Tucker House Nursing And Rehabilitation Center

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: An initial tour of the Food Service Department (FSD) was conducted on September 29, 2025, at 9:45 a.m. with Employee E3, Food Service Director, which revealed the following: Observations in the area near the compacting dumpster revealed a large blue container (10 gallons) of roofing adhesive, a case of four silver pouches of roofing sealant with 6 long screws and several tubes of roofing caulk. Also, a large pile of old resident equipment including a bedside commode, wheelchair, leg rests, walker, bedside nightstand and a microwave oven piled up next to the trash compactor. Observation in the dry food storage room revealed a large cardboard box of dishware sitting directly on the floor. Observation in the walk-in freezer revealed no thermometer to monitor temperatures. Observation in the walk-in cooler revealed a stainless-steel pan of cooked roast…

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 that trash and recyclables were properly disposed of in the receiving and dumpster area.Findings include: An initial tour of the Food Service Department was conducted on September 29, 2025, at 9:45 a.m. with Employee E3, Food Service Director, (FSD) which revealed the following: Observations in the area near the compacting dumpster revealed a large blue container (10 gallons) of roofing adhesive, a case of four silver pouches of roofing sealant with 6 long screws and several tubes of roofing caulk. Also, a large pile of old resident equipment including a bedside commode, wheelchair, leg rests, walker, bedside nightstand and a microwave oven piled up next to the trash compactor. Interview with the FSD on September 29, 2025, at 9:50 a.m. confirmed the above findings. Interview with the Administrator on September 29, 2025, at 1:20 p.m. confirmed that the facility recently had roof work completed and that these chemicals and other debris should not be left outside of the dumpster. 28…

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

Based on observations, review of facility policies and interviews with staff, it was determined that the facility failed to ensure that staff were knowledgeable of smoking policies during one of one smoke breaks observed (September 30, 2025, morning smoke break). Findings include: Review of facility policy, Smoking Safety Policy dated October 3, 2024, revealed, It is the facility policy to provide a safe environment for our residents, staff and visitors by defining and enforcing safe smoking practices. Continued review revealed, The facility will maintain safety equipment near and/or at the designated smoking area: emergency fire blanket, fire extinguisher . [and] aprons for residents if they are not on their possession. Review of the facility's smokers list revealed that four residents required smoking aprons, including Resident R83. Observation on September 30, 2025, at 9:31 a.m. of the morning smoke break revealed that Resident R83 was smoking in the designated smoking area. Resident R83 had a cigarette hanging from her lips while seated in her wheelchair with her hands resting…

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 resident clinical record, interview with staff and review of facility policy, it was determined that the facility failed to notify the ordering physician of a critical laboratory results for one of eight resident records reviewed (Resident R2).Findings include: Review of the facility policy titled, 'Clinical Guideline; Labs and Diagnostics', dated 2021, without date and Month, indicated; 'Facility staff will notify the ordering prescriber of results that are outside of clinical reference ranges or per prescribers' order. The prescriber or designee prescriber will sign and date that notification has occurred, and this can be done manually or by e-signature, if available'.Review of Resident R2's clinical record revealed that Resident R2 was admitted in the facility on August 30, 2025. Resident R2's diagnoses included Malignant Neoplasm of Unspecified site of Right Female Breast (commonly known as breast cancer, is a cancerous tumor that develops in breast tissue. These tumors are characterized by their ability to grow rapidly, invade surrounding tissues, and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview with residents and staff and review of facility documentation, it was determined that facility failed to ensrue that residents' clothing was properly identified for two of eight residents reviewed. (Resident R1, and Resident R2) Findings include: Review of facility policy 'Laundry Services - Personal Clothing, Handling,' unknown date, indicates that all resident clothing must be labeled clearly with the resident's name upon admission or upon new clothing being brought in, and personal clothing is separated from facility linens. Interview with Resident R1and Resident R1's relative, on fourth floor unit, at 11:45 am, revealed that he has been waiting to receive his personal laundry for about two weeks. Interview with facility's laundry aides, Employee E3 and E4, on [DATE] at 12:10 p.m., revealed that delayed personal laundry services has been an ongoing issue, stating that nurse aides need to label residents' clothing otherwise we will wait until someone complains and asks for their belongings…

