3, documented the daily respiratory assessment or what Resident R1's vital signs were on July 3, 2025.Review 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 review of the clinical records, review of facility policies and interviews with staff, it was determined that the facility failed to ensure that a resident was free of significant medication error for tone of five residents reviewed for medication administration. This deficiency was cited as past non-compliance. (Resident R1) Findings include: Review of an undated facility policy: Medication and Treatment Orders, revealed that Orders for medications and treatments will be consistent with principles of safe and effective order writing. Medications shall be administered only upon the written order of a person duly licensed and authorized to prescribe such medications in this state. Upon admission, the admitting nurse will review the transfer record of the newly admitted patient. The admitting nurse will then notify the attending physician or on-call physician to review admission medications on the transfer record. After medications are reviewed with the physician, the admitting nurse or designee will input the approved medications from the transfer record into the PCC Emar…

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 a clean, comfortable, homelike environment for three of three resident floors observed. (First, Second, and Third floors) Findings include: Observations on October 22, 2024 at 9:00 a.m revealed a large dining room on the Third floor just across from the elevator. There were four dining room tables and five stained and soiled dining room style chairs. The room was wallpapered and two of the four walls had large windows. Surveyors were brought to the room by Employee E2, the Director of Nursing for the use of a conference room during the four day survey. Observation on October 22, 2024 at 10:01 a.m. revealed Resident R74's room had five stained ceiling tiles. Observation on October 22, 2024 at 10: 14 a.m. of Resident R110's room revealed an overhead ceiling light on in her room with a large amount of dead bugs in it. Observation on October 22, 2024 at 10:55 a.m. of Resident R56's room revealed a ceiling tile along the wall was missing and there were four stained ceiling tiles.…

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 facility documentation, review of clinical records, and staff interview it was determined that the facility failed to ensure medication regimen reviews were completed monthly by a licensed pharmacist and failed to ensure recommendations were reviewed timely by the physician for 13 of 33 resident records reviewed (Resident R20, R22, R24, R39, R73, R83, R91, R92, R110, R121, R127, R130, R132) Findings Include: Review of facility policy, Consultant Pharmacist Provider Requirements revised January 2021 indicates a system is established where the pharmacist recommendations regarding customers' (residents') drug therapy are communicated to those with authority and/or responsibility to implement and/or respond to the recommendations in an appropriate and timely fashion. The policy continues to explain that reviewing medication/drug regimen, which includes all drugs currently ordered for the customer (resident), including prn (as needed) and routine drugs, are reviewed 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 observation, review of facility policies and procedures and interviews with staff and residents, it was determined that the facility failed to implement an effective infection prevention and control progam related to enhanced barrier precautions, personal protective equipment and catheter care for three of three floors reviewed. (First, Second, and Third floors). Findings include: Review of facility policy, Enhanced Barrier Precautions, dated April 2024, revealed, Enhanced barrier precautions (EBP) are an infection control intervention used in conjunction with Standard Precautions expanding the use of Personal Protective Equipment (PPE) during high contact resident care activities to reduce the risk of transmission of multidrug-resistant organisms (MDROs) when contact precautions do not otherwise apply. Further review revealed, Enhanced barrier precautions are indicated for residents with any of the following wherever they reside in the facility: Wounds and /or indwelling medical devices, regardless of…

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

Based on a review of facility documentation, facility policies and staff interviews, it was determined that the facility failed to maintain an effective antibiotic stewardship program that includes antibiotic use protocols and a system to effectively monitor antibiotic usage for eight of ten months of antibiotic stewardship program data reviewed. (January 2024 through October 2024). Findings Include: Facility policy titled Antibiotic Stewardship (revised 2016), indicated that Antibiotics will be prescribed and administered to residents under the guidance of the facility's Antibiotics Stewardship Program. The purpose of our Antibiotic Stewardship Program is to monitor the use of antibiotics in our residents. Review of facility policy titled Antibiotic Stewardship- Review and Surveillance of Antibiotic Use and Outcomes (revised 2016), indicated that Antibiotic usage and outcome data will be collected and documented using a facility-approved antibiotic surveillance tracking form. The data will be used to guide decisions for improvement of individual resident antibiotic prescribing…

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

Based on review of facility policies and staff interviews, it was determined that the facility failed to have an Infection Preventionist (IP) that worked at least part time at the facility. Findings include: Review of facility policy, Infection Preventionist (revised 2016), revealed the infection preventionist is responsible for coordinating the implementation and updating of our established infection prevention and control policies and practices. Review of facility documentation for the months of January 2024 through October 2024 revealed January 2024 and February 2024 were the only months that infections and antibiotic use was being monitored. During a phone interview on October 28, 2024 at 1:35 p.m., Infection Preventionist, Employee E12, stated she is still employed at the facility, but has not been in the facility since June 2024. Interview with Director of Nursing, Employee E2, on October 28, 2024 at 1:55 p.m. confirmed the facility failed to designate a part time infection preventionist. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1) Management

Based on review of facility policy, observations, and interviews with staff, it was determined that the facility to provide sufficient space in relation to dining and recreation services for one of three floor reviwed. (third floor). Findings include: Review of facility policy, Resident Rights, revised February 2021, revealed, Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: a dignified existence. Review of facility policy, Dignity, reviewed February 2021, revealed, Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life and feelings of self-worth and self-esteem. When assisting with care, residents are supported in exercising their rights. For example, residents are provided with a dignified dining experience. Review of facility policy, Dining Room Audits, revised October 2017, revealed, Our facility audits the food and nutrition services department regularly to ensure that resident needs are met and that dining is a…

