University City Rehabilitation And Healthcare Ctr

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 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 to medication administration (Residents R110, R117, R49 and R53) and Enhanced Barrier Precautions for two of 10 residents reviewed (R32, R49). Findings include: Review of facility policy titled, Administering Medications, revised April 2019, revealed 25. Staff follows established facility infection control procedures (e.g., handwashing, antiseptic technique, gloves, isolation precautions, etc.) for the administration of medications, as applicable. An observation of medication pass with Employee E7, Licensed Nurse on 1st Floor Cart 1, on January 7, 2026 at approximately 9:27 AM, on the first floor nursing unit revealed an open employee [NAME] energy drink can, the opening covered by an empty medicine cup, while administering medications to Residents R110 (9:10 AM), R117 (9:36 AM)…

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

Based on observations and interviews, it was determined that the facility failed to ensure that two of two passengers elevators were in operating condition. (#1 and #2 elevators) Findings include: Review of information reported to the State Survey Agency on May 23, 2025 included a concern regarding the elevators not working properly in the facility since December 2024. Concerns regarding resident's not going to dialysis treatment on the first floor due to an inoperable elevator on May 3, 2025 was also reported in the to the State Survey Agency on May 23, 2025. Review of facility documentation received on June 9, 2025 from the facility regarding the elevators indicated that on December 11, 2024 at 1:24 p.m. someone from the facility reported #2 passenger elevator as being shut down. Continued review of the documentation indicated that on December 12, 2024 elevator technicians arrived at 11:40 a.m. left the elevator out of services, and indicated in the above referenced documentation additional resources required. Review of facility documentation received on June 9, 2025 from 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, and staff interviews, it was determined that the facility failed to ensure that a 1 out of 3 residents reviewed was assess for self administration of medications. (Resident R3). Finding include: During an observation in Resident R3's room on May 28, 2025 at 2:30 p.m. a bottle of the above referenced medicated lotion was observed a 2nd time sitting on top of the resident's dresser, and not secured. In addition, a medication cup with 3 white pills were observed on the resident's bedside table. When resident asked if they were left there for him to take, Resident R2 reported, yes, the nurses leave them here for me all the time. During an interview with Employee E7 (licensed nurse) on May 28, 2025 at 2:50 p.m. the licensed nurse confirmed that she provided the resident with his medication in his room, and did not observe him take it. She reported that the three pills that were observed in the resident's medication cup were 2-5 milligram tablets of the medication, baclofen, that is prescribed for chronic pain, and 1-5 milligram tablet of oxycodone that is…

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 interviews and review of facility policy, it was determined that the facility failed to ensure that grievences were investigated and prompt efforts were made to resolve grievances for 1 out of 2 residents reviewed (Resident R1). Findings include: Review of the facility policy, Grievances Complaints, Filings, with a revision date of April 2017 indicated that all grievances, complaints or recommendations stemming from resident or family groups concerning issues of resident care in the facility will be considered, and that actions on such issues will be responded to in writing, including a rationale for the response. The policy also stated that upon receipt of a grievance and/or complaint, the grievance officer or designee will review and investigate the allegations and submit a written report of such findings within five (5) working days of receiving the grievance and/or complaint. Continued review of the policy indicated that the grievance officer and associated…

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

Based on review of clinical records, facility policy and interview with staff, it was determined that the facility failed to conduct a complete and through investigation for an allegation of potential abuse/neglect for 1 out of 2 residents reviewed (Resident R1). Findings include: Review of the facility policy, Abuse, Neglect, Exploitation or Misappropriation - Reporting, with a revision date of September 2022 indicated that reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state and federal agencies (as required by current regulations), and are thoroughly investigated by facility management. The policy also stated that the administrator provides supporting documents and evidence related to the alleged incident to the individual in charge of the investigation. Review of Resident R1's May 2025 physician orders included the diagnoss of hypertension (high blood pressure); cerebral infarction (a stroke); cognitive communication deficit (difficulty performing activities of daily…

