Monumentalpostacutecare At Woodside Park

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility documentation, review of clinical records, and interviews with staff, it was determined that the Nursing Home Administrator and the Director of Nursing failed to effectively manage the facility related to ensuring that hot water temperatures in resident bathroom hand sinks and shower rooms were maintained at a safe temperature. This failure placed residents on three of three nursing units at risk of serious injury from a burn and resulted in an Immediate Jeopardy situation. (First floor East, Second floor East and West) Findings include: Review of the Nursing Home Administers (NHA) job description revealed that the NHA is responsible for the overall management and operation of the facility, ensuring that high-quality healthcare services are delivered in a safe, compliant, and resident-centered environment. The Administrator enforces all regulations related to the level of healthcare provided, resident safety, and the protection of residents' personal property and individual rights.…

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

Based on observations, staff interviews, and clinical record reviews, the facility failed to ensure staff followed infection control practices by not wearing a gown during tracheostomy care and incontinence care for one of 29 residents reviewed for tracheostomy care and incontinence care (Resident R127).Findings Include: Review of the facility policy titled Enhanced Barrier Precaution revealed that Enhanced Barrier Precautions (EBP) are an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDROs) in nursing homes. Enhanced Barrier Precautions involve gown and glove use during high-contact resident care activities for residents known to be colonized or infected with an MDRO, as well as those at increased risk of MDRO acquisition (e.g., residents with wounds or indwelling medical devices). High-contact resident care activities include:DressingBathing/showeringTransferringProviding hygieneChanging linensChanging briefs or assisting with toiletingDevice care or use: central line, urinary catheter, feeding tube, tracheostomy/ventilator…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 interview and facility documentation, it was determined that the facility failed to report to the State Survey Agency and conduct an investigation related to an allegation of neglect for one of 9 residents reviewed. (Resident R2) Findings include:A review of the Incident and Accidents Documentation policy, which was undated, revealed The facility will document unusual occurrences and events. Guidelines q. The following occurrences warrant an incident report a. Actual, alleged, or suspected abuse, including verbal abuse, oral, written or gestured, sexual abuse, harassment, coercion, assault, physical abuse, hitting, slapping, pinching, kicking, pushing, pulling, rough hanging, etc.On September 4, 2025, at 2:45 p.m., an interview was conducted with the Administrator, Employee E1, who reported that the facility was not aware of any incontinence neglect, with respect to Resident R2. Employee E1 further reported that the Human Resources Director, Employee E11, was out sick, and the facility was unable to provide the nurse aide personnel file for Employee E14, who had been…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, observation, and staff interviews, it was determined that the facility failed to provide adequate supervision to prevent a fall and to ensure that an air mattress was properly fastened to the bed for two out of nine residents reviewed. (Residents R1 and R8).Findings include:A review of the undated facility policy title Incident and Accidents Documentation revealed The facility will document unusual occurrences and events. Guidelines q. The following occurrences warrant an incident report a. Actual, alleged, or suspected abuse, including verbal abuse, oral, written or gestured, sexual abuse, harassment, coercion, assault, physical abuse, hitting, slapping, pinching, kicking, pushing, pulling, rough hanging, etc.Clinical record review revealed that Resident R1 was admitted to the facility on [DATE], with diagnoses of cerebral infarction, falls, pain, acute kidney failure, encephalopathy (disease of the brain), muscle weakness, cognitive…

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

Based on review of clinical records and staff interview, it was determined that the facility failed to maintain complete documentation of resident's clinical records for one of 9 resident records reviewed (Resident R9).Findings include:A review of the Incident and Accidents Documentation policy, which was undated, revealed The facility will document unusual occurrences and events. Guidelines q. The following occurrences warrant an incident report a. Actual, alleged, or suspected abuse, including verbal abuse, oral, written or gestured, sexual abuse, harassment, coercion, assault, physical abuse, hitting, slapping, pinching, kicking, pushing, pulling, rough hanging, etc.On September 4, 2025, at 2:35 p.m., an interview was conducted with the Administrator, Employee E1, and the weekend supervisor, Employee E13. They reported that on August 24, 2025, at 6:00 p.m., an incident occurred in the front lobby involving Resident R9 during a visit with the resident's family. Employee E13, who responded to the situation, confirmed that there was no documentation in Resident R9's clinical record…

