Burgh Care Center

Based on review of the facility's infection control policies and procedures, facility documentation, and staff interview, it was determined that the facility failed to implement an antibiotic stewardship program for seven of 11 months (May 2025, June 2025, July 2025, August 2025, September 2026, October 2025, and November 2025).Findings include: Review of facility policy Antibiotic Stewardship dated 2/11/26, indicated the purpose of the antibiotic stewardship program is to monitor the use of antibiotics in our residents. Review of facility policy Antibiotic Stewardship - Review and Surveillance of Antibiotic Use and Outcomes dated 2/11/26, indicated the IP (infection preventionist), or designee, will review antibiotic utilization as part of the antibiotic stewardship program and identify situations that are not consistent with the appropriate use of antibiotics. Review of facility-provided documentation for May 2025 revealed an Order Listing Report printed on 12/9/25, at 12:02 p.m. The printed report failed to include evidence that antibiotic monitoring was completed for May 2025.…

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

Based on review of facility policy, facility in-service documentation, personnel files, and staff interviews, it was determined that the facility failed to provide training on Effective Communication for five of five staff members (Licensed Practical Nurse (LPN) Employee E6, Registered Nurse (RN) Employee E7, Nurse Aide (NA) Employee E8, NA Employee E9, and NA Employee E10).Findings include: Review of facility policy In-Service Training, All Staff dated 2/11/26, indicated all staff are required to participate in regular in-service education. Required training topics include the following: Effective communication with residents and family (direct care staff); Resident rights and responsibilities; Preventing abuse, neglect, exploitation, and misappropriation of resident property including dementia management and resident abuse prevention; elements and goals of the facility QAPI (Quality Assurance and Performance Improvement); the infection prevention and control program standards, policies and procedures; Behavioral health; and the compliance and ethics program standards, policies,…

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

Based on review of facility policy, facility in-service documentation, personnel files, and staff interviews, it was determined that the facility failed to provide training on Resident Rights for five of five staff members (Licensed Practical Nurse (LPN) Employee E6, Registered Nurse (RN) Employee E7, Nurse Aide (NA) Employee E8, NA Employee E9, and NA Employee E10).Findings include: Review of facility policy In-Service Training, All Staff dated 2/11/26, indicated all staff are required to participate in regular in-service education. Required training topics include the following: Effective communication with residents and family (direct care staff); Resident rights and responsibilities; Preventing abuse, neglect, exploitation, and misappropriation of resident property including dementia management and resident abuse prevention; elements and goals of the facility QAPI (Quality Assurance and Performance Improvement); the infection prevention and control program standards, policies and procedures; Behavioral health; and the compliance and ethics program standards, policies, and…

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

Based on review of facility policy, facility in-service documentation, personnel files, and staff interviews, it was determined that the facility failed to provide training on Abuse, Neglect, and Exploitation for five of five staff members (Licensed Practical Nurse (LPN) Employee E6, Registered Nurse (RN) Employee E7, Nurse Aide (NA) Employee E8, NA Employee E9, and NA Employee E10).Findings include: Review of facility policy In-Service Training, All Staff dated 2/11/26, indicated all staff are required to participate in regular in-service education. Required training topics include the following: Effective communication with residents and family (direct care staff); Resident rights and responsibilities; Preventing abuse, neglect, exploitation, and misappropriation of resident property including dementia management and resident abuse prevention; elements and goals of the facility QAPI (Quality Assurance and Performance Improvement); the infection prevention and control program standards, policies and procedures; Behavioral health; and the compliance and ethics program standards,…

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

Based on review of facility policy, facility in-service documentation, personnel files, and staff interviews, it was determined that the facility failed to provide training on the Quality Assurance and Performance Improvement (QAPI) program for five of five staff members (Licensed Practical Nurse (LPN) Employee E6, Registered Nurse (RN) Employee E7, Nurse Aide (NA) Employee E8, NA Employee E9, and NA Employee E10).Findings include: Review of facility policy In-Service Training, All Staff dated 2/11/26, indicated all staff are required to participate in regular in-service education. Required training topics include the following: Effective communication with residents and family (direct care staff); Resident rights and responsibilities; Preventing abuse, neglect, exploitation, and misappropriation of resident property including dementia management and resident abuse prevention; elements and goals of the facility QAPI; the infection prevention and control program standards, policies and procedures; Behavioral health; and the compliance and ethics program standards, policies, and…

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

Based on review of facility policy, facility in-service documentation, personnel files, and staff interviews, it was determined that the facility failed to provide training on Infection Control for five of five staff members (Licensed Practical Nurse (LPN) Employee E6, Registered Nurse (RN) Employee E7, Nurse Aide (NA) Employee E8, NA Employee E9, and NA Employee E10).Findings include: Review of facility policy In-Service Training, All Staff dated 2/11/26, indicated all staff are required to participate in regular in-service education. Required training topics include the following: Effective communication with residents and family (direct care staff); Resident rights and responsibilities; Preventing abuse, neglect, exploitation, and misappropriation of resident property including dementia management and resident abuse prevention; elements and goals of the facility QAPI (Quality Assurance and Performance Improvement); the infection prevention and control program standards, policies and procedures; Behavioral health; and the compliance and ethics program standards, policies, and…

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

Based on review of facility policy, facility in-service documentation, personnel files, and staff interviews, it was determined that the facility failed to provide training on Compliance and Ethics for five of five staff members (Licensed Practical Nurse (LPN) Employee E6, Registered Nurse (RN) Employee E7, Nurse Aide (NA) Employee E8, NA Employee E9, and NA Employee E10).Findings include: Review of facility policy In-Service Training, All Staff dated 2/11/26, indicated all staff are required to participate in regular in-service education. Required training topics include the following: Effective communication with residents and family (direct care staff); Resident rights and responsibilities; Preventing abuse, neglect, exploitation, and misappropriation of resident property including dementia management and resident abuse prevention; elements and goals of the facility QAPI (Quality Assurance and Performance Improvement); the infection prevention and control program standards, policies and procedures; Behavioral health; and the compliance and ethics program standards, policies, and…

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

Based on review of facility policy, facility in-service documentation, personnel files, and staff interviews, it was determined that the facility failed to provide training on Dementia Management and Resident Abuse Prevention for five of five staff members (Licensed Practical Nurse (LPN) Employee E6, Registered Nurse (RN) Employee E7, Nurse Aide (NA) Employee E8, NA Employee E9, and NA Employee E10) and failed to ensure that three of three sampled Nurse Aides received a minimum of 12 hours of in-service education per year (NA Employee E8, NA Employee E9, and NA Employee E10).Findings include: Review of facility policy In-Service Training, All Staff dated 2/11/26, indicated all staff are required to participate in regular in-service education. Required training topics include the following: Effective communication with residents and family (direct care staff); Resident rights and responsibilities; Preventing abuse, neglect, exploitation, and misappropriation of resident property including dementia management and resident abuse prevention; elements and goals of the facility QAPI…

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

Based on review of facility policy, facility in-service documentation, personnel files, and staff interviews, it was determined that the facility failed to provide training on Behavioral Health for five of five staff members (Licensed Practical Nurse (LPN) Employee E6, Registered Nurse (RN) Employee E7, Nurse Aide (NA) Employee E8, NA Employee E9, and NA Employee E10).Findings include: Review of facility policy In-Service Training, All Staff dated 2/11/26, indicated all staff are required to participate in regular in-service education. Required training topics include the following: Effective communication with residents and family (direct care staff); Resident rights and responsibilities; Preventing abuse, neglect, exploitation, and misappropriation of resident property including dementia management and resident abuse prevention; elements and goals of the facility QAPI (Quality Assurance and Performance Improvement); the infection prevention and control program standards, policies and procedures; Behavioral health; and the compliance and ethics program standards, policies, and…

