Graduate Post Acute

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of clinical records, facility documentation, and resident and staff interviews, it was determined that the facility failed to provide quality care related to wound care and medication administration for two of eight residents reviewed (Residents R100, R151).Findings include:Clinical record review revealed Resident R100 was admitted to the facility on [DATE] with a diagnosis that included surgical amputation, type 2 diabetes mellutis (failure of the body to produce insulin) with diabetic peripheral angiopathy with gangrene (a severe complication of diabetes where poor circulation (peripheral angiopathy) leads to tissue death (gangrene) in the limbs, most commonly the feet), and panlobular emphysema (a type of chronic obstructive pulmonary disease characterized by the destruction of the alveoli (air sacs) throughout the entire lung lobule). Interview with Resident R100 on September 23, 2025 at 11:22 a.m. revealed staff has not changed his/her wound dressings in 2 days.Observation on September 23,…

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

Based on clinical record review and staff interviews, the facility failed to ensure that resident weights were obtained as ordered to monitor nutritional status for one of 25 residents reviewed (Resident R7)Findings Include:Record review for Resident R7 dated June 3, 2025, revealed that the physician recommended to monitor weight.Record review for Resident R7 dated July 11, 2025, revealed that the physician recommended to monitor weight and it was revealed an order was placed for monthly weights.Review of physician order for Resident R7 dated July 9, 2025, revealed an order for monthly weights on 15th of every month.Review of the resident's weight documentation showed that no weights were recorded for the months of June 2025, July 2025 and August 2025, as ordered.Review of weight for Resident R7 revealed that on May 7, 2025, the resident weighed 137.6 lbs. and on September 18, 2025, resident weighed 116 pounds representing a 15.7% weight loss over the periodReview of nutritional progress note for Resident R7 dated September 19, 2025, revealed that the resident triggered for…

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

Based on observations, reviews of clinical records and review of facility policies and procedures, it was determined that the facility failed to provide adequate treatment, assessment and monitoring for the care and maintenance of mid line catheter line in accordance with professional standards of practice for one of one residents reviewed for intravenous catheter care. (Resident R30).Findings include:Review of facility policy Peripheral and Midline (A a long (3 to 8 inches, or 7 to 20 centimeters) thin, soft plastic tube that is put into a small blood vessel) IV (intravenous) Dressing Changes, dated October 2024, revealed that 1. Perform site care and dressing change at established intervals or immediately if the integrity of the dressing is compromised (e.g., damp, loosened or visibly soiled).2. Maintain sterile dressing (transparent semi-permeable membrane [TSM] dressing or sterile gauze) for all peripheral catheter sites.3. The type of dressing is based on the condition of the resident and his or her preference. Select a dressing that will minimize the need for dressing…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 record, staff interviews and observations, it was determined that the faciity failed to obtain physician orders to administer oxygen via nasal canula for two fo two residents reviewed for respiratory care. (Resident R158 and Resident R100)Findings include: Review of facility policy titled Oxygen Therapy, no date, revealed Oxygen (02) is administered appropriately to residents to improve oxygenation and provide comfort to residents experiencing respiratory difficulties. Oxygen is administered by licensed staff with a physicians order. In an emergency oxygen can be administered and order should be received as soon as possible. Clinical record review revealed Resident R100 was admitted to the facility on [DATE] with a diagnosis that included surgical amputation, type 2 diabetes mellutis with diabetic peripheral angiopathy with gangrene (a severe complication of diabetes where poor circulation (peripheral angiopathy) leads to tissue death (gangrene) in the limbs, most commonly the…