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

Based on staff interviews, review of facility policy and the review of clinical records, it was determined that the facility failed to notify the physician when residents did not receive their hemodialysis treatment from the onsite dialysis center for 2 out of 2 residents reviewed (Resident R1 and Resident R2). Findings include: Review of the facility policy, End Stage Renal Disease dated September 2010 indicated that residents with end-stage renal disease (ESRD) will be cared for according to currently recognized standards of care. Review of Resident R1's May 2025 physician orders included the diagnoses of hypertension (high blood pressure); cerebral infarction (a stroke); cognitive communication deficit (difficulty performing activities of daily living safely & efficiently as well as communicating effectively); end stage renal disease (the gradual loss of kidney function reaches an advanced state) and dependance on renal dialysis (the process of filtering the blood of a person whose kidneys are not working normally). Review of Resident R1's May 2025 physician orders included a…

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

Based on observations, staff interviews, review of facility policy and the review of clinical records, it was determined that the facility failed to ensure that medications were properly labeled and stored according to professional standards for 1 out of 3 residents reviewed (Resident R3). Findings include: Review of the facility policy, Medication Labeling and Storage with a revision date of February 2023 indicated that the nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner, and that medications are stored in an orderly manner in cabinets, drawers, carts, or automatic dispensing systems. Continued review of the policy indicated that each resident's medications are assigned to an individual cubicle, drawer, or other holding area to prevent the possibility of mixing medications of several residents. Review of the May 2025 physician orders for Resident R3 included the diagnoses of glaucoma (an eye condition that can lead to vision loss or blindness); chronic obstruction pulmonary disease (COPD-a progressive lung…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on the review of clinical records, interviews with staff, it was determined that the facility failed to administer medication as ordered by the physician for one of 8 residents reviewed. (Resident R1). Findings Include: Interview with Resident R1 conducted on May 8, 2025, at 10:00 a.m. revealed that the nurse does not apply the moisturizer cream, she is supposed to do it all the time. Review of Resident R1's clinical record revealed resident was admitted to the facility on [DATE]. Review of physician orders for Resident R1 revealed an order dated February 26, 2025, which indicated Apply moisturize cream within 3 mins of shower to lock in moisture (CervaVe, Eucerin, Cetaphil, Aveeno) Repeat application as needed to establish dry areas. Review of Resident R1's clinical record revealed that the resident receives showers on Tuesdays and Fridays during the week. Review of April 2025's Medication Administration Record for Resident R1 revealed resident was receiving moisturizer as ordered on Fridays, after…

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 resident and staff interviews, it was determined that the facility failed to maintain the facility in a clean, comfortable, and homelike condition for four of 15 residents reviewed (R12, R13, R14 and R15). Findings include: Observations during a tour of the facility on March 25, 2025, at 11:15 a.m. revealed the following concerns: Observations on March 25, 2025, at 11:15 a.m., in room [ROOM NUMBER], revealed that the room had a very strong urine odor. Interview with Resident R12, room [ROOM NUMBER] Bed D revealed that the room always smells of stale urine as Resident R14, who is in Bed A in room [ROOM NUMBER], always urinates on the floor. She said that is goes on every day. She said that the room is also very cold, that when the nurse aides come in the turn down the temperature on the heating unit under the window. She said that she has been complaining about this, but nothing is done. She said that her bed is broken, that the head of the bed does not go up all the way. She also said…

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 ensure that residents were evaluated for self-administration of medications for two of 30 residents reviewed (Residents R114 and R12). Findings include: Review of facility policy, Self-Administration of Medications dated February 2021, revealed, Residents have the right to self-administer medications if the interdisciplinary team has determined that it is clinically appropriate and safe for the resident to do so. Continued review revealed, Residents who are identified as being able to self-administer medications are asked whether they wish to do so. Observation on January 21, 2025, at 11:12 a.m. revealed that Resident R114 had two containers of eye drops at her beside; latanoprost ophthalmic solution 0.005% (treats glaucoma - damage to the optic nerve in the eye) and brimonidine tartrate ophthalmic solution 0.2% (treats glaucoma). Resident R114 stated that she feels the nursing staff do not consistently administer 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 policies, clinical record reviews and interviews with staff, it was determined that the facility failed to ensure that a resident's right to request or refuse medical treatments were accurately reflected in the resident's record for one of 30 residents reviewed (Resident R86). Findings include: Review of facility policy, Advance Directives dated September 2022, revealed, The resident has the right to refuse medical or surgical treatment, whether or not he or she has an advance directive. Review of physician's orders for Resident R86 revealed an order, dated June 27, 2024, for Advance Directives: Full Code (allows for all interventions needed to restore breathing or heart functioning, including chest compressions, a defibrillator and insertion of a breathing tube). Review of Resident R86's care plan, dated initiated May 24, 2024, revealed, I do not have an advanced care directive: Full Code. Review of Resident R86's POLST form (Pennsylvania Orders for Life-Sustaining Treatment), dated and signed by the resident on March 27, 2023, revealed that 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, review of clinical record, review of facility documentation, and interviews with staff, it was determined the facility failed to to ensure that residents were free from resident to resident abuse for two of 30 residents reviewed. (Resident R77) Findings include: Review of facility's policy titled, Abuse, Neglect, Exploitation and Misappropriation Prevention Program, revised April 2021, revealed that Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation . The program's objective is to maintain care for all residents and particularly those with behavioral, cognitive or emotional problems. Review of information dated August 4, 2024, and submitted to the state Survey Office on August 4, 2024, indicated, Resident R77 (BIMS 9) was in the dining room during dinner and another resident, Resident R37, started to hit Resident R77 in the left arm with her cane because she stated that Resident R77 always tries to eat her food.…