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

Based on review of facility policy, review of personnel files, and staff interview, it was determined that the facility failed to properly screen an employee by failing to conduct a criminal background check prior to the start of employment for two of five personnel files reviewed (Nurse Aide (NA) Employee E4 and NA Employee E5).Findings include: Review of facility policy Abuse, Neglect, Exploitation and Misappropriation Prevention Program dated 2/11/26, indicated to conduct employee background checks and not knowingly employ or otherwise engage in any individual who has: been found guilty of abuse, neglect, exploitation, misappropriation of property, or mistreatment by a court of law; had a finding entered into the state nurse aide registry concerning abuse, neglect, exploitation, mistreatment of residents or misappropriation of their property; or a disciplinary action in effect against his or her professional license by a state licensure body as a result of a finding of abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property. On 4/7/26, at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, facility documents, clinical record reviews and staff interview it was determined that the facility failed to initiate a thorough investigation for injury of unknown origin for one of two residents reviewed (Resident R10)Findings include: Review of facility policy Abuse, Neglect, Exploitation or Misappropriation- Reporting and Investigating dated 2/11/26, indicated that all reports of resident abuse (including injuries of unknown origin), are reported to local, state, and federal agencies, and thoroughly investigated by facility management. 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 residents. The individual conducting the investigation as a minimum:Reviews the documentation and evidenceReviews the resident's medical record to determine the resident's physical and cognitive status at the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, facility documentation, clinical record review, and staff interview, it was determined that the facility failed to ensure residents had the capacity to understand the terms of the admission agreement for one of three residents (Resident R64).Findings include: Review of facility policy admission Criteria dated 2/11/26, indicated an objective of the admission criteria is to review with the resident, and/or his/her representative, the facility's policies and procedures relating to resident rights, resident care, financial obligations, visiting hours, etc. Review of the Resident Assessment Instrument 3.0 User's Manual effective October 2025 indicated that a Brief Interview for Mental Status (BIMS) is a screening test that aides in detecting cognitive impairment. The BIMS total score suggests the following distributions:13-15: cognitively intact 8-12: moderately impaired 0-7: severe impairment Review of the clinical record revealed Resident R64 was admitted to the facility on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and resident and staff interview, it was determined that the facility failed to promote a multidisciplinary approach with care conferences for two of six residents reviewed (Resident R36, R40).Findings include: Review of the clinical record indicated Resident R40 was admitted [DATE]. Review of Resident R40's Minimum Data Set, MDS (minimum data set a periodic review of assessment needs) dated 2/2/26, indicated diagnosis of epilepsy (chronic brain disorder characterized by recurrent, unprovoked seizures), spinal stenosis ( narrowing of space within the spine, which can compress the spinal cord and nerves) and chronic obstructive pulmonary disease(lung disease causing restricted airflow and breathing problems). Review of Resident R40's Multidisciplinary Care Conference sign in sheet dated 4/2/26, included the following disciplinary: social worker, dietary and therapy. Review of Resident R40's Multidisciplinary Care Conference sign in sheet dated 1/8/26, included the following…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of clinical records, and staff interview, it was determined that the facility failed to make certain that residents received proper treatment for pressure ulcers for one of three residents (Resident R6).Findings include: Review of the admission record indicated Resident R6 admitted to the facility on [DATE]. Review of Resident R6's Minimum Data Set (MDS - a periodic assessment of care needs) dated 2/2/26, indicated the diagnoses of anemia (the blood doesn't have enough healthy red blood cells), high blood pressure, and End Stage Renal Disease (ESRD -kidneys cease to function on a permanent basis leading to the need for a regular course of long-term dialysis or a kidney transplant to maintain life). Review of Resident R6's care plan dated 3/7/26, indicated skin integrity: weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate (drainage). Review of Resident R6's progress note dated 1/30/26, indicated writer 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 review of facility policies, observations, clinical records, and staff interviews it was determined that the facility failed to make certain that appropriate treatments and services were provided for the use of a urinary catheter (a flexible tube inserted into the bladder to drain urine) for two of two residents (R1, and R73).Findings include: Review of the facility Catheters Care; Urinary last reviewed 2/11/26, Indicated the purpose of this procedure is to prevent infection of the resident's urinary tract. Be sure the catheter tubing and drainage bag are kept off the floor. Review of the admission record indicated Resident R73 was admitted to the facility on [DATE], with the diagnoses of neoplasm of prostate (abnormal growth of cells in the prostate gland), diabetes (a long-term condition in which the body has trouble controlling blood sugar and using it for energy), and obstructive uropathy (a blockage in the urinary tract that prevents normal urine flow). Review of the admission record 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical record review, and staff interviews it was determined that the facility failed to create a care plan for the care and management of a colostomy (a surgical operation in which a piece of the colon is diverted to an artificial opening in the abdominal wall so as to bypass a damaged part of the colon) for two of two residents (Resident R59, and R72).Findings include: Review of facility policy Colostomy/Ileostomy Care dated 2/11/26, indicated the purpose is to provide guidelines that will aid in preventing exposure of the resident's skin to fecal matter. Review the resident's care plan to assess for any special needs of the resident. Review of the admission record revealed that Resident R59 was admitted to the facility on [DATE]. Review of Resident R59's Minimum Data Set (MDS - a periodic assessment of care needs) dated 2/9/26, indicated diagnosis of malnutrition (lack of nutrients in the body), anal cancer, and difficulty walking. Section H0100 appliances 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of resident clinical records, facility policy and staff interview it was determined the facility failed to provide consistent and complete communication with the dialysis (treatment that helps body remove extra fluid and waste products) center for one of five residents (Resident R6).Findings include: Review of the facility policy Hemodialysis dated 2/11/26, indicated that the facility will assure that each resident receives care and services for the provision of hemodialysis consistent with professional standards of practice. This will include the ongoing assessments of the resident's condition and monitoring for complications before and after dialysis treatments received at a certified dialysis facility. Ongoing communication and collaboration with the dialysis facility regarding dialysis care and services. Review of the admission record indicated Resident R6 admitted to the facility on [DATE]. Review of Resident R6's Minimum Data Set (MDS - a periodic assessment of care needs) dated 2/2/26,…

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, observations, and staff interviews, it was determined that the facility failed to properly store medical supplies in one of two medication carts (Fourth Floor South Cart).Findings: Review of facility Storage of Medications policy dated 2/11/26, indicated the facility stores all drugs and biologicals in a safe, secure, and orderly manner. Drugs and biologicals are stored in the packaging, containers, or other dispensing systems in which they are received. Drugs that have missing, incomplete, improper, or incorrect labels are returned to the pharmacy for proper labeling. Review of facility Labeling of Medication Containers policy dated 2/11/26, indicated all medication maintained in the facility are properly labeled in accordance with current state and federal guidelines and regulations. Any medication packaging that are inadequately or improperly labeled are returned to the issuing pharmacy. Only the dispensing pharmacy can label or alter the label on medication package. During a medication cart review on 4/6/26, at 10:21 a.m. the following were…

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, facility documents, clinical record review, and staff interview it was determined that the facility failed to ensure residents had the capacity to understand the terms of a binding arbitration agreement (a binding agreement by the parties to submit to arbitration all or certain disputes which have arisen or may arise between them in respect of a defined legal relationship, whether contractual or not) for one of three residents (Resident R64).Findings include: Review of facility policy admission Criteria dated 2/11/26, indicated an objective of the admission criteria is to review with the resident, and/or his/her representative, the facility's policies and procedures relating to resident rights, resident care, financial obligations, visiting hours, etc. Review of the Resident Assessment Instrument 3.0 User's Manual effective October 2025, indicated that a Brief Interview for Mental Status (BIMS) is a screening test that aides in detecting cognitive impairment. The BIMS total…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to make certain that an influenza immunization was offered to one of five residents (Resident R26).Findings include: Review of facility policy Influenza, Prevention and Control of Seasonal dated 2/11/26, indicated all residents and staff are offered the vaccine prior to the onset of the influenza season. Review of facility policy Vaccination of Residents dated 2/11/26, indicated all residents will be offered vaccines that aid in preventing infectious diseases unless the vaccine is medically contraindicated or the resident has already been vaccinated. Review of the clinical record revealed Resident R26 was admitted to the facility on [DATE]. Review of Resident R26's Minimum Data Set (MDS - a periodic assessment of care needs) dated 2/7/26, indicated diagnoses of high blood pressure, anxiety, and depression. Question O0250: Influenza Vaccine indicated Resident R26 did not receive the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to make certain that a COVID-19 vaccination was offered to two of five residents (Residents R26 and R48).Findings include: Review of facility policy Coronavirus Disease (COVID-19) - Vaccination of Residents dated 2/11/26, indicated each resident is offered the COVID-19 vaccine unless the immunization is medically contraindicated or the resident has already been immunized. Review of the clinical record revealed Resident R26 was admitted to the facility on [DATE]. Review of Resident R26's Minimum Data Set (MDS - a periodic assessment of care needs) dated 2/7/26, indicated diagnoses of high blood pressure, anxiety, and depression. Question O0350 was coded no for Resident's COVID-19 vaccination is up to date. Review of Resident R26's clinical record indicated the resident last received a COVID-19 vaccination on 11/5/21. Review of Resident R26's clinical record failed to include documentation…

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 documentation, and staff interviews, it was determined that the facility failed to make certain that equipment was in safe operating condition for one of two of the facilities crash carts (a cart that contains supplies in the event of an emergency), (Fourth Floor) and one of two Automated External Defibrillator (AED-a portable, electronic device designed to diagnose and treat life-threatening cardiac arrhythmias), (Fourth Floor). Findings include: Review of facility Crash Cart policy dated [DATE], indicated to establish a standardized approach for the maintenance, accessibility, and utilization of crash carts to support timely responses to medical emergencies. All contents must be within expiration dates. Review of facility Automatic External Defibrillator, Use and Care of policy dated [DATE], indicated personnel have completed training on the initiation of cardiopulmonary resuscitation (CPR) and basic life support, including defibrillation, for victims of sudden cardiac…

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, facility policy, and staff interview, it was determined that the facility failed to ensure comfortable air temperature levels were provided for one of two nursing units (2nd floor).Findings Include: Review of the facility policy Safe and Homelike Environment, dated 7/24/25, indicated in accordance with residents' rights, the facility will provide a safe, clean, comfortable and homelike environment, allowing the resident to use his or her personal belongings to the extent possible. The facility will maintain comfortable and safe temperature levels. The facility should strive to keep the temperature in common resident areas between 71 and 81 degrees Fahrenheit. During an interview and tour on 1/29/26, at 10:45 a.m., with the Nursing Home Administrator (NHA) the following areas indicated inadequate temperatures: 2nd Floor:room [ROOM NUMBER] - 64 degrees Fahrenheitroom [ROOM NUMBER] - 66 degrees Fahrenheitroom [ROOM NUMBER] - 67 degrees Fahrenheitroom [ROOM NUMBER] - 66 degrees Fahrenheitroom…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical record and staff interview it was determined that the facility failed to make certain consistent dialysis communication was maintained for two of three residents (Resident R1 and Closed Record Resident CR1).Findings include: Review of facility policy Hemodialysis dated 7/24/25, indicated the facility will ensure that each resident receives care and services for the provision of hemodialysis consistent with professional standards of practice. This will include ongoing communication and collaboration with the dialysis facility regarding dialysis care and services. The licensed nurse will communicate to the dialysis facility via telephone communication or written format, such as a dialysis communication form or other form. Ongoing assessment and oversight of the resident before, during and after dialysis treatments. Review of the admission record indicated Resident R1 was re-admitted to the facility on [DATE], with the diagnosis of End Stage Renal Disease (ESRD -kidneys…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of clinical records, facility documents, and staff interviews, it was determined that the facility failed to provide behavioral services from outside vendors in a timely and accurate manner for two of three residents (Resident R2 and CR1).Findings include: Review of the facility policy Use of Outside Resources dated 7/24/25, indicated the facility assumes responsibility for obtaining services that meet professional standards and principles that apply to professionals providing services. The facility assumes responsibility for the timeliness of the services provided by those professionals. Review of the admission record indicated that Resident R2 admitted to the facility on [DATE]. Review of Resident R2's Minimum Data Set (MDS - a periodic assessment of care needs) dated 9/3/25, indicated the diagnosis of high blood pressure, diabetes (a long-term condition in which the body has trouble controlling blood sugar and using it for energy), and anxiety (intense, excessive, and persistent worry and fear…