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

Based on observation and interview with staff, it was determined that the facility failed to ensure that essential dining equipment in the dining room pantries and essential resident equipment was maintained in proper working order for three of three floors reviewed. (First, second, and third floors). Findings Include: Observation on October 23, 2024 of the dining room on the second floor at 12:02 p.m. revealed black mold under sink in the serving pantry area. Further observation revealed a cabinet was broken on bottom under steam table. Observation on October 23, 2024 of the dining room on the first floor at 12:10 p.m. revealed a dining room pantry area with an ice machine with an out of order not currently working. The hand sink was dirty with dirt residue in the sink and around the water handles and spout of the sink. Under the hand sink the cabinet had black mold. There was a double fridge that was not working, the inside and outside of it was dirty with liquid residue. There was a display refrigerator that was not turned on. In the pantry area there was a refrigerator with a…

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

Based on review of facility documentation and interview with staff, it was determined the facility failed to provide timely notice of non-medical coverage (NOMNC) for three of three residents reviewed. (Resident R158, R314, R315). Findings Include: Review of facility beneficiary notice worksheet completed for the past six months revealed resident R315 was discharged home on September 11, 2024. There was no documentation showing that a Notice of Non-Medical Coverage (NOMNC) was reviewed with the resident prior to discharge. Review of facility beneficiary notice worksheet completed for the past six months revealed resident R314 was given a discharge date of June 2, 2024 but remained at the facility. Review of facility beneficiary notice worksheet completed for the past six months revealed resident R158 was given a discharge date of September 1, 2024 but remained at the facility. Interview with the Director of Nursing Employee E2 on October 24, 2024 at 1:03 p.m. confirmed the facility did not have NOMNC's for the resident reviewed and that the facility was not completing the Notice 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 review of facility policy, review of employee files, and staff interview, it was determined that the facility failed to conduct required criminal background checks in a timely manner prior to employment for one of five new hired employees. (Employee E23) Findings Include: Review of the facility policy titled, Abuse, Neglect, Exploitation and Misappropriation Prevention Program with a revision date of April 2021 states, Policy Statement-Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms. Further review of policy states, 4. Conduct employee background checks and not knowingly employ or otherwise engage any individual who has: been found guilty of abuse, neglect, exploitation, misappropriation of property, or mistreatment by a court of law; had a finding entered into the state nurse aide registry…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and interviews with staff, it was determined that the facility failed to notify the resident representative of the resident being transferred to the hospital twice for falls for one of 33 residents reviewed (Residents R24) Findings include: Clinical record review revealed Resident R24 was admitted to the facility on [DATE] with the following diagnoses: Hypertension, Hyperlipidemia, Schizoaffective Disorder, Chronic Obstructive Pulmonary Disorder, and Brief Psychotic Disorder. Review of Resident R24's clinical record revealed the resident has a Guardian in place for her care. Further review of Resident R24's clinical record revealed he resident has had several falls at the facility that resulted in the resident being taken to the hospital. Review of a nursing progress note from August 3, 2024 revealed: late entry note for 8/4/2024 1930, resident had a fall in the hallway, she hit her head on the floor obtaining a 0.5 cm shin tear to her right eyebrow area. she was transferred 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 interviews with residents and staff and observations, it was determined that the facility failed to provide activities that enhanced the resident's interactions for one of three floors observed. (Third floor) Findings Include: Observation made of several resident rooms on the Third floor on October 22, 2024 revealed the resident's did not have updated activities calendars posted in their rooms. All resident rooms observed on the Third floor had calendars posted that were from the month of September 2024. Interview with the Assistant Director of Activities Employee E11 on October 23, 2024 at 10:11 a.m. revealed that there was currently no calendar that was made for the month of October 2024. Employee E11 revealed that he had trouble creating the calendar therefore one was never made or given to residents throughout the facility. Employee E11 revealed that there was currently no Director of Activities employed at the facility. Observation on October 22, 2024October 23, 2024 and October 24, 2024 of the Third floor hallway by the nurses station revealed residents gathered…

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, interview with staff and review of facility policy, it was determined that the facility did not ensure a resident received care in accordance with profession standards of practice when the facility failed to notify the physician for further instructions for a missed anti-anxiety medication for one resident of 33 clinical records reviewed (Resident R39). Findings include: Review of the facility's policy titled Medication shortage/Unavailable Medication last revised April 2018 states that when medications are not received or are unavailable to the resident the licensed nurse will urgently initiate action in correspondence with the attending physician and the pharmacy. The policy indicates when a medication shortage is noted nursing should immediately initiate action to obtain the medication. Nursing notifies the pharmacy and obtains the status of the order. Using the facility's emergency stock can be utilized. The same policy indicates that if the medication is not obtainable…

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

Based on review of personnel files and interviews with staff, it was determined that the facility failed to ensure that nursing staff had specific competencies and skill sets necessary to care for residents' needs for four of four personnel files reviewed. (Employees E14, E15, E16, E17) Findings Include: Review of facility personnel files were made for competencies related to Medication Administration, Infection Control, Catheter Care, and Wound Care. Review of licensed nurse Employee E14's personnel file revealed that the employee was hired by the facility on May 6, 2021 as a licensed nurse. Review of licensed nurse Employee E15's personnel file revealed that the employee was hired by the facility on July 29, 2024 as a licensed nurse. Review of licensed nurse Employee E16's personnel file revealed that the employee was hired by the facility on June 5, 2024 as a licensed nurse. Review of licensed nurse Employee E17's personnel file revealed that the employee was hired by the facility on August 9, 2018 as a licensed nurse. Interview on October 25, 2024, at 10:05 a.m. the Human…

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 interview with staff, it was determined that the facility did not complete yearly performance review for nurse aides for two of four employees reviewed. (Employees E18 and E19) Findings Include: On October 23, 2024 at 11:00 a.m. with the facilities human resources director Employee E8 was interviewed and employee personnel records were requested for evidence of 12-hour trainings and yearly performance reviews for nurse aides. Four employee personnel records were requested including employee personnel record for nurse aides Employee E18 and E19. Interview on October 25, 2024 at 9:52 a.m. with the facilities human resources director Employee E8 revealed there were no completed yearly performance reviews completed for nurse aides Employee E18 and E19 even though they had been employed at the facility for over a year. Employee E8 stated that the facility had identified this as an issue and they are waiting for the staff educator Employee E12 to return the facility. Employee E8 revelealed Employee E8 is currently working at another facility helping out…