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

Based on 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 3 residents reviewed for hospitalization. (Resident R15) Findings include: Review of nursing note for Resident R15, dated August 6, 2024, revealed that Resident R15 was admitted to the hospital for chest pain. Further review of Resident R15's clinical record revealed that there was no documented evidence that the resident and his representative were provided with a written notice of the facility bed-hold policy at the time of Resident R15's facility-initiated transfer to the hospital. Interview with the Nursing Home Administrator, Employee E1, on January 24, 2025 at 9:36 a.m. that Resident R15 and his representative were not provided with the bed hold policy, that included information explaining the duration of the bed-hold, bed hold reserve payment and permitting return to a bed at the facility. 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, review of facility policies, clinical record reviews and interviews with residents and staff, it was determined that the facility failed to develop baseline care plans related to bathing and enhanced barrier precautions for two of 30 residents reviewed (Residents R114 and R277). Findings include: Review of facility policy, Activities of Daily Living (ADL), Supporting dated March 2018, revealed, Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with hygiene (bathing, dressing, grooming, and oral care). Interview on January 21, 2025, at 11:13 a.m. Resident R114 stated that she wants to have a real shower, that she only gets provided with a basin of water to wash herself in bed and that she has not had her hair washed since her admission to the facility. Review of Resident R114's admission MDS (Minimum Data Set - a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, review of facility policies, clinical record reviews and interviews with residents and staff, it was determined that the facility failed to provide assistance with bathing and eating for two of 30 residents reviewed (Residents R114 and R78). Findings include: Review of facility policy, Activities of Daily Living (ADL), Supporting dated March 2018, revealed, Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Continued review revealed, Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with hygiene (bathing, dressing, grooming, and oral care) [and] dining (meals and snacks). Interview on January 21, 2025, at 11:13 a.m. Resident R114 stated that she wants to have a real shower, that she only gets provided with…

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

Based on observations, review of facility policies, clinical record reviews and interviews with residents and staff, it was determined that the facility failed to administer medications in a timely manner for three of 30 residents reviewed (Residents R107, R277 and R278). Findings include: Review of facility policy, Administering Medications dated April 2019, revealed, Medications are administered in a safe and timely manner. Continued review revealed, Medications are administered within one (1) hour of their prescribed time. Interview on January 21, 2025, at 1:16 p.m. Resident R107 stated that she did not receive her medications that were scheduled for 9:00 p.m. until after midnight last night. Resident R107 continued that medications are often administered late. Review of Resident R107's Medication Administration Records (MAR) for January 2025 revealed that she was scheduled to receive the following medications at 9:00 p.m.: amitriptyline (treats depression), clobazam (prevents seizures), carbamazepine (prevents seizures), lacosamide (prevents seizures) and levetiracetam (prevents…