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 the consulting pest control reports, , and interviews with staff and residents, it was determined that the facility failed to maintain an effective pest control program in the resident care areas for three of three nursing floors. (2nd floor, 3rd Floor and 4th floor) Findings include: An observation of Resident room [ROOM NUMBER] on December 27, 2024, at 10:56 a.m. with Employee E4, Nurse Aide, revealed that there were live roaches inside the drawer of nightstand. There was also dead roaches inside and around the night stand. Dark colored numerous tiny spots were observed inside the drawer which appeared like roach/pest droppings. Resident room was observed with trash, food particles on the floor. Interview with Resident R1 on December 27, 2024, at 11:00 a.m. stated he saw a mice came out of the wall that morning. Resident pointed to a whole in baseboard to indicate the location where the mice came out. Interview with Resident R1 on December 27, 2024, at 11:05 a.m. stated he…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, review of clinical records, observation, and staff interview it was determined that the facility failed to develop and implement a comprehensive care plan related to mobility, vision, and pressure ulcers for four of 35 residents reviewed (Residents R65, R1, and R102). Findings Include: Review of facility policy Baseline Care Plan, Comprehensive Care Plan and Ongoing Care Plan Updates dated April 1, 2022, revealed the facility will develop and implement a comprehensive person-centered care plan for each resident. The comprehensive care plan will describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. Review of Resident R65's quarterly Minimum Data Set (MDS - federally mandated resident assessment and care screening) dated August 21, 2024, revealed the resident was cognitively impaired and had diagnoses of hemiplegia (paralysis on one side of the body) affecting the left side and…

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

Based on review of facility policy, clinical records, and staff interviews, it was determined that the facility failed to ensure that a resident's care plan was updated/revised to reflect the resident's specific care needs for two of five residents reviewed (Residents R85, R89). Findings include: Review of facility policy titled Care Plans (dated April 2022) indicated that the interdisciplinary team must review and update the care plan when there has been a change in the resident's condition. Clinical record review revealed Resident R85 was admitted to the facility August 3, 2023 with a diagnosis that included but not limited to diabetes mellitus (chronic disease that causes high blood sugar levels), anxiety disorder, and dementia. Review of Resident R85's clinical record revealed Resident R85 had a significant weight loss from June 2024 through November 2024. Further review of Resident R85's clinical record revealed an order, dated October 08, 2024, for two house shakes a day for weight loss. Review of Resident R85's care plan revealed interventions that included one house shake to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of clinical record, observations, and staff interview, it was determined that the facility failed to provide nail care for a dependent resident for one of 30 residents reviewed (Resident R65). Findings Include: Review of Resident R65's quarterly Minimum Data Set (MDS - federally mandated resident assessment and care screening) dated August 21, 2024, revealed the resident was cognitively impaired and had diagnoses of hemiplegia (paralysis on one side of the body) affecting the left side and muscle weakness. Further review of the MDS revealed Resident R65 was dependent on staff for personal hygiene. Review of Resident R65's comprehensive care plan revised August 25, 2021, revealed the resident had an activities of daily living self-care performance deficit related to decreased mobility. Intervention revised on September 30, 2019, included to check nail length and trim and clean on bath day and as necessary. Review of Resident R65's nursing [NAME] (a documentation system that enables nurses to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of select facility policies and procedures, clinical record review, and staff interview, it was determined that the facility failed to implement treatment and services for incontinence management for one of five residents reviewed with incontinence concerns (Resident R137). Findings include: Review of Resident R137's clinical record revealed that the resident was admitted to the facility on [DATE] with the diagnoses of Neuromuscular Dysfunction of Bladder (a condition that occurs when the nerves and muscles that control the bladder don't work properly. This can be caused by damage to the brain, spinal cord, or nerves, and can lead to a loss of bladder control). Review of physician order for Resient R137, dated October 24, 2024, indicated an order for urinary Foley catheter size 16FR (french)/10ML. On November 12, 2024, at 11:07 a.m., it was observed that Resident R137 had a Foley Catheter of 18FR/10ML. At the time of the finding, confirmed the same Employee E4, a Registered Nurse. 28 Pa Code…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, review of clinical record, and staff interview, it was determined that the facility failed to evaluate and address the nutrition needs of each resident in a timely manner for two of four residents reviewed for nutrition (Resident R84 and R107). Findings Include: Review of facility policy Weight Assessment and Intervention dated February 15, 2022, revealed the nursing staff and the Registered Dietitian will cooperate to prevent, monitor, and intervene for undesirable weight loss for the residents. Further review of facility policy revealed if a weight loss is significant, the Registered Dietitian should discuss with the interdisciplinary team and make recommendations. Per the facility policy, significant weight change is defined as more or less than 5% within 30 days, and more or less than 10% within 6 months. Review of Resident R84's comprehensive Minimum Data Set (MDS - federally mandated resident assessment and care screening) dated February 5, 2024, revealed the resident…