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 interview with staff, it was determined that the facility failed to provide pharmaceutical services to ensure accurate receiving, dispense and administration of medication to meet the needs of a resident according to professional standards of practice relating to medication administration for 1 of 33 residents reviewed (Resident R39 ) Findings include: Review of the facility's policy titled Medication shortage/Unavailable Medication last revised April 2018 states that when medications are not received or are unavailable to the resident the licensed nurse will urgently initiate action in correspondence with the attending physician and the pharmacy. The policy indicates when a medication shortage is noted nursing should immediately initiate action to obtain the medication. Nursing notifies the pharmacy and obtains the status of the order. Using the facility's emergency stock can be utilized. The same policy indicates that if the medication 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 observation and review of clinical records and facility policies, it was determined that the facility failed to ensure that residents' medication inlcuded the date that the medication was opened in accordance with currently accepted professional principles two of four residents' medication administration observed. (Resident R26 and R136). Findings include: Review of the facility's policy titles, Administering Medications revised April 2019, indicates the expiration/beyond use date on the medication label is checked prior to administering. When opening a multi-dose container, the date opened is recorded on the container On October 24, 2024, at 9:00 a.m. surveyor observed Licensed Practical Nurse (LPN) Employee E13 administering 2 units from an opened vile Aspart (insulin) to Resident R26. Further observation revealed the medication did not include the date when it was originally opened. On October 28, 2024, at 11:53 a.m. surveyor observed LPN, Employee E10 administering aspirin to Resident R136. Further observation revealed the medication did not include the date when 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 review of facility policy and interviews with staff, it was determined that the facility failed to maintain an effective, comprehensive, data-driven quality assurance and performance improvement program (QAPI) that focuses on indicators of the outcomes of care and quality of life as required. Findings include: Review facility policy titled, Quality Assurance and Performance Improvement (QAPI) Program -Governance and Leadership states the QAPI program is overseen and implemented by the QAPI committee, which reports its findings actions and results to the administration and governing body. The administration whether a member of the QAPI committee or not is ultimately responsible for the QAPI program and for interpreting its results and findings to the governing body. The governing body is responsible for ensuring that the QUAPI program is implemented and maintained to address identified priorities, is sustained through transition of leadership and staffing is adequately resourced and funded sufficient to conduct the activities of the program, is based on data, resident 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, interview with residents and staff interview, it was determined that the facility failed to ensure residents received and were offered pneumococcal vaccines for one of 33 residents reviewed. (Resident R22) Findings Include: Interview held with Resident R22 on October 22, 2024 at 1:11 p.m. revealed the resident wanted to have the pneumococcal vaccine but had not yet been offered it by the facility. Review of the resident's clinical record revealed no information regarding the resident being educated on or offered the vaccination over the past year. On October 24, 2024 at 3:15 p.m. and interview with was held with the Director of Nursing Employee E2 and she confirmed that the facility had not yet offered pneumococcal vaccines to this resident or to any other resident in the facility. Employee E2 revealed that an issue she found after becoming employed this year with the facility is that the facility had no practice in place for offering residents on a yearly basis. Employee E2 revealed that the facility was currently working without an 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 staff and resident interviews and the review of facility documentation, it was determined that the facility failed to conduct a complete and through investigation for a resident's allegation of missing cigarettes and the facility failed to ensure that residents in the facility were protected from further potential abuse related to an allegation of an alleged perpetrator stealing money and jewelry for 1 out of 3 residents reviewed. (Resident R2) Findings include: Review of the facility policy, Accidents and Incidents-Investigating and Reporting, that the facility identified as being their abuse investigation policy, dated July 2017, indicated that all accidents or incidents involving residents, employees, visitors, vendors, etc., occurring on our premises shall be investigated and reported to the administrator. The policy also indicated that the nurse supervisor/charge nurse and/or the department director or supervisor shall promptly initiate and document the investigation of the accident or incident to include, but not limited to, the date and time the accident or incident…

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, 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 regarding a resident who was storing and consuming alcohol at the facility, sustained a fall, required transfer to the hospital and diangnosis of right hip fracture, which resulted in an Immediate Jeopardy situation for one out of three residents reviewed (Resident R1). Findings include: Review of the job description for the Nursing Home Administrator (NHA) provided by the facility indicated that the primary purpose of the position is to manage the facility in accordance with current applicable federal, state, and local standards, following all facility policies and applying them uniformly to all employees, in addition to ensuring the highest degree of quality care is provided to the facility residents at all times. The duties and responsibilities of NHA included, but are not limited to: reviewing policies and procedures periodically, at least annually, and make…

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, staff interviews and review of pest control logs, it was determined that the facility failed to ensure an effective pest control environment. Findings include: During an interview with the facility's maintenance director on September 13, 2024, at 9:55 a.m. the maintenance director reported that the facility contracted for pest control services twice a week. It was also explained that books are located on each nursing unit on the 1st, 2nd and 3rd floor, and the kitchen where staff document sightings of roaches, bugs, flies mice on the unit, in resident rooms, and in the kitchen. Review of the pest control contract provided by the facility indicated that the kitchen, dining room, staff cafeteria, vending machine areas and nursing stations will be serviced on a regular basis with all other areas will be serviced as necessary. Continued review of the contract indicated that interior and exterior deficiencies will be noted and reported to the maintenance personnel (e.g. gaps under doors, holes…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and interview with staff, it was determined that the facility did not develop a comprehensive, person-centered care plan related to wound care for one of nine resident records reviewed (Resident R2). Findings include: Review of clinical documentation revealed that Resident R2 was admitted to the facility on [DATE], and had diagnoses of obesity, gout (a condition which causes pain in the joints, especially those of the feet), muscle weakness, urinary incontinence, and stage three (injuries caused by prolonged pressure on an area of skin, stage three extends through the outer layers of skin and into the tissue underneath) pressure ulcers of the left and right buttocks. Continued review revealed that a skin assessment was completed for Resident R2 upon his admission by licensed nursing staff. This assessment stated, the resident has an open area on his left and right buttock that are dime sized. This assessment was confirmed by the wound specialist, Licensed Nurse Practitioner,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and interview with staff and residents, it was determined that the facility did not ensure that wound care was completed appropriately to treat pressure ulcers for four of five residents with wounds reviewed (Residents R1, R2, R3, and R4). Findings include: Review of clinical documentation for Resident R1 revealed that he was admitted to the facility on [DATE], and had diagnoses of congestive heart failure (a condition in which the heart pumps ineffectively and causes an excess of fluid to build up in the body, especially around the lungs), hypertension (high blood pressure), chronic kidney disease, and gout (a condition which causes pain in the joints, especially those of the feet). Review of wound assessment and treatment notes written by the wound care specialist, Licensed Nurse Practitioner, Employee E4 revealed the following: On June 11, 2024, Employee E4 recommended that Resident R1 receive wound care consisting of, Daily and PRN (as needed) .Cleanse with normal saline…

