Champion City Nursing And Rehabilitation Center

Based on review of facility policy, observations and staff interview, it was determined that the facility failed to properly store food products and maintain proper infection control practices in the main kitchen and dish room which created the potential for cross contamination in the designated main kitchen, dish room. The facility policy entitled Food Preparation and Service dated 10/29/25, indicated Food and nutrition employees prepare, distribute, and serve food in a manner, that complies with safe food handling practices. During an observation of the main designated kitchen on 3/23/26, at 9:45 a.m. the following was observed: -(2) cups were stored in the flour bin -(2) packages uncooked ground pork stored improperly -(1 )open bag of hashbrowns in the freezer, open, not dated -(2) cases ice cream stored on walk in freezer floor -(5) individual ice cream, open, walk in freezer During tray line observation of the main designated kitchen on 3/24/2026 at 11:42 a.m. -11:49 a.m. server observed picking up Salisbury steaks with gloved hands, opened warming cart door, did not change…

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 policy and staff interview, it was determined that the facility failed to implement an antibiotic stewardship program for 12 of 12 months (March 2025, through February 2026) Findings include: Review of facility Antibiotic Stewardship policy dated 10/29/25, indicated that antibiotics will be prescribed and administered to residents under the guidance of the facility's antibiotic stewardship program. Review of the facility's Infection Control Program from March 2025, through February 2026, failed to include documented evidence that antibiotic (medications used to treat infections) monitoring and ensuring appropriate usage was completed. During an interview on 3/25/26, at 10:51 a.m. Director of Nursing reviewed the facilities infection control documents with State Agency (SA) and was unable to provide the facilities antibiotic stewardship program and stated, I haven't been here that long. We just hired a new infection preventionist, and we will be working to get all the infection control in order. During an interview on 3/26/26, at 9:00 a.m. Director 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, closed clinical records, resident fund account statements and staff interview it was determined that the facility failed to convey resident funds and close accounts upon discharge within 30 days for three out of three closed resident records (Closed Resident Records CR186, CR187, and CR188).Findings include:Review of facility policy Conveyance of Resident Funds dated 10/29/25, indicated the resident's personal funds and a final accounting of funds are returned to the resident, the resident's representative or to the resident's estate (individual or probate jurisdiction per state law), as applicable, within thirty (30) days from the date of the resident's discharge or eviction from the facility, or death. Review of the clinical record revealed Closed Resident Record CR186 was admitted to the facility on [DATE], with diagnoses of high blood pressure, hyperlipidemia (high levels of fats in the blood), and unsteadiness on feet. Review of documentation indicated Closed 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 policies, clinical record review, and staff interview, it was determined that the facility failed to make certain resident medication regimens were free from potentially unnecessary psychotropic (substances that act on the brain to alter cognition, perception, and mood) medications for four of five residents (Residents R13, R16, R37, and R139).Findings include: Review of facility policy Psychotropic Medication Use dated 10/29/25, indicated residents do not receive psychotropic medications that are not clinically indicated and necessary to treat a specific condition documented in the medical record. Medications in the following categories are considered psychotropic medications and are subject to prescribing, monitoring, and review requirements specific to psychotropic medications: anti-psychotics, anti-depressants, anti-anxiety medications, and hypnotics/sedatives. Review of facility policy Medication Regimen Reviews dated 10/29/25, indicated a licensed pharmacist reviews 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 the necessary resident information was communicated to the receiving health care provider for five of six residents sampled with facility-initiated transfers (Residents R8, R12, R35, R180 and R184), failed to notify the resident or resident's representative of the facility bed-hold policy (an agreement for the facility to hold a bed for an agreed upon rate during a hospitalization) for four of six resident hospital transfers (Residents R12, R35, R180 and R184), and failed to notify the Office of the State Long-Term Care Ombudsman upon transfer to the hospital for five of six resident hospital transfers (Residents R12, R35, R168, R180, and R184).Findings include: Review of facility policy Transfer or Discharge Documentation last reviewed 10/29/25, indicated when a resident is transferred or discharged , details of the transfer or discharge will be documented in 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 the Resident Assessment Instrument User's Manual, clinical records, and staff interview, it was determined that the facility failed to make certain that comprehensive Minimum Data Set assessments were completed in the required time frame for three of seven residents (Residents R28, R36, and R48).Findings include: Review of the Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which provides instructions and guidelines for completing required Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2025, indicated that an admission MDS assessment was to be completed no later than 14 calendar days following admission (admission date plus 13 calendar days). Resident R28 had an admission date of 1/17/26, with an MDS completion date of 1/30/26. The MDS was signed off as completed 2/4/26, five days after the due date.Resident R36 had an admission date of 1/21/26, with an MDS completion date of 2/3/26. The MDS was signed off as completed 2/4/26, one day after the due date. Resident R48 had…

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 interviews, it was determined that the facility failed to develop and implement a baseline care plan to include instructions needed to provide effective and person-centered care of the residents for three of four residents reviewed (Resident R6, R24, and R147).Findings include: Review of the facility policy Baseline Care Plan last reviewed 10/29/25, indicated a baseline plan of care to meet the resident's immediate health and safety needs is developed for each resident within forty-eight hours of admission. The baseline care plan includes instructions needed to provide effective, person-centered care of the resident that meet professional standards of quality care and must include the minimum healthcare information necessary to properly care for the resident including but not limited to the following:Initial goals based on admission orders and discussion with the resident/representative.Physician ordersDietary ordersTherapy servicesSocial service The baseline care…

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

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 perform timely and accurate post-fall documentation and failed to make certain that residents were provided appropriate treatment and care in accordance with professional standards of practice for two of five residents (Residents R10 and R13), and failed to provide 1:1 supervision during a suicidal ideation for one of two residents (Resident R181). indings include: Review of facility policy Assessing Falls and Their Causes dated 10/29/25, indicated staff are to observe for delayed complications of a fall for approximately forty-eight (48) hours after an observed or suspected fall, and will document findings in the medical record. Review of the facility Registered Nurse (RN) job description indicated major duties and responsibilities include assesses for changes in residents' status, notifying the physician and resident's family or representative and documenting accordingly. 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 and clinical records and staff interview, it was determined that the facility failed to obtain physician order for a urinary catheter (insertion of a tube into the bladder to remove urine) for three of four residents (Resident R4, R9, and R125), failed to make certain that appropriate treatments and services were provided for the use of a urinary catheter as required for three of four residents (Resident R9, R125, and R180), and failed to ensure that care was provided in a manner which maintained resident dignity for two of four residents (Resident R125, and R180). The facility policy entitled Foley Catheter Insertion, male resident dated 10/29/25, indicated that the physician's order should be verified. Review of facility policy Care Plans, Comprehensive Person-Centered dated 10/29/25, indicated that 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…