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

Based on the review of clinical records and interviews with staff and resident, it was determined that the facility failed to ensure that pain management was provided consistently as ordered by the physician for one of two residents reviewed for pain management. (Resident R123)Findings include:Interview with Resident R123 on September 22, 2024, at 1:03 p.m. revealed that she was not receiving pain medication as ordered. She stated when she was not receiving pain medication when her pain level was 10 of a scale of 10. Resident stated that staff told her that the medication which was ordered by the physician was not available from the pharmacy.Review of physician orders for Resident R123 dated September 4, 2025, revealed orders for Oxycontin (Narcotic pain medication) extended release 20 mg every 12 hours for pain.Review of Medication Administration Record for the month of September 2025 revealed that on September 20, 2025, at 9:00 p.m., September 21, 2025, at 9:00 a.m., and September 21, 2025, at 9:00 p.m., resident did not receive Oxycontin as ordered by the physician.Interview with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of clinical records, staff and resident interviews, it was determined that the facility failed to provide culturally competent, trauma care in accordance with professional standards of practice, accounting for the resident's past experiences and preferences in order to eliminate and/or mitigate triggers that may cause re-traumatization of the resident for two of two residents sampled for post-traumatic stress disorder(PTSD). (Resident R4 and R104).Findings include:A review of the clinical record revealed that Resident R4 was admitted to the facility, with diagnoses to include non-traumatic subarachnoid hemorrhage(a collection of blood that accumulates between the inner layer of the skull), major depressive disorder (a common mental health condition characterized by persistent feelings of sadness, loss of interest, and low energy levels that can significantly impact daily life and post-traumatic stress disorder (PTSD)( a mental health condition that develops after experiencing or witnessing 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 clinical records and staff interviews, it was determined that the facility failed to ensure a response to the consultant pharmacist's recommendation related to the potentially unnecessary medications in a timely manner for one of five residents reviewed. (Resident R7)Findings include: Review of pharmacy consultant report for June 20, 2025, revealed a pharmacy consultant recommendation for Resident R7 which stated, Currently receiving Wellbutrin can contribute to difficulty sleeping of dosed at bedtime. Please consider changing the time to 9:00 a.m. Further review of the recommendation revealed that the recommendation was acknowledged and signed. There was no evidence that the facility implemented the recommendation until September 24, 2025, after the pharmacy review was requested by the survey team. Review of pharmacy consultant report for July 30, 2025, revealed a pharmacy consultant recommendation for Resident R7 which stated MD order indicate medications may be crushed. Resident is receiving medication(s) which should not be crushed. Please update these orders…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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.Findings include: Observations of the trash room conducted on September 22, 2025, at 10:15 a.m. revealed that the trash room door was open and the trash bins were exposed; two large trashcans were overflowing with refuse exposed to open air, and severe foul odor was observed. Continued observations revealed dirty gloves, debris, food, were scattered on the floor around the trash bins. Observations in the receiving area revealed four uncovered grey trash bins exposed and filled with trash. A foul, white, milky liquid was observed pooling across the receiving area floor. The liquid appeared to be leaking from the construction trash container and had spread into multiple walking and delivery zones used by staff to transport food into the facility. Continued observations confirmed trash from the kitchen was mistakenly placed in the construction trash bin. Flies were observed in the receiving area, in the trash room and construction trash…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 job's descriptions, review of facility documentation and interviews with staff, it was determined that the Nursing Home Administrator and Director of Nursing failed to effectively manage the facility to ensure that adequate supervisor was provided to one of 10 residents reviewed (Resident R1). This failure resulted in Resident R1 exiting the third floor via elevator and walking out the front entrance of the facility. Resident R1 was located two hours after the resident exited the facility approximately 1.2 miles away from the facility in a busy [NAME] area. This failure placed the resident at high risk for injury and was identified as an Immediate Jeopardy of past non-compliance. (Resident R1) Findings include: Review of the job description of the Nursing Home Administrator (NHA) revealed that, the primary purpose of the job position is to direct the day-day-day functions of the Center in accordance with current feferral, state, and local standards, guidelines and regualtions that govern…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interview with staff and residents, it was determined that the facility failed to ensure an effective pest control program resulting in presence of rodents on one of four units observed (2nd floor unit) Findings include: Review of facility policy 'Pest Control,' indicates that facility maintains an on-going pest control program to ensure that the building is kept free of insects and rodents. Observations on April 7, 2025, at 11:45 am, on 2nd floor unit, revealed a rodent in room [ROOM NUMBER]; finding confirmed with licensed nurse, employee E3. Interview with E3, revealed that she observes rodents one to two times each working shift. Interview with Resident R1, on April 7, 2025, at 12:45 pm, revealed the resident has seen rodents in the room, further stating that mouse traps placed in the room were ineffective. Interview with Resident R2, on April 7, 2025, at 1:00 pm, revealed concern of continuous rodent infestation in facility. 28 Pa Code 201.18(a)(b)(1) Management 28 Pa Code 201.14(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, staff interview, and clinical record review, it was determined that the facility failed to administered medications timely in accordance with physician orders, for one of one resident observed during medication administration. (Resident R2) Findings include: Review of Resident R2's April 2025 physician orders and Medication Administration Record (MAR) indicated the following medications scheduled to be administered at 9:00 a.m.: Acetaminophen Tablet 325 MG (Acetaminophen), Give 2 tablet by mouth every 4 hours as needed for Mild Pain More than 3 doses in 48 hours, notify physician/advanced practice provider(APP).Do not exceed 3mg/day. (standing order) (Ordered on 7/11/2024). Allopurinol Oral Tablet 100 MG (Allopurinol), Give 0.5 tablet by mouth one time a day for gout (Ordered on 7/11/2024). Amiodarone HCl Oral Tablet 200 MG (Amiodarone HCl), Give 1 tablet by mouth one time a day for AFib (Ordered on 2/24/2025). {Atrial fibrillation (AFib), or A-fib, is a common heart rhythm disorder where the heart's upper chambers (atria) beat irregularly and rapidly,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, clinical record review, review of facility policy and staff interview, it was determined that the facility failed to provide appropriate respiratory care and services for one of seven residents reviewed (Resident R3). Findings include: Review of the Facility Policy and Guidelines for Implementation of Oxygen Administration indicated that the nurse should review and follow the physician's orders while administering oxygen via nasal canula. Review of Resident R3's clinical record revealed that the resident was initially admitted to the facility on [DATE]; diagnosed with Dependence on Supplemental Oxygen. Review of clinical record indicated that Resident R3 was ordered, dated March 15, 2025, oxygen at 2 Liters/Min, via nasal cannula, continuously, every shift for shortness of breath. On April 01, 2025, at 11:01 a.m., Resident R3 was observed with Oxygen at 6 liters/min, via nasal canula., and not 2 liters/min, as ordered by the physician; and the same it was confirmed with a Registered Nurse,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 record, and resident interview it was determined that that the facility failed to ensure dependent residents received the necessary assistance to maintain personal hygiene for one of six residents reviewed (Resident R1). Findings Include: Review of facility policy Activities of Daily Living (ADL) revised March 2018 revealed appropriate care, and services will be provided for residents who are unable to carry out activities of daily living (ADLs) independently, with the consent of the resident and in accordance with the plan of care. Review of Resident R1's clinical record revealed the resident was admitted to the facility on [DATE], was alert and oriented x 3 (alert to person, place, and time) and able to make needs known. Review of Resident R1's care plan dated March 12, 2025, revealed Resident R1 had an activities of daily living self-care performance deficit related to recent fall with hip fracture. Intervention dated March 13, 2025, revealed Resident R1…

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

Based on interviews with staff and resident representatives, review of facility documentation,and clinical records, it was determined that the facility failed to inform a resident of facility policy of cannabis use/administration in the facility prior to the admission which resulted in a resident who was on cannabis for seizure disorder did not receive the prescribed medication as ordered by the physician. Findings Include: Review of facility admission documentation signed by the resident and facility representative dated 1/31/2025 revealed that viii.) Pharmacy Services. Federal law requires the Facility to contract with a licensed pharmacist and provide pharmaceutical services to meet the needs of residents. Physicians prescribe medications to residents, and pharmacists fulfill medication orders. The Facility obtains routine and emergency medications and biologicals for all Residents through an agreement with a pharmacy. This pharmacy is the preferred provider and provides pharmacy services to most of the residents. The Resident is permitted to bring prescription 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 review of clinical records, and staff interviews, it was determined that the facility failed to ensure under the Transfer and Discharge Facility requirements, that the information provided to the receiving provider included necessary information, including a copy of the resident's discharge summary, to ensure a safe and effective transition of care one of five resident records reviewed. (Resident R2) Findings Include: Review of the clinical record revealed that Resident R2 was admitted to the facility on [DATE] and discharged to another facility on 12/13/2026. Resident was admitted with diagnosis of cervical stenosis and laminectomy Review of hospital discharge summary for Resident R2 dated 12/6/2024 revealed that the resident was scheduled for a post operative orthopedic visit on 12/16/2024. Review of clinical record revealed that the resident was transferred to another skilled nursing facility on 12/13/2024 with a discharge summary created and provided by the facility to the transferring 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 review of clinical record, review of job's descriptions and interviews with staff, it was determined that the Nursing Home Administrator and Director of Nursing did not effectively manage the facility to ensure that adequate supervision was provided to on one of one resident reviewed (Resident R1) at risk for elopement. This failure resulted in Resident R1 exiting the third floor via elevator and walking out the front entrance doors. Resident R1 was unable to be located for over 24 hours. This failure placed the resident at high risk for injury and was identified as an Immediate Jeopardy of past non-compliance. (Resident R1) Findings include: Review of the Nursing Home Administrator's (NHA) job description revealed that the purpose of this position is to direct the day-to-day functions of the Center in accordance with current federal, state, and local standards, guidelines and regulations that govern nursing Centers to assure that the highest degree of quality care ban be provided to our residents at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of clinical records, as well as resident and staff interviews, it was determined that the facility failed to maintain clinical records that were complete and accurately documented for one of four residents reviewed (Resident R1) . Findings include: Review of Resident R1's clinical record revealed that the resident was admitted to the facility on [DATE], for skilled nursing care. The resident had been an inpatient at an acute care hospital and had undergone a surgical procedure on his right plantar (sole of foot) foot. Review of December 2024 physician orders revealed an order dated December 25, 2024, to cleanse right plantar foot with normal saline and gently pat dry, dress with non adherent dressing, then cover with ABD pad and kerlix, secure with transpore white tape daily every night shift for wound. Additional review of the clinical record did not reveal any documentation that the wound care regimen had been completed as ordered by the primary care physician. An interview was conducted with…