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, interviews with resident and staff, review of clinical records and facility policy, it was determined that the facility failed to maintain a peripheral inserted central catheter (PICC) consistent with professional standards of practice and in accordance with physician orders and the comprehensive person-centered care plan, for one of 24 residents reviewed (Resident R110). Findings include: Review of the facility policy titled Central Venous Catheter Care and Dressing Changes, revised on March 2022 states, The purpose of this procedure is to prevent complications associated with intravenous therapy, including catheter-related infections that are associated with contaminated, loosened, soiled, or wet dressings. Perform site care immediately if the integrity of the dressing is compromised (e.g., damp, loosened or visibly soiled) and at least every 7 days. Resident R110 clinical records revealed the resident was admitted to the facility on [DATE] diagnosed with osteomyelitis (bone infection) 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 observations, review of facility policies and interviews with staff, it was determined that the facility failed to ensure that drug records are in order and that an account of all controlled drugs is maintained and periodically reconciled for three of three medication carts reviewed (first floor front, middle and back medication carts). Findings include: Review of facility policy, Controlled Substances dated November 2022, revealed, Controlled substance inventory is monitored and reconciled to identify loss or potential diversion in a manner that minimizes the time between loss/diversion and detection/follow-up. Continued review revealed, Nursing staff count controlled medication inventory at the end of each shift, using these records to reconcile the inventory count. The nurse coming on duty and the nurse going off duty make the count together and document and report any discrepancies to the director of nursing services. Observation on January 21, 2025, at 10:31 a.m. with Employee E10, licensed nurse, of the first floor front medication cart revealed that there was no…

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 insulin pens were labeled in accordance with currently accepted professional principles for two of three medication carts reviewed (first floor back and middle medication carts). Findings include: Review of facility policy, Administering Medications dated April 2019, revealed, When opening a multi-dose container, the date opened is recorded on the container. Continued review revealed, Insulin pens are clearly labeled with the resident's name or other identifying information. Observation on January 21, 2025, at 11:32 a.m. of the first floor back medication cart with Employee E11, licensed nurse, revealed the following: An aspart (rapid acting) insulin (medication used to lower blood sugar levels) pen for Resident R122 that was opened and undated; A glargine (long acting) insulin pen for Resident R25 that was opened and undated; A lispro (rapid acting) insulin pen the was opened, undated and was not labeled with a resident's name; A degludec (long…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, clinical record reviews and interviews with residents and staff, it was determined that the facility failed to provide foods in accordance with residents' preferences for two of 30 residents reviewed (Residents R278 and R40). Findings include: Review of Resident R40's clinical record revealed that the resident was alert and oriented. The resident was provided a regular textured diet with fortified meals three times a day. Interview with Resident R40 on January 21, 2025, at 12:00 p.m. indicated he does not receive the correct food at meal time as follows: Requested for lunch on January 21, 2025, tuna salad received chicken Requested for lunch on January 22, 2025. coffee but received a tea bag, with no hot water nor cream. Request for lunch on January 23, 2025, kielbasa and received chicken. Interview on January 21, 2025, at 1:19 p.m. Resident R278 stated that she eats a vegetarian diet and that she had not been getting vegetarian protein options with her meals. Observation, at the time 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 observations, interviews with staff, review of clinical records and facility policy, it was determined the facility failed to utilize enhanced barrier precautions during medication administration for one of three reviewed residents with feeding tubes (Resident R105). Findings included: Review of the facility policy for Enhanced Barrier Precautions revised March 2024 states, Enhanced barrier precautions (EBP's) are utilized to reduce the transmission of multi-drug-resistant organisms (MDROs) to residents. Policy Interpretation and Implementation revealed examples of high-contact resident care activities requiring the use of gown and gloves for EBP's include device care or use. Review of Resident R105's clinical record revealed that ther esident was admitted to the facility with Oropharyngeal dysphagia (difficulty swallowing) malnutrition (lack in proper nutrition) and required a gastrostomy tube ( a surgical feeding tube inserted in the stomach through the abdomen. that allows delivery of nutrition, fluids, and medications). Review of Resident R105's care plan for 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 and interviews with residents and staff, it was determined that the facility failed to ensure that call devices were functional and accessible to residents for two of 30 residents reviewed (Residents R55 and R78). Findings include: Interview on January 21, 2025, at 1:42 p.m. Resident R55 stated that his callbell did not work. Observation, at the time of the interview, confirmed that the callbell was non-functional. Observation and interview on January 21, 2025, at 2:39 p.m. with the Nursing Home Administrator, confirmed that Resident R55's callbell did not work. Observation on January 22, 2025, at 9:30 a.m. revealed that Resident R78's callbell was on the floor. Resident R78 stated that he was unable to reach the callbell and had no other way to call for assistance. Resident R78 was soft-spoken and unable to yell or call out in a tone loud enough to be heard outside of his room. Observation on January 23, 2025, at 9:17 a.m. revealed that Resident R78's callbell was on the floor and out of the resident's reach. Interview on January 23, 2025, at 12:16 p.m.…

