Heritage Ridge Senior Living At Windy Hill

Based on observations, clinical record review and resident and staff interview, it was determined that the facility failed to implement interventions to prevent future falls or accidents for one of three residents reviewed for falls (Resident 9).Findings include: During an Interview with Resident 9 on June 8, 2026, at 12:05 PM, they were observed to have a soft cast on their left arm. The resident stated that a while ago they had fallen in the bathroom and fractured their arm. Clinical record review for Resident 9 revealed that on March 15, 2026, the resident had a fall in the shower room when a nurse aide was assisting the resident in pulling up their pants. The x-ray report revealed that the resident had suffered fractures to their left humerus bone. Review of the accident report revealed that the immediate intervention at the time of the fall was to educate the nurse aide who was assisting the resident at that time to ensure that the resident was holding onto something when dressing their lower body. Further review of the residents' care plan (an outline of an individual's health…

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

Based on observation and staff interview, it was determined that the facility failed to properly store resident medications on one of three nursing units reviewed (first floor North Cherry Blossom Lane) and properly dispose of resident medications on one of three nursing units reviewed (second floor Magnolia Lane). Findings include: Observation during the medication pass on the first floor North Cherry Blossom Lane Nursing Unit on June 11, 2026, at 9:06 AM revealed a medication cart being utilized by Employee 9, licensed practical nurse. Observation of the medication cart revealed the following: There were several unsecured and unidentified medication tablets found at the bottom of the drawers that included: at least three white colored round pills, one capsule, one blue oblong tablet, a white oblong tablet, and a red and clear capsule. These medications were observed at the bottom of the drawers that held the pre-packaged pill blister packets. There was also an accumulation of debris at the bottom of the drawers that held the loose medications. The above findings were reviewed in 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 clinical record review and resident and staff interview, it was determined that the facility failed to provide routine dental services for two of 18 residents (Residents 44 and 9).Findings include: Observation of Resident 44's mouth on June 8, 2026, at 11:35 AM revealed several missing and broken teeth. Interview with Resident 44's friend at this time revealed that she used to have a partial (artificial teeth designed to replace one or more missing teeth while preserving remaining natural teeth) but indicated that Resident 44's partial no longer fits her. She stated that Resident 44 is served food cut up due to her partial not fitting and stated Resident 44 does not like her mechanically altered diet. Clinical record review revealed the facility admitted Resident 44 on January 9, 2025. Review of Resident 44's plan of care-initiated January 20, 2025, revealed Resident 44 has the potential for oral and dental issues. There was no evidence in Resident 44's clinical record that the facility offered or assisted Resident 44 dental care since admission. Interview with the Director…

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 select facility policies and procedures, observation, and staff interview, it was determined that the facility failed to prevent the potential spread of infection during medication administration pass for two of five residents observed (Residents 72 and 88), and ensure an environment free from the potential spread of infection on one of three nursing units (300-Unit).Findings include: Review of the facility's current policy entitled Handwashing/Hand Hygiene revealed facility staff are to use an alcohol-based hand rub. or alternatively soap. and water for the following situations, which include; before and after direct contact with residents, before preparing or handling medications, after contact with objects (like medical equipment), in the immediate vicinity of a resident, and after removing gloves. Observation on June 9, 2026, at 11:45 AM revealed the freezer in the 300-unit pantry refrigerator was being used to store ice cream. Two medical type ice packs with resident names on them were observed in the freezer with the ice cream. Concurrent interview with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff interview, it was determined that the facility failed to ensure that the resident and/or their representative received written notice of transfer and written notice of the facility bed-hold policy at the time of transfer for three of five residents reviewed for hospitalization (Residents 28, 59, and 65).Findings Include:Nursing documentation for Resident 65 dated May 15, 2025, at 11:58 PM revealed that the resident had a change in condition and 911 was called. A Medication Administration Note dated May 16, 2025, at 5:36 AM revealed that Resident 65 was admitted to the hospital for a urinary tract infection.A review of the census for Resident 65 revealed that the resident returned to the facility on May 21, 2025. Clinical record review revealed no documentation to indicate that Resident 65 and/or their representative received a written notice of transfer and a written notice of the facility bed-hold policy at the time of transfer. Documentation was also requested by the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and resident and staff interviews, it was determined that the facility failed to provide services to maintain a resident's range of motion ([NAME]) for one of two residents reviewed for ROM concerns (Resident 19).Findings include:Interview with Resident 19 on July 9, 2025, at 10:30 AM revealed that he receives no follow through after therapy discharges him. He said the therapist will tell him that staff are going to do exercise to his legs, but it either does not happen or does not happen consistently.Clinical record review of a physical therapy Discharge summary dated [DATE], revealed that resident was to receive a restorative active range of motion program (resident can move extremity on his own) and passive range of motion (staff move the extremity through range of motion) program to his lower extremities. Review of the facility's task documentation revealed that Resident 19 was receiving a restorative active assist range of motion program to his bilateral lower extremities…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, review of select facility policies and procedures, and staff interview, it was determined that the facility failed to implement interventions promote acceptable parameters of nutritional status for one of five residents reviewed for nutritional concerns (Residents 28).Findings include: The facility policy entitled Weight assessment and Intervention, last reviewed without changes February 26, 2025, revealed residents are weighed upon admission and at intervals established by the interdisciplinary team. Weights are recorded in each unit's weight record chart and in the individual's medical record. Any weight change of five pounds or more since the last weight assessment is retaken the next day for confirmation. Undesirable weight change is evaluated by the treatment team whether the criteria for significant weight change has been met. The physician and the multidisciplinary team identify conditions and medications that may be causing weight loss or increasing the risk of weight…