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

Based on a review of regulations, documents submitted to the State agency and staff interviews it was determined that the facility failed to notify the State agency of a change in the facility's Medical Director at the time of the change. Findings include: Review of the facility's data indicated Doctor Employee E1 was the Medical Director effective 1/1/20. During an interview on 10/14/25, at 1:00 p.m. the Nursing Home Administrator indicated Doctor Employee E1 no longer worked there and the new Medical Director was Doctor Employee E2 effective 7/24/25. During an interview on 10/14/25, at 1:00 p.m. the Nursing Home Administrator confirmed the facility failed to notify the State agency of a change in the facility's Medical Director at the time of the change. 28 PA Code: 201.14(a) Responsibility of licensee.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and staff interview, it was determined the facility failed to provide a bed frame, a mattress and functional furniture in resident rooms on one of three units (Third Floor). Findings include: Review of the Code of Federal Regulations (CFR) 483.90(e)(2) -The facility must provide each resident with-- (i) A separate bed of proper size and height for the safety and convenience of the resident; (ii) A clean, comfortable mattress; (iii) Bedding, appropriate to the weather and climate; and (iv) Functional furniture appropriate to the resident's needs. Observation on 5/19/25, at 3:00 p.m., of the Third-Floor nursing unit indicated the following: - room [ROOM NUMBER] (dual occupancy room) was missing one bed frame, two mattresses, and furniture. - room [ROOM NUMBER] (dual occupancy room) was missing one bed frame, two mattresses, and furniture. - room [ROOM NUMBER] (single occupancy room) was missing one bed frame, one mattress, and furniture. - room [ROOM NUMBER] (single occupancy room) was missing…

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

Based on a review of facility policies, four week cycle menu, and staff interviews it was determined that the facility failed to have a Registered Dietitian review and approve the four week cycle menu and nutritional substitutes prior to implementation for ten out of ten months (June 2024 to December 2024; January 2025 to March 2025). Findings include: The facility Food and nutritional services policy last reviewed 9/18/24, indicated each resident is provided with a nourishing, well-balanced diet that meets his or her daily nutritional and special dietary needs. Review of the facility four week cycle menu and nutritional substitutes did not include a signed review from June 2024 to March 2025 by Registered Dietitian Employee E7. During an interview on 4/1/25, at 1:41 p.m. the Nursing Home Administrator (NHA) confirmed that the facility failed to have a Registered Dietitian review and approve the three week cycle menu and nutritional substitutes prior to implementation from June 2024 to March 2025 as required. 28 Pa Code: 211.6(a) Dietary services.

Based on review of facility policy, observations, and staff interviews, it was determined the facility failed to properly monitor essential equipment and log dish machine temperatures per shift in the main kitchen for ten of ten months (June 2024 to December 2024; January 2025 to March 2025). Findings include: The facility Dish machine temperature policy dated 9/18/24, indicated to complete a test run before putting any dishes into the dish machine. If the machine reaches the required temperature, record the temperature on the dish machine monitoring log. During a tour on 4/1/25, at 9:51a.m. observations of dish machine/ dish-room area, a posting with required dish machine temperatures read: (wash-140 F; rinse 120F ; final rinse 120F). Tour of the kitchen did not find a per shift log of the temperatures for the dish machine. During a tour on 4/1/25, at 12:48 p.m. observations of the dish washing machine with Dietary manager Employee E5 and Corporate director of dining services Employee E6, tour of the kitchen did not find a per shift log of the temperatures for the dish machine.…

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, observations, and staff interviews, it was determined that the facility failed to prevent cross contamination during a dressing change for one of three residents (Resident R22) failed to prevent cross contamination during a medication pass for two of three residents (Resident R9 and R12) and failed to ensure an infection control surveillance plan was implemented and staff and residents were tested in accordance with national standards. Findings include: Review of the facility policy Administering Medication last reviewed 9/18/24, indicate staff follows established facility infection control procedures (e.g., handwashing, antiseptic technique, gloves, isolation precaution, etc.) for the application if medications. Review of the facility policy Handwashing/Hand Hygiene last reviewed 9/18/24, indicate the facility considers hand hygiene the primary means to prevent the spread of infection. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personal, residents, and visitors. 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 the facility's infection control policies and procedures and staff interview, it was determined that the facility failed to implement an antibiotic stewardship program for ten of ten months (June 2024 through February 2025). Findings include: Review of facility policy Antibiotic Stewardship Program Policy dated 9/18/24, indicated the purpose of the facility's antimicrobial stewardship program is to monitor the use of antibiotics in the residents. If an antibiotic is ordered the indications for use will be included. Review of the facility's Infection Control surveillance for October 2024 through February 2025, failed to include documentation to indicate that antibiotic monitoring was completed. During an interview on 4/4/25, at 8:51 a.m., the IP (infection preventionist) Employee E8 was unable to provide antibiotic monitoring from June 2024 until September 2024. October 2024 through February 2024 failed to include documentation including diagnoses and responses to indicate that antibiotic monitoring was completed. IP, Employee E8 stated, I am still just learning…

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

Based on a review of select facility policy and staff interview, it was determined the facility failed to designate a qualified individual(s) onsite, who is responsible for implementing programs and activities to prevent and control infections (January 2025 to March 2025). Findings included: The Centers for Medicare and Medicaid Services regulation §483.80(b)(3) states the facility must designate one or more individuals as the infection preventionist who are responsible for the facility's Infection Prevention and Control Program. The IP (infection preventionist) must work at least part-time at the facility, physically work onsite in the facility, have primary professional training in nursing, medical technology, microbiology, epidemiology, or other related field, cannot be an off-site consultant or perform the IP work at a separate location. During an interview on 4/4/25, at 8:51 a.m., the IP, Employee E8 stated, I am still just learning what to do. IP Employee E8 started this role in January 2025. IP, Employee E8 became certified as of 3/27/25. During an interview on 4/4/25, at…

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

Based on review of facility policy, facility documents, and staff interview, it was determined that the facility failed to provide training on Quality Assurance and Performance Improvement (QAPI) for five of five staff members (Employee E21, E26, E27, E28, and E29). Findings include: Review of facility education documents for the year 2024, revealed the following concerns: Review of Nurse Aide (NA) Employee E21's facility provided information did not include training on QAPI. Review of NA Employee E26's facility provided information did not include training on QAPI. Review of NA Employee E27's facility provided information did not include training on QAPI. Review of NA Employee E28's facility provided information did not include training on QAPI. Review of NA Employee E29's facility provided information did not include training on QAPI. During an interview 4/4/25, at 2:30 p.m. Human Resource (HR) Employee E30 confirmed that the facility failed to provide training on Quality Assurance and Performance Improvement (QAPI) for five of five staff members. (Employee E21, E26, E27, E28, and…

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

Based on review of facility documentation, interview with residents and observations the facility failed to implement an activites program that met residents needs for four of six residents (Resident R300, R301, R302 and R303). Findings include: During resident interviews on 4/1/25 and 4/2/25 residents indicated that they did not feel the activities were meeting their needs. Resident R300, R301, R302, and R303 indicated they would like to have different types of activities, more variety, outside activities, to include if you don't smoke being able to go outside, creative and challenging activities, that keep them interested in things. They feel like there aren't sufficient activities to keep them interested. Review of the resident activity calendars from: January with facility activities ending at 2pm in Janaury of 2025 For February of 2025 activities ending at 3pm on 4 days of the month (the other activities ending at 2pm. March activities ending at 3pm. Review of the resident activity calendar indicated that independent activites included word searches, board games, reading,…

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

Based on review of facility documentation and staff interview it was determined that the facility failed to employed a qualified activities director from October of 2024 to April of 2025. Findings include: Federal Regulation indicates the following: §483.24(c)(2) The activities program must be directed by a qualified professional who is a qualified therapeutic recreation specialist or an activities professional who- (i) Is licensed or registered, if applicable, by the State in which practicing; and (ii) Is: (A) Eligible for certification as a therapeutic recreation specialist or as an activities professional by a recognized accrediting body on or after October 1, 1990; or (B) Has 2 years of experience in a social or recreational program within the last 5 years, one of which was full-time in a therapeutic activities program; or (C) Is a qualified occupational therapist or occupational therapy assistant; or (D) Has completed a training course approved by the State. Review of Activity Director Employee E25 file failed to include any of the above documentation or information. During an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical record, and staff interviews, it was determined that the facility failed to maintain a complete record of pre and post dialysis assessments for three out of five sampled resident records (Resident R20, R38, and R233). Findings include: The facility Hemodialysis care policy 9/18/24, indicated that hemodialysis (a treatment for advanced kidney failure that filters wastes, salts, and fluid from your blood) devices may only be accessed by personnel who have received training and demonstrated clinical competency. Review of Resident R20's clinical record revealed, the resident was admitted to the facility on [DATE], with diagnoses of dependence on renal dialysis (acts like an artificial kidney, removes waste and fluid from the body), end stage renal disease (the final stage of chronic kidney disease where the kidney can no longer filter waste and excess fluids from the blood effectively), and heart failure (a condition where the heart muscle doesn't pump blood as well as it…