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, observation, clinical record review and interview with staff and residents, it was determined that the facility did not ensure that physician assessments were accurately completed and documented to reflect the actual condition of the residents for four of nine records reviewed (Residents R1, R2, R3, and R4). Findings include: Review of facility policy titled, Physician Visits, revised April 2013, revealed that during physician visits The attending physician must perform relevant tasks .including a review of the resident's total program of care and appropriate documentation. Review of clinical documentation for Resident R1 revealed that he was admitted to the facility on [DATE], and had diagnoses of congestive heart failure (a condition in which the heart pumps ineffectively and causes an excess of fluid to build up in the body, especially around the lungs), hypertension (high blood pressure), chronic kidney disease, and gout (a condition which causes pain in the joints,…

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, interviews with staff and reviews of policies and procedures, it was determined that the facility failed to ensure that five of seven residents were receiving treatment and care in accordance with professional standards of practice as indicated in their comprehensive person-centered care plan. (Residents R1, R2, R3, R4, and R5) Findings include: Review of the policy titled administering medications dated April, 2019 revealed that medications were to be administered in a safe and timely manner as prescribed by the attending physician. The policy also indicated that medications were to be administered in accordance with the prescribed orders, including any required time frames. The policy said that the licensed individual administering the medication was required to document in the clinical record the date and time the medication was administered, the dosage, the route of administration, the injection site if applicable, any complaints or symptoms for which the drug was administered, any results achieved and when those results were observed 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.

Based on review of clinical records, facility documentation and interviews with staff, it was determined that the facility did not obtain, clarify and/or follow physican orders related to laboratory studies in a timely manner for one of four records reviewed (Resident R2). Findings include: Review of the clinical record for resident R2 revealed that the resident was admitted to the facility for skilled nursing care on March 14, 2013. The admitting diagnoses included but were not limited to; obstructive uropathy (a disorder of the urinary tract that causes a restriction in the flow of urine), chronic kidney disease (a disease of the kidneys that can lead to kidney failure) hypertension (high blood pressure), malignant neoplasm of prostate (cancer of the prostate gland), diabetes (a condition in which the body does not produce enough insulin to regulate blood sugar effectively) and history of urinary tract infections. Additional review of the clinical record for resident R2 revealed an entry in the progress notes dated January 22, 2024, documenting that the resident left 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 observation and interview, it was determined that the facility failed to ensure that the call bell alert system was in working order for one of three nursing units (first floor nursing unit). Findings include: During an observation tour of the nursing care unit located on the first floor of the facility on February 29, 2024, at approximately 11:30 a.m. the surveyor initiated the call bell alert system in Resident room [ROOM NUMBER] at the bed by the window. The surveyor noted that the call bell alert system did not sound and the visual aid did not light for resident room [ROOM NUMBER]. The surveyor checked with staff at the nursing station and staff confirmed that nurse call bell for room [ROOM NUMBER] had not been activated. Interview on February 29, 2024, at approximately 12:30 p.m. with the maintenance director, Employee E3, confirmed that the call bell alert system was not working for the resident in room [ROOM NUMBER] (window bed). 28 Pa. Code 201.18(b)(3) Management 28 Pa. Code 205.67(k) Electric…

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 and interview 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 failed to notify the resident and the resident's representative(s) of the transfer to the hospital and the reasons for the transfer for two of 32 residents reviewed. (Resident R91 and R71). Findings Include: Review of MDS (Minimum Data Set-Assessment of resident care needs) for Resident R91 dated December 15, 2023, revealed that the resident was admitted to the facility on [DATE], and had a BIMS score of 10 which indicated that the cognitive status was moderately impaired. Review of nursing note for Resident R91 dates December 7, 2023, revealed that the resident experienced a change in condition related to abnormal vital signs. Resident R91 was assessed by the physician who recommended that the resident to be sent out to the hospital for further assessment and evaluation. Resident R91 was discharged to the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff interview, it was determined that the facility failed to ensure that the resident and resident representative receive written notice of the facility bed-hold policy at the time of a facility-initiated transfer to a hospital for two of 32 residents reviewed. (Resident R91 and R71) Findings include: Review of MDS (Minimum Data Set-Assessment of resident care needs) for Resident R91 dated December 15, 2023, revealed that the resident was admitted to the facility on [DATE], and had a BIMS score of 10 which indicated that the cognitive status was moderately impaired. Review of nursing note for Resident R91 dates December 7, 2023, revealed that the resident experienced a change in condition related to abnormal vital signs. Resident R91 was assessed by the physician who recommended that the resident to be sent out to the hospital for further assessment and evaluation. Resident R91 was discharged to the hospital on December 7, 2023. Review of Resident R71's clinical record…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, clinical record reviews, review of facility policy and interviews with staff, it was determined that the facility failed to develop comprehensive person-centered care plan related to hearing needs and behavioral needs for three of 33 residents reviewed. (Residents R7, R113, R10) Findings include: Review of facility policy titled, Care plans, Comprehensive Person-Centered, revised December 2016, indicated that the comprehensive, person-centered care plan will describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychological well-being; aid in preventing or reducing decline in the resident by focusing on a rehabilitative program . Interview with Resident R7 conducted on January 9, 2024, at 11:14 p.m. revealed that the resident had difficulty understanding the surveyor during the survey screening process. Further interview with the resident, at the time of the observation, revealed that the resident is hard of hearing…