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

Based on review of facility policy, review of clinical record, and staff interview, it was determined that the facility failed to ensure that pain management was provided to residents consistent with standards of professional practice for one of one resident reviewed for pain (Resident R70). Findings Include: Review of facility policy Administering Pain Medication dated April 1, 2022, revealed the purpose of the policy was to provide guidelines for assessing the resident's level of pain prior to administering pain medications. Review of facility policy revealed staff should obtain the location and intensity of the pain. Staff should evaluate the effectiveness of non-pharmacological interventions and administer pain medications as ordered. Further review of facility policy revealed staff should document per facility protocol in the resident's electronic health record. Review of Resident R70's quarterly Minimum Data Set (MDS - federally mandated resident assessment and care screening) dated September 7, 2024, revealed the resident was cognitively impaired and 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of clinical records, staff and resident interviews, it was determined that the facility failed to identify the resident's possible triggers that may cause re-traumatization related to post-traumatic stress disorder (PTSD) for one of one resident sampled with a diagnosis of PTSD. (Resident R 81) Findings include: A review of the clinical record revealed that Resident R81 was admitted to the facility on [DATE], with diagnoses to include suicidal ideations, major depressive disorder, and (PTSD) Further review of the clinical record for Resident R81 revealed that the resident was sexually and physically abused by his father as a child. Resident R81's current care plan on August 29, 2024, revealed a care plan for PTSD. Further review of the care plan failed to identify possible triggers that may cause re-traumatization. Interview with the Director of Nursing, Employee E1, on October 18, 2024, at 11:00 a.m. confirmed that Resident R81's plan of care for PTSD did not identify the resident's possible…

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 and procedure and interviews with staff, it was determined that the facility failed to maintain an effective infection control program related to hand hygiene during one of the six Medication Administration Reviews, and during peg tube dressing change for one of one resident review with a feeding tube Findings include: Review of facility policy title Hand Hygiene, and Enhanced Barrier Precautions (EBP), indicated that the staff will follow established infection control procedures such as hand washing, antiseptic technique, gloves, and isolation precautions for administration of medications, care, and treatments, as applicable. Observation conducted during medication administration to Resident R 85 on November 13, 2024, 9:11 a.m., with Licensed nurse, Employee E5, revealed that with bare hands Employee E5, touched the drawer of the medication cart, computer mouse, and medication-blister-pack; and without disinfecting her hands; the employee picked up medication tablet, Olanzapine Oral Tablet 10 milligram, and Klonopin Oral Tablet 0.5…