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, resident observations, resident and staff interviews, and grievance review, it was determined that the facility failed to have sufficient nursing staff to provide nursing and related services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of two of two residents (Residents R20 and R77). Findings Include: The job description for the Nursing Home Administrator dated 10/29/24, specified the primary purpose of the job is to manage the facility in accordance with current applicable, federal, state, and local standards, guidelines, and regulations the govern long-term care facilities. It is the NHA job to follow all facility policies and to ensure the highest degree of quality care is provided to the residents at all times. The job description for the Director of Nursing dated 9/16/24, specified it is the responsibility of the DON to organize, develop, and direct the overall operations of the Nursing Service Department in accordance 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 review of facility policy, Nursing staff personnel records, nurse training documentation and staff interview, it was determined that the facility failed to ensure the facility had sufficient nursing staff with the appropriate competencies and skills sets to provide tracheostomy care for four of four staff members (Licensed Practical Nurse, Employee E1, Registered Nurse Supervisor E2, LPN, Employee E9 and LPN, Employee E11). Findings include: During an interview on 3/31/25, at 11:26 a.m. LPN, Employee E1 was asked if they were trained on tracheostomy care. LPN, Employee E1 indicated it was their first day and the facility did not train or educate LPN, Employee E1 on tracheostomy care. LPN, Employee E1 confirmed they were assigned to Resident R34 and indicated they had experience in pediatric trach care. Review of 4 of 4 employee files (LPN, Employee E1, RN Supervisor, Employee E2, LPN, Employee E9 and LPN, Employee E11) on 3/31/25, failed to include evidence they were educated and competent on tracheostomy care. Review of the facility assessment on 3/31/25, at 2:06 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 policy, personnel records, and staff interview it was determined that the facility failed to complete annual performance evaluations for three out of five nurse aides (NA) (NA Employee E26, E27, and E29). Findings include: Review of nurse aide performance evaluations completed by the facility failed to include a performance evaluation for Nurse Aide Employee E26, with a hire date of 8/21/07. Review of nurse aide performance evaluations completed by the facility failed to include a performance evaluation for Nurse Aide Employee E27, with a hire date of 11/1/19. Review of nurse aide performance evaluations completed by the facility failed to include a performance evaluation for Nurse Aide Employee E29, with a hire date of 7/19/22. During an interview 4/4/25, at 2:30 p.m. Human Resource (HR) Employee E30 confirmed that the facility failed to complete annual performance evaluations for three of five nurse aides as required. 28 Pa Code: 201.20 (a)(b)(d) Staff development. 28 Pa Code: 201.14 (a) Responsibility of licensee.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility documentation, clinical records and staff interview it was determined that the facility failed to correctly label medication for two of four residents (Resident R2 and Resident R17) and failed to implement pharmaceutical services to ensure accurate provision of medications for two of four residents (Resident R4 and Resident R77). Findings include: Review of the facility policy, Medication Regimen Review dated 9/18/24, indicated the Medication Regimen Review (MRR) or Drug Regimen Review, is a thorough evaluation of the medication regimen of a resident, with the goal of promoting positive outcomes and minimize adverse consequences and potential risks associated with medication. The MRR includes a review of the medical record in order to prevent, identify, report, and resolve medication related problems, medication errors, or other irregularities. Review of facility policy, Emergency Drug Services dated 9/18/24, indicated Pharmacy will provide any prescriptions and supplies requested by…

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

Based on facility policy review, observations, and resident and staff interviews, it was determined that the facility failed to maintain a safe, clean, and home-like environment for one of seven sampled residents (Resident R71). Findings include: The facility Homelike environment policy last reviewed 9/18/24, indicated that residents are provided with a safe, clean, comfortable and homelike environment with characteristics that include a sanitary and orderly environment. During observations on 4/3/25, at 2:27 p.m. observations of Resident R71 room was observed with chocolate milk on the floor, clear fluid on floor, cups, clothes on floor and one jacket on floor. During observations on 4/3/25, at at 2:53 p.m. observations of Resident R71 room was observed with chocolate milk on the floor, clear fluid on floor, cups, clothes on floor and one jacket on floor. Observations done with Nurse aide Employee E3 During an interview on 4/3/25, at 2:54 p.m. Nurse Aide Employee E3 stated: we will have housekeeping clean this. During observations on 4/5/25, at 9:32 a.m. observations of 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 documents, facility policy, clinical records, and resident staff interviews, it was determined that the facility failed to implement written policies and procedures to prohibit and prevent abuse, neglect, and exploitation of residents for one of five residents (Resident R34). Finding include: Review of facility policy Abuse: Protection from Abuse dated 9/18/24, indicated neglect is defined as the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. The facility must identify occurrences and patterns of potential mistreatment/abuse. Residents will be protected during the abuse investigation. Reporting and filing of accurate documents relative to incident must be completed, and regardless of how minor an accident or incident may be, it must be reported to the department supervisor as soon as such accident/incident is discovered or when such…

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, resident record, investigation documents and staff interview, it was determined that the facility failed to report an allegation of neglect failed to report an allegation of neglect for one of five sampled residents (Resident R70). Findings include: The facility Protection from abuse policy dated 6/2023, last reviewed 9/18/24, indicated that each resident has the right to be free from abuse. Abuse means the willful infliction of injury, unreasonable confinement, intimidation or punishment resulting in physical harm, pain, or mental anguish. Neglect is defined as the failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. Neglect refers to failure through inattentiveness, carelessness or omission. The reporting and filing of accurate documents relative to incidents of abuse and reporting to state agencies as required include the Department of Health, Department of Aging, and Area Agency on Aging as appropriate. 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, resident records, admissions documentation and staff interview it was determined that the facility failed to provide a comprehensive review of resident admission rights and maintain admission documentation for one out of four sampled records (Resident R69). Findings include: The facility Resident rights policy last reviewed 9/18/24, indicated that residents will be informed of their rights and responsiblities. Review of Resident R69's admission record indicated he was admitted on [DATE]. Review of Resident R69's MDS assessment (MDS: Minimum Data Set assessment-a periodic assessment of resident care needs) dated 12/20/24, indicated that he had diagnoses that included diabetes (metabolic disorder impacting organ function related to glucose levels in the human body) and dementia (a condition characterized by memory loss and progressive or persistent loss of intellectual functioning), and hypertension (a condition impacting blood circulation through the heart related to poor…

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 complete a significant change Minimum Data Set (MDS- assessments completed indicating a change in condition of a resident requiring change in care) assessment for one of four residents reviewed (Residents R281). Findings include: Review of the Resident Assessment Instrument 3.0 User's Manual (reference used to complete an MDS) effective October 2024, indicated that the facility must conduct a comprehensive assessment of a resident within 14 days after the facility determines, or should have determined, that there has been a significant change in the resident's physical or mental condition. A significant change is a major decline or improvement in a resident's status that: 1. Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions, the decline is not considered self-limiting; 2. Impacts more than one area of the resident's health status; and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based review of facility policy, clinical records, smoke observations and staff interviews, it was determined that the facility failed to develop and implement comprehensive care plans for one of two sampled residents (Resident R283). Findings include: The facility Smoking policy last reviewed 9/18/24, indicated that the facility has established and maintain safe resident smoking practices. A resident smoke status is evaluated upon admission, quarterly and upon a significant change. Review of Resident R283's admission record indicated he was admitted on [DATE]. Review of Resident R283's new admission nurse evaluation dated 3/27/25, indicated he had diagnoses that included hypertension (a condition impacting blood circulation through the heart related to poor pressure), hyperlipidemia (elevated lipid levels within the blood), and history of alcohol abuse. Review of Resident R283's smoke evaluation dated 3/27/25, indicated that he was identified as a smoker, he must be supervised during smoking, and he must wear a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical record review, and staff interviews, it was determined that the facility failed to make certain that residents were provided appropriate treatment and care for two of four residents (Resident R4 and R77). Findings include: Review of facility policy Administering Medications dated 2/12/25, indicated medications are administered in accordance with prescriber order, including any required time frame. Resident R4 was admitted to the facility on [DATE]. Review of Resident R4 MDS (minimum data set - a periodic assessment of resident needs) dated 2/26/25, had diagnosis of atrial fibrillation (irregular and often very rapid heart rhythm), neoplasm of breast (kind of breast cancer that begins in the cells of of the breast tissue) and osteoarthritis (joint disease in which tissues break down over time). Review of Resident R4 clinical record included hospital discharge record with physician order for a pureed diet. Review of resident R4 clinical record physician orders failed to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility documents, clinical records, and resident and staff interviews, it was determined that the facility failed to ensure that residents had proper assistive devices to maintain adequate hearing for one of two residents reviewed (Resident 34). Findings include: Review of the facility Hearing Impaired Resident, Care of dated 9/18/24, revealed staff will assist hearing impaired residents to maintain effective communication with clinician, caregivers, other residents and visitors. Staff will assist the resident (or representative) with locating available resources, scheduling appointments, and arranging transportation to obtain needed services. Staff must assist residents with the care and maintenance of hearing devices, and help those who have lost or damaged hearing devices in obtaining services to replace devices. Review of Resident R34's clinical record revealed that Resident R34 was admitted to the facility on [DATE], with diagnoses of tracheostomy (tube inserted through the neck to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical records, and staff interviews, it was determined that the facility failed to make certain that residents received the necessary services and ensure wound care recommendations were implemented timely for one of four residents (Resident R16). Findings include: Review of the facility Pressure Injury Risk Assessment dated 9/18/23, indicated risk factors that increase a resident's susceptibility to develop or not heal pressure injuries include impaired/decreased mobility and exposure of skin to urinary and fecal incontinence or other sources of moisture. Review of the facility Pressure Ulcers/Skin Breakdown policy dated 9/18/24, indicated staff and practitioner will assess and document an individual's significant risk factors for developing pressure ulcers. The physician will order pertinent wound treatments, including application of topical treatments. Review of the facility Care Plans, Comprehensive Person-Centered policy dated 9/18/24, revealed a comprehensive,…

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, clinical record review, and interview, the facility failed to have physician order specifications relating to size of indwelling catheter (a thin, flexible tube inserted into the bladder through the urethra to drain urine) and balloon inflation amount (secures catheter to bladder) for one of three residents (Resident R48). Findings include: Review of the facility policy Catheter Care, Urinary dated 9/18/25, indicated the purpose of this procedure is to prevent urinary catheter associated complications including urinary tract infections. Review the residents care plan to assess for any special needs of the resident. Review of admission record indicated Resident R48 was admitted to the facility on [DATE]. Review of Resident R48's Minimum Data Set (MDS- a periodic assessment of care needs) dated 2/14/25, indicated diagnoses of obstructive uropathy (blockage of the urinary flow), hypertension (high blood pressure) and heart failure (the heart doesn't pump the way it should). Section H0100…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical record review, and staff interviews, it was determined that the facility failed to ensure a resident received sufficient fluid intake to maintain proper hydration and health for one of four residents (Residents R20) and address a significant weight loss for one of four residents (Resident R68). Findings include: Review of facility policy Weighting and Measuring the Resident dated 9/18/24, indicated weights will be obtained to provide a baseline and an ongoing record of the resident's body weight as an indicator of the nutritional status and medical condition of the resident. The weight and all assessment data obtained while weighing the resident must be documented in the resident's medical record. Report significant weight loss/ weight gain to the nurse supervisor. The threshold of significant unplanned and undesired weight loss for one month is 5%, greater than 5% is severe. Review of facility policy Nutritional Assessment dated 9/18/24, revealed the dietician, 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 review of facility policy, clinical record review, observation, and staff interview, it was determined that the facility failed to ensure that residents with an enteral feeding tube (PEG - a tube inserted in the stomach through the abdomen) received appropriate treatment and services to prevent potential complications for one of two residents (Residents R281). Findings include: Review of facility policy Enteral Nutrition last reviewed 9/18/24, indicated adequate nutritional support through enteral nutrition is provided to residents as ordered. The use of enteral nutrition is based on the results of the comprehensive nutritional assessment, and is consistent with current standards of practice, the resident's advance directives, treatment goals and facility policy. Review of the clinical record indicated that Resident R281 was admitted to the facility on [DATE]. Review of Resident R281's Minimum Data Set (MDS- a periodic assessment of care needs) dated 1/31/25, indicates readmission on [DATE], 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.