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

Based on review of facility documentation, observations, and resident and staff interviews, it was determined that the facility failed to provide food that was palatable and served at the proper temperature for two of 4 residents reviewed (Resident R1 and R2). Findings include: Review of facility policy, under food preparation, cooking and holding Time/Temperatures, revised November 2022, revealed that the danger zone for food temperatures is above 41 degrees Fahrenheit (F) and below 135 degrees Fahrenheit. This temperature range promotes the rapid growth of pathogenic microorganisms that cause foodborne illness. Foods must be maintained at or below 41 degrees F or at or above 135 degrees F. Interview conducted on December 9, 2024, at 11:00 a.m. with Resident R1 revealed that food is cold. Interview conducted on December 9, 2024, at 9:30 a.m. with Resident R2 revealed that food is cold and burnt. Observations during a test tray conducted with the facility Cook, Employee E5, conducted on December 9, 2024, at 1:15 p.m. revealed that juice registered at 58 degrees F; canned pineapple…

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 reviews of resident clinical records, facility policies and procedures, and interviews with staff and residents, it was determined that the facility failed to follow physician orders for one of 4 residents reviewed. (Resident R2) Findings include: Review of facility policy titled, Administering Medications dated 2001 reveled that the individual administering the medication initials the resident's MAR (Medication Administration Record) on the appropriate line after giving each medication and before administering the next ones. The individual administering the medication records in the resident's medical record must indicate the date and tie the medication was administered. Further review revealed that topical medications used in treatments are recorded on the resident's treatment record (TAR). An initial interview conducted on December 9, 2024 with Resident R2 at 9:30 a.m. revealed that the resident did not have a topical ointment applied to the skin as prescribed by her physician for days and today. Follow up interview conducted at 2:30 p.m. revealed that the resident still…

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 record review, and staff interviews, it was determined that the facility failed to maintain clinical records on each resident in accordance with accepted professional standards related to documentation of risk and benefits of the influenza vaccine, pneumococcal vaccine and COVID-19 vaccine for seven of eight resident records reviewed. (Residents R342, R347, R341, R81, R346, R103 and R64). Findings include: Review of facility policy titled Influenza Vaccine (revised March 2022, Prior to the vaccination , the resident or residents legal representative will be provided information and education regarding the benefits and potential side effects of the influenza vaccine. Provisions of such education shall be documented in the resident's medical record. Review of the facility policy titled pneumococcal Vaccine revised October 2023, revealed residents have the right to refuse vaccination. If refused appropriate information is documented in the resident's medical record. For each resident that receives the vaccine, the date of the vaccination, lot number, expiration date, person…

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 facility policy, review of clinical record review, observations and staff interviews, it was determined that the facility failed to maintain an effective infection control program during medication administration for residents (Residents R75, R23 and R15) for 3 out of 3 residents observed during medication administration. Findings include: Review of facility policy on Medication Administration with revision date of April 2019 revealed under section Policy Statement stated that medications are administered in a safe and timely manner and as prescribed. Under section Policy Implementation and Interpretation. #2 The Director of Nursing Services supervises and directs all personnel who administer medications and or have related functions. #25 staff follows established facility infection control procedures. Example and washing antiseptic technique, gloves, isolation precautions, etcetera for the administration of medications as applicable. Review of Resident R75's clinical record revealed that…

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

Based on observation, clinical record review and staff interview, it was determined that the facility failed to ensure that a resident was evaluated for self administration of medications for one of 24 residents reviewed. (Resident R9) Findings include: Review of facility policy titled Administering Medications revised April 2019, revealed that for residents not in their rooms or otherwise unavailable to receive medication on the pass, the MAR may be flagged. After completing the medication pass, the nurse will return to the missed resident to administer the medication. If a drug is withheld, refused, or given at a time other than the scheduled time, the individual administering. Residents may self-administer their own medications only if the attending physician, in conjunction with the interdisciplinary care planning team, has determined that they have the decision-making capacity to do so safely. Review of Resident R9's clinical records revealed that resident R9 had a BIMS (brief interview for mental status, an assessment to monitor cognition) score of 12 which indicated 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and resident interviews, it was determined that the facility failed to maintain the facility in a clean, comfortable, and homelike condition for three of 26 residents reviewed (Resident R11, Resident R2 and Resident R341). Findings include: Observations during the initial tour of the facility on April 21, 2024, revealed the following concerns: Observations on April 21, 2024, at 10:25 a.m., in room [ROOM NUMBER] Bed B, revealed that the room was very dark even though Resident R11 had her overbed light on. Interview with Resident R11 revealed that she was upset that her room was so dark, and that the blind on her window has not worked since she was admitted to the room. Interview with nurse aide, Employee E4, on April 22, 2024, at 10:00 a.m. confirmed that she was aware that Resident R11's window blind was missing the pull chain to raise it up to let the light in. Interview with Maintenance Director on April 23, 2024, at 12:15 p.m. confirmed that the blind in room [ROOM NUMBER]B was broken…