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 facility documentation and interviews with staff, it was determined that the facility failed to maintain ongoing communication between the facility and a dialysis provider for two of two dialysis residents reviewed (Residents R138 and R141). Findings include: Review of Resident R138's clinical record revealed that the resident was admitted on [DATE], with diagnoses including of end stage renal disease (condition where the kidney reaches advanced state of loss of function). Further review of Resident 138's clinical record revealed that the resident has dialysis treatments three times per week on Monday, Wednesday and Friday at Dialysis Direct. Dialysis days are Monday, Wednesday & Friday with a pickup time of 9:30 a.m. for a 10:00 a.m. chair time. A review of Resident R138's dialysis communication book revealed that the bottom of the report, to be completed upon return to the facility following dialysis, was not completed on December 31, 2023, or January 3, 2024. The top…

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 and facility documentation, and staff interviews, it was determined the facility failed to implement a complete drug regimen review process for two of 32 residents reviewed (Resident R63, and R73). Findings Include: Review of the undated Medication Regimen Review Policy revealed, The consultant pharmacist will review the drug regimen of all residents at least monthly and report any observed irregularities in drug use and other drug therapy recommendations to the director of nursing and attending physician. Further review revealed, The physician accepts and acts upon suggestion or rejects and provides an explanation for disagreeing, Resident R63 was admitted to the facility on [DATE], with diagnoses including type 2 diabetes mellitus (condition results from insufficient production of insulin, causing high blood sugar). A review of the medication regimen review completed on September 7, 2023, by the consultant pharmacist, revealed a recommendation to re-evaluate the current…

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 interviews with facility staff, it was determined that the facility failed to ensure that it was free of medication error rate of five percent or greater. Findings include: On January 10, 2024, at 09:18 a.m., observed that Employee E30, a Licensed Nurse, administered to Resident R52, Nifedipine ER (Extended Release) Tablet, 24 Hour, 90 milligrans (mg), one tablet by mouth one time a day for Hypertension (Hypertension is a condition in which the force of the blood against the artery walls is too high). Also on January 10, 2024, at 9:18 a.m., observed that Employee E30, administered to Resident R52, Potassium Chloride ER Tablet Extended Release 20 MEQ, one tablet by mouth one time a day for Hypokalemia (a lower-than-normal potassium level in the bloodstream. Potassium helps carry electrical signals to cells in the body. It is critical to the proper functioning of nerve and muscles cells, particularly heart muscle cells). On January 10, 2024, at 9:18 a.m., observed that Employee E30, was to crush these Extended-Release tablets,…

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, observations, and staff interviews, it was determined that the facility failed to make certain that medications were stored at the proper temperature in one of two medication refrigerators reviewed. Findings include: Review of CDC guideline on Vaccine Storage and Handling Toolkit, reviewed in January 2023, indicated as follows: Vaccines licensed for refrigerator storage should be stored at 2°C-8°C (36°F-46°F). (https://www.cdc.gov/vaccines/hcp/acip-recs/general-recs/storage.html). Monitoring vaccine storage equipment and temperatures are daily responsibilities to ensure the viability of your vaccine supply and the safety of your patients. Implementing routine monitoring activities can help you identify temperature excursions quickly and take immediate action to correct them, preventing loss of vaccines and the potential need for revaccination of patients. (https://www.cdc.gov/vaccines/hcp/admin/storage/toolkit/storage-handling-toolkit.pdf). On January 12, 2024, at 10:30 a.m. during an observation of the Medication Storage Room of First Floor, 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 review of facility documentation, observations, and resident and staff interviews, it was determined that the facility failed to provide food that was palatable and served at the proper temperature for five of eleven residents reviewed (Residents R5, R1, R3, R2 and R6). Findings include: Review of undated facility policy titled, Food: Preparation, indicated that all foods will be held at appropriate temperatures, greater than 135 degrees Fahrenheit for hot holding, and less than 41 degrees Fahrenheit for cold holding. Interview with Resident R7 on January 9, 2024, at 11:17 a.m. revealed that food always arrives cold. Interview with Resident R37 on January 11, 2024, at 11:35 a.m. revealed that in the rooms, food is cold. During a group interview, held on January 10, 2024, at 10:08 a.m. with Residents R76, R58, R45. R152, R27, R153, R37, R127, R30, R77, R71, and R10 revealed that food is not appetizing and palatable. Observations during a test tray conducted with Employee E27, Food Service Director (FSD), on January 11, 2024, at 12:43 p.m. revealed that the chicken bacon…

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

Based on review of facility policy, observation, and interviews with staff, it was determined that the facility did not ensure that food was stored in accordance with professional standards for food service safety. Findings include: Review of facility policy on food brought by family/ visitors reveal that under policy statement Food brought to the facility by visitors and families is permitted. facilities staff will strive to balance resident choice a home like environment within nutritional and safety needs of residents. Under section Policy Interpretation and Implementation, #7. Food brought by family of visitors that is left with the resident which shown later will be labeled last word in a manner that it is clearly distinguishable from facility prepared food. #a. Non-perishable foods will be stored in a resealable container with tight fitting lids, intact fresh food may be stored without a lid. #b. Perishable foods must be stored in a resealable container. in the refrigerator containers with label over the residence laying the item and the used by date. #8. the nursing 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.