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, policy and procedure review and interviews with staff, it was determined that the facility failed to assure an ongoing collaboration with the dialysis facility for the provision medications as ordered by the physician before and after hemodialysis treatment for one of one residents on renal dialysis. (Resident R1) Findings include: A review of the facility policy titled Administering Medications dated April 1, 2022 revealed that the licensed nurse was responsible for administering and documenting in the clinical record the administration of medications and treatments according to the orders, in required time frames, as set forth by the physician. A review of the policy titled Dialysis dated April 1, 2022 revealed that it was the facility's responsibility to ensure that the dialysis services were managed so that each resident attain or maintain their highest practicable physical, mental and psychosocial well-being. The policy indicated that it was the responsibility of the facility to ensure that the resident's needs related to dialysis treatment was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and staff interviews it was determined that the facility failed to maintain resident care areas and personal belongings in a clean and homelike environment for three of three nursing units (2nd, 3rd, and 4th floor Nursing Units). Findings Include: Observations on January 26, 2024, at 11:50 a.m. in room [ROOM NUMBER] revealed the floors were sticky to touch and there was a red juice stain next to the window bed. Further observations revealed Resident R115's wheelchair was dirty with significant build-up of food/debris along the frame of the chair. Observations on January 26, 2024, at 12:00 p.m. revealed residents seated in the 3rd floor dining room and lunch was about to start. The floors were observed to be dirty from breakfast with breakfast food spillage and wrappers on the floor. Further observations revealed a breakfast tray was left out on a table in the corner of the room. Observations on January 29, 2024, at 11:15 a.m. in the 3rd floor dining room revealed spillage stains on 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 policy, review of facility documentation, review of clinical records, and staff interviews it was determined that the facility failed to report allegations of resident abuse to the state agency as required for two of four abuse allegations reviewed (Resident R22 and R32). Findings Include: Review of undated facility policy Abuse revealed allegations of abuse are reported per Federal and State Law. Further review of facility policy revealed the facility will ensure that all alleged violations involving abuse are reported to the administrator of the facility and to other officials, including to the State Survey Agency. If an allegation is considered reportable, the designee will make an initial (immediate or within 24 hours) report to the State Agency. A follow up investigation will be submitted to the State Agency within five working days. Review of facility documentation revealed an incident report with a witness statement by Registered Nurse, Employee E14, dated May 24, 2023, that the 4th floor unit manager reported that Resident R22 alleged that a nurse…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, review of clinical records and facility documentation, it was determined that the facility failed to ensure a complete and through investigation to rule about abuse and/or neglect for an injury of an unknown origin for 1 out of 33 residents reviewed (Resident R32). Findings include: Review of the facility's undated Abuse policy indicated that during the investigation of injuries of unknown origin or suspicious injuries must be immediately investigated to rule out abuse. The policy also indicated that when an incident or suspected incident of abuse is reported, the administrator or designee investigation will include the following: investigating who was involved, obtaining witness statements, resident statements, resident roommate statements, in addition to other investigative areas. Continued review of the policy indicated that during the investigation of injuries of unknown origin or suspicious injuries must immediately investigated to rule out abuse. The policy also indicated that when an…

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

Based on 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 two of 33 residents reviewed (Residents R22 and R471). Findings include: Review of Resident R22's clinical record revealed that the resident was transferred to the hospital on September 4, 2023, after a fall and October 28, 2023, due to lung cancer. Further review of Resident R22's clinical record failed to reveal documentation of a written hospital transfer notice provided by the facility to the Office of the State Long-Term Ombudsman. Review of Resident R471's clinical record revealed that the resident was transferred to the hospital on November 4, 2023, January 3, 2024, and January 27, 2024, related to Resident R471 having Hematemesis (vomiting of blood). Further review of Resident R471's clinical record failed to…