Based on review of facility policy, observations, and staff interviews, it was determined that the facility failed to implement a care plan for intravenous therapy for one residents of two residents (Resident R24). Findings include: Review of the facility Care Plans, Comprehensive Person-Centered policy dated 9/18/24, revealed a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs in developed and implemented for each resident. Review of Resident R24's clinical record indicates an admission date of 2/25/25, with the diagnosis of high blood pressure, cellulitis (bacterial infection of skin) of left lower limb, and sepsis (a serious condition that occurs when the body has extreme reaction to an infection). Review of Resident R24's Minimum Data Set (MDS - a periodic assessment of care needs) dated 3/2/25, indicated diagnoses were current. Review of physician orders dated 2/25/25, indicated to change Resident R24's PICC line (thin tube that's inserted through a vein in your arm and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, resident record review, and staff interview, it was determined that the facility failed to develop care plans with identified triggers for residents with the diagnosis of Post Traumatic Stress Disorder (PTSD - a mental and behavioral disorder that develops related to a terrifying event) to prevent re-traumatization for three of three sampled residents (Resident R33, R38, and R42). Findings include: The facility Trauma informed care policy dated [DATE], indicated all staff are provided in-services about trauma and trauma informed care. Trauma results from an event, series of events, or circumstance that is experienced by an individual and has lasting adverse effects. A trigger is a stimulus that prompts recall of a previous traumatic event. Care plans that address past trauma identify and decrease exposure to triggers. Review of Resident R33's admission record indicated she was admitted on [DATE]. Review of Resident R33's MDS assessment (MDS: Minimum Data Set assessment-a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the pharmacy recommendations, clinical record, and staff interview, it was determined that the facility failed to act on the pharmacy medication recommendations in a timely manner for one of five sampled residents (Resident R38). Findings include: The facility Medication regimen review policy dated 9/14/24, indicated that the drug regimen of each resident is reviewed at least once a month by a licensed pharmacist. Facility staff shall act upon all recommendations according to procedures for addressing medication regimen review irregularities. Review of Resident R38's admission record indicated he was originally admitted [DATE]. Review of Resident R38's MDS assessment (MDS: Minimum Data Set assessment-a periodic assessment of resident care needs) dated 9/4/24, indicated he had diagnoses that included Post-Traumatic Stress Disorder (PTSD - a mental and behavioral disorder that develops related to a terrifying event), chronic kidney disease (a loss of kidney function resulting in the swelling of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy, clinical record review, and staff interview it was determined the facility failed to ensure PRN orders for psychotropic drugs are limited to 14 days for one of five residents (Resident R12), failed to identify a diagnosed specific condition for treatment, and failed to monitor the effectiveness or adverse consequences of psychotropic medication use for one of five residents (Resident R82) reviewed. Findings Include: Review of facility policy Psychotropic Medication Use dated 9/18/24, indicated residents will not recieve medications that are not clinically indicated to treat a specific condition. As needed (PRN) psychotropics will be limited to 14 days. PRN orders cannot be reordered unless the physican pr prescirber evaluates the resident and documents the appropraiteness of the medication. Review of the clinical record indicated Resident R68 was admitted to the facility on [DATE], readmitted on [DATE], with diagnoses of high blood pressure, dementia he loss of cognitive functioning-…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical record review, and staff interview it was determined that the facility failed to make certain that residents are free from significant medication errors for two of six residents (R6 and R77). Findings: Review of facility policy Administering Medications dated 2/12/25, indicated medications are administered in accordance with prescriber order, including any required time frame. Review of the clinical record indicated Resident R6 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses of Influenza A, hypoxemia (abnormally low levels of oxygen in the blood), and sleep apnea (a sleep disorder where breathing is interrupted repeatedly during sleep characterized by loud snoring and episodes of stop breathing). Review of Resident R6's Minimum Data Set (MDS - a periodic assessment of care needs) dated 2/7/25, indicated diagnoses were current. Review of Resident R6's physician order dated 2/1/25, indicated starting on 2/3/25, to administer one capsule…

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, observations and staff interview it was determined that the facility failed to properly store medical supplies and biologicals in one of four medication carts (4th floor north hall medication cart) and one of two medication rooms (4th floor medication room). Findings include: A review of the facility policy Storage of Medications last reviewed 9/18/24, indicates the facility stores all drugs and biologicals in a safe, secure and orderly manner. A review of the facility policy Administering Medications last reviewed 9/18/24, indicated when opening a multi-dose container, the date opened is recorded on the container. During an observation on 4/4/25, at 9:44 a.m. of the 4th floor North medication cart contained the following: . 1 tube zinc oxide . 1 box lidocaine patches . 1 tube skin protectant . 1 60 cc flush piston with the expiration date of 8/2/.24 During an observation on 4/4/25, at 9:56 a.m. the 4th floor Medication room contained the following: . A box containing four opened wound vac kits. The area under the sink contained: . A Box of opened…

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, meal tray observations, staff and resident interviews, it was determined that the facility failed to provide menu selections according to the resident's preference for one of seven sampled residents (Resident R56). Findings include: The faciliity Food and nutritional services policy last reviewed 9/18/24, indicated that reasonable efforts will be made to accomodate residents' choices and preferences. During meal tray observations on 4/2/25, at 11:27 a.m. Second floor observations of first meal cart was being passed and lunch included the following: chicken a la king, peas, chilled peaches, a biscuit, coffee/juice. During meal tray observations on 4/2/25, at 11:36 a.m. Resident R56 lunch tray was observed with a single portion of protein. Resident R56 lunch ticket read to provide Double portion. During an interview on 4/2/25, at . 11:37 a.m. Resident R56 stated: the double portion is missing. During an interview on 4/2/25, at 12:41 p.m. information dissemenitated to Nursing Home Administrator (NHA) that the facility failed to provide menu…

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

Based on review of facility policy, facility scheduled mealtimes, meal delivery observations, resident council group interviews, resident and staff interviews it was determined that the facility failed to ensure that meals were served at regularly scheduled times for one of three meal observations (4/1/25-breakfast). Findings include: The facility Food and nutritional services policy last reviewed 9/18/24, indicated that meals will be provided within 45 minutes of scheduled meal time. During observation on 3/31/25, meal time posting stated the following meal time (breakfast arrives at 7:30 a.m.; lunch arrives at 11:30 a.m.; and dinner arrives at 5:30 p.m.). During an interview on 3/31/25, at 2:40 p.m. Resident R44 stated: the food is cold because it sits upstairs and then one hour later the trays are passed. During meal observations on 4/1/25, at 8:54 a.m. breakfast tray carts were observed on the Second floor. During an interview on 4/1/25, at 8:56 a.m. the Director of Nursing (DON) stated about tray time arrivals: the tray carts arrived 15 minutes ago. During an interview on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of clinical records, facility documents, and staff interviews, it was determined that the facility failed to schedule an appointment for outside services in a timely manner for two of two residents reviewed (Resident R34 and R77). Findings include: Review of Resident R34's clinical record revealed that Resident R34 was admitted to the facility on [DATE], with diagnoses of tracheostomy (tube inserted through the neck to assist breathing) status, repeated falls, and gastro-esophageal reflux disease without esophagus (also known as GERD, occurs when stomach acid frequently flows back into the esophagus, leading to irritation and discomfort.) Review of Resident 34's MDS (Minimum Data Set, periodic assessment of resident care needs) dated 2/28/25, indicated diagnoses were current. Review of Resident R34's physician order dated 3/11/25, indicated the resident was scheduled a tracheostomy evaluation on 3/19/25, at 10:00 a.m. Review of Resident R34's clinical record on 3/31/25, at 11:32 a.m. failed to…

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

Based on review of facility documentation and previous surveys and results of the current survey, it was determined that the facility Quality Assurance Performance Improvement (QAPI) committee failed to correct quality deficiencies and ensure that plans to improve the delivery of care and services effectively addressed deficiencies. Findings include: The facility deficiencies and plans of corrections for a State Survey and Certification (Department of Health) survey ending March 13, 2025, revealed that the facility developed plans of correction that included quality assurance systems to ensure that the facility maintained compliance with cited nursing home regulations. Findings of the current survey ending April 5, 2025, included deficiencies that were repeated from previous surveys and were new that reached of harm and potential harm (F600 as repeated and F695 as current). An interview on April 5, 2025, with Nursing Home Administrator confirmed that the facility had a previous deficiency on March 13,2025 and current deficiencies for F600 and F695, failed to correct quality…