Based on observations and an interview with staff, it was determined that the facility did not ensure that garbage and refuse was disposed of properly. Finding include: An initial tour of the Food Service Department was conducted on January 9, 2024, at approximately 9:38 a.m. with Employee E21, Foodservice Director (FSD), which revealed the following: Observations on the receiving area revealed plastics and debris and plastics around the main garbage and receiving area. Further observation revealed three grey colored trashcans were overflowing with trash and opened, which exposed the trash inside to open air. Interview with the FSD on January 9, 2023, at 9:50 a.m. confirmed the above findings. 28 Pa. Code 201.18(b)(3) Management 28 Pa. Code 201.14(a) Responsibility of Licensee

Based on the review of facility Quality Assurance Performance Improvement program, Performance Improvement Program plan, facility documentation, and interview with staff, it was determined that the facility failed to demonstrate and maintain an effective quality improvement program with systems and reports demonstrating systematic identification, reporting, investigation, analysis, and prevention of adverse events and performance indicators. Findings include: Review of facility Policy under section Policy Statement, the facility shall develop, implement and maintain an on ongoing facility wide data-driven QAPI program that is focused on the outcomes, care and quality of life for our residents. Under section Policy Interpretation and Implementation: The objectives of the QAPI program are to: #1. provide a means to the current and potential indicators for outcomes of care and quality of life, #2. Provide a means to establish and implement performance improvement projects to correct identified negative or problematic indicators, #3. Reinforce and build upon effective systems 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 a review of facility documentation, it was determined that the facility was not maintaining an effective pest control program. Findings include: A review of facility Pest Control policy revised May 2008, states that this facility maintains an on-going pest control program to ensure that the building is kept free of insects and rodents. Observations on January 9, 2024, at 10:25 a.m., in room [ROOM NUMBER] revealed four glue traps for rodents beside the HVAC unit under the window, along the wall, beside the nightstand and under the bed. Interview with Resident R147 revealed that he saw a mouse that morning and that they just run right past the traps and never get stuck in the glue, and he expressed concerns that it is so bad that he was afraid that they would get into his bed. Observations on January 9, 2024, at 10:40 a.m., in room [ROOM NUMBER] revealed small flies buzzing around an unopened apple juice container on the overbed table. Observations on January 9, 2024, at…

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

Based on a review of facility documentation and staff interview, it was determined that the facility failed to ensure its nurse aide staff was receiving in-service training to be proficient and competent and that the training be no less that 12 hours annually for six of six nurse aide staff training information reviewed (E10, E11, E12, E13, E22 & E23). Findings Include: Review of the nurse aide annual training information provided during the survey revealed that there were no training logs to review for nurse aides E10, E22 and E23. Review of the nurse aide annual training information provided during the survey revealed that nurse aides E11, E12 and E13 training logs did not contain any training since January 2023, and did not meet the twelve hours of annual training requirement. An interview with the Director of Nursing on January 12, 2024, at 9:15 a.m. confirmed that these nurse aides did not meet the minimum required hours of training. 28 Pa. Code 201.14(a) responsibility of licensee.

Based on a group interview, observations and interviews with staff, it was determined that the facility failed to display proper contact information for the State Survey Agency, including the Hotline number on all three nursing floors (First, Second and Third Floors). Findings include: A group interview was held on January 10, 2024, at 10:00 a.m. with ten alert and oriented residents (Residents R76, R58, R152, R37, R127, R30, R77, R71, R10 and R111) who regularly attend resident council meetings. When asked if they knew how to contact the Pennsylvania Department of Health (DOH) with a complaint, all residents said no. When asked again if anyone knew how to contact DOH, they all shook their head no, and Resident R111 said that he never saw this number posted, and that he wanted it. Observations of First, Second and Third Floors on January 10, 2024, at 11:45 a.m. with the Director of Nursing (DON) revealed that the State Department of Health contact information was not posted on any of the three nursing floors as required. Interview with the DON on January 10, 2024, at 12:00 p.m.…

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

Based on observations, interview with residents and staff, it was determined that the facility did not ensure that most recent survey results were accessible to residents on three of three nursing units observed (First, Second and Third Floors). Findings include: Group interview conducted on January 10, 2024, at 10:00 a.m., with alert and oriented Residents R76, R58, R152, R37, R127, R30, R77, R71, R10 and R111 revealed that the residents did not know where the results for the most recent survey from state agency were located. Observations during a tour with the Director of Nursing on January 10, 2024, at 11:45 a.m. revealed that only first floor had a binder of survey results which did not contain any survey results since January 2023. Observations on the Second and Third floors revealed that there were no survey results available for review. The above findings were confirmed by Director of Nursing on January 10, 2024, at 12:00 p.m. 28 Pa Code 201.18(b)(1)(3) Management 28 Pa Code 201.18(e)(1) Management 28 Pa Code 201.29(a) Resident Rights