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 employee personnel record review and staff interview, it was determined that the facility failed to complete a performance evaluation of each nurse aide at least once every 12 months for three of three nurse aides reviewed (Employees 7, 8, and 9).Findings include:The facility noted the following hire dates for three employees reviewed for performance evaluations (EPR, employee performance review): Employee 7's hire date of November 5, 1991, last EPR was November 14, 2023Employee 8's hire date of June 24, 1996, last EPR was May 26, 2024.Employee 9's hire date of October 31, 2017, last EPR was October 18, 2023.A request to review the annual performance evaluations revealed no documented evidence that the facility completed performance evaluations for Employee 7, 8, and 9 (nurse aides) at least once every 12 months. Interview with the Nursing Home Administrator on July 10, 2025, at 9:40 AM confirmed that performance evaluations were not completed annually on the three employees requested. 28 Pa. Code 201.19 (2) Personnel policies and procedures

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff interview, it was determined that the facility failed to develop and implement an individualized person-centered care plan to address dementia and cognitive loss displayed by three of five residents reviewed (Residents 33, 52, and 61). Findings include: Clinical record review for Resident 33 revealed the facility admitted her on March 26, 2025, with diagnosis including Dementia (loss of memory, language, problem-solving, and other thinking abilities that interfere with daily life). A review of Resident 33's admission Minimum Data Set Assessment (MDS, a form completed at specific intervals to determine care needs) dated March 31, 2025, indicated that the facility assessed Resident 33 as having a diagnosis of dementia. The facility determined that a care plan for dementia and cognitive loss would be developed. A review of Resident 33's care plan revealed that there was no indication that the facility had developed and implemented a person-centered care plan to address 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 observation and staff interview, it was determined that the facility failed to store food items in a safe and sanitary manner, maintain equipment in a sanitary condition, and prepare food items in accordance with professional standards in the facility's main kitchen.Findings include:Initial tour of the facility's main kitchen with Employee 6, Director of Dining Services, on July 8, 2025, at 10:00 AM revealed the following:A walk-in freezer contained a cardboard box with several items packaged in slide lock plastic bags. One bag contained baked beans with no label or dates. The other bag contained peeled, whole bananas with no label or dates. A concurrent interview with Employee 6 revealed it was unclear on when the items were packaged or the use by date.The top shelf of a storage unit located under the circulating fans in the walk-in freezer contained several packages of sliced flavored bread. There was a significant accumulation of ice on three of the bread packages. The dry goods storage area contained metal shelving units on wheels. The floor under four of the observed…

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, review of select facility policies and procedures, and staff interview, it was determined that the facility failed to offer recommended pneumococcal immunizations for five of five residents reviewed for immunizations (Resident 11, 18, 19, 23 and 29).Findings include:The policy entitled Pneumococcal Vaccine, last reviewed February 26, 2025, indicates that prior to or upon admission, residents will be assessed for eligibility to receive the pneumococcal vaccine, and when indicated, will be offered the vaccine within 30 days of admission. Administration of the pneumococcal vaccines or revaccinations will be made in accordance with the current CDC (Center for Disease Control and Prevention) recommendations at the time of the vaccinations.Review of Resident 11's clinical record revealed that the facility admitted her on January 28, 2021. Documentation in Resident 11's clinical record revealed that she received a pneumococcal vaccine (Prevnar 13) prior to her admission in 2016, and the PPSV23 in 2001. According to the CDC guidance entitled Pneumococcal…