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 interview it was determined that the facility failed to provide appropriate respiratory care relating to CPAP/BIPAP (a continuous positive airway pressure machine used to keep airways open while you sleep/a positive airway pressure machine when breathing in and breathing out) for one of three residents (Residents R36), and that the facility failed to maintain oxygen equipment for two of three sampled residents (Residents R122 and R157). Findings include: Review of the facility policy Oxygen Administration last reviewed 10/29/25, indicated dated 1/2/25, indicated the purpose of this procedure is to provide guidelines for safe oxygen administration. Verify that there is a physician's order for this procedure. Review the physician orders of facility protocol for oxygen administration. Review the residents' care plan to assess any special needs of the residents. Review of the facility policy Fire safety and prevention last reviewed 10/29/25, 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 four residents (Resident R171), and failed to ensure that monitoring of residents' access site was completed for three of four residents (Resident R11, R47, and R171). Findings include: Review of the facility policy Hemodialysis dated 10/29/25, 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. The facility will monitor and document the status…

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 clinical records and staff interview, it was determined that the facility failed to provide documentation that medication regimen reviews (MRR) were completed and reviewed by the resident's attending physician monthly for five of five residents (Residents R13, R16, R24, R37, and R139).Findings include: Review of facility policy Medication Regimen Reviews dated 10/29/25, indicated a licensed pharmacist reviews the medication regimen of each resident at least monthly. The consultant pharmacist provides the director of nursing services and medical director with copy of all medication regimen reports. Upon receiving the MRR report from the pharmacist, the director of nursing reviews the recommendations with the attending physician, responds to the report, and documents what (if any) actions were taken to address them. Review of the clinical record indicated Resident R13 was admitted to the facility on [DATE]. Review of Resident R13's Minimum Data Set (MDS - a periodic assessment of care needs)…

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, and staff interviews, it was determined that the facility failed to properly store medications in four of five medication carts (Second Floor Medication Cart, Third Floor Medication Cart, Fourth Floor Front Medication Cart, and Sixth Floor Back Medication Cart) and one of three medication rooms (Sixth Floor Medication Room), and failed to properly secure a medication cart while not in use for one of five medication carts (Fifth Floor East Front Medication Cart). Findings include: Review of the facility policy Medication Storage last reviewed [DATE], indicated medications will be stored in a manner that maintains the integrity of the product, ensures the safety of the resident's and is in accordance with the Department of Health guidelines. Medications will be stored in the original, labeled containers received from the pharmacy. Expired, discontinued and/or contaminated medications will be removed from the medication storage area and disposed of in accordance…

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, menu, observations, and staff interviews, it was determined that the facility failed to follow the menu for two of two lunch meal (lunch meal Monday 3/23/26, and Tuesday 3/24/26). The facility policy entitled Food and Nutrition Services dated 10/29/25, indicated each resident is provided with a nourishing, palatable, well-balanced diet that meets hir or her daily nutritional and special dietary needs, taking into consideration the preferences of each resident. Review of facility policy Tray Identification dated 10/29/25, indicated that appropriate identification shall be used to identify various diets. A review of the menu indicated that the menu for lunch on 3/23/26, was as follows:Chicken and biscuits, carrots, cranberries, gelatin, and juiceDuring an observation of lunch on 3/23/26, the third floor failed to include the following:Resident R71 was missing finger food items, magic cup, peanut butter and jelly sandwich, and milk were missing from trayResident R180 was missing magic cup on trayResident R127 was missing magic cup on trayResident R29 was…

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

Based on review of facility policy, Quality Assurance attendance records, and staff interview, it was determined that the facility failed to conduct Quality Assessment and Assurance (QAA) meetings at least quarterly with all of the required committee members for three of four quarters (April 2025 through June 2025, July 2025 through September 2025, and October 2025 through December 2025).Findings include: A review of the QAA Committee meeting sign-in sheets from the period of April 2025 through June 2025, did not reveal that the Director of Nursing or Infection Preventionist were in attendance. A review of the QAA Committee meeting sign-in sheets from the period of July 2025 through September 2025, did not reveal that the Director of Nursing was in attendance. A review of the QAA Committee meeting sign-in sheets from the period of October 2025 through December 2025, did not reveal that the Director of Nursing was in attendance. During an interview on 3/27/26, at 12:55 p.m. Regional Nursing Home Administrator Employee E25 confirmed that the facility failed to conduct QAA meetings 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, clinical record review, observations, and staff interviews, it was determined that the facility failed to implement enhanced barrier precautions for one of four residents (Residents R180), failed to implement an infection control program that included a system of surveillance to identify possible communicable diseases or infections for nine of twelve months (March, April, May, September, October, November, and December 2025, and January and February 2026), and failed to prevent cross contamination during a dressing change for one of three residents (Resident R2).Findings include: Review of the facility policy Enhanced Barrier Precautions (EBP) dated 10/29/25, indicated EBP's are utilized to prevent the spread of multi-drug-resistant organisms for residents. EBP refers to infection prevention and control interventions designed to reduce the transmission of organisms during high contact resident care activities. Review of facility policy Surveillance for Infections dated…

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 policy, facility provided documentation, and staff interviews, it was determined the facility failed to designate a consistent qualified individual(s) onsite, who is responsible for implementing programs and activities to prevent and control infections for seven of 12 months (February 2025, through September 2026).Findings included: Review of facility Infection Preventionist policy dated 10/29/25, indicated the infection preventionist is responsible for coordinating, implementing, and updating the infection prevention and control program. The infection preventionist is scheduled with enough time to properly assess, develop, implement, monitor, and manage the infection prevention and control program, address training requirements, and participate in required committees. Evidence of training is provided through a certification. During entrance meeting on 3/23/26, at 9:00 a.m. Nursing Home Administrator stated a new Infection Preventionist was hired and was identified as the facilities Infection Preventionist (IP). During a review of the facilities…

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 documents and observations and staff interviews it was determined the facility failed to maintain an effective pest control program related to fruit flies in the dish room (Main Kitchen). During an observation on 3/26/26 at approximately 9:35 a.m. in the dish room of the Main Kitchen there were three gold fly sticky traps full of fruit flies. As staff were doing dishes several fruit flies were observed in the area. Review of facility provided documentation included pest-control logs dated from 9/17/25-2/11/26. The following treatments to the kitchen area were provided on the following dates: 9/17/25 crack/crevice spray to baseboards in kitchen10/29/25 crack/crevice spray to kitchen, dining room, maintenance hall11/19/25 crack/crevice spray to baseboards, kitchen, maintenance hall, front lobby12/3/25 crack/crevice spray to kitchen, maintenance hall1/21/26 crack/crevice spray to baseboards in kitchen, dish room, maintenance hall2/11/26 crack/crevice spray to baseboards in kitchen During an interview on 3/26/26 at 10:00 a.m. Dietary Manager Employee E21 confirmed the facility…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of facility documents, clinical record review, and staff interview, it was determined that the facility failed to ensure resident rights to make informed decisions and choices about important aspects of residents' health, safety and welfare by making certain residents understand the Notice of Medicare Non-Coverage (NOMNC) form and failed to ensure the agreement is explained to the resident and his or her representative in a form and manner that he or she understands for one of three residents (Resident R77).Findings include: Review of the Resident Assessment Instrument 3.0 User's Manual effective October 2019 indicated that a Brief Interview for Mental Status (BIMS), is a screening test that aides in detecting cognitive impairment. A BIMS total score of 0-7: suggests severe cognitive impairment. Review of Resident R77's admission record indicated the resident was admitted to the facility on [DATE]. Review of Resident R77's demographic information available in the electronic medical record…