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

Based on staff interviews and a review of employee credentials, it was determined that the facility failed to employ a qualified director of food and nutrition services, as required (Employee E8) Findings include: Observation tour on November 19, 2024 at 10:00 a.m. with Employee E8, Food Service Director (FSD) stated that his responsibilities included the oversight of ordering, receiving, storing and preparation and service of food and that he had been working at the facility for one and one half years. Interview on November 19, 2024 at 1:00 p.m. with Employee E8 , Food Service Director, confirmed that he was not a certified dietary manager (CDM); or a certified food manager (CFM); or had a national certification for food service management and safety from a national certifying body; or had an associate's or higher degree in food service managementor hospitality from an accredited institution; and that he had not received frequently scheduled consultations from a qualified dietician. Review of Employee E8's credentials revealed that Employee E8 did not meet the statutory…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 and review of facility provided documentation, it was determined that the facility activities program was not directed by a qualified professional as required. Findings include: Interview with the nursing home administrator (NHA) on November 19, 2024 at 10:00 a.m., stated that facility currently does not have an activities program director. Interview with Regional staff, Director of guest services, employee E17, on November 20, 2024 at 1:00 p.m., confirmed that facility currently does not have a qualified activities director. Review resident council meeting minutes, dated June 26, 2024, indicates that topics/issues discussed were related to what we can do while outside. Review of resident council meeting minutes, dated July 31, 2024, indicates topics/issues discussed related to 'celebrating birthdays - both for patients and staff.' 28 Pa Code 201.189(e)(6) Management

Based on a review of personnel files and interviews with staff, it was determined that the facility did not ensure that nursing staff had specific competencies and skills sets necessary to care for residents' needs for three out of five personnel files reviewed. (Employees E9, E18, E16) Findings include: Review of Employee E9's personnel file revealed that the employee was hired on October 1, 2024 by the facility as licensed nurse. Continued review revealed that there was no indication that the employee received skill competency training related to resident rights, person centered care, communication, basic nursing skills, basic restorative services, skin and wound care, medication management, pain management, infection control, identification of changes in condition, and cultural competency. Review of Employee E18's personnel file revealed that the employee was hired on August 21, 2024 by the facility as nurse aide. Continued review revealed that there was no indication that the employee received skill competency training related to resident rights, person centered care,…

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

Based on observation, interviews with staff and residents and review of facility documentation, it was determined that the facility did not maintain an effective pest control program to ensure that the facility was free of pests for one of four floors. (5th floor) Findings include: Review of facility policy, Preventive Maintenance Policy and Procedure, Review of Infection Control Practices, revised January 8, 2024, revealed: Pest Management: The facility will provide a pest free environment by contract with a pest control vendor for appropriate service on a periodic basis whether weekly, monthly or as needed. As well, all staff are educated in maintaining the proper cleanliness of the facility and storing food in appropriate containers. Interview on November 21, 2024 at 11:00 with Employee E14, Unit Manager of 5th floor, confirmed that there have been multiple mice sightings on the fifth floor. We have a log to document pest sightings and the pest control company treats the area or rooms. Review of the pest control company's reports revealed thirteen sightings from October…

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

Based on review of facility provided documentation and interview with staff, it was determined that facility did not ensure to provide Notice Of Medicare Non-Coverage (NOMNC) to one out of three residents reviewed (Resident R20) Findings include: Review of facility provided documentation 'Medicare A Patients Cut from Skilled Care with Benefits Days Remaining,' revealed that Resident R20 was Medicare to Medicaid pending effective August 19, 2024. Facility unable to provide NOMNC for Resident R20 upon multiple requests during survey from November 20, 2024 through November 22, 2024; finding confirmed with facility's Social Services, Employee E11. 28 Pa Code 201.29(f) Resident Rights