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

Based on clinical record review and interviews with staff, it was determined that the facility failed to ensure that comprehensive resident assessments were completed in a timely manner for three of six discharged records reviewed (Residents R67, R110 and R111). Findings include: Clinical record review for Resident R67 revealed that the resident had a fall and was transported by 911 (Emergency Medical Services) to the hospital on December 5, 2023. Further review revealed that no comprehensive Minimum Data Set (MDS- assessment of resident's care needs) was completed at discharge. Clinical record review for Resident R110 revealed that the resident was discharged home by the facility contracted transportation service on November 23, 2023. Further review revealed that no comprehensive MDS assessment was completed at discharge. Clinical record review for Resident R111 revealed that the resident was discharged home by the facility contracted transportation service with all his belongings in a wheelchair on November 23, 2023. Further review revealed that no comprehensive MDS assessment was…

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

Based on clinical record review, staff interview and review of facility policy, it was determined that the facility failed to ensure that a pain medication patch was properly label for one of 24 residents reviewed. (Resident R80) Findings include: Review of facility policy titled Administering Medications revised April 2019, revealed that for residents not in their rooms or otherwise unavailable to receive medication on the pass, the MAR may be flagged. After completing the medication pass, the nurse will return to the missed resident to administer the medication. If a drug is withheld, refused, or given at a time other than the scheduled time, the individual administering. Residents may self-administer their own medications only if the attending physician, in conjunction with the interdisciplinary care planning team, has determined that they have the decision-making capacity to do so safely. Review of Resident R80's clinical records revealed that Resident R80 has a diagnosis of CN'S vasculitis (central nervous system vasculitis a disease that causes inflammation of the small…

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 record , review facility policy and staff interviews, it was determined that the facility failed to ensure that a resident with limited range of motion received appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion for one of 26 residents reviewed (Resident R24). Findings include: Review on facility policy on Resident Mobility and Range of Motion revealed that under section Policy Statement: #1. Residents will not experience an avoidable reduction in range of motion (ROM). #2. Residents with limited range of motion will receive treatment and services to increase and/or prevent a further decrease in range of motion. Under section. Policy Interpretation and Implementation #6. The interventions may include therapies, the provision of necessary equipment and or exercises, and will be based on professional standards of practice and be consistent with state laws and practice acts. Review of Resident R23's clinical…

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 facility policy and observation and interviews, it was determined the facility failed to ensure appropriate enteral feeding practices relating to labeling for two of eight residents observed for tube feeding. (Residents R332 and R80). Findings include: Review of facility policy titled Enteral Nutrition revised 2018, revealed the primary function of enteral feeding is to promote adequate nutritional support through enteral nutrition is provided to residents as ordered. The nursing staff and provider monitor the resident for signs and symptoms of inadequate nutrition, altered hydration, hypo- or hyperglycemia, and altered electrolytes. The nursing staff and provider also monitor the resident for worsening of conditions that place the resident at risk for the above. The nurse confirms that orders for enteral nutrition are complete. Review of Resident R332's clinical record revealed that Resident R332 had the diagnoses of absence of larynx (removal of voice box), diabetes type 2 (long term condition in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of clinical records, review of facility documentation, review of facility policy and staff interviews, it was determined the facility failed to implement a complete drug regimen review process for two of 26 residents reviewed (Resident R63 and R101). Findings Include: Review of the undated Medication Regimen Review Policy revealed, the consultant pharmacist performs a medication regimen review (MRR) for every resident in the facility receiving medication. The attending physician documents in the medical record that the irregularity has been reviewed and what (if any) action was taken to address it. The consultant pharmacist provides the director of nursing and medical director with a written, signed and dated copy of all medication regimen reports. Review of Resident R63's medical record revealed that resident was admitted on [DATE], with diagnoses of chronic obstructive pulmonary disease (COPD, is a chronic inflammatory lung disease that causes obstructed airflow from the lungs). A review of…