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

Based on observations, review of facility policies, review of clinical records, and staff interviews, it was determined that the facility failed to ensure one resident had a physician order for a wander guard for one of 33 residents reviewed (Resident R62). Findings Include: Review of Resident R62's significant change Minimum Data Set (MDS - federally mandated resident assessment and care screening) dated November 3, 2023, revealed the resident had a diagnosis of dementia (the loss of cognitive functioning - thinking, remembering, and reasoning - to such an extent that it interferes with a person's daily life and activities). Further review of the MDS revealed Resident R62 had severe cognitive impairment and used a wheelchair for mobility. Review of Resident R62's comprehensive nursing evaluation, Section 11. Elopement Risk, dated January 3, 2024, revealed the resident was not at risk for elopement. Observations on January 29, 2024, at 2:10 p.m. with licensed nurse, Employee E13, revealed Resident R62 had a wander guard on the right wrist. Interview with licensed nurse, Employee…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, review of facility documentation, observations, review of clinical records, and staff interviews it was determined that the facility failed to ensure residents received adequate supervision and were free from accidents and hazards related to smoking, mechanically altered diets, and resident safety (Resident R40, R105, and 162). Findings include: Review of facility policy Smoking Safety, revised October 2022, revealed residents who smoke will be permitted to smoke in the designated outside smoking area. Residents must agree to and comply with the safe smoking practices and the conditions of the Smoking Safety Policy and Procedure. Residents will be assessed after admission by Nursing/ Social Services/designee and at a minimum, annually. Further review of facility policy revealed noncompliance with the safe smoking practices could pose significant negative impact on the safety of all residents and staff. Violations include smoking in areas not designated for smoking. Review of…

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

Based on clinical record review and observation, it was determined that the facility failed to ensure the proper care of indwelling urinary catheter and tubing for two of two residents observed with urinary catheters. (Residents R16 and Resident R59). Findings include: According to the facilities Catheter Care, Urinary policy, dated April 1, 2022, all 'catheter tubing and drainage bags are to be kept off the floor'. Review of Resident R16's clinical record revealed an admission date of November 9, 2021, with diagnoses that included retention of urine. A physician order was obtained on April 24, 2023, for the use of an indwelling foley catheter. Observation made on January 26, 2024, at 10:36 a.m. revealed that Resident R16's urinary catheter drainage bag and tubing extended out and lying directly on the floor underneath the bed. Observation conducted of Resident R59 on January 26, 2024, at 10:45 a.m. revealed that Resident R59 was laying in bed with the urinary catheter drainage bag and tubing extended out and lying directly on the floor. 28 Pa. Code 211.12 (d)(1)(3)(5) Nursing…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, review of clinical records, and staff interviews, it was determined the facility failed to ensure adequate monitoring to identify and apply relevant approaches to maintain acceptable parameters of nutritional status for one of six residents reviewed for nutrition (Resident R78). Findings Include: Review of facility policy Weight Assessment and Intervention revised February 15, 2022, revealed the nursing staff and Dietitian will cooperate to prevent, monitor, and intervene for undesirable weight loss for the residents. Review of facility policy indicated the registered dietitian will review monthly weights by the 10th of the month to follow individual weight trends over time. Negative trends will be assessed and addressed by the registered dietitian whether or not the definition of significant weight change is met. Continued review of facility policy revealed significant weight changes are defined as: more or less than 5% within 30 days; and more or less than 10% within 6…

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 review and interviews with staff, it was determined that the facility failed to ensure appropriate enteral feeding practices related to labeling for one of three residents reviewed for tube feedings (Resident R74). Findings include: Review of facility policy, Enteral Feeding dated last revised January 2, 2021, revealed that, tube feeding formula will be labeled with residents name, date and time hung'. It also revealed that syringes should be dated and labeled with the resident name. Review of care plan for R74 revealed the use of tube feed related to dysphasia. Observation on January 2, 2024, at 11:29 a.m. revealed Resident R74 resting in bed. Next to his bed hanging in a feeding pump was an opened, undated, unlabeled bottle of tube feed. On the bedside table, rested 3 opened, undated, unlabeled syringe bottles. Interview, at the time of the observation, the Director of Nursing confirmed that it is the expectation of nurses to label, date and time all tube feed and supplies. 28 Pa Code 211.12(d)(5) Nursing services