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of clinical records, review of facility policy, facility documentation and resident and staff interviews, it was determined that the facility failed to ensure that residents were free from misappropriation and exploitation of property related to authorized use of resident's funds for two of two residents reviewed. (Resident R1 and Resident R22). Findings include: Review of facility policy titled Abuse Prohibition last revised October 24, 2022, revealed that the facility prohibits abuse, common mistreatment, common neglect, misappropriation of resident property, and exploitation for all patients. The center will implement an abuse prohibition program through the following: screening potential hires, training of employees, prevention of occurrences, identification of possible incidents or allegations which need investigation, investigation of incident and allegations, protection of patients during investigation and reporting of incidents investigations. Further review of this policy defined types…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy review of clinical records and staff interview it was determined that the facility failed to conduct and complete a thorough investigation to rule out misappropriation of resident funds for two of two resident records reviewed. (Resident R 1, and Resident R 22) Findings include: Review of facility policy titled Abuse Prohibition last revised October 24th, 2022, revealed that the facility prohibits abuse, common mistreatment, common neglect, misappropriation of resident property, and exploitation for all patients. The center will implement an abuse prohibition program through the following: screening potential hires, training of employees, prevention of occurrences, identification of possible incidents or allegations which need investigation, investigation of incident and allegations, protection of patients during investigation and reporting of incidents investigations. Further review of this policy defined types of abuse which include Exploitation is defined as the act or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of clinical records, review of the Resident Assessment Instrument and staff interviews, it was determined that the facility failed to conduct a significant change Minimum Data Set Assessments (MDS - a federally mandated standardized assessment process conducted at specific intervals to plan resident care) for a resident who had a deterioration in Range of Motion (ROM) and in Activities of Daily Living (ADL) for one of twenty residents reviewed (Resident R67). Findings include: Review of the RAI (Resident Assessment Instrument) Manual revealed that A significant change is a decline or improvement in a resident's status that: 1. Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions, is not self-limiting 2. Impacts more than one area of the resident's health status; and 3. Requires interdisciplinary review and/or revision of the care plan. Review of Resident R67's clinical record revealed that Resident R67 was admitted to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, clinical record review, it was determined that the facility failed to develop a baseline care plan within 48 hours of admission related to oxygen therapy for one of 20 residents reviewed (Resident R75). Findings include: Review of facility policy on person centered care plan with the most recent revision date of October 24, 2022, revealed that under section Policy: The Center must develop and implement a baseline person-centered care plan within 48 hours of admission/readmission for each resident that includes the instructions needed to provide effective and person-centered care that meets professional standards of quality care. Observation conducted during tour of the fourth-floor unit conducted on November 19, 2024, at 10:34 AM revealed that Resident R75 was in bed. Further Resident R75 was on Oxygen via Tracheostomy collar connected to an Oxygen concentrator. Further, the Oxygen concentrator was running at 3 liters/minute. Follow-up observation conducted on November 22, 2024, at 9:56 am…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, review of clinical records, observation, and staff interview, it was determined that the facility failed to develop and implement a comprehensive care plan related to indwelling catheter for one of 20 residents reviewed (Resident R22). Findings include: Review of facility policy on person centered care plan with the most recent revision date of October 24, 2022, revealed that under section Policy: A comprehensive individualized care plan will be developed within seven days after completion of the comprehensive assessment and review and revise the care plan after each assessment. The care plan will be prepared by the interdisciplinary team. Review of Resident R22's clinical record revealed that Resident R22 was admitted to the facility on [DATE], with diagnoses of Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting Left Non-Dominant Side (paralysis/weakness to one sideof the body), Chronic Kidney Disease, Retention of Urine Unspecified. Review of Resident R22'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 facility provided documentation, review of clinical records and interview with staff, it was determined that facility failed to update care plans related to bleeding, weight loss, tube feed occlusion, advanced directives, and hospice care for three out of 22 residents reviewed. (Resident R63, R86, R15) Findings include: Review of facility provided policy 'Person Centered Care Plan,' revised on [DATE], indicates that a comprehensive, individualized care plan will be developed within seven days after completion of the comprehensive assessment (admission, annual or significant change in status) and review and revise the care plan after each assessment. After each assessment means after each assessment known as the Resident Assessment Instrument (RAI) or Minimum Data Set (MDS). Review of Resident 63's nurses notes dated [DATE], revealed a general note stating met with patients fiancé accompanied by patient relations director related to issues noted. Despite repeated education and counseling…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, review of clinical records, review of facility policy and interview with staff, it was determined that the facility failed to administer oxygen as ordered by the physician for one of three residents on oxygen therapy. (Resident R75) Findings include: Review of Resident R75's clinical record revealed that Resident R75 was admitted to the facility on [DATE], with diagnoses of Chronic Obstructive Pulmonary Disease (COPD) with tracheostomy. Review of Resident R75's physician's orders revealed an order for O2 (Oxygen) concentrator set to 6 liters/min every day and night shift-Start Date 10/31/2024. Review of admission MDS (minimum data set-a federally required resident assessment conducted at a specific interval) dated November 7, 2024, section O0110 (Special Treatments, Procedures, and Programs), C1(Oxygen) revealed that Resident R75 was on oxygen on admission and while a resident. Review or Resident R75's care plan for COPD, revealed an intervention to administer oxygen as ordered/indicated.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, review of facility policies, review of clinical record and interviews with staff, it was determined that the facility failed to maintain effective infection control practices related to barrier precautions and personal protective equipment for one of one resident observed (Residents R52). Findings include: Review facility policy on Enhanced Barrier Precautions (EBP) with revision date of March 1, 2022, revealed that under section Policy: In addition to standard precautions Enhanced Barrier Precautions will be used when contact precautions do not otherwise apply for novel or targeted multi drug resistant organisms. Enhanced Barrier Precautions is based on the Centers for Disease Control and Prevention, (CDC) guidance, implementation of personal protective equipment (PPE- refers to protective items or garments worn to protect the body or clothing from hazards that can cause injury and to protect residents from cross-transmission) used in nursing homes to prevent the spread of multi drug…

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

Based on observations, resident and staff interviews, and a review of facility documentation, it was determined that the facility failed to provide food and drink that was palatable and served at palatable temperatures for five of five residents. (Residents R3, R4, R5, R6, R7) Findings include: A review of resident council minute notes for June 26, 2024, indicated food terrible ran out of soda. A review of resident council minute notes for August 28, 2024, indicated food cold, + last one served, need additional hand to wheel out the cart on 3rd floor. On September 18, 2024, at 11:48 a.m. interview was held with Resident R4 who revealed dissatisfaction with the food by stating I'm diabetic and I'm getting regular ginger ale, food is a 'slap' I buy my own food, pork chops are too hard too chew A test tray interview was conducted with Dietary Director Employee E5 on September 18, 2024, at 12:52 p.m. The interview indicated that the appropriate serving temperature for hot foods is 135 degrees Fahrenheit (F) or above, while cold foods should not exceed 41 degrees Fahrenheit (F). The test…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, resident and staff interviews and review of the pest control logs and pest control company invoices, review of facility policies and documentation, it was determined that the facility failed to maintaining an effective pest control program in four of four nursing units. (2nd Floor, 3rd Floor, 4th Floor and 5th Floor) Findings include: A review of facility Pest Control policy revised January 2024, states that a pest control program is established at each location to ensure an environment is free of insects and rodents. A review of resident council minute notes for August 28, 2024, indicated mice room [ROOM NUMBER]B, 309 A review of the second-floor pest logs at the facility revealed mice sighting as follows: August 20, 2024- mice in the rooms 209, 205- multiple mice August 28, 2024 -mice in room [ROOM NUMBER] September 17, 2024- 2nd floor hallway mice seen. A review of the third-floor pest logs at the facility revealed mice sighting as follows: August 7, 2024- 317 mouse 315-mouse going into…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, interviews with staff, and review of facility policy, it was determined that the facility failed to ensure that a resident's representative informed of the falls sustained by the resident for one of 7 residents reviewed (Resident R1). Findings include: A facility policy titled Change in Condition: Notification revised July 1, 2024, revealed A center must immediately inform the patient, consult with the patient's physician and notify consistent with their authority, the patient's representative. Review of Resident R1's Quarterly MDS (Minimum Data Set - a mandatory periodic resident assessment tool), dated August 23, 2023, revealed that the resident was admitted to the facility on [DATE], and had diagnoses including difficulty in walking, repeated falls, dementia (decline in memory or other thinking skills severe enough to reduce a person's ability to perform everyday activities), restlessness and agitation. Continued review revealed that the resident had a BIMS (Brief Interview 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 review of facility policy, clinical records, and staff interviews, it was determined that the facility failed to ensure that a resident's care plan was updated/revised to reflect the resident's specific care needs for 1 of 7 residents reviewed (Residents R1). Findings include: Review of Resident R1's Quarterly MDS (Minimum Data Set - a mandatory periodic resident assessment tool), dated August 23, 2023, revealed that the resident was admitted to the facility on [DATE], and had diagnoses including difficulty in walking, repeated falls, dementia (decline in memory or other thinking skills severe enough to reduce a person's ability to perform everyday activities), restlessness and agitation. Continued review revealed that the resident had a BIMS (Brief Interview of Mental Status) of 12, which indicates that the resident was moderately cognitively impaired. Review of Resident R1's care plan, dated initiated August 10, 2024, revealed that the resident was at risk for falls and the goal was for the resident…