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

Based on the review of clinical records, review of facility policy, staff interviews, it was determined that the facility failed to provide adequate supervision and failed to maintain an environment free of potential hazards for one resident with elopement risk (Resident R14). One of four residents reviewed. (Resident R1) Findings include: Review of undated facility policy Resident Elopement Follow-Up Procedure, revealed that Guidelines: After an elopement,. The following actions will be initiated: 1) A photograph will be taken and placed at the reception desk identifying the resident as an elopement risk. 2) The receptionist will be familiarized with the resident. 3) Elopement Risk will be added to resident's Care Plan. 4) An elopement assessment will be conducted for residents on incident and at least quarterly thereafter. 5) If a president is no longer an elopement risk, he/she will be reassessed and care [plan will be updated as appropriate. The facility strives to prevent resident/patient elopement. The facility also recognizes mobility as a strength to be supported and…

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

Based on observations, and interview with staff and residents, it was determined that facility failed to ensure that resident were assisted out of bed as per resident's preference for nine of 69 residents observed (Resident R10, R11, R12, R13, R14, R15, R16, R17, R18) Findings include: Review of facility policy 'Quality of Care: Activities of Daily Living - Prevent Deterioration,' indicates that based on the comprehensive assessment of a resident, the facility must ensure that a resident's abilities in activities of daily living do not diminish unless circumstances of the individual's clinical condition demonstrate that diminution was unavoidable. Interview with licensed nurse, employee E4, on April 9, 2025 at 10:50 am, revealed that residents are to be assisted out of bed by 11:00 am. Interview with Resident R11, on April 9, 2025, at 11:15 am, revealed that he is paralyzed on right side of body and requires assistance with transfer from bed to chair. Interview with Resident R11 revealed that the resident prefers to be placed in wheelchair during day shift (7-3 shift). Further…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 interview with residents, it was determined that facility did not provide a clean, comfortable, homelike environment for four of 20 rooms observed (common shower room, Resident R8's room, room#225-B, room [ROOM NUMBER]-A) Findings include: Review of facility policy related to 'Physical environment: common areas,' states that the facility will be maintained to protect the health and safety of residents, personnel and the public. Observations of common shower room on unit 2-West, on April 9, 2025, at 10:30 am, revealed used towels on floor and used paper towels on floor in toilet stall. Further observations revealed shower gel/shampoo bottles on floor in shower stall. Further observations revealed used hygiene products on shower bed; shower bed appeared unclean. Findings confirmed with facility's director of nursing. Observations in room [ROOM NUMBER] revealed stained ceiling tile near bed B; upon interview with resident R7 it was revealed that during rainy weather water leaks through the…

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

Based on observations, interviews with staff, and a review of facility procedures, it was determined that the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. Findings include: Review of facility policy titled, Storage of Refrigerated Foods Policy, revised March 9, 2024, indicated that staff must label and note pull date on all food items when removing from freezer. Further review revealed that refrigerated food held for more than 24 hours will be marked to indicate the date the food will be consumed or discarded. A follow-up tour of the main kitchen was conducted on Thursday, January 9, 2025, at 10:45 p.m. with the Food Service Director (FSD), Employee E13. Observations at 10:46 a.m. revealed a bucket with soapy water and rag was standing on the preparation table in the cooking area meanwhile the cook was assembling sandwiches. Observations of the main refrigerator at 10:50 p.m. revealed three rolls of 10-pound ground beef, a bag of raw mixed chicken, and a bag of raw chicken thighs were unlabeled and…

