Inglis House

Based on review of facility policy, review of facility documentation, review of clinical records, and staff and resident interviews it was determined that the facility failed to provide pressure ulcer treatment consistent with standards of professional practice for one of three residents reviewed (Resident R1).Findings Include:Review of facility policy Skin Integrity: Wound Monitoring revised September 22, 2016, revealed when a new wound is identified the licensed nurse will measure the wound and document findings in the electronic medical record (EMR), and notify the Registered Nurse, and Physician. The physician's order for wound care treatments should include cleansing agent, frequency, and dressings as indicated. Review of Resident R1's quarterly Minimum Data Set (MDS - federally mandated resident assessment and care screening) dated June 27, 2025, revealed the resident was cognitively intact and had a diagnosis of paraplegia (paralysis of the legs and lower body). Continued review of Resident R1's MDS revealed the resident was at risk of developing pressure ulcers/injuries…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 wandering in the hallways of the facility on an electric wheelchair, and accessing the fire stairway entrance door, falling down a flight of stairs while strapped to the wheelchair. Resident R1 required transfer to the hospital and diagnosed with rib fractures, a fracture of the right clavicle, a subdural hematoma and closed dislocation of left finger and five stiches to the right top of the head. This deficiency was identified as Immediate Jeopardy Past Noncompliance. (Resident R1) Findings include:Review of the Nursing Home Administrator's (NHA) job description revealed that the Administrator is responsible for directing the day-to-day operations 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 clinical record, faciltiy documentation, facility policy, and staff interviews it was determined the facility failed to ensure there was a sufficient number of nursing staff available to provide care for one of seven residents reviewed. (Resident R1) Findings include: Review of the facility policy titled, Resident Safety revised on September 22, 2016; revealed nurse aides will make safety/hygiene rounds on all resident to ensure that the environment is safe and that resident hygiene needs are met. It is recommended that rounds be made every 2-3 hours. Continued review of policy revealed under bullet number 8 indicates Provide two or more person assist when necessary during transfer to ensure staff and resident safety. Further review of facility policy revealed under Care Plan Documentation section indicated, Assistive devices, safety measures, amount of assistance required by the resident to be documented in the approach/interventions section of the plan of care. Review of Resident R1's…

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

Based on observations and interviews with staff, it was determined that the facility did not ensure that food was stored, prepared, distributed and served in accordance with professional standards for food service safety. Findings include: Review of facility policy titled, Solarium Dishwasher Usage, Revised March 19, 2025, revealed that, Chemical solutions shall be maintained at the correct concentration and Results of concentration checks shall be recorded. Further review revealed that for high temperature dishwashes, the was temperature should be 150-165 degrees Fahrenheit and The final rinse temperature shall be 180°F. Corrective actions shall be taken for final temperatures below the required final rinse temperatures. Review of facility policy titled, Food Preparation in Kitchen, dated March 12, 2018, revealed that all food products that are taken out of the original container or opened for food prep must be covered, labeled & dated. Initial tour of the Foodservice Department conducted on March 17, 2025, with the Foodservice Director (FSD), Employee E4, revealed the following…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 failed to properly dispose of facility garbage. Findings include: Initial tour of the Foodservice Department garbage area conducted on March 17, 2025, with the Foodservice Director (FSD), Employee E4, revealed the following: Observations of the trash area revealed debris and dirty plastics (gloves, cups, utensils) observed scattered on the ground around the dumpster. Further observations revealed severe urine like odor; opened gray trash bin filled with waste; and five large and opened cardboard boxes. Interview with Food Service, Employee E4 along duration of the tour confirmed observations of the dumpster area. 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 201.18(b)(3) Management 28 Pa. Code 207.2(a) Administrator's responsibility