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

Based on observations, staff and resident interviews, and review of facility documentation, it was determined that the facility failed to ensure a comfortable air temperature levels for 4 out of 4 residents reviewed receiving dialysis treatment (Resident R5,R6, R7an R8). Findings include: Review of the Home Hemodialysis Coordination Agreement, between the hemodialysis center that is located inside the facility indicated that it is the facility's responsibility to ensure that the dialysis center located inside the facility is compliant with all applicable, laws, rules and regulations, including licensure and certification requirements Continued review of the Home Hemodialysis Coordination Agreement, also indicated that the facility will provide and safe and sanitary environment for dialysis treatments, provide utilities to the dialysis company, including electricity, gas and HVAC (heating, ventilation, and air conditioning), and also be responsible for the maintenance of its own equipment that is not provided by the dialysis company. The Centers for Medicare and Medicaid Services…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 documentation, and the state survey reporting system, it was determined that the facility failed to ensure that allegations of abuse and neglect were reported to the state survey agency for 4 out of 4 residents reviewed (Resident R1, R2, R3 and R4). Findings include: Review of the facility policy, Abuse Prohibition, with a revision date of October 2, 2022 indicated that immediately upon receiving information concerning a report of suspected or alleged abuse, mistreatment, or neglect, the Administrator or designee will report allegations to the appropriate state and local authority(s) involving neglect, exploitation or mistreatment (including injuries of unknown source), suspected criminal activity, and misappropriation of patient property, no later than 2 hours after the allegation is made, if the event results in serious bodily injury, or within 24 hours if the event does not result in serious bodily injury. Continued review of the policy indicated that the facility would initiate an investigation within 24 hours of an allegation 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 and review of facility documentation, it was determined that the facility failed to conduct a complete and thorough investigation regarding allegations of abuse/neglect for 4 out of 4 residents reviewed (Resident R1, R2, R3 and R4). Findings include: Review of the facility policy, Abuse Prohibition, with a revision date of October 2, 2022 indicated that immediately upon receiving information concerning a report of suspected or alleged abuse, mistreatment, or neglect, the Administrator or designee will report allegations to the appropriate state and local authority(s) involving neglect, exploitation or mistreatment (including injuries of unknown source), suspected criminal activity, and misappropriation of patient property no later than 2 hours after the allegation is made if the event results in serious bodily injury or within 24 hours if the event does not result in serious bodily injury. Continued review of the policy indicated that the facility would initiate an investigation within 24 hours of an allegation of abuse, protect patients from further harm…