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

Based on review of facility policy, observation, and staff interview it was determined that the facility failed to maintain the confidentiality of residents' medical information on one of five nursing units (Fifth Floor Nursing Unit).Findings include: Review of facility policy Confidentiality of Information and Personal Privacy dated 10/29/25, indicated the facility will safeguard the personal privacy and confidentiality of all resident personal and medical records. During an observation on 3/26/26, at 8:34 a.m. the 5 East Front Medication Cart outside of a resident room was left unattended with the computer screen open with identifiable information any passerby could see resident personal and confidential information. During an interview on 3/26/26, at 8:35 a.m. Licensed Practical Nurse Employee E13 confirmed the above observation and that the facility failed to maintain the confidentiality of residents' medical information as required. 28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa. Code: 201.29(c.3) Resident rights.28 Pa. code: 211.5(b) Medical records.28 Pa. Code:…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, observations and staff interviews it was determined that the facility failed to provide a clean, safe, comfortable, and homelike environment for one of five floors (Third floor).Findings include: Review of the facility policy Homelike Environment dated 10/29/25, indicated the residents are provided with a safe, clean, comfortable, and homelike environment and encouraged to use their personal belongings to the extent possible. During a tour with the Director of Operations Employee E9 on 3/23/26, from 1:38 p.m. to 2:07 p.m. of the Third floor, the following were observed: room [ROOM NUMBER] had unpainted plaster on the bathroom wallroom [ROOM NUMBER]'s vent cover was missing and the bathroom doorknob was missingroom [ROOM NUMBER] was missing four ceiling tiles in the room, vent cover was loose, and had two brown ceiling tiles in the bathroomroom [ROOM NUMBER] was missing a piece of the vent coverroom [ROOM NUMBER] was missing a piece of the vent coverroom [ROOM NUMBER] had…

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 one of five personnel files reviewed (Nurse Aide (NA) Employee E6).Findings include: Review of facility policy Abuse, Neglect, Exploitation and Misappropriation Prevention Program dated 10/29/25, indicated the facility will conduct employee background checks and not knowingly employ or otherwise engage 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 concern 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 finding abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property. Review of NA Employee E6'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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of the RAI (Resident Assessment Instrument), clinical records, and staff interviews it was determined that the facility failed to make certain that resident assessments were accurate for one of three residents (Residents R9).Findings include: The Resident Assessment Instrument (RAI) User's Manual, which gives instructions for completing Minimum Data Set (MDS) assessments (periodic assessments of resident care needs), dated October 2025, indicated the following: Section K0310; Discharge Status: Weight Gain of 5% or more in the last month or gain of 10% or more in last 6 months. Code 0, no or unknown: if the resident has not experienced weight gain of 5% or more in the past 30 days or 10% or more in the last 180 days or if information about prior weight is not available Code 1, yes on physician-prescribed weight-gain regimen: if the resident has experienced a weight gain of 5% or more in the past 30 days or 10% or more in the last 180 days, and the weight gain was planned and pursuant to 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 facility policy, clinical records and staff interviews, it was determined that the facility failed to develop a care plan for one of four residents (Resident R6) to accurately reflect the current status of the resident.Findings include: Review of the facility policy Care Plan, Comprehensive Person-Centered last reviewed 10/29/25, indicated a comprehensive, person-centered care plan that included measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. The comprehensive care plan will include but not inclusive of:Measurable objectives and timeframesDescribes services that are to be furnished to attain or maintain the residents' highest practicable physical, mental and psychosocial well-being.Identify problem areas and their causes and develop interventions that are targeted and meaningful to the residents. Review of the clinical record indicated Resident R6 admitted to the facility on [DATE]. 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 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 resident's reviewed (Resident R4, R159).Review of the clinical record indicated Resident R4 was admitted [DATE]. Review of Resident R4's MDS (minimum data set a periodic review of assessment needs) dated 2/18/26, indicated diagnosis of fracture left femur, chronic obstructive pulmonary disease (common lung disease causing restricted airflow and breathing problems) and dysphasia (difficulty swallowing). Review of Resident R4's Multidisciplinary Care Conference sign in sheet dated 3/12/26, included the following disciplinary: social worker, dietary and activities. Review of clinical record indicated Resident R159 was admitted to the facility on [DATE]. Review of Resident R159's Minimum Data Set (MDS-a mandated assessment of a resident's abilities and care needs) assessment, dated 1/3/26, indicated the diagnoses end stage renal…

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 in accordance with professional standards of practice for one of four residents (Resident R169).Findings include: Review of the facility Registered Nurse (RN) job description indicated major duties and responsibilities include assesses for changes in residents' status, notifying the physician and resident's family or representative and documenting accordingly. Review of the clinical record revealed Resident R169 was admitted to the facility on [DATE]. Review of Resident R169's Minimum Data Set (MDS - a periodic assessment of care needs) dated [DATE], indicated diagnoses of high blood pressure, hyperlipidemia (high levels of fats in the blood), and cognitive communication deficit. Review of a nursing progress note dated [DATE], completed by Licensed Practical Nurse (LPN) Employee E30 stated, Around 1705 (5:05 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical records and staff interview, it was determined that the facility failed to properly monitor weight and nutrition status by failing to obtain weights for one of three residents (Resident R9).Findings include: Review of facility policy Weight Assessment and Intervention dated 10/29/25, indicated that resident weights are monitored for undesirable or unintended weight loss or gain. Residents are to weighed upon admission and at intervals established by the interdisciplinary team. Any weight change of 5% or more since the last weight assessment is retaken the next day for confirmation. If the weight is verified nursing will immediately notify the dietitian in writing. Unless notified of significant weight change, the dietitian will review the unit weight record monthly to follow individual weight trends over time. The threshold for significant unplanned and undesired weight loss will be based on the following criteria: a) 1 month: 5% weight loss is significant; greater…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, and staff interviews it was determined that the facility failed to provide a resident special eating equipment for one of five residents (Resident R35).Based on observations, and staff interviews it was determined that the facility failed to provide a resident special eating equipment for one of five residents (Resident R35). Findings Include: Review of the admission record indicated Resident R35 was admitted to the facility on [DATE]. Review of Resident 35 's MDS indicated the diagnosis of anemia (low iron in the blood), high blood pressure and hyperlipidemia (high fat in the blood). Review of Resident R35's physician orders dated 7/4/25 indicated Resident to use scoop dish for all meals. During an observation completed on 3/23/26, at 12:40 p.m. Resident R35 was observed with a regular white plate on his lunch tray. During an interview completed on 3/23/26 at 12:40 p.m. Nurse Aid (NA) Employee E6 confirmed Resident R35's meal ticket indicated the use of a scoop dish and confirmed 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 facility policy, observation, and staff interview it was determined that the facility failed to properly contain garbage in two of four outside dumpsters to prevent the potential for rodent and insect infestation (dumpster one, three). The facility policy entitled Food-Related Garbage and Refuse disposal dated 10/29/25, indicated all garbage and refuse containers are provided with tight-fitting lids or covers and must be kept covered when stored or not in continuous use. During an observation of the facility's outdoor trash receptacles on 3/23/26, at 9:30 a.m. Dietary Manager Employee E21 confirmed that the lid/covers were not closed on dumpster one and three. During an interview on 3/24/26, at 12:30 p.m. Dietary Manager Employee E21 confirmed that the facility failed to properly contain garbage in the outside trash receptacles to prevent the potential for rodent and insect infestation. 28 Pa. Code 201.18(b)(3) Management.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy, clinical record review and staff interview, it was determined that the facility failed to provide accurate and timely documentation related to the COVID-19 (a respiratory disease) vaccine for one of five residents (Resident R16).Findings include: Review of facility policy Coronavirus Disease(COVID-19)- Vaccination of Residents dated 10/29/25, indicated that each resident is offered the COVID-19 vaccine unless the immunization is medically contraindicated or the resident is fully vaccinated. The resident or representative can accept or refuse a COVID-19 vaccine. The vaccine can be provided at the facility. Review of Resident R16's clinical record indicated the resident was admitted to the facility on [DATE]. Review of Resident R16's Minimum Data Set (MDS - a periodic assessment of care needs) dated 2/17/26, indicated diagnoses of depression, dementia (a group of symptoms that affects memory, thinking and interferes with daily life), and insomnia (difficult sleeping). MDS Section O-…