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

Based on observations and an interview with staff, it was determined that the facility did not ensure that garbage and refuse was disposed of properly. Findings include: An initial tour of the Food Service Department was conducted on Tuesday, January 7, 2025, at 9:57 a.m. with Employee E16, Cook, which revealed that the blue dumpster was fully open and overflowing with cardboard boxes. Additional piles of cardboard and boxes was observed on the ground on all four sides of the dumpster. Follow up observation with the Food Service Director (FSD), Employee E13, conducted on Thursday, January 9, 2025, at 10:32 a.m. revealed that the blue dumpster remained fully open and overflowing with cardboard and carboard boxes. Additional piles of cardboard and boxes was observed on the ground on all four sides of the dumpster. Interview with the FSD at 10:32 a.m. on Thursday, January 9, 2025, confirmed the above findings. 28 Pa. Code: 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(3) Management

Based on review of facility documentation, review of clinical records, and interviews with staff, it was determined that the facility failed to notify the Office of the State Long-Term Care Ombudsman of facility-initiated emergency transfers to the hospital and that a resident's representative was made aware of a facility-initiated transfer, for one of four residents reviewed. (Residents R136) Findings Include: Review of nursing notes for Resident R136 dated April 21, 2024, at 11:37 p.m. revealed that the resident had a seizure and was transferred to a local hospital for evaluation at approximately 11:25 a.m. Further review revealed a note, dated July 24, 2024, at 6:27 a.m., which indicated that Resident R136 was admitted to the local hospital for altered mental status on July 23, 2024. Further record reviews for Residents R136 revealed that no documentation was available for review at the time of the survey to indicate that the Office of the State Long-Term Care Ombudsman was notified of the facility-initiated emergency transfers and discharges. Review of documentation provided by…

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

Based on clinical record review and interviews with staff, it was determined that the facility failed provide appropriate bed hold notice to a resident's representative of a facility-initiated transfer to the hospital for one of four residents reviewed related to transfers (Resident R136). Findings include: Review of Resident R136's admission MDS (Minimum Data Set - a mandatory periodic resident assessment tool), dated February 26, 2024, revealed that the resident had severely impaired cognition. Review of nursing notes for Resident R136 revealed a note, dated April 21, 2024, at 11:37 p.m. which indicated that the resident had a seizure and was transferred to a local hospital for evaluation at approximately 11:25 a.m. Further review revealed a note, dated July 24, 2024, at 6:27 a.m., which indicated that Resident R136 was admitted to the local hospital for altered mental status on July 23, 2024. Review of Resident R136's clinical record revealed that there was no bed hold notice available for review in the resident's record. Interview with the Social Services Director, Employee E9,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, clinical record review and interview with staff, it was determined that the facility did not ensure that resident assessments accurately reflected resident status related to restraints for two of 34 records reviewed (Residents R9, R38). Findings include: Review of clinical documentation revealed that Resident R9 was most recently admitted to the facility on [DATE], and had diagnoses of schizophrenia (a chronic mental illness characterized by a disconnect from reality, disorganized thinking and speech, and changes in behavior), anxiety, and dementia (progressive degenerative disease of the brain) Review of the most recent MDS (Minimum Data Set- a periodic assessment of resident care needs) completed on September 22, 2024, revealed that in section P- Restraints and Alarms, it was documented that the resident's chair prevents rising and that this restraint was used less than daily. Observations conducted on January 8, 2025, at 1:15 p.m. revealed that Resident R9 was ambulating at will through…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff interview, it was determined that the facility failed to update Pennsylvania Pre-admission Screening Resident Review (PASRR) of one resident with a new diagnosis of a serious mental disorder, out of 34 sampled residents reviewed (Residents R 103). Findings include: Review of Resident R103's clinical record revealed; the resident was admitted to the facility on [DATE], and had diagnoses including Acute Kidney Failure (Acute kidney injury happens when the kidneys suddenly can't filter waste products from the blood; when the kidneys can't filter wastes, harmful levels of wastes may build up), Injury of Unspecified Body Region, and Type 2 Diabetes Mellitus (a disease that occurs when the body doesn't use insulin properly, resulting in high blood sugar levels). Review of Pennsylvania Pre-admission Screening Resident Review (PASRR- an in-depth mental health assessment to determine appropriate services and placement) Level I Form of R 103 indicated that it was completed 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 observation, clinical record review and interview with staff and residents, it was determined that the facility did not develop a comprehensive care plan related to dementia, smoking, and pain management for 3 of 34 records reviewed (Residents R7, R28, R155). Findings include: Review of clinical records revealed that Resident R7 was admitted to the facility on [DATE], and had diagnoses that included Type 2 Diabetes Mellitus (a disease that occurs when the body doesn't use insulin properly, resulting in high blood sugar levels), and Dementia (a general term for a group of brain conditions that cause a decline in mental abilities). Review of Resident R7's current care plan revealed that there was no care plan was developed for the dementia care. During an interview with the Nursing Home Administrator, and the Director of Nursing, on January 13, 2025, at 12:20 p.m., it was confirmed that no care plan was developed for the Dementia care needs of Resident R7. Observations conducted on January 10, 2025, 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 clinical record review and interview with staff, it was determined that the facility did not ensure that care plans were updated in a timely manner for one of 34 records reviewed related to hospice (Resident R31). Findings include: Review of clinical documentation revealed that Resident R31 was admitted to the facility on [DATE], and had diagnoses including, congestive heart failure (an accumulation of fluid around the heart which makes it more difficult for the heart to beat effectively), ventricular tachycardia (a heart rhythm where the ventricles constrict abnormally fast, putting the resident at risk of cardiac arrest), and presence of pacemaker (a device implanted into the chest to regulate heart rhythm). Further review revealed a physician order dated October 10, 2023, which read Pacemaker .to be turned off due to hospice status. Review of the care plan revealed that it had been updated that same day to read the same. A physician order was found to discontinue hospice care dated December 2, 2024.…