Based on review of facility protocol, observations, and staff interviews, it was determined that the facility failed to implement proper use of personal protective equipment (PPE) for resident's on enhanced barrier precautions during wound care and medication administration as ordered by the physician for four of 35 resident reviewed. (Resident R18, R78, R93, R112) Findings Include: Review of an undated facility policy Enhanced Barrier Precaution Review of physician orders for Resident R18 dated February 25, 2025, revealed that the resident was ordered for enhanced barrier precaution ESBL (Extended-Spectrum Beta-Lactamase, an enzyme produced by some bacteria that makes them resistant to certain antibiotics, including penicillin and cephalosporins) in the urine. Observation of the Resident R18's wound care on March 19. 2025, at 11:30 a.m. revealed that there was a sign placed outside the resident room to alert the staff and visitors of resident's enhanced barrier precaution status. The sign indicated to use gown, gloves for wound care along with other resident care activities with a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and staff interviews, it was determined that the facility failed to provide confidentiality of residents' personal health information during medication administration for one of two staff observed (Employee E6 and failed to ensure residents' privacy was maintained before entering rooms for two of 35 residents reviewed (Residents R9 and R62). Findings include: Observation of the first floor revealed on March 19, 2025, at 9:10 a.m. revealed that there was no nurse/staff at the medication cart. It was observed that there was numerous medication packet on top of the medication cart with resident's name, room number, name of medication and dosage of the medication printed on it. A medication administration observation was requested with Employee E6, Licensed Practical Nurse. Continued observation on March 19, 2025, at 9:20 a.m. revealed that Licensed Practical Nurse, Employee E6, was administering medication to the assigned residents. It was observed the medication packets were still on top of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, clinical record review, and interviews with residents and staff, it was determined that the facility did not ensure timely revision of the comprehensive care plan related to wounds for one of 35 records reviewed (Resident R93). Findings include: Review of clinical documentation revealed that Resident R93 was admitted to the facility on [DATE], and had diagnoses including, but not limited to, Multiple Sclerosis, Muscle Weakness, Pressure Ulcer of the Sacral Region, and Open Wound of Lower Back and Pelvis. Review of the resident's physician orders revealed an order, revised March 18, 2025, for Santyl (an ointment used to treat wounds) to right ischium (area including the lower back and pelvis), every day shift for pressure wound. Review of the resident's care plan revealed that care plans had been developed for impaired skin integrity, specifying only left lower arm abrasion and scattered bruises and bruising of the left forearm and not the resident's current pressure wound to the right…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 interviews with staff, it was determined that the facility failed to meet professional standards related to medication administration for one of five residents reviewed (Resident R167). Findings include: According to the Pennsylvania Code Title 49, Professional and Vocational Standards Department of State, Chapter 21 State Board of Nursing, Chapter 21.145 Functions of the LPN (Licensed Practical Nurse) requires the following: (a) The LPN is prepared to function as a member of the health care team by exercising sound nursing judgement based on preparations, knowledge, skills, understandings, and past experiences in nursing situations. The LPN participates in the planning, implementation, and evaluation of nursing care in settings where nursing takes place. (b) The LPN administers medication and carries out the therapeutic treatment ordered for the patient in accordance with the following: (d) The Board recognizes codes of behavior as developed by appropriate practical nursing associations as the criteria for assuring safe and effective…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 policy, observations, and staff interviews, it was determined that the facility failed to provide appropriate tracheostomy care for one of two residents reviewed receiving respiratory services. (Resident R43) Findings include: Review of facility policy titled, Tracheostomy- Care of dated March 3, 2028, revealed that consistent and proper care will be applied to prevent obstruction, growth of bacteria, respiratory complications, or skin breakdown. A review of Resident R43's clinical records revealed that the resident was admitted on [DATE], with diagnoses including, encounter for attention to tracheostomy. Further review of Resident R43's clinical records revealed a physician order dated, May 25, 2023, which indicated cuffed trach every shift, clean around tracheostomy and evaluate and document skin condition. Further review revealed an order dated May 25, 2025, for Trach:Blvona #6- Cuffless, indicating the tracheostomy tube size. Observations conducted on March 19,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, 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 four of four residents sampled for post-traumatic stress disorder(PTSD) care. (Resident R158, R113, R102, and R130). Findings include: A review of the clinical record revealed that Resident R158 was admitted to the facility, with diagnoses to include traumatic spinal cord dysfunction, depression (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 traumatic event, such as a natural disaster, war, violent crime, or personal loss) A quarterly Minimum Data Set assessment (MDS- a federally…

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

Based on a review of facility documentation and interviews with staff, it was determined that the facility failed to complete performance reviews for five of five nurse aides' personnel files reviewed related to performance reviews as required (Employees E13, E14, E15, E16 and E17). Findings include: On March 19, 2025, annual performance reviews for Employees E13, E14, E15, E16 and E17 were requested from the Nursing Home Administrator and Director of Nursing. Facility did not provide annual performance reviews for Employees E13, E14, E15, E16 and E17 Interview on March 20, 2025, 1:16 p.m. the Nursing Home Administrator revealed that the facility had not completed any performance reviews for any staff for the current year or the past year, including Employees E13, E14, E15, E16 and E17. 28 Pa. Code 201.19(2) Personnel policies and procedures