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, facility documentation, incidents submitted to the local State field office, and staff interviews it was determined that the facility failed to submit a report of an allegation of misappropriation of resident property in a timely manner to the local State field office for one of five sampled residents (Resident R2).Findings include: Review of facility policy Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigation dated 10/30/25, indicated all reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state, and federal agencies (as required by current regulations), and thoroughly investigated by facility management. Findings of all investigations are documented and reported. If resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately…

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, facility documents and staff interviews, it was determined that the facility failed to ensure residents were assessed, and provided necessary treatment and services, consistent with professional standards of practice, for a pressure ulcer (PU/PIs- injuries to skin and underlying tissue resulting from prolonged pressure on the skin) for one of three residents (Resident R1).Findings include: Review of facility policy Wound Care dated 10/30/25, indicated the purpose is to provide guidelines for the care of wounds to promote healing. Verify that there is a physician's order for the procedure. Review the resident's care plan to assess for any special needs of the resident. The following information should be recorded in the resident's medical record:Type of wound care given.The date and time the wound care was given. The position in which the resident was placed. The name and title of the individual performing the wound care. Any changes in the resident's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, observation, and resident and staff interview, it was determined that the facility failed to obtain professional podiatry services for four of two residents reviewed for skin conditions (Resident R1, R2, R3, and R4).Findings include:Review of the facility's Resident Council Minutes dated 8/25/25, revealed Resident R1, R2, and R3 would like to see the podiatrist. Review of the admission record indicated Resident R1 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident R1's Minimum Data Set (MDS - a periodic assessment of care needs) dated 8/5/25, indicated diagnoses of multiple sclerosis (damages the protective cover around nerves called myelin in your central nervous system), mononeuropathy (damage that occurs to single nerve) of bilateral lower limbs, and unsteadiness on feet. Review of Resident R1's clinical record failed to include an order to consult podiatry. During an interview on 10/15/25, at 2:44 p.m. Resident R1 stated they need to see 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 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 three residents reviewed (Resident R6).Findings include:Resident R6 was admitted to the facility on [DATE].Resident R6 has diagnosis of bipolar disorder (mental health condition that causes extreme mood swings, these include emotional highs and lows also known as depression) , enteropathy (disease of the small intestine), and hypertension (the force of blood pushing against your artery wall is consistently too high).Review of facility submitted documentation dated 10/9/25, indicated:On October 8, 2025, a small bulge was observed on R6 left shoulder by her son, leading to a medical evaluation by a facility provider. A subsequent X-ray on October 9, 2025, confirmed that her left shoulder was dislocated. During the evaluation, the cognitively intact R6's (BIMS 13.0 - brief interview mental status) indicated the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and interviews with staff, it was determined that the facility did not ensure that a physician s timely wrote, signed, and dated progress notes at each visit for one of four residents reviewed (Resident R4).Findings include:Review of the facility Physician Visits policy dated 4/2/25, revealed the attending physician must make visits in accordance with applicable state and federal regulations. The attending physician must perform relevant tasks at the time of each visit, including a review of the resident's total program of care and appropriate documentation. A physician visit is considered timely if it occurs not later than ten days after the visit was required. Review of the admission record indicated Resident R4 was admitted to the facility on [DATE], and readmitted [DATE]. Review of Resident R4's Minimum Data Set (MDS - a periodic assessment of care needs) dated 7/3/25, indicated diagnoses of urinary tract infection, muscle weakness, and cognitive communication deficit. Review…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy and clinical records, and staff and resident interviews, it was determined that the facility failed to ensure that a dental appointment was scheduled for two of four residents reviewed (Resident R2 and R5).Findings include:Review of the facility's Resident Council Minutes dated 8/25/25, revealed Resident R2 and R5 would like to see the dentist. Review of the admission record indicated Resident R2 was admitted to the facility on [DATE]. Review of Resident R2's Minimum Data Set (MDS - a periodic assessment of care needs) dated 8/9/25, indicated diagnoses of anxiety, depression, and chronic pain syndrome. Review of Resident R2's physician order dated 5/2/25, indicated to consult dental as needed. During an interview on 10/14/25, at 2:37 p.m. Resident R2 stated they have not seen a dentist. Documentation by the facility's contracted dental provider dated 10/9/25, failed to reveal Resident R2 was seen by the dentist.Review of the admission record indicated Resident R5 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 staff interview it was determined that the facility failed to provide medical record access for one of seven residents (Resident R1).Findings include:Facility documentation indicated Resident R1 was admitted on [DATE].Review of Resident R1's MDS (minimum data set a periodic assessment of basic needs) dated 12/11/24, revealed diagnoses of diabetes mellites, end stage renal disease and atherosclerosis of the arteries (disease of the arteries characterized by the deposition of plaques of fatty material on their inner walls). Review of facility provided documentation indicated a request for medical records 4/22/25 by a law firm. Resident R1's daughter, who was her emergency contact was listed on her death certificate. During an interview on 7/23/25, at 3:30 p.m., the Nursing Home Administrator could not provide documentation that the medical records were sent and that the initial request was made several months ago.28 Pa. Code 201.29(a)Resident rights.

Based on review of facility policy, observations and staff interviews it was determined the facility failed to ensure comfortable air temperature levels were provided for 22 of 25 residents (Resident R1, R2, R3, R4, R5, R6, R7, R8, R9, R10, R11, R12, R13, R14, R15, R16, R17, R18, R19, R20, R21, and R22). Findings include: Review of the facility policy Homelike Environment dated 2/3/25, indicated the facility will provide residents with a safe, clean, comfortable, and homelike environment. The policy further stated the facility staff and management maximizes, to the extent possible comfortable and safe temperatures (71°F - 81°Fahrenheit). Review of Title 42 Code of Federal Regulations §483.10(i)(2) Housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior. During an interview on 4/8/25, at approximately 3:15 p.m. Maintenance Employee E1 stated the boiler (a closed tank where water is heated under pressure, and then used for hot water or heating a building) stopped functioning on 4/5/25. At this time, temperature logs since the boiler…