Based on review of personnel files and staff interviews it was determined that the facility failed to ensure that nurse aides were able to demonstrate competency in skills and techniques necessary to care for residents for one nursing staff reviewed (Employee E8) Findings Include: Review of nurse aide, Employee E8's, personnel file revealed the nurse aide was hired by the facility on October 10, 2023. Further review of nurse aide, Employee E8's, personnel file revealed no competencies were available to ensure the nurse aide was competent in skills and techniques necessary to care for residents needs including activities of daily living such as personal hygiene, transfers, and mobility. Interview with the Nursing Home Administrator, Employee E1, and Regional Registered Nurse, Employee E4 on January 31, 2024, at 1:30 p.m. confirmed that there was no documentation available to review to show that licensed nursing staff had been evaluated for competencies. 201.20 (b) Staff development. 201.20 (d) Staff development.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical and facility documentation, it was determined that the facility failed to ensure that medically related social services were provided to a resident who was cognitively impaired, and the recommendation of guardianship was made, to ensure treatment and care concerns were being made in the best interest of the resident, for 1 out of 33 residents reviewed (Resident R120). Findings include: Review of the January 2024 physician orders for Resident R120 included the following diagnosis: cerebral infarction (a stroke); dysphasia (difficulty swallowing); cognitive communication deficit (a type of communication problem that affects an individual's cognition, which involves problems with thinking, remembering, judging and problem-solving); peripheral vascular disease (a condition in which an individual's narrowed arteries reduce blood flow to an individual's arms or legs); acquired absence of the left leg above the knee ( left leg amputation above the knee). Review of the resident's…

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

Based on review of facility policy, review of clinical records, and staff interview it was determined that the facility failed to ensure that the physician documented that the pharmacist's identified irregularities were reviewed and failed to document the action taken or not taken to address the irregularities for one of five residents reviewed (Resident R14). Findings Include: Surveyor requested the policy regarding monthly medication reviews on January 31, 2024, at 12:45 p.m. Subsequently the facility provided the policy Drug Regimen Free From Unnecessary Drugs, revised October 24, 2022. Review of facility policy Drug Regimen Free From Unnecessary Drugs revealed the policy did not address the time frames for steps in medication regimen review or steps the pharmacist must take when an irregularity requires urgent action. Review of Resident R14's clinical record revealed clinical notes by the consultant pharmacist dated 8/8/2023, 9/12/2023, 9/22/2023, and 10/10/2023 that the medication regimen was reviewed. Recommendations were made to prescriber and to see medication regimen 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 interviews with staff and review of facility documentation, it was determined that the facility failed to ensure that resident electronic signatures on admission documents were safeguarded to prevent unauthorized use of the signatures for one out of two residents reviewed (Resident R121). Findings include: Review of the Electronic Signature policy dated April 1, 2022, indicted that this policy addressed the usage of electronic signatures for medical records and agreements throughout the operations of the facility. Continued review of the policy indicated that when electronic signatures are used, safeguards to prevent unauthorized access, reconstruct information, and minimize fraud must be in place. The policy indicated that safeguards included but are not limited to (1) Verification of a person's identity before assigning the unique qualifier (2) System security roles to control what sections/areas individuals can access or enter data based on the individual's role, security role and unique identifier (3) A specific computer lock out time that is activated when there has…

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

Based on observation and interviews with residents and staff, it was determined that the facility failed to ensure that essential equipment needed for resident care was in safe operating condition. Findings Include: A tour of the facility on October 26, 2023 at 9:45 a.m. it was revealed that there were serval pieces of broken equipment in the facility. Interview with Licensed nurse, Employee E6 on October 24, 2023, at 12:14 p.m. revealed we need new equipment. Employee E6 revealed the facility only has two or three working hoyer lifts for the entire facility and sometimes people have to wait to get care. Observation of the second floor shower room on October 24, 2023 at 11:15 a.m. revealed one sit to stand broken in the shower room area and one hoyer lift broken in the shower room area not being used. Observation on the third floor on October 24, 2023 at 1:15 p.m. revealed a hoyer lift in the hallway with the battery exposed with a piece of tape attached. Licensed nurse, Employee E7 attempted to place the battery in to turn the weight scale on but it would not work. Observation on…