Based on review of facility records and interviews with staff, it was determined that the facility did not ensure that the record for reconciliation of controlled drugs was complete related to missing signatures on the Narcotic Count Sheet for one of five medication carts reviewed (3 North cart A). Findings include: Interview with licensed nurse, employee E7, on March 19, 2025, at 12:30 p.m. revealed that at each change of shift, the oncoming and outgoing nurses must verify that the recorded number of narcotics for each resident is consistent with the actual supply available, and it is the expectation that both nurses must sign the Narcotic Count Sheet after the reconciliation has been performed and verified. Review of the narcotic reconciliation documentation for the medication cart on the 3 North unit revealed that between the dates of March 12, 2025, and March 18, 2025, seven of 44 required nurse signatures were absent. Employee E7 confirmed that the signatures were absent. 28 Pa Code 211.9(a)(1) Pharmacy services 28 Pa Code 211.12(d)(5) Nursing services

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, clinical record review and interviews with staff, it was determined that the facility failed to ensure that medications were stored and labeled properly related to labeling of open liquid medications, disposition of medication for discharge residents, and securing the cart lock when the nurse was not in sight for three of five medication carts reviewed (1 North cart A, 1 South cart B, and 3 North cart A). Findings include: Observation of first floor north cart one on March 19, 2024, at 9:30 a.m. with Employee E6, Licensed Practical Nurse, revealed that there was Insulin Degludec pen (treats diabetes by increasing your body's insulin levels to decrease your blood sugar. This medication is an injection) with no open date or expiration date. There was polyvinyl alcohol eye drop, and [NAME] tears eye drops both opened with no open date or expiration date/date to discard. Interview with Licesed staff, Employee E6, at the time of the observation confirmed that insulin pen should be discarded…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 and staff interviews, it was determined that the facility failed to follow physician orders for one of seven residents (Resident R2). Findings include: A review of the clinical record indicated that Resident R2 was admitted to the facility on [DATE], with diagnosis that included paraplegia (paralysis of the legs and lower body), , polyneuropathy (condition of peripheral nerve are damaged), pressure ulcer of sacral, cramp and spasm. Review of Resident R2's Minimum Data Set (MDS - a periodic assessment of care needs) dated January 29, 2025, revealed a Brief Interview for Mental Status (BIMS) of 15 which indicated that the resident was cognitively intact. Review of Resident R2's physician orders dated January 11, 2025, indicated a wound treatment cleanse sacrum with soap and water, pat dry and apply foam dressing. Every evening shifts every other day for treatment. On February 25, 2025, at 10:22 a.m. an interview with the Resident R2 revealed that license nurse, Employee E8…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff and resident interviews and review of facility documentation, it was determined that the facility failed to ensure that a resident's grievance was filed and investigated for or 1 out of 3 residents reviewed (Resident R2). Findings include: Review of the facility policy, Grievances, with a revision date of November 2023 indicated that grievances can be submitted orally or in writing. The policy indicated that the employee receiving the grievance will immediately notify the Director or designee of the program to which the grievance is related. The policy also indicated that the Director or designee will contact the individual who filed the grievance within 24 hours after being informed of the grievance to review the issues/concerns with the individual. Continued review of the policy indicated that the Director or designee will initiate the grievance form by documenting the discussion with the individual, which will include, but not limited to, the date and time the complaint was received, the nature…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interviews and the review of clinical records, it was determined that the facility failed to ensure that a person-centered plan of care was developed for a resident with a diagnosis of heart failure for 1 out of 3 resident's reviewed (Resident R1). Findings include: Review of the facility's Person Centered Care Plan Process, with a revision date of September 24, 2018, indicated that the care plan is developed through review of the resident's history, medical problems, assessment by each discipline, input from the resident and/or representative, and completion of the minimum data set assessment (MDS-a periodic assessment of a resident's needs). Continued review of the policy indicated that each resident's identified problem (s) are to be addressed on the plan of care and in the electronic medical record. The policy further explained that each problem will have a specific, realistic, measurable goal with a timeframe for completion. Review of Resident R1's October 2024 physician order included 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 interviews and the review of clinical records, it was determined that the facility failed to ensure that daily weights were obtained as ordered by the physician for a resident with a diagnosis of health failure, for 1 out of 3 residents reviewed (Resident R1). Findings include: Review of the resident's October 2024 physician order included the following diagnosis: obesity, paraplegia (the symptoms of paralysis that mostly affects the movement of the lower body); multiple sclerosis (an autoimmune disease that affects the central nervous system which includes the brain, spinal cord and optic nerves; depression (a mood disorder that causes a persistent feeling of sadness and loss of interest); hypertension (high blood pressure), and heart failure (a condition in which the heart muscles can't pump blood as well as it should). Review of the resident's Quarterly Minimum Data Set assessment dated [DATE], indicated that the resident was awake, alert, and oriented. Review of information submitted to the State…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interviews and review of clinical records, it was determined that the facility failed to ensure that physician monitoring a resident with a diagnosis of heart failure for 1 out of 3 residents reviewed (Resident R1). Findings include: Review of the facility policy, Attending Physician Services, with a revision date of January 2019 indicated that the physician's oversight of services includes writing orders for care and