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 job descriptions, clinical records and staff interviews, it was determined that the Nursing Home Administrator (NHA) and the Director of Nursing (DON) failed to effectively manage the facility to prevent the elopement of a resident (Resident R1), which created an immediate jeopardy situation for one of five residents. Findings include: The job description for the Nursing Home Administrator dated 10/29/24, specified the primary purpose of the job is to manage the facility in accordance with current applicable, federal, state, and local standards, guidelines, and regulations the govern long-term care facilities. It is the NHA job to follow all facility policies and to ensure the highest degree of quality care is provided to the residents at all times. The job description for the Director of Nursing dated 9/16/24, specified it is the responsibility of the DON to organize, develop, and direct the overall operations of the Nursing Service Department in accordance with current federal, state and local standards, guidelines and regulations that govern the facility. Based…

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 documents, and staff interviews it was determined the facility failed to designate a physician to serve as medical director. Findings Include: Review of the facility's medical director contract dated 12/1/23, signed by Doctor of Osteopathic Medicine (DO), Employee E14 indicated a medical group is to provide medical directorship and oversight services for the facility and to provide clinical medical services to the patients on each unit as medically necessary. It was stated the medical group agrees to assign physicians to provide such services. Review of information submitted to the Department of Health, on 3/12/25, at 1:30 p.m. revealed Medical Director, Employee E16 was the designated Medical Director of the facility since 1/1/20. During an interview on 3/12/25, at 2:47 p.m. Regional Clinical Specialist, Employee E9 stated Medical Director, Employee E15 works for a medical group. It was indicated she became the facility's Medical Director within the last seven to eight months. During an interview on 3/13/25, at 1:18 p.m. Medical Director, Employee E15…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical record review and staff interview, it was determined that the facility failed to fully investigate an incident to eliminate possible abuse or neglect for one of three residents (Resident R1). Findings include: Review of the facility Accidents and Incidents-Investigating and Reporting policy reviewed 9/1/24, indicated all incidents involving residents shall be investigated and reported to the administrator. It was indicated witnesses and their accounts of the incident must be included in the Report of Incident/Accident Form. Review of Resident R1's admission record indicated he was admitted on [DATE], with diagnoses of opioid abuse, alcohol abuse, psychoactive substance abuse, and cerebral infarction (commonly referred to as a stroke, occurs when the blood supply to the brain is interrupted, leading to a lack of oxygen and nutrients to brain cells.) Review of information submitted to the Department of Health on 2/26/25, indicated on 2/25/25, Resident R1 had an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical record review, resident and staff interviews it was determined that the facility failed to provide discharge planning for resident needs prior to discharge for one of three residents (Resident R1). Findings include: Review of the facility policy Discharging the Resident last reviewed 9/18/24, indicated the resident should be consulted about the discharge process. The resident's condition must be assessed and documented at discharge including skin assessment, if medical condition allows. All ambulatory residents being discharged must be transported to the pickup area by wheelchair. All the necessary equipment and supplies should be assembled to discharge the resident. Review of Resident R1's admission record indicated he was admitted on [DATE], with diagnoses of opioid abuse, alcohol abuse, and other psychoactive substance abuse, and cerebral infarction (commonly referred to as a stroke, occurs when the blood supply to the brain is interrupted, leading to a lack 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 clinical records, as well as staff interviews, it was determined that the facility failed to ensure a physician completed the initial visit for one of three residents (Resident R2). Findings include: Review of the facility policy Physician Services last reviewed 9/18/24, indicated the medical care is supervised by a licensed physician. Physician visits are provided in accordance with current OBRA (Omnibus Budget Reconciliation Act, also known as Nursing Home Reform Act of 1987, which set forth federal standards of how care should be provided to residents) regulation and facility policy. Review of Resident R2's clinical record indicated admission to the facility on 2/7/25, with diagnoses of anemia, bacteremia, and heart failure. Review of Resident R2's clinical record revealed a new patient visit was completed by Certified Registered Nurse Practitioner, Employee E17 on 2/11/24. The facility failed to ensure the resident's initial visit was conducted by a physician. Review of Resident R2's clinical record revealed a history and physical visit completed by Medical…

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 record review and staff interviews, it was determined that the facility failed to ensure that residents were provided a written notice of his or her rights and services provided, as well as all rules and regulations governing resident conduct and responsibilities during their stay in the facility prior to or upon admission for two of four residents (Residents R2 and R3). Findings include: Review of the facility provided admission Packet included: application for admission, personal information, legal representation, choice of funeral home, income information, provision of services, charges and billing, Medicare/Medicaid programs, personal finances, transfers, bed holds, resident responsibilities, personal properly, notice of privacy practices, authorization of treatment, grievance procedures, and the facility arbitration agreement. Review of resident records conducted on 10/1/24, revealed the following: Resident R2 was admitted on [DATE], with no signed admission agreement, or authorization to treat…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical record review, and staff interviews, it was determined that the facility failed to ensure the physician was appropriately notified of a change in condition for one of three residents reviewed (Resident R1). Findings include: Review of facility policy Acute Condition Changes - Clinical Protocol dated [DATE], indicated before contacting a physician about someone with an acute change of condition, the nursing staff will collect pertinent details to report to the physician. Phone calls to attending or on-call physicians should be made by an adequately prepared nurse who has collected and organized pertinent information, including the resident/patient's current symptoms and status. The nursing staff will contact the physician based on the urgency of the situation. For emergencies, they will call or page the physician and request a prompt response (within approximately one-half hour or less). Review of facility policy Management of Hypoglycemia dated [DATE], 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, job descriptions, clinical record review, and staff interviews, it was determined that the facility failed to provide care and services to meet the accepted standards of practice for one of five residents reviewed (Resident R1). Findings include: Review of the facility's Licensed Practical Nurse (LPN) Supervisor job description indicated the LPN will prepare and administer medications as ordered by the physician. Review of facility policy Administering Medications dated 3/27/24, indicated the individual administering the medication checks the label THREE (3) times to verify the right resident, right medication, right dosage, right time, and right method (route) of administration before giving the medication. Review of facility policy Intramuscular Injections dated 3/27/24, indicated an intramuscular (a technique used to deliver a medication deep into the muscles, allowing the bloodstream to absorb the medication quickly) injection can be administered in the following sites: -…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical record review, and staff interviews, it was determined that the facility failed to make certain that residents were provided appropriate treatment and care by failing to implement the facility's hypoglycemia protocol and failing to notify the physician timely of a change in condition for one of five residents reviewed (Resident R1). Findings include: Review of facility policy Acute Condition Changes - Clinical Protocol dated [DATE], indicated before contacting a physician about someone with an acute change of condition, the nursing staff will collect pertinent details to report to the physician. Phone calls to attending or on-call physicians should be made by an adequately prepared nurse who has collected and organized pertinent information, including the resident/patient's current symptoms and status. The nursing staff will contact the physician based on the urgency of the situation. For emergencies, they will call or page the physician and request a prompt response…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical record review, and interviews with staff, it was determined that the facility failed to ensure that residents are free of significant medication errors for one of five residents reviewed (Resident R1). Findings include: Review of the facility's Licensed Practical Nurse (LPN) Supervisor job description indicated the LPN will prepare and administer medications as ordered by the physician. Review of facility policy Administering Medications dated 3/27/24, indicated the individual administering the medication checks the label THREE (3) times to verify the right resident, right medication, right dosage, right time, and right method (route) of administration before giving the medication. Review of facility policy Intramuscular Injections dated 3/27/24, indicated an intramuscular (a technique used to deliver a medication deep into the muscles, allowing the bloodstream to absorb the medication quickly) injection can be administered in the following sites: - Vastus lateralis…

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, observation and staff interview it was determined that the facility failed to ensure infection control and prevention practices were implemented on one of two nursing units observed (3rd floor). Findings include: Review of facility policy Infection Control Plan dated 12/11/23, indicated the facility would ensure that the highest standards of Infection Control Practices are met. During an observation on 10/1/24, at 12:30 p.m., revealed urine soaked linens on Resident R4's bed during lunch service. Resident R4 stated that NA's would be back after lunch to get them. During an interview on 10/1/24 at 2:15 p.m., Nursing Home Administrator and Director of Nursing confirmed that the facility failed to properly maintain infection control practices for the 3rd floor. 28 Pa. Code 207.2(a) Administrators Responsibility 28 Pa. Code 211.10(c)(d) Resident care policies

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of clinical records, facility documentation, and staff interviews, it was determined that the facility failed to protect a resident from neglect by not providing appropriate assistance with transfers using a mechanical lift for one of four residents (Resident R1). Findings include: Review of facility policy Abuse and Neglect dated 3/27/24, indicated neglect is defined as the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Review of facility policy Lifting Machine, Using a Mechanical dated 3/27/24, indicated a least two (2) nursing assistants are needed to safely move a resident with a mechanical lift. Mechanical lifts may be used for tasks that [NAME] transferring a resident from bed to chair. Review of the clinical record indicated Resident R1 was admitted to the facility on [DATE]. Review of Resident R1's Minimum Data Set (MDS - a periodic assessment of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility documents, facility policy, clinical records, and staff interviews, it was determined that the facility failed to implement written policies and procedures to prohibit and prevent abuse, neglect, and exploitation of residents for one of four residents (Resident R1). Finding include: Review of facility policy Abuse and Neglect dated 3/27/24, indicated neglect is defined as the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Review of facility policy Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating dated 3/27/24, indicated 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 to other officials according to state law. Review of the clinical record indicated Resident R1 was admitted…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical record review, investigation documentations, and staff interviews, it was determined that the facility failed to conduct a thorough investigation to rule out neglect for one of four residents (Resident R1). Findings include: Review of facility policy Abuse and Neglect dated 3/27/24, indicated neglect is defined as the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Review of facility policy Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating dated 3/27/24, indicated all reports of resident abuse, neglect, exploitation, or theft/misappropriation of resident property are reported to local, state, and federal agencies and thoroughly investigated by facility management. Review of facility policy Lifting Machine, Using a Mechanical dated 3/27/24, indicated a least two (2) nursing assistants are needed 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 review of job descriptions, clinical records and staff interviews, it was determined that the Nursing Home Administrator (NHA) and the Director of Nursing (DON) failed effectively manage the facility to prevent the elopement of a resident and effectively manage the facility to ensure that proper supervision, assessments, and interventions were provided to ensure safe smoking for residents as required. Findings include: The signed job description for Nursing Home Administrator dated 12/4/23, indicated the purpose of this position is to manage the facility in accordance with current federal, state, and local standards governing long-term facilities and to ensure that the highest degree of quality care is provided to the residents at all times. The signed job description for Director of Nursing dated 3/29/24, indicated the purpose of this position is to plan, organize, develop, and direct the overall operation of the Nursing Service Department in accordance with current federal, state, and local standards, guidelines, and regulations that govern the facility to ensure…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical record review, resident and staff interviews it was determined that the facility failed to provide discharge planning for resident needs prior to discharge for one of three residents (Resident R1). Findings include: Review of the facility's Discharging a Resident without a Physician's Approval policy last reviewed 4/1/24, indicated a physician order should be obtained for all discharges, unless a resident or representative is discharging himself or herself against medical advice. Should a resident, or their representative request an immediate discharge, the resident's attending physician will be promptly notified. The order for an approved discharge must be signed and dated by a physician and recorded in the resident's medical record no later than 72 hours after the discharge. If the resident or representative insists upon being discharged without approval of attending physician, the resident and/or representative must sign a release of responsibility form. Should…