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

Based on review of clinical records, review of facility policy, and interview with staff, it was determined the facility failed to complete weekly weights for a resident with a significant weight loss for one of eight residents reviewed. (Resident R1) Findings Include: Review of Resident R1 Minimum Data Set (MDS- assessment of resident care needs) dated June 28, 2023, revealed the diagnoses of hypertension (when the pressure in your blood vessels is too high [140/90 mmHg or higher]), cellulitis of lower left lower limb (a deep infection of the skin caused by bacteria), hyperlipidemia, hyperkalemia (an elevated level of lipids like cholesterol and triglyceride in your blood), systemic inflammatory response syndrome (is an exaggerated defense response of the body to a noxious stressor), major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life). Review of clinical records revealed a physician order for weekly weights on Monday for four weeks starting October 2, 2023.…

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 of the food and nutrition services, review of facility policy, and interviews with staff and residents, it was determined that the facility failed to ensure that each resident received food at safe and appetizing temperatures on one of three nursing floors (Third floor) Findings Include: Review of facility policy titled, Food Temperatures dated January 17, 2019 states, 2. All cold food items must be maintained and served at a temperature of 41 degrees or below. Further review of the policy states 6. Food sent to the units for distribution (such as meals, snacks, nourishments, oral supplements) will be transported and delivered to maintain temperatures at or below 50 degrees for cold foods and at or above 125 degrees for hot foods. Point of service temperatures should be palatable to the taste. Observation of signage on the Third floor stated that lunch starts at 12:15 p.m. and ends at 1:15 p.m. Observation of the Third-floor dining hall revealed the food arrived on the unit to the tray line at 12:10 p.m. Observation revealed several times Director of Dining,…

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, facility documentation, clinical records, observations, and interviews with residents and staff, it was determined that the facility failed to ensure proper documentation regarding treatment and services for one of eight residents reviewed. (Resident R1) Findings Include: Review of facility policy dated January 3, 2022 Refusal of Care states, Residents have a right to refuse any portion of their plan of care. However, since the refusal may be harmful to the resident's health and well being the interdisciplinary team will make every effort to obtain complaint with the plan of care. Further review revealed, If the resident continues to refuse, the refusal is documented in the medical record. The refusal and reason are documented in the electronic medical record. Review of Resident R1's Minimum Data Set (MDS- assessment of resident's care needs) dated June 28, 2023 revealed diagnoses of hypertension (when the pressure in your blood vessels is too high [140/90 mmHg or higher]), cellulitis of lower left lower limb (a deep infection of the skin caused…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, resident and staff interviews and review of housekeeping aide's job description, it was determined that the facility failed to ensure a safe, clean, homelike environment in one of three nursing units. (4th Floor) Findings include: Review of the housekeeping service aide job description revealed that the housekeeping aide provides cleaning services to provide a safe, sanitary, comfortable and homelike environment for residents, staff and the public. The essential duties and responsibilities included to clean (dust, dry mop, wet mop, sanitize, scrub) assigned resident rooms, bathroom and common areas daily according to facility procedures. Clean walls, ceilings, windows, mirrors, waxes floors according to department procedures and cleaning schedules, disposes of trash and waste, including bio-hazards waste and other materials that require special handling. Observations conducted during a tour of the 4th floor on October 15, 2023, between 5:45 p.m. - 7:00 p.m. revealed the following: -on 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 observations, review of pest control documentation and resident and staff interviews, it was determined that the facility failed to maintain an effective pest control program in one of three nursing units. (4th floor). Findings include: Observations conducted on October 15, 2023 between 5:45 p.m.- 7:00 p.m. revealed the following: -7 dead bugs were observed laying on the floor at the head of the B-bed. -there was a soiled blanket on the floor of room [ROOM NUMBER], upon opening the door a number of naps were observed flying on top of the blanket and inside the bathroom. -there was a live roach crawling on the floor in room [ROOM NUMBER]. -a live roach was observed inside the bathtub in room [ROOM NUMBER]. The above findings were confirmed at the time of the observation with Licensed nurse, Employee E3. - live live roaches were observed running around room [ROOM NUMBER]. Interview with Resident R4 at the time of the observation revealed that the resident confirmed that roaches are always in the room and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, review of clinical records and family and staff interviews, it was determined that the facility failed to ensure that a resident with an indwelling catheter received timely care for one of one resident reviewed. (Resident R1) Findings include: Review of Resident R1's clinical record revealed that the resident was admitted to the facility on [DATE], with the diagnosis of bladder dysfunction. Review of Resident R1's October 2023, physician orders revealed an order for a Foley catheter to straight drainage every shift due to urinary retention, size 14/10 French. Family interview conducted on October 15, 2023, at 6:10 p.m. revealed that the the family member was concern with the urine bag from the urinary catheter being completely full and laying on the floor. Observations conducted at the time of the family interview confirmed that Resident R1's urinary catheter bag was completely full and laying directly on the floor underneath the resident's bed. Resident R1 was observed in bed. Interview…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and staff interview, it was determined that the facility failed to ensure a safe, functional and sanitary environment on one of three nursing units (4th Floor) Findings include: Observations conducted of the 4th Floor on October 15, 2023, between 5:45 p.m.-7:00 p.m. revealed the following: -the toilet paper holder was missing in the bathrooms of room [ROOM NUMBER] and room [ROOM NUMBER]. -the toilet tank cover was removed from the toilet in the bathroom of room [ROOM NUMBER] and there were feces in the toilet. -the toilet located inside the central shower room had a sign posted indicating that the toilet was out of order and feces were left on the toilet. The above findings were confirmed with Licensed nurse, Employee E3 at the time of the observations. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1) Management