treatment, conducting required visits, and reviewing residents' total program of care, including medications and treatments. The policy also indicated that the attending physician will evaluate residents based on medical necessity record progress notes, and that progress notes will be documented at each visit, and contain pertinent aspects of the resident's condition, current status and goals, and an evaluation of changes in the health status of the resident and the rationale for starting, continuing and discontinuing medications and other treatments. Continued review of the policy…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of clinical records, review of facility policies, review of facility investigation, review of facility policies and staff interview, it was determined that the facility failed to ensure that residents were free from neglect for one of 35 residents reviewed (Resident R147). Findings include: Review of facility policy on abuse dated December 20, 2018, revealed that under section Purpose: To prohibit physical abuse, mental abuse, verbal abuse, sexual abuse, neglect, involuntary seclusion, deprivation of goods and/or services by staff, exploitation, and misappropriation of property for all residents. Under Section Policy number two, physical abuse, mental abuse, verbal abuse, sexual abuse, neglect, involuntary seclusion, deprivation of goods and or services by staff, exploitation and misappropriation of property will be prohibited. Residents will be free from physical abuse, mental abuse, verbal abuse, sexual abuse, neglect, corporal punishment and voluntary seclusions, deprivation of goods and 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 review of facility policy, clinical record review and interview with staff, it was determined that the facility did not ensure that a resident was free from misappropriation of property for one of 35 records reviewed (Resident R128). Findings include: Review of facility policy titled Abuse, Neglect and Exploitation Reporting and Investigation, most recent revision date December 20, 2018, revealed that the purpose of the policy was to prohibit .misappropriation of property for all residents. Further review revealed that misappropriation of resident property means the deliberate misplacement .or wrongful (temporary or permanent) use of a resident's belongings .without the resident's consent. Review of facility document titled In-service: misappropriation of items and goods, undated, revealed that package handling procedures include all domestic boxes/packages should be delivered to the designated pick-up locations, and security does not sign or hold packages for staff or residents behind the work post.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, observations, facility provided documentation and review of documentation from the Center of Disease and Control Prevention (CDC), it was determined that the facility did not ensure to develop and implement a care plan that includes measurable objectives, interventions and time frames for how staff will meet the residents' needs related to catheter care and enhanced barrier precautions for two of 35 residents reviewed (Residents R84 and R77) Findings include: Review of facility's policy titled 'Person-Centered Care Plan Process,' revised September 24, 2018, Identified problems are to be addressed on the care plan in the electronic medical record, per [NAME] policy and procedure guidelines. Observations on first floor unit, 1 North, on May 22, 2024 at 1:30 p.m. revealed a sign and supplies next to Resident R84's room and Resident R77's room for enhanced barrier precautions. In accordance with https://www.cdc.gov/hicpac/workgroup/EnhancedBarrierPrecautions.html, Enhanced…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 ensure that a resident was free from an excessive dose of pain medication for one of 35 records reviewed (Resident R165). Findings include: Review of clinical documentation revealed that Resident R165 was admitted to the facility on [DATE], with diagnoses of paraplegia (paralysis that affects all or part of the trunk, legs, and pelvic organs), acquired deformity of chest and rib, other psychoactive (affecting the function of the brain) substance abuse in remission, generalized anxiety disorder, and major depressive disorder. Review of nursing notes for Resident R165 revealed a note written by Licensed Nurse Practitioner Employee E6 on May 14, 2024, which stated, Fentanyl (a controlled narcotic pain medication which is applied via a patch placed on the skin for long acting delivery of the medication) 50 mcg [per hour patch] was unintentionally ordered and applied on 5/13/24, however patient made aware previous…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on reviews of dietary policies and procedures, interviews with residents and staff and observations of the food and nutrition services, it was determined that foods were not prepared and served by methods to conserve nutritive value, flavor and appearance. ( Residents R1, R2 and R3) Findings include: Review of the policy titled Food and Beverage Serving Temperature Requirements dated February 14, 2022, revealed that it was the responsibility of the food and nutrition services department to serve foods and beverages to the residents that were palatable, attractive and at safe and appetizing temperatures. The policy also indicated that serving temperatures for hot foods were 140 degrees Fahrenheit and cold foods 40 degrees Fahrenheit. This policy also indicated that the minimum holding temperatures for hot foods was 135 degrees Fahrenheit and the minimum holding temperature for cold foods was 41 degrees Fahrenheit. Interviews with Residents R1, R2 and R3 at 11:00 a.m., on April 10, 2024 revealed that hot…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff interview, it was determined that the facility did not ensure that physician's orders were followed or clarified regarding the administration of two medications for one of eleven residents reviewed (Resident R3). Findings Include: Review of the medical record revealed that Resident R3 was admitted on [DATE], with diagnosis including, but not limited to neuromuscular bladder dysfunction (also known as Neurogenic Bladder, is when a person lacks bladder control due to brain, spinal cord or nerve problems) and insomnia (trouble falling and/or staying asleep). Further review of the clinical record for Resident R3 revealed an January 23, 2023, physician order for Lithostat Tablet 250 mg (Acetohydroxamic Acid), give 250 mg by mouth three times a day for Neurogenic bladder. A review of the Medication Administration Record (MAR) for March 2024, for Resident R3 revealed that the Lithostat was administered three times a day March 1, 2024, through March 15, 2024, morning dose.…