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 one of three nursing floors in a clean, comfortable, and homelike condition. (Third floor) Findings include: Observations on January 9, 2024, at 10:45 a.m., in room [ROOM NUMBER] revealed the HVAC unit was open at the top with no vents, the sink in the bathroom just dripped when the hot water was turned on, and wood on the side of the sink was peeling apart, and there was a hole in the wall below the sink. Interview with Resident R43 revealed that the sink has been that way for a long time, and it is frustrating not having hot water to wash up. Observations on January 9, 2024, at 10:45 a.m., in room [ROOM NUMBER] revealed that neither the hot nor the cold water worked on the sink in the room. According to the daughter of Resident R56 during a family interview on January 9, 2024, at 10:45 a.m., this sink has not worked for months. Further observation in room [ROOM NUMBER] revealed that the dresser at bed A had a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff interviews, it was determined that the PASRR (Preadmission Screening and Resident Review) was not appropriately completed according to the resident assessment for one of 7 residents reviewed related to PASRR assessments (Resident R34). 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 disability. 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, clinical record review, and staff interviews, it was determined that the facility failed to revise a resident's care plan related to the discontinuation of eteral feeding for one of 32 residents reviewed (Resident R128). Findings include: Review of Resident R128's clinical record revealed that the resident was admitted in the facility, on October 25, 2022. Resident R128's diagnoses included Dysphagia (Dysphagia is a medical term for difficulty swallowing. Dysphagia can be a painful condition), and Protein-Calorie Malnutrition (Protein-Calorie Malnutrition describes a wide range of clinical conditions resulting from mild to severe undernutrition). Review of physician order for Resident R128, dated June 27, 2022, indicated an order for Enteral Feed every shift, and it was discontinued on October 26, 2022. Review of physician order for R128, dated October 27, 2023, indicated an order for one time a day, every shift, administer Jevity 1.5 via continuous Feed @ 50ml x8hrs, for total volume 400mL. Check tube placement prior to administration. Further review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, review of clinical records, review of facility policy, and staff interviews, it was determined that the facility failed to provide a communication device to maintain optimal communication for one of 32 residents reviewed. (Residents R108) The findings include: Review of facility policy titled, Accommodations of Needs revised 2020, indicated that non-English speaking residents will be provided with communication boards or language lines. Interview with Resident R108, on January 10, 2024, at 12:43 p.m. revealed resident spoke to surveyor in Spanish. Review of Resident R108's clinical record revealed that the resident was admitted to the facility on [DATE], with diagnoses including Alzheimer's disease (disorder that causes problems with memory, thinking, and behavior), altered mental status, and cognitive communication deficit. Interview with Registered Dietitian, Employee E23, conducted on January 11, 2024, at 1:52 p.m. revealed that Resident R108 only spook Spanish and that it was difficult…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, and interviews with staff, it was determined that the facility failed to follow physician order related to medications administration and hospice services for two of 33 residents reviewed (Resident R90 and R128). Findings Include: Review of clinical record for Resident R90 revealed that the resident was admitted to the facility on [DATE], with diagnosesof deep vein thrombosis (DVT, A blood clot in a deep vein, usually in the legs), obstructive uropathy (disorder of the urinary tract), and glaucoma (a group of eye conditions that damage the optic nerve). Review of the physician approved medication list revealed the following medications were approved and were to be provided to resident R90 during his stay in the facility: acetaminophen (for pain), apixaban (anticoagulant), dorzolamide (for eye pressure), and finasteride (urinary tract retention medication). Review of Resident R90's medication administration documentation revealed that two of four medications, (dorzolamide 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, review of facility policies, review of clinical records and interviews with resident representatives and staff, it was determined that the facility failed to obtain an appointment with a hearing specialist for one of 32 residents reviewed (Resident R7). Findings include: Interview with Resident R7 conducted on January 9, 2024, at 11:14 p.m. revealed that the resident had difficulty understanding the surveyor during the survey screening process. Further interview with the resident, at the time of the observation, revealed that the resident is hard of hearing and that she was supposed to receive hearing aids but still had not received them. Review of facility documentation for Resident R7, titled, report of consultation, dated June 14, 2022, revealed that the resident had hearing loss and was a candidate for bilateral hearing aids. Review of documentation titled Audiology Consultation for resident R7, dated November 16, 2022, revealed that the resident required assistive listening device (hearing aid). Further review of facility documentation provided titled,…

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 reviews and interviews with staff, it was determined that the facility failed to ensure that weights were monitored for one of 37 residents reviewed (Resident R8) Findings include: Review facility policy on Weight Assessment and Intervention, under section Policy Statement revealed that the multi-disciplinary team will strive to prevent, monitor and intervene for undesirable weight loss for our resident. Under section Policy Interpretation and Implementation revealed that #3. Any weight change of more than 3 lbs. (pounds) since the last weight will be retaken. The validated weight will be placed in the patient's medical records. #4. The dietitian will review the unit weight record by the 15th of the month to follow individual weight trends overtime. Negative trends will be evaluated by the treatment team whether or not the criteria for significant weight change has been met. #5. The threshold for significant unplanned and undesired weight loss will be based on the following criteria: #a. One month - 5% weight loss is significant,…

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 staff interview, it was determined that the facility failed to ensure that licensed nursing staff had the proper competencies including catheter care, tube feeding care and post dialysis care for four of four licensed nurse training records reviewed (E14, E15, E16 & E17). Findings include: Review of the provided facility policies did not reveal any policy related to nursing competencies. Review of training records provided did not reveal competencies requested including catheter care, tube feeding care and post dialysis care for Employees E14, E15, E16 and E17. Interview with the Director of Nursing on January 12, 2024, at 9:05 a.m. confirmed that there was no documentation available to review to show that licensed nursing staff had been evaluated for competency in catheter care, tube feeding care and post dialysis care. 28 Pa. Code: 211.12(d)(1) Nursing services 28 Pa. Code 211.12(d)(5) Nursing services

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, observation, review of clinical record, interview with staff and residents it was determined that the facility failed to ensure that medications were administered in accordance with professional standards for two of 37 residents reviewed. (Resident R18 and Resident R19) Findings include: Review of facility policy on Administering Oral Medication revealed that purpose: The purpose of this procedure is to provide guidelines for the safe administration of medications. Under section Steps in the Procedure, #10 confirm the identity of the resident, #16 allow the resident to swallow oral tablets or capsules at his or her comfortable pace, #21 remain with a resident until all medications have been taken. Review of Resident R19's clinical record revealed that Resident R18 was admitted to the facility on [DATE]. Further review of Resident R19's clinical record revealed that Resident R18 had the diagnoses of generalized Idiopathic Epilepsy, Edema, Cerebrovascular Disease, 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 review of facility documentation, facility policies, and staff interviews, it was determined that the facility failed to implement an effective antibiotic stewardship program that includes a system to effectively monitor infections and antibiotic usage. Findings include: Review of facility policy on surveillance for infection dated September 2017 revealed that under Policy Statement, The infection preventionist will conduct ongoing surveillance for healthcare-associated infections and other epidemiologically significant infections that have substantial impact and potential resident outcome and that may require transmission based precautions and other preventative interventions. Under section Policy Interpretation and Implementation revealed that #1. The purpose of the surveillance of infection is to identify both individual cases and trends of epidemiologically significant organisms and healthcare associated infections to guide appropriate interventions and to prevent future infections, #3. Infections that will be included in routine surveillance include those with A.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations of the resident rooms, and interviews with staff, it was determined that the facility failed to maintain essential equipment in safe operating condition. Findings Include: A tour of the first floor of the facility was conducted on January 9, 2024, and January 11, 2024. On January 9, 2024, at 12:16 p.m., and on January 11, 2024, at 1:19 p.m., observations in room [ROOM NUMBER], Bed B, revealed the side enabler of resident bed was unstable and unsteady, and the air-mattress was not blowing up. On January 11, 2024, at 1:19 p.m., the findings were confirmed with a Licensed Nurse, E 29. 28 Pa Code 207.2 (a) Administrator's responsibility