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

Based on review of personnel records and interview with staff, it was determined that the facility did not provide requested evidence of competency trainings for licensed nursing staff. Findings include: On January 10, 2024, at 1:45 p.m. the surveyor requested skills competency evaluations for Licensed Nurses. The requested skills were to be related to medication administration, dementia and behavioral, catheter, tracheostomy care, wound care, and abuse prevention and reporting. In an interview on January 10, 2024, at 1:54 p.m. with Educator, Employee E12, stated that the facility was unable to supply the surveyor with all the requested skills competencies for the nurses, stating that they didn't have them. 28 Pa. Code: 211.12(d)(1) Nursing services 28 Pa. Code 211.12(d)(5) Nursing services

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on closed clinical record review, and interviews with staff, it was determined that the facility failed to ensure that controlled medications were disposed in a timely manner for one of 3 closed records reviewed (Resident R162). Findings include: Review of clinical documentation for Resident R162 revealed that she was admitted to the facility on [DATE], and discharged from the facility against medical advice on October 24, 2024. While a resident, she had an order for Morphine Sulfate (Concentrate) Solution 20 MG/ML Give 0.25 milliliter by mouth every three hours as needed for Pain/SOB hospice, and Lorazepam Concentrate 2 MG/ML Give 0.25 milliliter by mouth every 6 hours as needed for anxiety/agitation. Morphine is a Schedule 2 controlled medication, which are classified as high potential for misuse, dependence, and addiction. Lorazepam is a schedule 4 controlled substance which has a lower potential for abuse than schedule 2 substances, however, the abuse of a schedule 4 medication may lead to physical or…