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

Based on review of clinical record, review of facility documents and interview with staff, it was determined that the facility failed to ensure that the physician's order were followed. For one of two residents reviewed. Findings include: Review of facility policy on Pain management. With the most recent revision date of July 28th, 2010, reveal that under section Purpose: To establish the measurement and interventions to be applied for pain management. Review of Section Policy: Pain Descriptors. Pain intensity maybe described using a number on a 10 point scale. Or by the terms mild, moderate, severe and excruciating. Mild pain will be defined as they score between 1 to 3 on a 10 point scale. Moderate pain will be defined as a score between 4 to 6 on a 10 point scale. Severe pain will be defined as a score between 7 to 10 on a 10 point scale. Excruciating pain. Worst pain imaginable will be defined as a score of 10 on a 10 point scale. Under section Pain Interventions: Pharmacological. The primary care provider or consultant will recommend an or prescribe any pharmacological…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, facility policy and interviews with staff, it was determined that the facility did not ensure that food was distributed at appropriate temperatures and one of two dining rooms observed. Findings include: Review of facility policy on Food and Beverage Serving Temperatures Requirements with the most recent revision date of August 6, 2020, revealed that under section Purpose: To ensure that food safety practices and general requirements for keeping food at specified temperatures for service to residents are maintained. Section Policy revealed that food that is prepared and cooked in the [NAME] kitchen is transported to service areas in an enclosed cart to the dining rooms/solariums. Food temperatures are taken before the food is transported from the kitchen to the dining room and recorded. Once the food arrives in the dining rooms/solariums, it will be placed in the steam table wells to maintain temperature. Temperatures will be taken during the serving process to make sure that time…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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's policies, review of clinical records and staff interviews, it was determined that the facility failed to ensure that an alleged violations involving resident neglect was reported to the State Survey Agency (Department of Health) for one of three residents reviewed (Resident R1). Findings include: Review of grievance dated September 25, 2023, by Resident R1 revealed that the resident reported, he did not receive incontinence care in a timely manner during the 11:00 p.m. to 7:00 a.m. shift. He also reported that he did not receive wound care during the shift. Review of a statement by Resident R1 obtained by the social worker dated September 18, 2023, alleged that the resident did not receive incontinence care for approximately 5 hours from the 11:00 p.m. to 7:00 a.m. nursing aide assigned to the resident. Resident stated he had to wait for approximately 5 hours because the nurse aide stated she had to help someone else. Resident also stated he rang the call bell. Interview with Resident R1 dated December 20, 2023, at 11:30 a.m. stated few weeks ago he had…