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

Based on a review of policy, observation and staff interview, it was determined that the facility failed to properly maintain kitchen equipment in a sanitary condition and failed to properly label and date food products in the walk in cooler creating the potential for unsafe conditions and the potential for cross contamination in the main kitchen. Findings include: A review of the facility Preventing Foodborne Illness-Employee Hygiene and Sanitary Practices policy dated 3/27/24, Food and nutrition services employee will follow appropriate sanitary procedures to prevent the spread of foodborne illness. During an observation of the main designated kitchen on 5/20/24, at 8:50 a.m. the following was observed: - 4 bags of buns-no label or date During an observation of the main designated kitchen on 5/20/24, at 9:15 a.m. the following was observed: -inside of ice machine brown debris During an interview on 5/21/24 at 2:35 p.m. Director of Dietary Employee E8 confirmed the facility failed to properly label and date food products and maintain kitchen equipment as required. 28 Pa. Code:…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the Resident Assessment Instrument User's Manual, resident clinical records, and staff interview, it was determined that the facility failed to make certain that Minimum Data Set assessments were completed accurately for three out of six sampled resident records (Resident R20, R39, and R40). Findings include: Review of Resident R20's admission record indicated admission date of 9/22/2020, with diagnoses that included end stage renal disease (kidneys can no longer work as they should), diabetes (high sugar in the blood), hypertension (high blood pressure). Review of Resident R20's Minimum Data Setyt (MDS- a periodic assessment of care needs) dated 3/18/24, section O, failed to include the treatment of dialysis. During an interview on 5/23/24, at 10:00 a.m. the Director of Nursing confirmed Resident R20's MDS assessment was not completed accurately as required. Review of the admission record indicated R39 was admitted to the facility on [DATE]. Review of Resident R39's MDS dated [DATE],…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical records, medication administration records, resident and staff interview it was determined that the facility failed to provide glucose monitoring as per physician's order for two out of four sampled resident records (Resident R40 and Resident R53) and failed to have a physician orders to provide pacemaker monitoring for one of two sampled resident records (Resident R32). Findings include: The facility Diabetes-clinical protocol policy last reviewed 3/27/24, inidcated that the physician and staff will summarize factors that are contributing to the resident's diabetes or glucose tolerance. The physician will order appropriate lab test, for example periodic finger stick test, and adjust treatments based on these results and other parameters. Examples of blood glucose monitoring include monitoring glucose levels at least twice weekly, monitoring blood glucose levels twice to four times daily, and monitoring three to four times a day if intensive insulin therapy or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy review, observations, and staff interviews, it was determined that the facility failed to maintain sanitary conditions of respiratory equipment for three of six residents reviewed (Resident R7, R274, and R30) and failed to obtain physician orders for one resident with a tracheostomy (Resident R30). Findings include: Review of the facility policy Procedures for changing oxygen tubing update 5/2024, indicated this procedure is to ensure the storage and change of respiratory equipment to meet infection control requirements. 1. The nursing staff will change all oxygen and nebulizer tubing weekly per the facility guidelines. 2. The tubing will be dated and labeled. 3. When not in use it will be stored in a plastic bag. Review of the facility policy Tracheostomy Care dated 3/27/24 indicates the purpose of this procedure is to guide tracheostomy care and the cleaning of reusable tracheostomy cannulas. Check physician orders. Review of Resident R7's Minimum Data Set (MDS - a periodic assessment…

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 resident clinical records, facility policy and staff interview it was determined the facility failed to provide care and treatments related to dialysis care for one of six residents (Resident R22) and failed to provide consistent and complete communication with the dialysis center for four of six residents (Resident R20, R22, R32, and R61). Findings include: Review of the facility policy Care of a Resident With End Stage Renal Disease (kidney failure) dated 3/27/24, indicated education and training of staff includes the handling of grafts (a synthetic tubing to connect the artery and vein) and fistulas (arteriovenous fistula - a connection made by a surgeon of an artery to a vein for vascular access for dialysis), and agreements will identify how information will be exchanged between facilities. Review of the facility policy Hemodialysis Access Care dated 3/27/24, indicated the general medical nurse should document in the resident's record very shift as follows: location of the catheter,…

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, nursing staff personnel records, nurse training documentation and staff interview, it was determined that the facility failed to ensure that nursing staff received annual in-service education for five of five nursing personnel (Nurse Aide (NA) Employees E13, E14, and E15, Licensed Practical Nurse (LPN) Employee E16, and Registered Nurse Supervisor (RN) Employee E17). Findings include: The facility In-service training policy dated 3/27/24, indicated that the facility will provide in-service training for all personnel. All mandatory in-service requirements must be completed annually as a condition of continued employment. Training topics include residents ' rights, abuse, neglect and exploitation, behavioral health, infection control, compliance and ethics, effective communication, and quality assurance and performance improvement. Review of NA Employee E13's personnel record indicated she was hired to the facility on [DATE]. Review of NA Employee E13's personnel record did not…

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, personnel files and staff interview it was determined that the facility failed to complete annual nurse aid employee evaluations for two of three sampled records (Nurse aide (NA) Employees E13 and E14). Findings include: Review of facility policy In-Service Training dated 3/27/24, indicated the facility completes a performance review of nurse aides at least every 12 months. Review of NA Employee E13's personnel record indicated she was hired on 10/28/20. Review of NA Employee E13's personnel record indicated the last performance review was 5/3/22. Review of NA Employee E14's personnel record indicated she was hired on 12/8/20. Review of NA Employee E14's personnel record indicated the last performance review was 5/2/22. Interview on 5/23/24, at 1:05 p.m. Human Employee E3 confirmed the facility failed to complete annual nurse aid employee evaluations as required. 28 Pa. Code: 201.18(b)(1) Management.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy, clinical record review, observation, and staff interview, it was determined that the facility failed to implement an infection control program that included a system of surveillance to identify possible communicable diseases or infections for 11 of 12 months (June 2023 - May 2024), and failed to implement enhance barrier precautions for five of five residents (Residents R3, R20, R22, R32, and R61 ) and failed to disinfect equipment, failed to perform hand hygiene between care for one of three residents (Resident R24), and failed to prevent cross contamination during a dressing change for one of three residents (Resident R17). Findings include: Review of facility policy Infection Control Plan dated 3/27/24, indicated the facility will monitor and identify trends or patterns of infection. To provide strategies to mitigate infection control risks while maintaining the quality of life of its residents. Review of facility policy Enhanced Barrier Precautions dated 3/27/24, indicated enhanced…

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

Based on review of the facility's infection control policies and procedures and staff interview, it was determined that the facility failed to implement an antibiotic stewardship program for 11 of 12 months (June 2023 - April 2024). Findings include: Review of facility policy Antibiotic Stewardship dated 3/27/24, indicated antibiotics will be prescribed and administered to residents under the guidance of the facility's antibiotic stewardship program. The purpose of the antibiotic stewardship program is to monitor the use of antibiotics in the residents. Review of the facility's Infection Control surveillance for June 2023 - May 2024, failed to include documentation to indicate that antibiotic monitoring was completed for 11 months (June 2023 - April 2024). During an interview on 5/23/24, at 9:45 a.m. the Director of Nursing confirmed that the facility failed to implement an antibiotic stewardship program that included a system of surveillance to monitor antibiotic use and lab correlation for infections for 11 of 12 months and was unable to produce the tracking records from June 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 records and staff interviews, it was determined that the facility failed to have a designated qualified Infection Preventionist (IP) working at least part time in the facility for six of 12 months June 2023 to November 2023 . Findings include: Review of the regulation 483.80(b) requires the facility to have a designated Qualified Infection Preventionist working at least part time at the facility. Review of former Interim Director of Nursing Employee E18's education records, she completed the required infection control certification on 11/15/23. Review of Registered Nurse Assessment Coordinator (RNAC) Employee E1's education records, she completed the required infection control certification on 11/14/22. During an interview on 5/23/24, at 9:35 a.m. Registered Nurse Assessment Coordinator (RNAC) Employee E1 indicated she took over the Infection Control Program last month (April 2024) when former Interim Director of Nursing Employee (DON) E18 left. Interview with the Director of Nursing on 5/23/24, at 2:13 p.m. confirmed the facility failed to have a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, observations and staff interviews it was determined that the facility failed to provide a clean, safe, comfortable, and homelike environment for one of five resident rooms (Resident R58). Findings include: Review of the facility policy Homelike Environment dated 3/27/24, indicated residents are provided with a safe, clean, comfortable, and homelike environment. Review of the admission record indicated Resident R58 was admitted to the facility on [DATE]. Review of Resident R58's Minimum Data Set (MDS - a periodic assessment of care needs) dated 3/21/24, indicated the diagnoses of Parkinson's Disease (disorder of the nervous system that results in tremors), bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs), and myasthenia gravis (a weakness and rapid fatigue of muscles under voluntary control). Observation on 5/20/24, at 10:35 a.m. Resident R58's room indicated a bifold closet door detached from closet and propped…