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

Based on observations, review of facility policies, review of facility documentation, clinical record review and interviews with staff, it was determined that the facility failed to maintain an effective infection control program related with Transmission Based Precautions for one of 34 residents reviewed ((Resident R113). Findings include: Review of literature review revealed that Enhanced Barrier Precautions are infection control interventions designed to reduce the transmission of novel or Multi-Drug Resistant Organisms. Enhanced Barrier Precautions require to employ the use of targeted personal protective equipment (PPE) during high contact patient/resident activities. On January 10, 2025, at 2:39 p.m., review of the door of the room of Resident R113 revealed a guiding description pasted on it, indicating that Resident R113 was on Enhanced Barrier Precautions. Review of the physician order for Resident R113 revealed that Resident R113 had an order dated July 11, 2024, to Cleanse G-tube site daily with soap and water, every day-shift. Observation on January 10, 2025, at 2:41…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, a review of clinical records, review of facility documentation and staff interviews, it was determined that the facility failed to develop and implement a comprehensive person-centered care plans regarding preventing a reinfestation of lice for one of ten residents reviewed. (Resident R2). Findings include: Review of clinical records revealed that Resident R2 was admitted to the facility on [DATE], with diagnosis to include bipolar disorder (disorder associated with episodes of mood swings ranging from depressive lows to manic highs). Further review of Resident R2's clinical record indicated that on May 31, 2024, he returned to the facility after a visit with his sister, and the next day was observed to have lice in his scalp and received treatment to himself, his roommate and there room and clothing. Further review revealed a similar incident that happened on April 16, 2024, when his sister brought in clothing for him which were infested with lice and resulted with the same treatments.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations of the physical environment, reviews of the pest control operators' service, reports and contract and interviews with residents and staff, it was determined that the facility failed to maintain an effective pest control program. Findings include: A review of the pest control operator's contracted service agreement revealed that it was the responsibility of the maintenance department staff to repair structural concerns (gaps under doors, holes in walls, screens, around pipes, crevices around windows or doorways, faulty downspouts). The service agreement indicated that the repairs to the physical environment were essential to eradicate pest and rodent problems. Observations of the physical enviornment of the facility revealed that the main kitchen, main dinning room, lobby, entrance to the facility, administrator's office, first floor nursing unit were located on the ground level of the building. Observations of the food and nutrition services department on April 2, 2024 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 review of facility documentation, observation, and staff interview, it was determined that the facility failed to ensure that food was prepared appropriately for nine of nine residents on a pureed diet (Residents R52, R125, R4, R113, R445, R34, R55, R66, and R87). Findings Include: Review of undated facility documentation Dysphagia Level 1/Pureed Diet revealed the consistency of pureed foods should be smooth and thick enough to mound on the plate, and similar in consistency to that of pudding. Review of facility documentation dated April 5, 2024, revealed the following nine residents were ordered a pureed diet: Residents R52, R125, R4, R113, R445, R34, R55, R66, and R87. Observations on April 2, 2024, at 12:08 p.m. revealed Resident R52 was having lunch in the dining room. Observations of Resident R52's lunch revealed the pureed chicken and green, pureed vegetable had a watery appearance and was runny on the plate. Observations on April 2, 2024, at 12:30 p.m. of the tray line steam table in the main kitchen with the Food Service Director, Employee E16, revealed when the…

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

Based on observations, review of facility policies, clinical record reviews and interviews with residents and staff, it was determined that the facility failed to maintain an effective infection prevention and control program related to infection surveillance, antibiotic usage and isolation precautions for four of four residents reviewed for antibiotics (Residents R45, R33, R124 and R15). Findings include: Review of facility policy, Infection Control undated, revealed, Surveillance data shall be routinely reviewed, and recommendations made for the prevention and control of additional cases. Continued review revealed, Investigates, controls and prevents infections in the facility; Decides what procedures, such as isolation, shall be applied to an individual resident; Maintains a record of incidents and corrective actions related to infections; Maintains a log of infections, of urinary catheters, residents with DRO [drug resistant organisms] and their room numbers and a log of residents on antibiotics. Further review revealed, When the Infection Control Program determines that a…