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

Based on review of personnel records and staff interviews, it was determined that the facility failed to properly document the dates of tuberculin skin test results for newly hired staff members on four of five personnel records reviewed (Employeess E17, E18, E19 and E20). Findings include: The Pennsylvania Code, Title 28, Chapter 201.22. Prevention, control and surveillance of tuberculosis (TB). (b) Recommendations of the Centers for Disease Control and Prevention (CDC), United States Department of Health and Human Services (HHS) shall be followed in screening, testing and surveillance for TB and in treating and managing persons with confirmed or suspected TB. The CDC Fact Sheet, CS 320275-C, Dated September 2020, states, The skin test reaction should be read between 48 and 72 hours after administration by a health care worker trained to read TST results. A patient who does not return within 72 hours will need to be rescheduled for another skin test. Review of employee personnel files for the Employees E17, E18, E19 and E20 revealed a PPD Information Form for each employee that 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 observation, staff and resident interview, it was determined that the facility failed to ensure that call bells were available and operable for resident use for three of 26 residents interviewed. (Residents R184, R8 and R22) Findings include: Interview with Resident R184 in room [ROOM NUMBER], Bed A, conducted on April 21, 2024, at 11:15 p.m. revealed that she was admitted a couple weeks ago and was having difficulty with her call bell. She stated that the call bell has not worked at all since Friday, April 19, 2024. She said that she told staff and they had the maintenance guy come and look at it, but did not fix it. When asked if she was given an alternate bell she said no, she just call to people in the hall if she needs something. When she pushed the call bell button, it did not light at the wall or in the hallway. Interview with nurse aide, Employee E4, in room [ROOM NUMBER] on April 22, 2024, at 10:00 a.m. confirmed that she was aware that the call bell for Bed A was not working and that…

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

Based on clinical record review, facility policy and interviews with staff, it was determined that the facility did not ensure that a physician assessment was completed related to unplanned weight loss for one of 2 residents with weight loss reviewed (Resident R4). Findings include: Facility Policy titled Weight Policy NutraCo reviewed 12/2022 stated any resident displaying a significant change in weight of greater than or equal to 5% gain/loss in one month will be reported to the Registered Dietitian and reweighed under #7. Dietary interventions will be recommended as needed. All significant weight changes will be reported to MD. Review of clinical documentation for Resident R4 revealed that that the resident was admitted to the facility March 8, 2018, with diagnoses of abnormal wight loss, vitamin D deficiency, difficulty in walking, muscle wasting and atrophy, legal blindness, other abnormalities of gait and mobility, peripheral vascular disease, dementia, and severe protein-calorie malnutrition. Review of the resident's weight documentation revealed that on November 1, 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 review of facility policy, pharmacy documentation, review of clinical records, interview with staff and residents, it was determined that the facility failed to ensure that medications were administered in accordance with professional standards for one of seven residents reviewed. (Resident R7) Findings include: Review of facility policy, titled Administering Medications, revised April 2019, indicated, Medications ordered for a particular resident may not be administered to another resident . Review of physician order for Resident R7 dated June 20, 2023, revealed an order for Diclofenac Sodium 1% Gel to be applied 4 grams to both knees' topically two times a day for knee pain. Further review revealed an updated order, dated January 29, 2024, for Diclofenac Sodium 1% Gel, apply to both knees topically four times a day for knee pain 1 gram per knee 4x daily. Interview with Resident R7 on February 8, 2024, at 10:49 a.m. revealed that staff had been putting someone else's medicine on my legs for a couple of months and that that medicine belonged to another person. 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.