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, newly hired personnel records and staff interview it was determined that the facility failed to properly screen an employee by completing a State background check prior to hire for one out of five personnel records (Dietary Aide Employee E6). Findings include: The facility Background screening investigations policy last reviewed 3/27/24, indicated that the facility conducts employment background screening checks, reference checks and criminal conviction investigation checks on all applications for positions. Background and criminal checks are initiated within two days of an offer of employment or contract agreement and completed prior to employment. Review of Dietary Aide Employee E6's personnel record indicated she was hired 3/22/24. Review of Dietary Aide Employee E6's punch detail report (a form showing when the employee clocks in and out of work) indicated that she worked on 3/26/24 for six hours. Review of Dietary Aide Employee E6's State background check was requested on 3/27/24, five days after the date of hire. During an interview on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical record reviews and staff interviews, it was determined that the facility failed to initiate a thorough investigation for incidents or accidents for two of three residents (Residents R71 and R4). Findings include: The facility Reporting Suspicion of a Crime policy dated 3/27/24, indicated all accidents of incidents involving residents, employees, visitors, vendors, etc., occurring on our premises shall be investigated and reported to the administrator. Review of clinical record indicated Resident R71 was admitted [DATE], with diagnoses which included chronic obstructive pulmonary disease, bipolar disorder, and major depressive disorder. A review of Resident R71's Minimum Data Set (MDS-a periodic assessment of resident care needs), dated 2/20/24, indicated diagnoses remained current. Review of Resident R71 nurse progress notes dated 2/23/24, at 10:56 p.m. revealed that the resident was able to escape the floor and make it to the 5th floor. Review of Resident R71 nurse…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy, observation, clinical record, and staff interview it was determined that the facility failed to ensure that residents receive necessary treatment and services to promote healing of a pressure ulcer (PU/PIs- injuries to skin and underlying tissue resulting from prolonged pressure on the skin) for one of four residents (Resident R17). Findings include: Review of the facility policy Dressings - Dry/Clean dated 3/27/24, indicated to verify that there is a physician order for the procedure. Review the resident's care plan, current orders, and diagnoses to determine if there are special resident needs. Review of the admission record indicated Resident R17 admitted to the facility on [DATE]. Review of Resident R17's Minimum Data Set (MDS- a periodic assessment of care needs) dated 4/20/24, indicated the diagnoses of atrial fibrillation (irregular heart rhythm), heart failure (heart doesn't pump blood as well as it should), and coronary artery disease (narrow arteries decreasing blood flow to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy, observation, clinical record review, and staff interview, it was determined that the facility failed to provide treatment and services to prevent further decrease in range of motion for two of two residents (Residents R39 and R58). Findings include: Review of the facility policy Assistive Devices and Equipment dated 3/27/24, indicated the facility maintains and supervises the use of assistive devices and equipment for residents. Devices and equipment are maintained on schedule and staff are required to demonstrate competency on the use of devices and equipment. Review of the admission record indicated R39 was admitted to the facility on [DATE]. Review of Resident R39's Minimum Data Set (MDS - a periodic assessment of care needs) dated 3/19/24, indicated the diagnoses of colon cancer, dementia (a general term for loss of memory, language, problem solving and other thinking abilities that are severe enough to interfere with daily life), and high blood pressure. Review of Resident R39's…

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

Based on review of resident clinical records and staff interviews it was determined that the facility failed to make certain that appropriate treatment and services were ordered and/or provided for one of three residents with a urinary catheter (Resident R3). Findings include: Review of the facility policy Catheter Care, Urinary last reviewed 3/27/24, indicate check the resident frequently to be sure he or she is not lying on the catheter and to keep the catheter tubing free of kinks, position the drainage bag lower than the bladder at all times to prevent urine from flowing back into the urinary bladder. Review of Resident R3's Minimum Data Set (MDS - a periodic assessment of care needs) dated 2/15/24, indicated admission date of 9/22/21, with diagnoses of heart failure (heart can't pump blood as well as it should), hypertension (high blood pressure), neurogenic bladder (lack of bladder control). Review of Resident R3 physician orders dated 5/14/24, indicate foley catheter size sixteen french with 10cc balloon. Observation 5/20/24, at 11:06 a.m. Resident R3 was sitting in his…

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, facility policy review, and staff interviews, it was determined that the facility failed to ensure Medication Regimen Reviews were completed by a consultant pharmacist at least monthly for one out of six sampled resident records (Resident R14). Findings include: The facility Consultant pharmacist services provider agreement policy last reviewed 3/27/24, indicated that regular and reliable consultant pharmacist services are provided to residents. The consultant pharmacist provides consultation on all aspects of the provision of pharmacy services in the facility. Specific activities that the pharmacist performs includes the medication regiment review of each resident at least monthly. The facility Medication regiment review policy last reviewed 3/27/24, indicated that the drug regiment of each resident is reviewed at least monthly by a licensed pharmacists and includes a reivew of the resident's medical chart. Review of Resident R14's admission record indicated he was initially…

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, observations, and staff interviews it was determined that the facility failed to accurately label and date open medications for one of two medication carts (third floor medication cart) and failed to properly store medical supplies and biologicals in one of two medication rooms (third floor medication room). Findings include: The facility Storage of medications dated 3/27/24, indicated that the facility stores all drugs and biologicals in a safe, secure, and orderly manner. Drugs and biologicals are stored in the packaging, containers, or other dispensing systems in which they are received. Drug containers that have missing, incomplete, improper, or incorrect labels are returned to the pharmacy for proper labeling before storing. Discontinued, outdated or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed. During an observation of the third floor medication cart on 5/21/24, at 11:47 a.m. the following was observed: One bottle of ketorolac eye drops no packaging, name, or date opened. One bottle of prednisone…

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 menu, observations, and staff interviews, it was determined that the facility failed to follow the menu for one of one lunch meal (lunch meal Monday 5/20/24). Findings include: A review of the menu indicated that the posted lunch menu was as follows: Liver,onions Mashed potatoes, gravy Green Bean Apple Cobbler During observation of lunch meal on the 4th floor on 5/20/24, at 12:05 p.m., it was revealed that all of the residents had the following instead: Liver,onions Mashed potatoes, gravy Corn or Carrots Apple Cobbler During an interview on 5/20/24, at 12:30 p.m. Dietary [NAME] Employee E9 confirmed a different lunch menu. He stated We did not have green beans. During an interview 5/21/24, at 2:30 p.m. Director of Dietary Employee E8 confirmed the Registered Dietitian did not approve the menu substitution and the posted menu's were not updated to reflect the change as required. 28 Pa. Code: 211.6(a)(b)Dietary services.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical records, incident reports and staff interviews, it was determined that the facility failed to make certain each resident received adequate supervision that resulted in an elopement (resident exits to an unsupervised or unauthorized area without the facility's knowledge) for one of eleven residents (Closed Record Resident CR1). Findings include: Review of the facility policy Accidents and Incidents dated 12/11/23, indicated all accidents or incidents involving residents, employees, visitors, vendors, etc., occurring on the premises shall be investigated and reported to the Nursing Home Administrator. Review of the facility policy Wandering and Elopements dated 12/11/23, indicated: The facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents. -If a resident is missing, initiate the elopement/missing resident emergency procedure. -Determine if the resident is out on…

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

Based on a review of clinical records and staff interview it was determined that the facility failed to ensure the presence of necessary documentation supporting the specific reason for discharge of one of six residents reviewed (Resident R1). Findings include: A review of the clinical record revealed that Resident R1 signed out AMA (Against Medical Advice) of the faciliy on December 1, 2023. Review of the resident's Discharge Summary revealed that the reason for the resident's discharge was for 30 day notice non payment and resident choice. Docmentation provided by the facility indicated the most current Notice of Proposed Involuntary Discharge or Transfer provided was dated September 25, 2023. Inteview with the Nursing Home Administrator on January 10, 2024, at 2:00 p.m. confirmed that the resident's was not provided a current notice for non payment prior to discharging AMA. 28 Pa. Code: 201.29(a)(c) Resident rights

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of facility policies, documents, observations, and resident and staff interviews, it was determined that the facility failed to follow a physician order, provide comprehensive skin assessments for a resident with sutures, and failed to coordinate post surgical appointments for one of three residents with skin impairment (Resident R1). Findings include: The facility Consult/outside appointment policy dated 1/1/23, indicated that the facility will obtain consultations and assist with resident transport to outside appointments on a timely basis in order to assist each resident with attaining and maintaining the individuals highest practicable well-being. All residents will be evaluated on Admission, Re-admission, monthly and as needed by the Primary Care Physician to determine the individual resident need for consultation services. Services not provided onsite at the facility shall be arranged in the community for continuity of care. The facility Wound care policy dated 11/2016, 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 review of facility policy, facility submitted documentation, clinical records, and staff interview, it was determined that the facility failed to make certain allegations of abuse and neglect are thoroughly investigated and report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within five working days of the incident to describe the results of the investigation, for one of two residents. (Resident R1). A review of facility policy Abuse and Neglect - Clinical Protocol, dated 1/18/23, indicated that facility management and staff will institute measures to address the needs of the residents and minimize the possibility of abuse and neglect. The management and staff, with physician support, will address situations of suspected or identified abuse and report them in a timely manner to appropriate agencies, consistent with applicable laws and regulations. A review of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policies, clinical records and staff interviews, it was determined that the facility failed to develop a comprehensive care plan for one of five residents (Resident R1). Findings include: A review of facility policy Care Plans, Comprehensive Person-Centered dated 1/18/23, indicated a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. A review of the clinical record revealed that Resident R1 was admitted to the facility on [DATE], with diagnoses Alzheimer's disease (a type of brain disorder that causes problems with memory, thinking and behavior; this is a gradually progressive condition), unspecified dementia with agitation (agitation in dementia is distressed affect that leads to poor moods and…

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