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

Based on review of facility policies, clinical record reviews and interviews with staff, it was determined that the facility failed to maintain an effective antibiotic stewardship program that included antibiotic use protocols and systems for monitoring antibiotic use, for four of four residents reviewed for antibiotics (Residents R45, R33, R124 and R15). Findings include: Review of facility policy, Infection Control undated, revealed, The facility will maintain an Infection Control Program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of disease and infection. During Entrance Conference on April 2, 2024, at 10:51 a.m. information pertaining to the facility's Antibiotic Stewardship program was requested. Review of progress notes for Resident R45 revealed a nurses note, dated March 27, 2024, at 10:41 p.m. which stated that the resident was readmitted to the facility after being hospitalized for a right foot infection. The note indicated that the resident was positive for MRSA (Methicillin-resistant…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, observations, and record reviewed, it was determined that the facility failed to ensure proper accommodation of needs for one of seven residents reviewed regarding appropriate wheelchair size. (Resident R47) Finding include: Review or Resident 47's clinical record revealed that this resident was admitted into the facility on December 4, 2023, with diagnoses including chronic kidney disease, unspecified dementia (irreversible, progressive degenerative disease of the brain), type 2 diabetes (failure of the body to produce insulin), pain in unspecified joints and muscle weakness. Review of Resident R47' s current care plan revealed that Resident R47 was at risks for falls related to ambulatory disfunction, decrease cognition, decreased mobility, and unsteady gait. Resident R47 was assessed by physical therapy on December 5, 2023, then provide a wheelchair. Review of physical therapy notes revealed that Resident R 47 was re-assessed on February 20, 2024, and it was determined that the resident's wheelchair was too small and required a larger wheelchair. 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record reviews and interviews with staff, it was determined that the facility failed to ensure that advanced directives were accurately reflected in residents' records for one of 35 residents reviewed (Resident R45). Findings include: Review of Resident R45's Significant Change MDS (Minimum Data Set - a mandatory periodic resident assessment tool), dated February 4, 2024, revealed that the resident was admitted to the facility on [DATE], and had diagnoses including cerebrovascular accident (damage to the brain from interruption of its blood supply), end stage renal disease (a medical condition in which a person's kidneys cease functioning on a permanent basis leading to the need for a regular course of long-term dialysis or a kidney transplant to maintain life), seizure disorder (abnormal electrical activity in the brain) and aphasia (loss of ability to understand or express speech, caused by brain damage). Continued review revealed that the resident had a BIMS (Brief Interview for Mental…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and interviews with residents and staff, it was determined that the facility failed to maintain a safe, comfortable and homelike environment on one of three nursing units reviewed (Two [NAME] unit). Findings include: Observation, on April 2, 2024, at 11:39 a.m. revealed that the window in room [ROOM NUMBER] was open and that there was no screen in the window. Observation, on April 2, 2024, at 11:57 a.m. revealed the front panel of the heating/air conditioning system in room [ROOM NUMBER] was falling off. Continued observation, on April 2, 2024, at 12:05 p.m. revealed a large hole in the wall above the baseboard by the bathroom. Interview, at the time of the observation, Resident R19 stated that the hole bothered her and wished that it could be repaired. Continued observation, on April 3, 2024, at 11:01 a.m. of the Two [NAME] unit revealed that following: room [ROOM NUMBER] there was a hole in the wall along the baseboard behind the A bed; room [ROOM NUMBER] the dresser by the B bed had a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of clinical records, facility policies and interviews with staff, it was determined that the facility failed to conduct a complete and thorough investigation of one incident during a resident incontinence care for one of 32 residents reviewed. (Resident R 442). Findings include: Review of Resident R442's clinical record revealed that the resident was admitted to the facility on [DATE], resident's cognition is intact. Resident R442 was transferred to facility for continued medical management and physical therapy/ occupational therapy services. Resident was transferred from the hospital after repeated falls, no head trauma and bilateral leg weakness and feeling anxious about ambulating. On April 2, 2024, at 1:05 p.m. a family interview was held with the Resident R442, resident's husband, and son. It was reported that on March 23 to 24, 2024 Resident R442 waiting a long time to receive incontinence care. Resident R442 reported that she was wet and soil for hours from Saturday, March 23 to Sunday,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, review of facility policy, clinical record reviews and interviews with residents and staff, it was determined that the facility failed to provide nail care for two of eight residents reviewed related to activities of daily living (Residents R45 and R70). Findings include: Review of facility policy Grooming - Hair and Nails revised January 31, 2024, revealed it is the policy of the facility to provide grooming services that promote an appropriately attractive appearance, improve morale, and prevent infections. Staff should provide fingernail care by cleaning fingernail beds and keeping fingernails trimmed and smooth Observation, on April 2, 2024, at 12:24 p.m. revealed that Resident R45's fingernails were long, overgrown, and had dirt underneath them. Interview, at the time of the observation, Resident R45 stated that he does not like long nails, that he needed his fingernails trimmed and cleaned, and that he was unable to do it himself due to his right-sided hand and arm weakness. 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 a review of facility documentation and interviews with staff, it was determined that the facility failed to complete performance reviews for two of two nurse aides reviewed as required (Employees E28 and E29). Findings Include: Review of undated facility documentation, Active Employees Over 1 Year, revealed that Employee E28 was hired by the facility as a nurse aide on July 12, 2022. Continued review revealed that Employee E29 was hired by the facility as a nurse aide on August 3, 2009. Annual performance reviews were requested for Employees E28 and E29. Interview on April 4, 2024, at 3:00 p.m. with the Nursing Home Administrator, Employee E1, revealed annual performance reviews were not completed for Nurse Aides, Employee E28 and E29. 28 Pa. Code 201.19(2) Personnel policies and procedures