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

Based on staff interviews, and review of clinical records, it was determined that the facility failed to ensure that residents received care and services for dialysis treatment that was consistent with professional standards of practice for dialysis care for 2 out of 4 residents reviewed for dialysis treatment (Resident R6 and R8). Findings include: Review of the facility policy, Dialysis: Hemodialysis (HD)-Communication and Documentation with a revision date of June 15, 2022 indicated that the facility staff will communicate with the certified dialysis facility regarding the ongoing assessment of the patient's condition by monitoring for complications before and after the patient receives the treatments. The policy also indicated that upon return to the facility, a licensed nurse will review the dialysis center communication form related to the resident treatment, evaluate and observe the patient, and complete the post-hemodialysis treatment section on the Hemodiaysis Comunication Record. Review of the August 2024 orders indicated that the resident was admitted into the facility on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, resident and staff interviews and a review of facility policies and documentation, it was determined that the facility failed to maintaining an effective pest control program in four of four nursing units. (2nd Floor, 3rd Floor, 4th Floor and 5th Floor) Findings include: A review of facility Pest Control policy revised January 2024, states that a pest control program is established at each location to ensure an environment is free of insects and rodents. Interview on July 8, 2024, at 11:05 a.m. with Resident R3 revealed that he sees mice all the time at night, that his roommate had a stroke and often drops food on the floor which he feels attracts the mice. Interview on July 8, 2024, at 11:14 a.m. with Resident R5 revealed that she saw mice coming in and out under the radiator under the window. Interview on July 8, 2024, at 11:22 a.m. with Resident R6 revealed that she sees a lot if mice and she is concerned that they get in her bed. Interview on July 8, 2024, at 11:35 a.m. with Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of clinical records, facility documentation and interviews with staff, it was determined the facility did not ensure proper supervision for one of three residents reviewed (Resident R1). Findings include: Review of Resident R1's clinical record revealed the resident was alert and oriented able to make life decisions and was his own responsible party. The resident was admitted to the facility on [DATE], diagnosed with Diabetes (body is not able to produce insulin resulting in high levels of sugar in the blood), fractured mandible (jaw) and malnutrition (Lack of sufficient nutrients in the body). Review of facility documentation revealed on May 28, 2024, Nurse's Aide (NA) Employee E3 who worked on the 3-11 pm shift made her rounds at 3:30 p.m. and discovered Resident R1 was not in his room and his tray from lunch was still there. At dinner time (approximately 5:30 p.m.) the aide asked the Licensed Practical Nurse (LPN) Employee E4 about Resident R1 since she had not seen him. The LPN indicated 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 observation, interview with residents, review of facility provided documentation and test tray, it was determined that the facility did not ensure to provide food that is at a safe and appetizing temperature during lunch meal for one of four units observed (Unit 5, 5th floor Nursing Unit) Findings include: Review of facility's Meal Services, revealed a food temperature protocol which indicated that the temperature for cold food should be less than or equal to 41-degree Fahrenheit and hot food should be greater than or equal to 135-degree Fahrenheit. Interview with Resident R1 on May 29, 2024, at 11:00 a.m. stated the food was not always served hot and often times received not on time. Resident stated he complained to the staff and the issue was not resolved. Interview with Resident R2 on May 29, 2024, at 11:00 a.m. stated hot food was not served hot and the quality of the food was not also good. Review of a grievance dated May 14, 2024, revealed a concern which indicated that the resident was unhappy with the food. Review of a grievance dated May 15, 2024, revealed 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 observations, interview with staff and review of facility provided documentation, it was determined that the facility did not provide a sanitary environment to help prevent the development and transmission of communicable diseases and infections related to hand hygiene and maintaining an effective prevention program related to infection surveillance. (Unit 3, 3rd floor). The facility failed to conduct an infection control surveillance for identifying, tracking and monitoring and or reporting infections, communicable diseases and outbreak among residents. Findings include: During medication administration observation on February 26, 2024 at 9:30 a.m. observed licensed nurse, employee E11, put on gloves prior to preparing medications; E11 proceeded to check residents vital signs and administered medications with gloves on, without hand hygiene before or after procedure. E11 did not disinfect blood pressure cuff after direct contact with resident. Review of facility infection control documentation conducted on February 27, 2024 at 10:22 a.m. with outgoing 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 resident council interview, staff interviews, and review of the established mealtime schedule, it was determined that the facility failed to ensure a nourishing snack was provided when 14 hours are between a substantial evening meal and breakfast on four of four nursing units. (2nd floor, 3rd floor, 4th floor, and 5th floor). Findings include: A review of the established meal schedule for the residents revealed the following scheduled mealtimes: On 2nd floor, breakfast is served at 9:00 a.m. and dinner is served at 5:30 p.m. On 3rd floor, breakfast is served at 8:45 a.m. and dinner is served at 5:15 p.m. On 4th floor, breakfast is served at 9:15 a.m. and dinner is served at 5:45 p.m. On 5th floor, breakfast is served at 8:15 a.m. and dinner is served at 4:45 p.m. The above schedule indicates an elapsed time between dinner and breakfast of 15 hours and 30 minutes. An interview conducted on February 27, 2024, at 10:37 a.m. during the resident council with nine alert and oriented residents, residents R5, R6, R7, R25, R26, R60, R61, R75, and R299, revealed that snack provided…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 residents and staff and review of facility documentation, it was determined that facility did not ensure residents were treated with dignity and care in a manner and in an environment that promotes the enhancement of their quality of life related to fresh air breaks for nine of 24 residents reviewed (Resident R17, R26, R61, R5, R7, R75, R299, R25, R6) Findings include: An interview with Resident R17 on February 23, 2024 at 10:45 am, on 3rd floor unit, revealed that the only time he has fresh air is when he is rushed out to the hospital, and no activities here An interview with Resident R26 on February 23, 2024 at 11:00 am, on 3rd floor unit, revealed that the last time I was outside for fresh air was when I was transferred for dermatology appointment, on January 30th, and I don't think they have enough staff to assist with activities An interview with facility's activities director, employee E13, on February 23, 2024, at 2:00 p.m., revealed that residents are assisted for fresh air breaks on 5th floor patio upon request and/or during physical therapy. Review…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, facility policy review, and staff interview, it was determined that the facility failed to provide residents access to grievance information on three out of four nursing units. (2nd, 3rd, 5th Nursing Floor Units). Findings include: On March 29, 2023, at 12:36 an interview was held with Resident R150 reported that he's not aware how to report grievance and desires to speak to a Grievance officer. An interview and observation on February 28, 2024, at 11:56 a.m., the Grievance Officer Employee, E7, it was revealed that the facility failed to display the contact information of independent entities where grievances could be filed, such as the State Survey Agency on 2nd, 3rd, 5th Nursing Floor Units. The poster containing the State Long-Term Care Ombudsman phone number was not positioned at wheelchair-accessible eye level but instead, it was placed at a height suitable for standing individuals. During the resident council group meeting that was held on February 27, 2024, at 10:37 a.m. with 7 alert and oriented Residents (R61, R5, R7, R75, R299, R25, R6) reported that…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff interviews, it was determined that the PASRR (Preadmission Screening and Resident Review) was not appropriately completed according to the resident assessment for one of three residents reviewed related to PASRR assessments (Resident R77). 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 I 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, review of clinical records, observations, and staff interviews, it was determined that the facility did not complete a comprehensive care plan for one of 24 residents reviewed (Resident R55). Findings include: Review of Resident R55's clinical record revealed that the resident was admitted to the facility on [DATE] with the diagnoses of spastic hemiplegia affecting the left nondominant side (refers to a condition characterized by muscle stiffness or spasticity and paralysis or weakness on the left side of the body, particularly in individuals for whom the left side is not the dominant side), chronic respiratory failure and congenital malformations of trachea. Review of Resident R55's physician orders revealed an order dated December 15, 2023, for Type of trach shilly size of trach #4 (spare trach kept at bedside) and ambu bag at bedside. Observation conducted on February 23, 2024, at 1:12 p.m., revealed that Resident R55 had a trach in place. Review of Resident R55's care plan…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of clinical records and interviews with residents and staff, it was determined that the facility did not ensure that residents receive treatment and medications in accordance to physician orders related to tube grips and medication via tube feeding for two of 24 residents reviewed (Resident R26 and Resident 47). Findings include: Review of Resident R26's clinical records revealed diagnosis of type 2 diabetes mellitus with hyperglycemia, morbid obesity, venous insufficiency, chronic pain, lymphedema, abnormalities of gait and mobility, repeated falls and difficulty walking. Review of R26's consult completed on January 30, 2024 by nurse practitioner, Employee E30 and medical director, Employee E29 for lower leg discoloration and painful nodules, with following findings: multiple tender nodules of the lower legs, bound down skin of ankles and dyspigmentation. Some areas of scale. Palpable pedal pulses. Diagnosis of phlebolith (small local, usually rounded calcification within a vein), stasis…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 provide appropriate urinary catheter care to prevent urinary tract infections for one of four residents with a urinary catheter (Resident R257). Findings include: Review of Resident R257's clinical record revealed that he was admitted to the facility on [DATE] with diagnoses of Chronic Obstructive Pulmonary Disease ( a disease that causes decreased air flow to the lungs), End Stage Renal Disease ( a didease of the Kiondeys that causes the kidneys to stop functioning), Benighn Prostatic Hypertrophy, Retention of Urine (Urine is not expelled from the bladder through normal urination). Further review of Resident R257's clinical record revealed a physician's order dated February 25, 2024, for bedside urinary drainage bag to have dignity cover two times a day for dignity and an order for indwelling catheter 22 FR (french) with 10cc balloon to bedside straight drainage for Retention of Urine. Observation of Resident R257 conducted…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 clinical records review, resident and staff interview, it was determined that the facility failed to follow physician orders for tracheostomy care and ensure proper respiratory care for two of two residents reviewed receiving respiratory care. (Resident 55). Findings include: Review of Resident R55s clinical record revealed that the resident was admitted to the facility on [DATE] with diagnoses included spastic hemiplegia affecting the left nondominant side (a condition characterized by muscle stiffness or spasticity and paralysis or weakness on the left side of the body), quadriplegia, unspecified (paralysis of all four limbs and typically the trunk as well, chronic respiratory failure, other congenital malformations of trachea. Review of physician order dated on December 15, 2023, for Resident R55, indicated an order for Type of trach shilly size of trach #4 (spare trach kept at bedside) and ambu bag at bedside. On February 23, 2024, at 1:12 p.m., Resident R55 was observed with…

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

Based on clinical record review and interview with staff, it was determined that the facility did not provide requested evidence of competency trainings for licensed nursing staff. Findings include: Initial request for documentation was made during the entrance conference on February 23, 2024, at 11:20 a.m. with Regional Licensed nurse, Employee E2, and interim Director of Nursing, Employee E14. Documentation was provided and reviewed at this time which indicated that the facility was to provide evidence of at least annual inservice training, including, but not limited to, infection prevention and control, resident confidential information, resident psychosocial needs, restorative nursing techniques, and resident rights, including nondiscrimination and cultural competency, personal property rights, privacy, preservation of dignity and the prevention and reporting of resident abuse. This information was again requested via email from Employee E1, the Nursing Home administrator, on Monday, February 26, 2024, at 2:34 p.m., on February 28, 2024, at 9:56 a.m., and a final time on…