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 employee education records and staff interview, it was determined that the facility failed to ensure that nurse aides received 12 hours of in-service training annually for three of three nurse aides reviewed (Employees 7, 8, and 9).Findings include:During a meeting with the Nursing Home Administrator and Director of Nursing on July 8, 2025, at 2:00 PM the surveyor asked for training records to indicate that nurse aides had received at least 12 hours of in-service training in the last year for Employees 7, 8, and 9 (nurse aides).Interview with the Nursing Home Administrator and Director of Nursing on July 10, 2025, at 10:05 AM confirmed there was no documented evidence that the above employees received the required 12 hours of annual in-service training. 28 Pa. Code 201.19 (7) Personnel policies and procedures28 Pa. Code 201.20(a)(6)(d) Staff development

Based on clinical record review, review of select facility policies and procedures, and staff interview, it was determined that the facility failed to thoroughly investigate a resident's injury of unknown origin for one of 18 sampled residents (Resident 12).Findings include:The policy entitled Abuse, Neglect, Exploitation, or Misappropriation Reporting and Investigating, last reviewed without changes on February 26, 2025, revealed if resident abuse, neglect, exploitation, misappropriation of resident property, or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator, and other officials according to state law. Upon receiving any allegations of abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source, the administrator is responsible for determining what actions (if any) are needed for the protection of the residents. All allegations are thoroughly investigated.Clinical record review revealed the facility admitted Resident 12 on May 19, 2024. Nursing documentation dated April 15, 2025, at 1:38 PM…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff interview, it was determined that the facility failed to provide care and services to maintain or improve the ability to perform activities of daily living for one of two residents reviewed for eating concerns (Resident 12).Findings include:Clinical record review for Resident 12 revealed an MDS (Minimum Data Set, assessment completed at specific intervals to determine care needs) assessment dated [DATE], that staff assessed Resident 12 as requiring the supervision with set up help only for eating. Resident 12's next MDS assessment dated [DATE], revealed staff assessed Resident 12 as now requiring extensive assistance of one staff for eating.There was no documented evidence in Resident 12's clinical record to indicate that the facility identified or assessed Resident 12's decline in her ability to perform this activity of daily living.Interview with Employee 2 (registered nurse assessment coordinator) on July 10, 2025, at 11:45 AM confirmed these findings and stated 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 and staff interview, it was determined that the facility failed to provide the highest practicable care regarding physician ordered medication parameters for one of one resident reviewed for concerns (Resident 43) and failed to provide the highest practicable care regarding pacemaker care for one of one resident reviewed (Resident 384). Clinical record review for Resident 43 revealed a diagnosis list that included hypertension (high blood pressure), essential hypertension, and paroxysmal atrial fibrillation (an irregular heartbeat that comes and goes). Review of Resident 43's current care plan revealed the resident has an altered cardiovascular status related to the medical history. An intervention included to administer medications as ordered. A review of the current physician orders for Resident 43 dated May 6, 2025, indicated for staff to administer Metoprolol Succinate ER Extended Release (a medication that is used to treat high blood pressure and/or heart rate) 25 milligrams (mg) give one tablet orally at bedtime related to essential…