Based on facility policy and observation, it was determined that the facility failed to ensure one of two medication carts observed remained locked on a secured nursing unit. (Second floor0. Findings include: Review of facility policy titled Grand Rx policy and Procedure Manual last revised June 1, 2020 revealed that to properly maintain security of all medications, employee are to keep medication carts always locked, unless in immediate attendance and not let medication cart sit in nursing station, hall, or lounge unlocked. Observation on second floor secured nursing unit on April 2,2024 at 11:00 a.m. revealed an unlocked medication cart in the hall with no employee in sight. Observed was a resident sitting in a wheelchair next to the open cart. Interview with Licensed nurse, Employee E24 at time of observation confirmed that the medication cart was unlocked, and that this employee was assigned to the medication cart and stepped away to assists to a resident in another room. 28 Pa.Code 211.9 (a)(1) Pharmacy Services 28 Pa. Code 211.12 (d)(1) Nursing Services

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record reviews, observations, and staff interviews, it was determined that the facility failed to ensure that the Facility's Assessment included a risk assessment for each resident environment to remain free of accident hazards for one of one nursing units observed (Second Floor Behavioral Health Nursing Unit) and one of one resident's reviewed (Resident R1). Findings include: A review of the Facility's Facility Assessment Tool no date, revealed: Purpose The purpose of the assessment is to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. Use this assessment to make decisions about your direct care staff needs, as well as your capabilities to provide services to the residents in your facility. Using a competency-based approach focuses on ensuring that each resident is provided care that allows the resident to maintain or attain their highest practicable physical, mental, and psychosocial well-being. The intent of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, observation and staff interviews, it was determined that the facility failed to prevent involuntary seclusion for four of four residents reviewed (Resident R1, R2, R3, and R4). Findings include: Observation tour of the second floor locked behavioral health unit on December 11, 2023, at 12:00 p.m. revealed upon entrance to the unit there are a set of two locked doors that prevent residents from entering or exiting the nursing unit without a staff swipe card which restricts the residents' movements to the unit. Upon entering the locked unit, it was observed that R1, R2, R3, and R4, were restricted to a side hallway of the T shaped locked behavioral health unit which further restricted the residents from the dining room and the shower room related to the behavioral health unit still being under renovations. An interview with the Administrator on December 11, 2023, at 1:30 p.m. where the Administrator was asked for evidence that the Resident / Representative received notification…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 develop a comprehensive care plan that included non-pharmacological interventions for a resident receiving PRN (as needed) psychotropic medications for one of four residents reviewed (Resident R1). Findings include: Review of Resident R1's clinical record revealed the resident was admitted to the second floor locked behavioral health unit on November 15, 2023, with a diagnosis to include Schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves). Review of Resident R1's Care Plan initiated on November 16, 2023, revealed a focus area of Resident receives Psychotropic medication with interventions to include non-medication inventions prior to medicating resident. Further review of the care plan revealed no non-pharmacological interventions mentioned that were to be attempted prior to administering PRN psychotropic medications. Review of a Nurse Progress note dated December 3, 2023, at 6:07 a.m. revealed: Received resident in bed sleeping. Around 3am…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 clinical records and staff interviews, it was determined that the facility failed to ensure that residents were free from unnecessary medications for one of four residents reviewed (Resident R1). Findings include: Review of Resident R1's clinical record revealed the resident was admitted to the second floor locked behavioral health unit on November 15, 2023, with a diagnosis to include Schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves). Review of a Nurse Progress note dated December 3, 2023, at 6:07 a.m. revealed: Received resident in bed sleeping. Around 3am resident was yelling and talking to self. PRN Chlorpromazine (Thorazine - antipsychotic medication) 50mg given. Around 5am resident fell asleep in her wheelchair in room. Further review of Resident R1's clinical record revealed no documented evidence that non-pharmacological behavioral approaches were attempted prior to administering the Chlorpromazine. Review of a Psychiatry Note dated December 3, 2023, at 9:38 a.m. revealed: Nursing staff called earlier around 0715 as…