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

Based on observation, review of facility policy, review of clinical records and staff interview, it was determined that the facility failed to ensure that feeding formulas were labelled according to professional standards for five of five residents with tube feeding observed (Residents R1, R2, R3, R4 and R5). Findings include: Review of facility policy on Enteral feeding with effective date of December 1, 2006, and a review date of September 22, 2022, revealed that under section Policy: #3. The licensed nurse is responsible to assure patency of the feeding tube, administration of nutritional products and medications, physician's orders, assessment of the tube and skin site and documentation of the enteral feeding process. #5 Documentation of the enteral feeding orders, volume, amounts, and care will be completed on the electronic medication administration record (eMAR). Under section Procedure #1 Assembly and initiation feeding #d. Set ups will be changed every 48 hours or when a new bottle is put up. #e. Tube feeding will be labelled with resident's name, room number, rate, date,…

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

Based on interviews with staff and residents, and the review of the clinical record and facility documentation, it was determined that the facility failed to ensure that 1 out of 3 residents reviewed were properly assessed to self-administer a supplement and medications (Resident R1). Findings include: Review of the facility policy, Self-Administration-Medication and Treatment, with a revision date of June 8, 2020, indicated that residents will be assessed by the interdisciplinary team to determine that the resident has or can achieve the skills needed to safety administer their own medications and/or treatments. The policy also indicated that registered nurse would complete the initial Self Administration of Medication Evaluation in the electronic medical record, and that if the resident is deemed appropriate to self-administer medications and/or treatments, the license nurse will obtain an order from the Primary Care Provider for the resident to self-administer. Continued review of the policy indicated that any significant changes to the resident's condition that may impact their…

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

Based on review of facility policy, review of resident clinical records, observation, and staff interview, it was determined that the facility failed to uphold the privacy and dignity of two of 4 residents utilizing catheter care (Residents R107, R113). Findings include: The facility Urinary Catheter -Insertion policy last reviewed 11/22/17, indicated the purpose of the urinary catheter is To ensure appropriate usage of indwelling catheters. It further revealed under Procedures, Equipment that dignity bag is part of the procedure. During an observation on July 24, 2023, at 1:51 p.m. Resident R113 was observed in the room utilizing a suprapubic catheter which was facing the door without a privacy cover on the urine collection bag. During an observation on July 25, 2023, at 9:28 a.m. Resident R107 was observed in the room utilizing a suprapubic catheter which was facing the door without a privacy cover on the urine collection bag. During an interview on July 25, 2023, at 9:59 a.m. observation were made with Director of Nursing who confirmed that the facility failed to uphold 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 policies and clinical records, as well as staff interviews, it was determined that the facility failed to develop care plans for diabetic management care needs and post traumatic stress disorder (PTSD) for two of 34 residents reviewed (Resident R24 and R16). Findings include: The facility's policy titled Person-Centered Care Plan Process last revised on January 22, 2012, indicated that the facility Each resident will have an individualized, comprehensive care plan established at the time of admission and updated accordingly. The plan of care is used as a working tool to assist the resident to attain or maintain his/her highest level of functioning. The plan of care is developed through review of the resident's history, medical problems, assessment by each discipline, input from the resident and/or resident representative when available, and completion of the minimum data set. During an interview with Resident R24 on July 24, 2023, at 12:55 p.m. it was revealed that resident had a diagnosis of…

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

Based on review of facility documentation and interviews with staff, it was determined that the facility failed to ensure that nurse aides received at least twelve hours of continuing education per year as required for one of six nurse aides reviewed (Employee E10). Findings include: Review of Employee E10 submitted employee documentation revealed the nurse aide had a hire date of January 3, 2022. Review of documentation provided by the facility revealed Employees E10 did not complete 12 hours of annual trainings as required and the annual trainings received did not include abuse or dementia training. Interview on July 27, 2023, at 1:30 p.m. with the Director of Nursing, Employee E2, confirmed the facility did not have documented evidence that Employee E10 completed 12 hours of annual training as required. 28 Pa. Code 201.20(a) Staff Development 28 Pa. Code 201.20(d) Staff Development