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 provide appropriate respiratory care and services for one of one resident reviewed (Residents 23).Findings include:Clinical record review revealed the facility admitted Resident 23 on December 26, 2019, with a diagnose of chronic obstructive pulmonary disease with (acute) exacerbation added on October 12, 2023. Observation of Resident 23 on July 8, 2025, at 10:50 AM and 1:25 PM revealed he was in his wheelchair with a nasal cannula (NC, tubing to deliver oxygen to the nose) on and running at 2.5 liters per minute (LPM).Observation of Resident 23 on July 9, 2025, at 10:53 AM revealed Resident 22 was in his wheelchair with oxygen on and running at 2.5 LPM.Review of Resident 23's physician orders revealed a current order for staff to administer Resident 23 oxygen continuous every shift at 1.5 liters via nasal canula.The findings were reviewed with the Nursing Home Administrator and Director of Nursing on July 9, 2025, at 12:00 PM.28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on clinical record review and resident and staff interview, it was determined that the facility failed to identify triggers related to a resident's diagnosis of Post-Traumatic Stress Disorder (PTSD), to provide culturally, competent, trauma-informed care, and to eliminate or mitigate re-traumatization for one of five residents reviewed for mood/behavior (Resident 59).Findings include:Clinical record review for Resident 59 revealed that the facility admitted him with a diagnosis of PTSD (PTSD, a mental and behavioral disorder that develops related to a terrifying event), on April 30, 2024.Interview with Resident 59 on July 9, 2025, at 8:45 AM revealed that he has PTSD that is triggered by loud noises, and other people screaming in the middle of the night. He said the screaming startles him and he wakes up panicked wondering what had happened. Further review of Resident 59's care plan revealed no evidence that the facility identified triggers (everyday situations that cause a person to re-experience the traumatic event as if it was reoccurring) for him related to his diagnosis…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff interview, it was determined that the facility failed to ensure a consultant pharmacist reviewed a resident's medication regimen monthly for one of five residents reviewed for potentially unnecessary medications (Resident 65).Findings include:Clinical record review for Resident 65 revealed that the resident was admitted on [DATE]. Clinical record review for Resident 65 revealed a diagnosis list that included Alzheimer's Disease (a brain disorder that affects memory, thinking, and cognitive abilities), cognitive impairment, and anxiety. Review of facility documentation for Resident 65 revealed a monthly medication regimen review dated April 10, 2025, from the consultant pharmacist. Further clinical record review for Resident 65 revealed no documentation that a licensed pharmacist completed required monthly medication regimen reviews for the resident during May and June 2025. Documentation for the completed monthly medication reviews was requested by the surveyor during…

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, observation, and staff and resident interview, it was determined that the facility failed to assist a resident to obtain routine dental care for one of one resident reviewed for dental concerns (Resident 23).Findings include:Observation and interview with Resident 23 on July 8, 2025, at 10:55 AM revealed he had several missing and broken bottom teeth. Resident 23 stated that he does not remember the last time he was offered dental services.Clinical record review revealed the facility admitted Resident 23 on December 26, 2019, with payment sources that included the state Medicaid benefit. Review of Resident 23's clinical record revealed a physician's order for a dental consult and follow up as needed on January 1, 2025. Further review of Resident 23's clinical record revealed his last dental visit was August 21, 2024.Interview with the Director of Nursing on July 10, 2025, at 10:19 AM confirmed Resident 23 did not receive dental care according to state plan. The facility failed to provide evidence that Resident 23 received routine prophylactic dental…

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 select policies and procedures, clinical record review, and staff interview, it was determined that the facility failed to ensure that nursing services met professional standards of quality according to the Pennsylvania Code Title 49, Professional and Vocational Standards, by failing to ensure licensed nursing staff were knowledgeable in the necessary care and services for one of one resident reviewed with a peripherally inserted central catheter (Resident CR1; Employee 3) Findings include: A request for the facility policy regarding a peripherally inserted central catheter (PICC, thin, soft, flexible tube inserted through a vein in the arm and passed through to the larger veins near the heart for the administration of fluids or medication) was made by the surveyor to the Nursing Home administrator (NHA) on December 11, 2024, at 11:20 AM and the Director of Nursing at 12:53 PM. A review of the policy provided by the facility titled, Intravenous Device Care, noted care of intravenous devices…

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

Based on observation and staff interview, it was determined the facility failed to store food and maintain food service equipment in a safe and sanitary manner and prevent the potential for food contamination in the facility's main kitchen. Findings include: An observation of the facility's main kitchen on July 30, 2024, at 9:37 AM revealed the following: A speed rack located beside the ovens was observed with trays of potatoes, as well as another tray at the bottom of the rack holding a container with a variety of equipment such as spatulas, spoons, labels, and pens. The tray contained dried spills and food splatter. A drawer unit under a preparation table across from the ovens was dusty, contained dried food debris, and food splatter. Lower shelves of preparation and storage tables throughout the kitchen where food preparation equipment was stored were observed with dust, crumbs, and dried spills. Flooring throughout the kitchen under preparation tables, steam tables, oven, coolers, and along wall edges, was observed with dirt and debris buildup, dried food, wrappers, soiled…