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 and Director of Nursing did not effectively manage the facility to make certain that necessary care and services were provided to residents to prevent sexual abuse for 2 of 2 residents (Resident R2 and R3), which created an immediate jeopardy situation for all 152 of 152 residents. Findings include: Review of CFR §483.70 Administration. A facility must be administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. The job description for the Nursing Home Administrator (NHA) specified the responsibility for overseeing the daily operation of the nursing facility, ensuring compliance with Pennsylvania state laws, Medicare/Medicaid, and federal regulations. This role involves managing staff, coordinating patients care, maintaining financial stability, and upholding the highest standards of resident care and safety. 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 records, and staff interview, it was determined the facility failed to ensure that residents' comprehensive care plans were reviewed and revised as needed to accurately reflect their current needs and services required by two of three residents sampled (Residents R1, and R2). Findings include: Review of the facility policy Care Plans, Comprehensive Person-Centered, dated 2/3/25, indicated a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychological and functional needs is developed and implemented for each resident. The interdisciplinary team reviews and updates the care plan: a. when there has been a significant change in the resident's condition; b. when the desired outcome is not met; c. when the resident has been readmitted to the facility from a hospital stay; and d. at least quarterly, in conjunction with the required quarterly assessment. Review of Resident R1's clinical record…

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

Based on a review of policy, observation and staff interview, it was determined that the facility failed to properly maintain kitchen equipment in a sanitary condition creating the potential for cross contamination in the main kitchen of the facility. Findings include: Review of facility policy Food Safety Requirements: Sanitation of the Kitchen dated 2/3/25, indicated that Food Service Staff maintain the sanitation of the kitchen through compliance with a written, comprehensive cleaning schedule. During an observation of the main designated kitchen on 2/3/25, initiated at 9:30 a.m., with Dietary Director Employee E25, the following was observed: - Walk-in cooler #3, at 9:45 a.m.; -- the cold air condenser fan covers had a build-up of dust, grime, and dark colored debris. -- the floor had a build-up of grime and dried food debris below stored cases of milk. - Walk-in cooler #4, at 9:50 a.m.; -- the cold air condenser fan covers had a build-up of dust, grime, and dark colored debris; areas around the cooler fans immediately adjacent to and on ceiling forward of the fans had a…

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

Based on policy, resident and staff interview interviews, and observations it was determined that the facility failed to make certain the grievance policy was posted prominently throughout the facility, failed to include an anonymous place and the address, email and phone number for the grievance officer for 5 of 5 nursing units. Findings include: §483.10(j) Grievances. §483.10(i) Notifying resident individually or through postings in prominent locations throughout the facility of the right to file grievances orally (meaning spoken) or in writing; the right to file grievances anonymously; the contact information of the grievance official with whom a grievance can be filed, that is, his or her name, business address (mailing and email) and business phone number; a reasonable expected time frame for completing the review of the grievance; the right to obtain a written decision regarding his or her grievance. Review of facility policy Filing Grievances/Complaints dated 2/3/25, indicated Our facility will help residents, their representatives (sponsors), other interested family members,…

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 interviews, it was determined that the facility failed to make certain that the necessary resident information was communicated to the receiving health care provider for three of six residents sampled with facility-initiated transfers (Residents R80, R105 and R124). Findings include: Review of the facility policy Transfer or Discharge, Facility-Initiated reviewed 1/15/24, and again on 2/3/25, indicated information conveyed to receiving provider, and documentation of transfer to include the resident's care plan goals, advanced directive information, specific instructions for ongoing care, resident representative information, and all information necessary to meet the resident's specific needs at the receiving facility. Review of the clinical record indicated Resident R80 was admitted to the facility on [DATE]. Review of Resident R80's Minimum Data Set (MDS - a periodic assessment of care needs) dated 1/13/25, indicated diagnosis of hypertension (high blood pressure),…

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 resident assessments were accurate for four of 12 residents (Residents R51, R90, R117, and R164). Findings include: The Resident Assessment Instrument (RAI) User's Manual, which gives instructions for completing Minimum Data Set (MDS) assessments (periodic assessments of resident care needs), dated October 2024, indicated that Section C: Cognitive Patterns, Question C0100 Should Brief Interview for Mental Status Be Conducted? (BIMS) should be coded as 0 if the resident is rarely/never understood, and that it should be coded 1, and the BIMS assessment should be completed if the resident is at least sometimes understood. Further review of the RAI indicated under Coding Tips rules for stopping the BIMS before it is complete: 1. All responses up to this point have been nonsensical (making no sense), 2. there has been no verbal or written response to any of the questions up to this…

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 five of seven residents (Residents R15, R22, R43, R45, and R50). Findings include: Review of the facility policy Assistive Devices and Equipment dated 2/3/25, indicated the facility maintains and supervised the use of assistive devices and equipment for residents. Staff are trained and demonstrate competency on the use of devices and equipment prior to assisting or supervising residents. Review of the admission record indicated R15 was admitted to the facility on [DATE]. Review of Resident R15's Minimum Data Set (MDS - a periodic assessment of care needs) dated 5/31/24, indicated the diagnoses of stroke (damage to the brain from an interruption of blood supply), anemia (the blood doesn't have enough healthy red blood cells), and atrial fibrillation (irregular heart rhythm). Review of Resident R15'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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, resident clinical records, observation, and staff interviews, it was determined that the facility failed to report, implement infection monitoring and management for COVID-19, and test residents timely for respiratory illnesses for two of two residents (Resident R80 and R369) and failed to prevent cross contamination during a medication pass for one of two residents (Resident R37). Finding include: Review of the facility Outbreak of Communicable Diseases reviewed 1/15/24, indicated outbreaks of communicable diseases within the facility are promptly identified and managed. An outbreak is defined as one case of an infection that is highly communicable or has serious implications. The administrator is responsible for communicating data about reportable diseases to the health department. The infection preventionist and director of nursing are responsible for managing surveillance data, monitoring ill residents and staff. Review of the Bureau of Epidemiology Respiratory Virus…

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, and resident and staff interviews, it was determined that the facility failed to determine the ability to safely self-administer medications for two of six residents reviewed (Resident R143, and R318). Findings include: Review of the facility's policy Self-Administration of Medication last reviewed 2/3/25, indicated residents have the right to self-administer medications if the interdisciplinary team has determined it is clinically appropriate and safe for the resident to do so. The staff and practitioner will document their findings and the choices of residents who are able to self-administer medications. Review of the admission record indicated Resident R143 was admitted to the facility on [DATE]. Review of Resident R143's Minimum Data Set (MDS - a periodic assessment of care needs) dated 11/5/24, indicated the diagnoses of Non-Alzheimer's Dementia (dementia caused by other diseases with symptoms forgetfulness, limited social skills, and impaired thinking…

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 R24). Findings include: Review of the facility policy Abuse Investigation and Reporting reviewed 1/15/24, indicated if an incident or suspected incident of resident abuse, mistreatment, neglect, or injury of unknown source is reported, the administrator will assign the investigation to an appropriate individual. The investigation must include interviews of any witnesses to the incident, the resident's roommate, family, and staff members on all shifts who have had contact with the resident during the period of the alleged incident. Witness reports will be obtained in writing. Either the witness will write his/her statement and sign and date it, or the investigator may obtain a statement, read it back to the member and have him/her sign and date it. Review of the facility policy…

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, and clinical records, facility documents, as well as staff interviews, it was determined that the facility failed to ensure documentation was timely entered for a resident after an unwitnessed fall occurred for one of three residents (Resident R24). Findings include: Review of the facility policy Charting and Documentation reviewed 1/15/24, indicated all services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident ' s medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. Review of the facility policy Change in a Resident's Condition or Status last reviewed 1/15/24, indicated the nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status. Review of Residents…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of facility policy, clinical records, and staff interviews, it was determined that the facility failed to assess, document, and notify physicians of an abnormal Capillary Blood Glucose (CBG) levels for one of four residents reviewed (Resident R134), and failed to appropriately respond to a resident's change in condition for one of four residents (Resident R368). Findings include: Review of facility policy Obtaining a Fingerstick Glucose Level reviewed 1/15/24, indicated that the procedure is to obtain a blood sample to determine the resident's blood glucose level. The person performing this procedure should record the following information in the resident's medical record: 1. The date and time the procedure was performed. 2. The name and title of the individual(s) who performed the procedure. 3. All assessment data obtained during the procedure. 4. If the resident refused the procedure, the reason(s) why and the intervention taken. 5. The blood sugar result. Follow facility 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.