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

Based on the review of clinical records and interview with staff, it was determined that the facility failed to notify the resident and the resident's representative(s) of the transfer to the hospital and the reasons for the transfer in a timely manner, in writing and in a language and manner they understood after a selected resident was transferred to the hospital for one of nine residents reviewed. (Resident R1) Findings Include: Review of MDS (Minimum Data Set-Assessment of resident care needs) for Resident R1 dated September 8, 2023, revealed that the resident had a BIMS score of 10 which indicated that the cognitive status was moderately impaired. Review of nursing note for Resident R1 dated October 13, 2023, revealed that the resident was transported out to the hospital related to an unwitnessed fall. Review of clinical record revealed no evidence that Resident R31's representative was notified of the transfer to the hospital and the reasons for the transfer in writing, and in a language and manner they understood. Interview with the Nursing Home Administrator, Employee E1, 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 clinical record review and staff interview, it was determined that the facility failed to ensure that the resident and resident representative receive written notice of the facility bed-hold policy at the time of a facility-initiated transfer to a hospital for one of nine residents reviewed. (Resident R1) Findings include: Review of MDS (Minimum Data Set-Assessment of resident care needs) for Resident R1 dated September 8, 2023, revealed that the resident was admitted to the facility on [DATE], and had a BIMS score of 10 which indicated that the cognitive status was moderately impaired. Review of Nursing note for resident R1 dated October 13, 2023, revealed that the resident was transported out to the hospital related to an unwitnessed fall. Further review of Resident R1's clinical record revealed that there was no documented evidence that Resident R1's representative was provided with a written notice of the facility bed-hold policy at the time of Resident R1's facility-initiated transfer to the…

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

Based on clinical record review and interviews with staff, it was determined that the facility failed to update and revise a resident's care plan after multiple falls one of nine residents reviewed (Resident R1). Findings include: Review of facility undated policy, titled, Fall Prevention Policy, indicated that the care plan will be reviewed and revised to reflect immediate interventions and ongoing interventions to prevent further falls. Review of Resident R1's clinical record revealed a nursing note dated, September 12, 2023, Resident R1 had a fall and hit the back of his head and was discharged to the hospital. Further review revealed a nursing note dated, October 12, 2023, at 5:04 p.m. which stated, resident was found on the floor in his room next to bed and was complaining of pain. Another nursing note dated, October 12, 2023, at 12:41 a.m. noted another fall, within 24 hours, resident was on floor beside bed. Resident R1 was discharged to the hospital. Review of Resident R1's care plan, dated revised May 31, 2023, revealed that Resident R1 was at risk for falls. 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.