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interviews, review of facility policy and review of the clinical record, it was determined that the facility failed to ensure that residents were provided with their personal belongings once discharged from the facility for 3 out of 3 residents reviewed (Residents R1, R2 and R3). Findings include: Review of the facility policy, Inventory of Resident Personal Belongings/Property, with a revision date of July 1, 2023, states that the facility will inventory and record all personal clothing and property belonging to each resident. Review of the policy also indicated that the purpose of the policy was to review the facility requirement for all resident personal items to be properly labeled and accounted for. Continued review of the policy stated that all items brought in for the resident must be taken to the receptionist and the receptionist/designee will complete an inventory by the resident/responsible party (if possible) and documented in the note section of the software. Continued review of the…

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

Based on interviews, review of facility policy and the review of clinical records, it was determined that the facility failed to ensure that a baseline plan of care was developed for 1 resident reviewed related to a resident's history of suicide attempts and bereavement for 1 out of 3 residents reviewed (Resident R2). Findings include: Review of the facility policy, Baseline Care Plan, Comprehensive Care Plan an Ongoing Care Plan Update, dated April 1, 2022 indicated that the facility will develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meets professional standards of quality care. The policy also indicated that the baseline care plan will be developed within 48 hours of a resident's admission and include the minimum health care information necessary to properly care for a resident including, but not limited to initial goals based on admission orders, physician orders, dietary orders, therapy services, social services and PASARR recommendations if applicable. 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 the review of clinical records, review of facility policy and interviews with staff, it was determined that the facility failed to ensure that residents were assessed by the physician prior to going out on leave of absences from the facility for 2 out of 3 residents reviewed (Resident R2 and Resident R3). Findings include: Review of the facility policy, Leave of Absence, with a revision date of October 22, 2022 indicated that it is the policy of the facility to coordinate, when appropriate, the preparation for and return from a leave of absence including, but no limited to physical, medical and medication needs of the resident. The policy stated that upon being informed of a request for a leave of absence, the nurse will ensure that there is a physician's order, perform any education needed and complete a plan of care. The policy also stated that the physician will provide an order for leave of absences (independent leave of absences-with no family or staff and supervised leave of abuse (with family or staff). The policy stated that residents admitted with substance abuse…

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.