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 make certain that weight loss was identified and addressed in a timely manner and failed to update an individualized care plan to address the resident's specific nutritional concerns and preferences for one of seven (Resident R121) records reviewed. Findings include: Review of facility policy Nutritional Assessment, dated 1/15/24, indicated as part of the comprehensive assessment, a nutritional assessment, including current nutritional status and risk factors for impaired nutrition , shall be conducted for each resident. Individualized care plans shall address, to the extent possible: a. The identified causes of impaired nutrition; b. The resident's personal preferences; c. Goals and benchmarks for improvement; d. Time frames and parameters for monitoring and reassessment. The Resident Assessment Instrument (RAI) User's Manual, which gives instructions for completing Minimum Data Set (MDS)…

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 provide appropriate care and services to residents receiving tube feedings for two of five residents reviewed (Residents R121, and R269). Findings Include: Review of facility policy Enteral Nutrition dated 1/15/24, indicated adequate nutrition support through enteral nutrition is provided to residents as ordered. The Nurse confirms that orders for enteral nutrition are complete. Complete orders include: - The enteral nutrition product; - The specific enteral access device (nasogastric, gastric, jejunostomy tube, etc.); - Administration method (continuous, bolus, intermittent); - Volume and rate of administration; - The volume/rate goals - Instructions for flushing Review of facility policy Nutritional Assessment, dated 1/15/24, indicated as part of the comprehensive assessment, a nutritional assessment, including current nutritional status and risk factors for impaired nutrition, shall be conducted for…

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, staff interviews, and clinical record review, it was determined that the facility failed to provide appropriate respiratory care related to oxygen management for one of four residents (Resident R122). Findings include: A review of the facility policy Respiratory Therapy last reviewed on 2/3/25, indicates obtain equipment (i.e., oxygen tubing, reservoir, and distilled water) change the oxygen cannula and tubing every seven days or as needed. A review of Resident R122's clinical record indicates an admission date of 6/24/22. A review of R122's Minimum Data Set (MDS-periodic assessment of care needs) dated 12/9/24, indicate the diagnosis of hypertension (high blood pressure), chronic obstructive pulmonary disease (COPD- constriction of airways) and anxiety. During an observation on 2/3/25, at 10:19 Resident R122 was in bed, her oxygen was on via nasal canula (thin flexible tube used to deliver oxygen). The oxygen tubing failed to be labeled with a date. During an interview completed on 2/3/25, at 12:03 p.m. Licensed Practical 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 clinical record review and staff interview, it was determined that the facility failed to ensure that residents received trauma-informed care to eliminate or mitigate triggers for residents with the diagnosis of Post Traumatic Stress Disorder (PTSD - a mental and behavioral disorder that develops related to a terrifying event) for three of 11 residents reviewed (Resident R23, R45, and R85). Findings include: Review of the facility policy Trauma Informed Care dated 2/3/25, indicated the purpose to guide staff in appropriate and compassionate care specific to individuals who have experienced trauma, and post-traumatic stress disorder in the context of the healthcare setting. Caregivers are taught strategies to help eliminate, mitigate or sensitively address a resident's triggers that are person-centered. Review of the clinical record indicated Resident R23 was admitted to facility on 8/15/24, with the diagnosis of anxiety, cerebellar ataxia (affects balance gait, and eye movements) and PTSD. Review of…

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

Based on clinical records and facility policy review, and staff interview, it was determined that the facility failed to ensure that a resident who displayed mental or psychosocial adjustment difficulties received appropriate treatment and services for one of eleven residents (Resident R23). Findings include: Review of the facility policy Trauma Informed Care last reviewed 2/3/25, indicated this facility supports a culture of emotional well-being and physical safety for staff, residents and visitors. Caregivers are taught strategies to help eliminate, mitigate or sensitively address a resident ' s triggers. As part of the comprehensive assessment, identify history of trauma or interpersonal violence when possible. Identifying past trauma or adverse experiences may involve record review or the use of screening tools. Review of the Social Services job description indicated it is the responsibility of Social Services to ensure that the medically related emotional and social needs of residents are met/maintained on an individual basis. Develop social assessment and care plan, which…

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 develop and implement individualized person-centered care plans to address dementia and cognitive loss displayed by one of four residents reviewed (Resident 35). Findings include: Review of the facility Dementia-Clinical Protocol policy last reviewed 2/3/25, indicated for an individual with a confirmed dementia diagnosis, the interdisciplinary team will identify a resident-care centered care plan to maximize remaining function and quality of life. Review of Resident R35's clinical record indicated she was admitted to the facility on [DATE], with a diagnosis of dementia (loss of memory, language, problem-solving, and other thinking abilities that interfere with daily life), anxiety, and depression. A review of Resident 35's Minimum Data Set Assessment (MDS, a form completed at specific intervals to determine care needs) dated 12/22/24, indicated that the facility assessed Resident R635 as having a diagnosis of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy review, clinical record review, and staff interview, it was determined that the facility failed to make certain that residents receiving psychotropic medications have adequate indication for use for two of five sampled residents (Resident R35 and R43). Findings include: Review of the facility policy Psychotropic Medication Use dated 2/3/25, indicated residents will not receive medications that are not clinically indicated. Review of Resident R35's clinical record indicated she was admitted to the facility on [DATE], with a diagnosis of dementia (loss of memory, language, problem-solving, and other thinking abilities that interfere with daily life), anxiety, and depression. A review of Resident 35's Minimum Data Set Assessment (MDS, a form completed at specific intervals to determine care needs) dated 12/22/24, indicated that diagnoses were current. Review of Resident R35's physician order dated 1/26/25, indicated to administer 1.5ml of 2mg/ml Haloperidol Lactate at bedtime for…

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 five medication carts (5th floor front hall medication cart) and one of three medication rooms (6th floor medication room). Findings include: A review of the facility policy Medication Labeling and Storage last reviewed 2/3/25, indicates medications for external use, as well as hazardous drugs and biologicals, are clearly marked as such, and are stored separately from other medications. A review of the facility policy Administering Medications last reviewed 2/3/25, indicated the expiration/beyond use date on the medication label must be checked prior to administering. When opening a multi dose container, the date opened shall be recorded on the container. During an observation on 2/3/25, at 12:12 p.m. the 5th floor front hall medication cart contained the following: . A bottle of Tums antacid tablets not labeled with date opened. . A small white bottle of shaving cream. . A can of sweet vanilla rainbow room…