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

Based on clinical record review and interview with staff, it was determined that the facility did not provide requested evidence of annual competency trainings and yearly performance reviews for nurse aides. Findings include: Initial request for documentation was made during the entrance conference on February 23, 2024, at 11:20 a.m. with Regional licensed nurse, Employee E2, and interim Director of Nursing, employee E14. Documentation requested included evidence of annual competency trainings and yearly performance reviews for nurse aides. This information was again requested via email from Employee E1, the Nursing Home administrator, on Monday, February 26, 2024, at 2:34 p.m., on February 28, 2024, at 9:56 a.m., and a final time on February 28, 2024, at 11:52 a.m. At the conclusion of the survey on February 28, 2024, at 2:30 p.m., the facility had not provided the required documentation. 28 Pa. Code: 211.12(d)(1) Nursing services 28 Pa. Code 211.12(d)(5) Nursing services

Based on interview with residents and staff and review of clinical records, it was determined that the facility did not provide pharmaceutical services to meet the needs of residents for one of 24 residents reviewed (Resident R26) Findings include: Review of facility's policy Medication Shortages/Unavailable Medications, revised on January 1, 2022, states when a missed dose is unavoidable, facility nurse should document the missed dose and the explanation for such missed dose on the MAR (Medication Administration Record) or TAR (Treatment Administration Record) and in the nurse's notes per facility policy. Such documentation should include the following information: 9.1 a description of the circumstances of the medication shortage 9.2 a description of pharmacy's response upon notification, and 9.3 action(s) taken Review of Resident R26's clinical records revealed diagnosis of atherosclerotic heart disease, high blood pressure, obstructive sleep apnea, venous insufficiency. Review of Resident R26's consult completed on January 30, 2024 by nurse practitioner, Employee E30 and medical…

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

Based on observation and staff interview, it was determined that the facility failed to properly label and dispense drugs for one out of three carts observed. (4th floor back hall cart) Findings include: Observation of the 4th floor back hall cart conducted on February 26, 20204 at 9:02 a.m. with Licensed nurse, Employee E17 revealed that a medication cup with 4 tablets (one red tablet, one yellow tablet and two white tablets) were observed inside the medication cart top drawer where the over the counter stock medications were located. Interview with Employee E17, Licensed Nurse, conducted at the time of observation confirmed that a medication cup with 4 tablets (one red tablet, one yellow tablet and two white tablets) were in the medication cart top drawer where the over the counter stock medications were located. Further, Employee E17 stated that it must have been left by the previous nurse. 28 Pa Code 211.12(c) Nursing services 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on observation, interview with residents, review of facility provided documentation and test tray, it was determined that the facility did not ensure to provide food that is at a safe and appetizing temperature during lunch meal for one of four units observed (Unit 3, 3rd floor Nursing Unit) Findings include: Review of facility's Food Handling, revealed All time/temperature control for safety food must maintain an internal temperature of 41 F (Fahrenheit) or lower, or 135 F (Fahrenheit) or higher while being held for service. Based on findings during resident council meeting on Tuesday, February 27, 2024 at 10:30 a.m. revealed that Residents R17, R26, R61, R5, R7, R75, R299, R25, and R6 complained of cold food temperatures served. Observations completed during a test tray with Dietary Manager, Employee E12, on Tuesday, February 27, 2024 at 12:30 p.m., on 3rd floor unit revealed that the lunch meal consisted of turkey burger, soup, fruit drink, dessert. The The following food temperatures were obtained: turkey burger - 112.8 F grape drink - 46.5 F mandarins/oranges - 44.5 F 28…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on 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 mice for four of four units (2nd floor, 3rd floor, 4th floor, and 5th floor). Findings include: An interview with alert and oriented Resident R29 on February 23, 2024, at 11:55 a.m., revealed that the resident regularly saw mice at night. An interview with alert and oriented Resident R59 on February 23, 2024, at 1:18 p.m., revealed that the resident had seen mice about twice since his admission on [DATE]. An interview was conducted on February 27, 2024, at 10:37 a.m. during the resident council with nine alert and oriented residents, residents R5, R6, R7, R25, R26, R60, R61, R75, and R299. This interview revealed pest control concerns including multiple sightings of mice per day, nurse aides not properly reporting mice and other pests, residents being unsure of where and how to report seeing pests, and holes in the wall…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 provide requested evidence of inservice trainings for nurse aides. Findings include: Initial request for documentation was made during the entrance conference on February 23, 2024, at 11:20 a.m. with RegionalLlicensed nurse, Employee E2, and interim Director of Nursing, Employee E14. Documentation requested included evidence of at least annual inservice training for nurse aides, including, but not limited to, infection prevention and control, resident confidential information, resident psychosocial needs, restorative nursing techniques, and resident rights, including nondiscrimination and cultural competency, personal property rights, privacy, preservation of dignity and the prevention and reporting of resident abuse. This information was again requested via email from employee E1, the Nursing Home administrator, on Monday, February 26, 2024, at 2:34 p.m., on February 28, 2024, at 9:56 a.m., and a final time on February 28, 2024, at 11:52 a.m. At the conclusion of the survey on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility documentation, clinical record review, resident and staff interviews, it was determined that the facility failed to ensure that intravenous antibiotic therapy was ordered for a resident was admitted for antibiotic therapy for one of eight residents. (Resident R1) Findings include: Review of resident R1's clinical record revealed, this resident was admitted to the facility on [DATE] with a diagnosis of diabetes (a chromic metabolic disease characterized by elevated levels of blood glucose (blood sugar)which leads to serious damage to the heart, blood vessels, eyes , kidneys , and nerves), liver cirrhosis (chronic liver damage which can lead to liver failure) a liver transplant, COPD (Chronic Obstructive Pulmonary Disease - a chronic inflammatory lung disease that causes obstructed airflow from the lungs), recently hospitalized for pneumonia (a lung infection that inflames air sacs in one or both lungs, which may fill with fluid) resulting in sepsis (the body's overactive and extreme…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, interview with staff, and review of facility provided documentation, it was determined that facility did not ensure that the resident environment remains as free from accident hazards as is possible and each resident receives adequate supervision to prevent accidents related to not following residents care plan for repositioning and bed not locked during repositioning for one of one residents' reviewed (Resident R2) Findings include: Review of Residents R2 clinical record revealed [AGE] year old patient admitted on [DATE] with medical diagnosis of spastic hemiplegia affecting left non-dominant side, tachycardia, traumatic subdural hemorrhage, intracranial injury with loss of consciousness of unspecified duration, quadriplegia, convulsions, muscle weakness, dysphagia, respiratory failure, infection and inflammatory reaction due to other internal prosthetic devices, implants and grafts, aphasia, congenital malformations of trachea, gastrostomy status, encephalitis and encephalopathy,…

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

Based on clinical record review and staff interview, it was determined that the facility failed to complete a discharge summary, which included a recapitulation of the resident's stay, the course of illness, corresponding treatment, discharge instructions, and a post-discharge care plan for one of three records reviewed (Resident R1). Findings include: Review of facility policy Discharge and Transfer, dated November 15, 2022, revealed, If patient is discharging home, an assisted living center or other community based/home alternative setting: -A Discharge Transition Plan is given to the patient, family member, or legal representative. - -A copy of the Discharge Transition Plan will be placed in the patient's medical record. A review of the clinical record revealed that Resident R1 was admitted to the facility with diagnoses including joint replacement surgery and post traumatic stress disorder. Review of clinical records revealed that Resident R1 was discharged home on October 15, 2023. A review of Resident R1's clinical record revealed a document My Transition Home dated October…