Based on observation, staff interviews, and review of facility policy, it was determined that the facility failed to ensure that all drugs and biologicals used in the facility were stored in accordance with professional standards for one of two medication carts observed (second floor cart). Findings include: Review of facility policy, Medication Labeling and Storage, revised February 2023, indicated that compartments containing medications and biologicals are locked when not in use, and trays or carts used to transport such items are not left unattended if open or otherwise potentially available to others. Observation of the second-floor cart with Employee E3, Licensed Practical Nurse, on February 8, 2024, at approximately 10:40 a.m. revealed that the medication cart was missing Resident R7's gel medication, Diclofenac Sodium Topical Gel 1%. Employee E3 proceeded into Resident R7's room and pulled open the residents unlocked right side drawer. Further observations revealed two tubes of Diclofenac Sodium Topical Gel 1% in Resident R7's drawer, unlocked. Interview with the facility…

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

Based on staff interviews, review of facility documentation, review of facility policy and the review of clinical records, it was determined that the facility failed to ensure that an allegation of possible sexual abuse was reported to the Nursing Home Administrator in a timely manner for one out of three residents reviewed (Resident R3). Findings include: Review of the facility policy, Abuse, Neglect, Exploitation and Misappropriation-Reporting and Investigating, with a revised date of September 2022, indicated that if resident abuse, neglect, exploitation, misappropriation of resident properly or injury or unknown sources is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law. Review of the January 2024 physician orders for Resident R3 included the diagnoses of contracted left knee, chronic pain, dysphagia (difficulty swallowing); legal blindness (a term that the government uses for an individual who can still see, but not as clearly as normal vision) and dementia (a term for a group of symptoms affecting memory,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interviews, review of the facility policy and review of facility documentation, it was determined that the facility failed to ensure that an allegation of abuse submitted to the State Survey Agency contained complete and accurate information for one out of three residents reviewed (Resident R3). Findings include: Review of the facility policy, Abuse, Neglect, Exploitation and Misappropriation-Reporting and Investigating, with a revised date of September 2022, indicated that if resident abuse, neglect, exploitation, misappropriation of resident properly or injury or unknown sources is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law. Review of the January 2024 physician orders for Resident R3 included the diagnoses of contracted left knee, chronic pain, dysphagia (difficulty swallowing); legal blindness (a term that the government uses for an individual who can still see, but not as clearly as normal vision) and dementia (a…

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

Based on observations, interview with resident and staff, and review of facility policy, it was determined that the facility did not ensure that a resident was provided with a shower as ordered by the physician and according to the resident's individual needs for one of 57 residents reviewed (Resident R7) Findings include: Review of facility's policy 'Bathing and Showering,' updated June 1, 2023, states the following: residents may be provided with either a shower or a tub bath as per their preference, and provisions and refusals of showers and/or tub baths will be documented in the medical record by the certified nursing assistant and/or licensed nurse. Review of Resident R7's physician orders revealed an order for bath/shower and skin check 7-3 shift twice weekly, Tuesdays and Fridays. Observations on Tuesday, December 26, 2023 at 11:32 a.m., on second floor unit, revealed nurse aide, Employee E3, provide morning bed bath hygiene care to Resident R7. Interview with Resident R7 on December 26, 2023 at 11:40 a.m., revealed that he preferred a shower during morning hygiene care.…

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

Based on observations, interview with staff and resident and review of facility policy, it was determined that facility did not provide food that accommodates resident's preferences for one of one residents reviewed. (Resident R7) Findings include: Review of facility's policy 'Resident Food Preferences,' revised July 2017, states the following: individual food preferences will be assessed upon admission and communicated to the interdisciplinary team, and the food services department will offer a variety of foods at each scheduled meal, as well as access to nourishing snacks throughout the day and night. Review of Resident R7's nutrition progress notes dated December 11, 2023 at 12:28 p.m., revealed resident w (with)/preferences for no pork, received meals w/pork multiple times. During interview with Resident R7 on December 26, 2023 at 12:00 p.m., it was noted that Resident R7's lunch meal tray ticket specified turkey cheese sandwich; meal ticket included Resident R7's dislikes, which included pork and chicken. Resident R7 was presented with lunch meal menu, which included 'chicken…

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, interview with staff and residents, it was determined that the facility failed establish and maintain an individual record transaction of resident's personal funds entrusted to the facility on the resident's behalf and the facility failed to provide resident with receipts for each transaction for one of seven residents reviewed. (Resident R1) Findings include: Interview with Nursing Home Administrator, Employee E1 conducted on August 9, 2023, at 10:17 a.m. revealed that Resident R1 had $3,350.00 which was deposited in the facility bank and was returned to the resident on the day of his discharge. Review of the Inventory of Personal Effects form under section Instructions: revealed that at the time of admission, record the resident's personal belongings by indicating the quantity of those items listed. The original copy shall be kept in the resident's medical record. The copy is given to the resident or resident representative. Update as needed throughout 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.