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 four of ten months (April 2024, May 2024, June 2024, July 2024). Findings include: Review of facility policy Infection Control Program reviewed 1/15/24, indicated antibiotics will be prescribed and administered to residents under the guidance of the facility's antibiotic stewardship program. The purpose of the facility's Antibiotic Stewardship Program is to monitor the use of antibiotics in the residents. Review of facility policy Surveillance for Infections, last reviewed 1/15/24, indicated The Infection Preventionist will conduct ongoing surveillance for Healthcare-Associated Infections (HAIs) and other epidemiologically significant infections that have substantial impact on potential resident outcome and that may require transmission-based precautions and other preventative interventions. The Infection Preventionist or designated infection control personnel is responsible for gathering 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 observation and staff interview, it was determined that the facility failed to maintain an effective call system for 12 of 20 resident restrooms on one of five floors (6th floor). Findings include: Review of facility policy Call System, Resident last reviewed 2/3/25, indicates residents are provided with a means to call staff for assistance through a communication system that directly calls a staff member or a centralized work station During a group interview on 2/4/25, at 10:15 a.m. Residents indicated that the call bell in the bathroom did not work and it didn't let staff know that they needed help. During an observation on 2/5/25, 10:30 am thru 11:08 a.m. of the sixth-floor resident restrooms the following rooms were observed to have call light cords that when pulled were unable to be alarmed: . 6010 . 6011 . 6012 . 6013 . 6016 . 6017 . 6018 . 6019 . 6020 . 6021 . 6023 . 6040 During an interview completed on 2/4/25, at 11:10 a.m. Nurse Aid (NA) Employee E26 confirmed the above observations. During an interview completed on 2/4/25, at 11:34 a.m. the Nursing Home…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility documentation and interviews with staff, it was determined that the facility failed to develop, implement, and maintain an effective training program that was sufficient to meet the requirement for facility-provided annual nurse aide education for three of five employee files (Nurse Aide (NA) Employees E3, E14, and E15). Findings include: Review of NA Employee E3's personnel record indicated she was hired to the facility on 9/9/20. Review of NA Employee E14's personnel record indicated she was hired to the facility on [DATE]. Review of NA Employee E15's personnel record indicated she was hired to the facility on 8/19/20. Review of annual in-service documentation and personnel records did not include an annual in-service training on Quality Assurance and Performance Improvement (QAPI), Communication, and Compliance and Ethics training. Interview on 2/5/25, at 1:54 p.m. the Director of Nursing confirmed that facility failed to develop, implement, and maintain an effective training…

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 records, admission documentation and staff interview, it was determined that the facility failed to maintain admission documentation for two of seven residents (Resident R1, R7). Findings include: Review of Resident R1 was admitted [DATE] with diagnoses that include dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), anemia and COPD (COPD, or chronic obstructive pulmonary disease, is a condition caused by damage to the airways or other parts of the lung that blocks airflow and makes it hard to breathe). Review of the Resident Assessment Instrument 3.0 User's Manual effective October 2019, 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 Resident R1 admission MDS assessment ( Minimum Data…

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

Based on clinical record review and staff interview, it was determined that the facility failed to ensure that clinical records were complete and accurate for four of seven residents reviewed (Residents R1, R2, R3 and R4). Review of Resident R1's admission record indicated the resident was admitted to the facility 6/18/24, with the diagnoses of dementia(a general term for loss of memory, language, problem solving that are severe enough to interfere with daily life), anemia and COPD (chronic obstructive pulmonary disease, is a condition caused by damage to the airways or other parts of the lung that blocks airflow and makes it hard to breathe). Review of Resident R1's EMR (electronic medical record) and paper file indicated no Inventory Sheet( form used to log resident belongings on admission). Review of Resident R2's admission record indicated the resident was admitted to the facility 7/1/24, with diagnoses of bipolar disorder, end stage renal disease and renal dialysis dependence. Review of Resident R2's EMR (electronic medical record) and paper file indicated no Inventory Sheet(…

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 pest control service logs, observations, and staff interview it was determined that the facility failed to maintain an effective pest control program for one out of two nurses stations (2nd floor) and two out of three rooms (2nd floor). Findings include: Review of records of invoices from pest control provider dated May-July 2024 , indicated that mouse traps were laid out; however, the record did not include evidence of efforts to eradicate mice on the 2nd floor nursing unit in July 2024. During observation on 7/25/24, the 2nd floor was observed with the following: At 10 a.m. observations of three glue traps beside the unit refrigerator. rooms [ROOM NUMBERS] glue traps in rooms under the heating units. During an interview on 7/25/24 at 10:30 a.m. Resident R5 indicated he has seen mice and cockroaches on the nursing unit. Review of the Minimum Data Set (MDS - periodic assessment of care needs) dated 6/27/24, indicated Resident R5 has a BIMS (Interview for Mental Status), cognitively intact. 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.

Based on a review of facility policies, observations and staff interviews, it was determined that the facility failed to properly monitor food expiration dates on four of five nursing unit food pantries (Third, Fourth, Fifth, and Sixth Floor Nursing Unit Food Pantries), and properly store utensils for food on one of five nursing units (Fourth Floor) creating the potential for food-borne illness. Findings include: Review of facility policy Food Safety Requirements- Use And Storage of Food And Beverage Brought In For Residents, Food Procurement, dated 1/15/24, indicated that food brought into the facility should be properly labeled and dated and will be used within three days or discarded. Cross contamination refers to the transfer of harmful substances or disease causing microorganisms to food by hands, surfaces, sponges, cloth towels, or utensils which are not cleaned after touching raw food, and then touch ready to eat foods. Physical Contamination of food are foreign objects that may inadvertently enter the food. During an observation on 3/21/24, at 11:43 a.m. the Fourth Floor…

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, observation, and staff interview, it was determined that the facility failed to accommodate the call bell needs of four of four residents (Resident R5, R18, R75, and R86). Findings include: Review of facility policy Answering the Call Light dated 1/15 /24, indicated all residents who are in bed or confined to a chair be sure the call light is within easy reach of the resident. Review of the clinical record indicated Resident R5 was admitted to the facility on [DATE]. Review of Resident R5's Minimum Data Set (MDS - a periodic assessment of care needs) dated 1/11/24, indicated diagnoses of hypertension (high blood pressure), heart failure (a progressive heart disease that affects pumping action of the heart muscles) and, Alzheimer's disease (a type of brain disorder that causes problems with memory, thinking and behavior). During an observation on 3/18/24, at 10:04 a.m. Resident R5 was observed lying in bed with his call light placed behind his dresser, completely out 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 record reviews and staff interviews, it was determined that the facility failed to initiate a thorough investigation that included statements from the witnesses and/or statements from the residents for injuries of unknown origin for one of six residents (Residents R38). Findings include: The facility Incidents and Accidents-Investigating and Reporting policy dated 1/15/24, indicated the charge nurse or nurse supervisor and/or department director or supervisor shall promptly initiate and document investigation of the accident or incident. The name of witnesses and their accounts of the incident must be included. The facility Abuse Investigation and Reporting policy, dated 1/15/24, indicated all injuries of unknown origin require a thorough investigation. It was indicated the person reporting the incident, any witnesses, the resident, and all staff members who had contact with the resident during the period of the alleged incident must be interviewed. All witness…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of clinical records, and staff interviews, it was determined that the facility failed to ensure that a comprehensive resident care plan was implemented related to post traumatic stress disorder status for one of three residents (Residents R114). Findings include: Review of Title 42 Code of Federal Regulations (CFR) §483.21 - Comprehensive Care Plans, the facility must develop and implement a comprehensive care plan for each resident that includes measurable objectives, and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment, and must be culturally competent and trauma informed. Review of the clinical record revealed that Resident R114 was admitted to the facility on [DATE]. Review of Resident 114's MDS (Minimum Data Set, periodic assessment of resident care needs) dated 3/13/24, indicated diagnoses of post-traumatic stress disorder (PTSD- a disorder in which a person has difficulty recovering after experiencing…