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

Based on a review of clinical records and staff interview, it was determined that the facility failed to provide care and services regarding bathing for one of three residents (Resident R1). Findings include: Review of Resident R1's MDS assessment (Minimum Data Set--MDS assessment: a periodic assessment of resident care needs) dated October 5, 2023, indicated that the resident required set up assistance for shower/bath and personal hygiene. Review of Resident R1's care plan initiated on October 5, 2023 indicated that the resident had altered musculoskeletal status and the resident was at fall risk. The care plan also indicated to provide transfer and ambulation assistance as needed. Review of Resident R1's shower and bed bath documentation dated the week of October 5, 2023, through October 15, 2023 did not indicate a shower was provided. During an interview on December 19, 2023, at 1:36 p.m. with Infection Control Nurse Employee E4 stated facility offered shower to all the residents two times a week. Employee E4 confirmed there was no documented evidence that the facility provided…

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

Based on clinical record review and staff interview, it was determined that the facility failed to ensure that laboratory studies were promptly obtained as ordered by the physician for one of three clinical records reviewed (Resident R2). Findings include: Review of Resident R2's physician progress note dated December 8, 2023, revealed that the resident had hematuria (blood in urine) and ordered for lab work CBC (Complete Blood Count) in the morning. Review of Resident R2's physician progress note dated December 11, 2023, revealed that the requested blood work CBC/BMP(Basic Metabolic Pattern) was still pending and the lab work was not sent over the weekend. Review of physician order for Resident R2 dated December 8, 2023, revealed orders to check CBC and BMP in the morning and notify physician with the results to follow up for anemia (A condition in which the blood doesn't have enough healthy red blood cells) and electrolytes. Review of clinical record for Resident R2 revealed no evidence that the requested lab work was not completed until December 12, 2023, until the physician…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and interviews with staff, it was determined that the facility did not develop a comprehensive care plan related to the use of a mechanical device for transfers for one of five records reviewed (Resident R1). Findings include: Review of clinical documentation for Resident R1 revealed that she had been admitted to the facility on [DATE], with diagnoses of Congestive Heart Failure (CHF, a condition where the heart does not pump effectively, leading to swelling of the limbs and fluid pressure on the lungs, making breathing more difficult), Morbid Obesity (defined as a body mass index of greater than 30), and Gout (which is a form of arthritis characterized by severe pain, redness, and tenderness in joints, which occurs when too much uric acid crystallizes and deposits in the joints). Further review revealed that Resident R1 was dependent on staff for transfer assistance. Interview with Employees E2, the Director of Nursing, on November 28, 2023, at 3:00 p.m. revealed that the…

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

Based on interviews with staff, review of faciltiy policy and review of the clinical record, it was determined that the facility failed to ensure that a resident's grievance related to medications not administered on time was investigated and resolved, and the resident was notified of the outcome (Resident R1). Findings include: Review of the facility policy, Grievance/Concern, with a revision date of July 19, 2023 indicated that concerns may be registered by telephone, mail, office, visit, or direct outreach to staff of with the National Compliance Department. The policy also stated that upon receipt of the grievance/concern, the Grievance/Concern Form, the form will be initiated by the staff member receiving the concern, and that the Administrator or designee will document the grievance/concern on the Grievance/Concern Log and the appropriate department manager will be notified. The policy stated that immediate action will be taken to prevent further potential violations of any patient right while the alleged violation is being investigated. The policy also state that the…

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

Based on the review of clinical records, review of facility policy and interview with staff, it was determined that the facility failed to ensure that physician orders were obtained for two residents with bed rails for 2 of 2 residents reviewed with bedrails. (Resident R1 and Resident R3). Findings include: Review of the policy, Bed Rails, with a revision date of September 1, 2022, the facility's bed rail evaluation will be completed upon admission, re-admission, quarterly, change in a bed or mattress, and with a significant change in condition. The policy also stated that if a bedrail is used, the facility must obtain informed consent from the patient or patient representative for the use of the bed rails and review the risks and benefits of bed rails with the patient or, if applicable, the patient's responsible party. Continued review of the policy indicated that the facility will obtain a physician's order for the use of the bed rail. Review of the September 2023 physician orders for Resident R1 included the following diagnosis: congestive heart failure (a condition in which an…

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

Based on interviews with staff, review of facility policy and review of clinical records, it was determined that the facility failed to ensure that complete and accurate clinical records were maintained for one out of 3 residents reviewed related to medication administration (Resident R2). Findings include: Review of the facility policy, Nursing Documentation, with a revision date of May 1, 2023 indicated that purpose of the policy is to communicate the patient' status and provide complete, comprehensive and accessible accounting of care and monitoring provided. The policy also stated that documentation includes information about the patient's status, nursing assessment and interventions, expected outcomes, evaluation of the patient's outcomes and responses to nursing care. Continued review the policy indicated that timely entry of documentation must occur as soon as possible after the provision of care and in conformance with time frames for completion as outlined by other policies and procedures. The policy also explained that each patient record specifies what nursing…

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

Based on clinical records review, and staff interview it was determined that the faciltiy failed to ensure that a bedrails were in a safe operating condition and replaced for one of two residents reviewed. (Resident R1) Findings include: Review of the September 2023 physician orders for Resident R1 included the diagnoses of congestive heart failure (a condition in which an individual's heart can't supply enough blood to meet your body's needs); diabetes (a disorder in which the body has high sugar levels for prolonged periods of time); depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), anxiety (an uncomfortable feeling of nervousness or worry about something that is happening or might happen in the future), and difficulty walking Review of Resident R1's Quarterly Minimum Data Set Assessment (MDS-a periodic assessment of a resident's needs) dated July 19, 2023, indicated that Resident R1 was cognitively intact. Review of information received by the State Agency, documented concerns regarding the resident's being placed in a bed with broken…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, observations and interviews with staff and residents, it was determined that the facility failed to provide appropriate colostomy (an operation that creates an opening for the colon, or large intestine, through the abdomen) supplies to residents who had colostomy for two of three residents reviewed. (Residents R4 and R5). Findings Include: Interview with Resident R4 on August 28, 2023, at 11:10 a.m. stated he was wearing a wrong type of colostomy. He stated the one that he was using was long and large colostomy bag, which prevented him from moving around in bed and out of bed during the daytime. Resident R4 stated he was told by the staff that there was no supply available for the appropriate colostomy supply. Observation of Resident R4's room with Employee E4, Licensed Practical nurse, on August 28, 2023, at 11:15 a.m. revealed that there was a empty box of colostomy bag. There were no colostomy wafers available to fit the appropriate bag in the room. Employee E4 stated there was none in the building and the staff was waiting for supplies.…

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