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, observation, and resident and staff interview, it was determined that the facility failed to accommodate resident needs regarding the accessibility of a call bell for two of 17 residents reviewed (Residents 25 and 53). Findings include: Clinical record review for Resident 25 revealed a diagnoses list that included: a need for assistance with personal care, weakness, and contracture of the muscles. A current care plan for Resident 25 revealed the resident is at risk for falling related to gait abnormality, a history of pain, incontinence, and other medical areas. An intervention listed on the care plan included to keep the call bell in reach. Observation of Resident 25 on July 31, 2024, at 9:48 AM revealed he was in bed. The call bell was observed not within reach with the call bell cord tucked between the resident's right side rail and mattress and the activator hanging down under the bed almost touching the floor. Observation of Resident 25 on August 1, 2024, at 11:10 AM revealed he was in bed. The call bell was observed out of his reach with the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, observation, and staff interview, it was determined that the facility failed to provide a written notice of the facility's bed hold policy to the resident or responsible party for two of seven residents reviewed for hospitalizations (Residents 8 and 13). Findings include: Review of Resident 8's clinical record revealed that she was admitted to the hospital on [DATE]. Resident 8 was still hospitalized at the time of the full health survey. There was no documented evidence in Resident 8's clinical record to indicate that the facility provided her responsible party written information on the facility's bed hold policy. Observation on August 2, 2024, at 12:15 PM confirmed that Resident 8's bed hold forms were still sitting in an envelope at the facility's front desk. Interview with the Director of Nursing on August 2, 2024, at 12:55 PM confirmed that if a resident's responsible party is unable to be contacted regarding a transfer, then the notice is sent out via the mail. 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 staff interview, it was determined that the facility failed to identify and refer a resident with a diagnosed mental disorder for level II review for one of one resident reviewed for PASRR (Pre-admission Screening and Resident Review) compliance (Resident 10). Findings include: The PA-PASRR-ID form (Pennsylvania Pre-admission Screening and Resident Review; PA-PASRR, federally required form to help ensure that all individuals are evaluated for serious mental disorder and/or intellectual disability to ensure applicants are not inappropriately placed in nursing homes for long term care) dated February 2016 and revised in September 2018, lists examples of serious mental illness including psychotic disorder and schizophrenia. The revised PA-PASRR-ID bulletin number 01-14-13, 03-14-10, 07-14-01, 55-14-01 dated March 1, 2014, revealed that nursing facilities are responsible for assuring the accuracy of information reported on the PA-PASRR-ID form. If the individual has a change in condition that affects target status a PA-PASRR-EV (Level II) will need 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 clinical record review and staff interview, it was determined that the facility failed to identify triggers related to a resident's diagnosis of Post-Traumatic Stress Disorder, to provide culturally, competent, trauma-informed care and eliminate or mitigate re-traumatization for one of one resident reviewed (Resident 10). Findings include: Clinical record review for Resident 10 revealed a current care plan entitled Behavioral Symptoms that identified her as having PTSD (Post Traumatic Stress Syndrome, a mental and behavioral disorder that develops from experiencing a traumatic event). The care plan goal was that Resident 10 would remain stable with interventions and medications as ordered. Further review of her care plan revealed that the facility failed to identify triggers that may retraumatize her related to her diagnosis of PTSD. A physician's progress note provided to the surveyor on August 2, 2024, at 9:30 AM dated November 24, 2004, indicated that Resident 10 was admitted from a personal care home after an alleged rape by another resident. The note also indicated…

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

Based on clinical record review and staff interview, it was determined that the facility failed to ensure a resident received or was offered pneumococcal conjugate vaccines for two of five residents reviewed for immunization concerns (Residents 7 and 168). Findings include: Clinical record review for Resident 7 revealed that the facility admitted her on March 12, 2024. Review of her immunizations in her clinical record revealed that there was no documentation related to the pneumococcal conjugate vaccines (vaccines administered to prevent pneumonia). Clinical record review for Resident 168 revealed that the facility admitted her on July 17, 2024. Review of her immunizations in her clinical record revealed that there was no documentation related to the pneumococcal conjugate vaccines. The Director of Nursing was made aware of concerns with Resident 7 and 168's pneumococcal vaccinations on August 2, 2024, at 1:01 PM. The facility failed to ensure the Residents 7 and 168 received the appropriate vaccinations as recommended. 28 Pa. Code 201.14(a) Responsibility of licensee 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.