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 interview it was determined that the facility failed to obtain a physician order and notify a physician of abnormal glucose readings via a Capillary Blood Glucose (CBG) level as ordered for two out of three residents (Resident R119 and R148). Findings include: Review of the clinical record indicated Resident R119 was admitted to the facility on [DATE], with diagnoses that included hemiplegia and hemiparesis following cerebral infarction, dysphasia and atrial fibrillation (irregular and often very rapid heart rhythm). Review of Resident R119's quarterly MDS assessment(minimum data assessment)- periodic assessment of resident care needs) dated 2/5/24, indicated the diagnosis remained current. Review of Resident R119 nurse progress dated 1/1/2024 indicated that Resident R119 was sent out to the hospital. Review of Resident R119's most recent physician order's indicate no order to send resident out to the hospital. During an interview on 3/21/2024, 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 clinical records, and staff interviews, it was determined that the facility failed to make certain that appropriate treatments and services were provided for the monthly change of a urinary catheter for one of five residents (Resident R15). Findings include: Review of the facility Catheter Care, Urinary policy dated 1/15/24, indicated the purpose of this policy is to prevent catheter-associated urinary tract infections. When indwelling catheters are changed the date and time the catheter care was given as well as name and title of individual providing catheter care must be documented. Review of the clinical record indicated that Resident R15 was admitted to the facility on [DATE], with diagnoses that included paraplegia (a specific pattern of paralysis (which is when you can ' t deliberately control or move your muscles) that affects your legs) and stage 4 pressure ulcer (caused by prolonged pressure on the skin and results in skin and tissue loss with exposure of muscle, bones, tendons, 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 review of facility policy, observations, staff interviews, and clinical record review, it was determined that the facility failed to provide appropriate respiratory care for one of three residents (Resident R107) and securely store oxygen for one of two storage locations. Findings include: Review of facility policy Oxygen Administration dated 1/15/24, indicated oxygen therapy via oxygen mask, nasal cannula (a lightweight tube placed in the nostrils to provide oxygen), and/or nasal catheter. Verify that there is a physician order for this procedure. Check that the tubing is connected to the oxygen and assure that it is free of kinks. Review of the clinical record indicated Resident R107 was admitted to the facility on [DATE]. Review of Resident R107's Minimum Data Set (MDS - a periodic assessment of care needs) dated 2/9/24, indicated diagnoses of hypertension (high blood pressure), asthma (condition where the airways narrow and swell), and cancer (a disease caused by an uncontrolled division of abnormal…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of clinical record review, and staff interviews it was determined that the facility failed to provide a resident with necessary behavioral interventions as ordered to maintain the highest practicable mental and psychosocial well-being for one out of eight sampled resident records (Resident R144). Findings include: Review of the facility's Behavioral Assessment, Intervention and Monitoring policy dated 1/15/24, indicated the facility will provide and residents will receive behavioral health services as needed to attain or maintain the highest practicable physical, mental and psychosocial well-being in accordance with the comprehensive assessment and plan of care. Behavioral health services will be provided by qualified staff who have the competencies and skills necessary to provide appropriate services to the residents. Review of Resident R144's admission record indicated Resident R144 was admitted on [DATE]. Review of Resident R144's MDS assessment (Minimum Data Set Assessment: A periodic…

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 four of five resident nursing units (Second floor, third floor, fourth floor, and fifth floor). Findings include: The facility Homelike environment policy dated 11/18/23, indicated that residents are provided with a safe, clean, comfortable, and homelike environment. The facility management and staff maximize the characteristics of the facility, these characteristics include a clean, sanitary and orderly environment. During observations with Maintenance Employee E3 on 1/10/24, the following resident rooms and flooring were observed from 8:55 a.m. - 10:13 a.m.: -At 8:55 a.m. the second floor nursing unit revealed the hallway, the perimeter (corners and edges) of the hallway, and resident room doorways throughout the unit were covered with dirt and grime appearing as a thick black/grey substance. -At 9:15 a.m. the third floor nursing…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, observation and resident and staff interview, it was determined that the facility failed to provide tracheostomy (tube surgically placed in the windpipe for breathing) care and services consistent with professional standards of practice for one of four residents (Resident R1). Findings include: Review of facility policy Tracheostomy Care dated 11/18/23, indicated the tracheostomy care should be provided as often as needed and at least once daily for established tracheostomies. Review of admission record indicated Resident R1 was admitted to the facility on [DATE]. Review of Resident R1's Minimum Data Set (MDS - periodic assessment of care needs) dated 11/16/23, indicated the diagnoses of respiratory failure (lungs are not getting enough oxygen), high blood pressure, and tracheostomy. Review of Resident R1's physician orders dated 12/23/23, indicated trach care every night shift and as needed. Review of Resident R1's care plan dated 11/16/23, indicated to provide trach care…

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

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 2 of 3 residents (Resident R2 and R3) and failed to have physician orders for care and identification of access sites for two of three residents (Resident R2 and R4). Findings include: Review of the facility policy End-Stage Renal disease dated 11/18/23, indicated staff caring for residents with End Stage Renal Disease (ESRD), including residents receiving dialysis care outside the facility, shall be trained in the care and special needs of theses residents. Agreements between this facility and the contracted ESRD facility include all aspects of how the resident's care will be managed, including how information will be exchanged between facilities. Review of the facility policy Hemodialysis Access Care dated 11/18/23, indicated the general 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.

Based on review of facility financial documents, interview with vendors and staff, it was determined that the facility failed to pay bills in a timely manner for services without which the residents' health and safety are impacted. Findings include: 28 PA Code Commonwealth of Pennsylvania Long Term Care Licensure Regulations subsection 201.14(g), dated July 24, 1999, revealed that a facility owner shall pay in a timely manner bills incurred in the operation of a facility that are not in dispute and that are for services without which the residents' health and safety are impacted. During a review of State Agency provided document, Service Termination Notice to Health Care Facility, dated 10/12/23, from facilities electric service provider, indicated that a termination of service notice was provided due to utility's service bills being overdue in the amount of $40,652.90. During an interview on 10/31/23, at 8:49 a.m., Nursing Home Administrator (NHA) confirmed that he does not receive service provider bills as they are sent to the corporate office in New Jersey and was unaware that a…

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