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and resident and staff interviews, it was determined that the facility failed to assure all equipment was effective to provide full visual privacy for each resident in seven of 13 resident rooms observed. (Rooms 235, 226, 233, 228, 236, 238, 232) Findings include: A tour on the second floor conducted on January 9, 2024, at 11:03 a.m. through January 10, 2024, revealed the following concerns: Interview held with resident in room [ROOM NUMBER] revealed that she feels exposed. Observations revealed room [ROOM NUMBER] had 7 missing window blind slats on the left side of the window. Observations of room [ROOM NUMBER] revealed a total of six vertical window blind slats were missing throughout the window. Observations of room [ROOM NUMBER] revealed two vertical window blind slats were missing. Observations of room [ROOM NUMBER] revealed that seven vertical window blind slats were missing on the right side of the window. Observations of room [ROOM NUMBER] revealed six vertical window blind slats…

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 and review of facility policy, it was determined that the facility failed to ensure that linens were handled by a professional laundering services in order to meet health care industry laundry standards. Findings include: Review of the facility document titled job description of laundry attendant, consists of utilization protective gear, operates computer operated washers, cleaning and sanitizing the work area including the machines, worktables and sorting area, and is responsible to perform laundry activities within a well-established guidelines to ensure that quality of standards and safety guidelines are being met. Review of the Center for Disease Control and Prevention (CDC) titled Laundry and Bedding Guidelines for Environmental Infection Control in Health-Care Facilities (2003). Contaminated textiles and fabrics often contain high numbers of microorganisms from body substances, including blood, skin, stool, urine, vomitus, and other body tissues and fluids. When textiles are heavily contaminated with potentially infective body substances,…

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 staff interviews, it was determined that the facility failed to ensure a clean, sanitary, functional environment for two of three nursing units and in the laundry room. (First floor, Second floor and Laundry room) Finding include: Observation on December 5, 2023 between the hours of 9:00 a.m. and 10:30 a.m. revealed the following: -There was no hand soap at the sink in rooms [ROOM NUMBERS]. -There was a urine spilled through out the bathroom floor and orange juice spilled on the floor by bed B in room [ROOM NUMBER] -The tube feeding formula had spilled on to the floor of bed B in room [ROOM NUMBER]. -There were two stool stains on the floor in room [ROOM NUMBER], reported by Resident R2. Interview with Resident R2 on December 5, 2023 at 2:30 p.m. revealed that the floor has still not been cleaned. -The blinds did not close in room [ROOM NUMBER] leaving the residents in beds A and B with limited privacy. -Flies were observed in room [ROOM NUMBER] around open food. -Open food and food…

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 with residents and staff, and review of facility policy, it was determined that the facility failed to ensure the resident call bell alert systems were functional properly for three residents on two nursing units. (Resident R3, Resident R4, Resident R5) Finds include: Review of facility policy titled Answering the call light dated March 2021 revealed the purpose of this procedure is to ensure a timely response to the resident's requests and needs. Further review of this policy states to be sure the call light is plugged in and functioning at all times. Observation during tour of the facility on December 5, 2023 at 9:00 a.m. revealed that Residents R3 and R4, and R5 had nonfunctioning call bells. Interview with Housekeeper, Employee E3 at time of interview confirmed that these call bells did not function properly. 28 Pa. Code 211.12(d)(1) Nursing Services 28 Pa. Code 210.18(b)(1) Managment

Based on clinical record review, observation, staff and resident interview, and review of facility policy, it was determined that the facility failed to maintain proper infection control practices to prevent the potential spread of infection for two of ten residents reviewed regarding isolation practices. Findings include: Review of facility policy titled Coronavirus Disease (Covid -19)- Resident Exposure, Quarantine and Isolation Dated October 2021, revised May 2023, states Residents will not be cohorted with other residents with confirmed Covid -19 infection unless they are confirmed to have Covid-19 infection through testing and outbreak status warrants cohorting infected residents due to multiple confirmed cases. Further review of this policy states that if cohorting, only residents with the same respiratory pathogen will be housed in the same room. Review of Resident R1's clinical record revealed that Resident R1 had the diagnosis of coronavirus disease. Observation of Resident R1's room on November 2, 2023, at 11:05 a.m. revealed that Resident R1 shared a room with two other…

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 interview with staff and residents, it was determined that the facility failed to ensure completed documentation related to catheter care and emptying of catheter drainage bag for one of one resident reviewed with a urinary catheter (Resident R1). Findings include: Observation of Resident conducted on September 14, 2023, at 11:23 a.m. revealed that resident was on a wheelchair, with half full urine bag hanging under the wheelchair covered with privacy bag. Further observation revealed that the tubing had clear light-yellow urine draining. Review of resident's diagnoses revealed diagnoses of but not limited to Urinary Tract Infection, Benign Prostatic Hyperplasia with Lower Urinary Tract Symptoms, Hydronephrosis with Ureteropelvic Junction Obstruction, Obstructive and Reflux Uropathy, Acute kidney Failure, Review of physician's orders revealed an order to perform foley catheter care every shift and as needed with an order date of August 25, 2023, and discontinue date of September 1, 2023. Review of June 2023, July 2023, and August 2023 TAR…

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.