Concordia at RP Home

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of clinical records, staff, and resident interviews, it was determined that the facility failed to provide Activity of Daily Living (ADL) assistance for one out of two residents (Resident R34). Findings include: Review of Resident R34's admission record indicated she was admitted [DATE], with diagnosis that included anemia (a problem of not having enough healthy red blood cells or hemoglobin to carry oxygen to the body's tissues), adult failure to thrive, and malnutrition. Review of Residents R34's Minimum Data Set (MDS - a periodic assessment of care needs) dated 3/27/25, indicated the diagnoses were current. Section GG- Functional Abilities revealed the resident needed partial/moderate assistance with showering and bathing. Review of Resident R34's care plan dated 2/24/24, last revised 3/26/25, revealed the resident had a decline in the ability to perform dressing and hygiene tasks and is at risk for further decline. Interventions indicated to monitor ability to participate in ADL's 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, 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 five residents (Resident R147). Findings include: Review of facility policy Wound Management Program, dated 6/30/24, indicated facility is committed to providing a comprehensive wound management program to promote the resident's highest level of functioning and well-being and to minimize the development of in-house acquired pressure injuries, unless the individual's clinical condition demonstrates they are unavoidable. Any resident with a wound receives treatment and services consistent with the resident's goals of treatment. Typically, the goal is one of promoting healing and prevention infection unless a 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 review facility polices, observations, clinical records, and staff and resident interviews it was determined that the facility failed to make certain that appropriate treatments and services were provided for the use of a colostomy as required for one of three residents (Resident R20). Findings include: Review of the clinical record indicated Resident R20 was admitted to the facility on [DATE]. Review of Resident R20's Minimum Data Set (MDS - a period assessment of care needs) dated 5/16/25, indicated diagnoses of intellectual disabilities, urinary incontinence, and colostomy status. Review of the clinical record revealed Resident R20 had a physician's order dated 9/12/18, for colostomy care every shift. No directions specified for order. A further review failed to reveal an order to change the colostomy bag and wafer, including size. Review of Resident R20's care plan dated 9/14/18, last reviewed 4/10/25, indicated to assess stoma and surrounding tissue every shift for signs and symptoms of skin…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, observations and staff interviews, it was determined that the facility failed to provide appropriate respiratory care and maintain oxygen equipment for one of three sampled residents (Resident R17). Findings include: The facility Oxygen administration policy last reviewed on 6/30/24, indicated that each resident ordered oxygen will follow current best practices including maintenance of best practices for infection control. Review of Resident R17's admission record indicated she was admitted on [DATE]. Review of Resident R17's MDS assessment (MDS: Minimum Data Set assessment-a periodic assessment of resident care needs) dated 4/9/25, indicated that she had diagnoses that included hypertension (a condition impacting blood circulation through the heart related to poor pressure), unspecified chronic obstructive pulmonary disease (COPD: a disease characterized by persistent respiratory symptoms involving breathlessness, coughing, and obstructed airflow to 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, resident records, medication incident reports, and staff interview, it was determined that the facility failed to implement pharmaceutical services to ensure availability and administration of prescribed medications for one of three sampled resident records (Closed Resident Record CR145). Findings include: The facility Resident medication regimen review policy last reviewed 6/30/24, indicated that the pharmacist will perform a prospective review of medications ordered at the time of dispensing. Any problems that are identified are addressed immediately before the medication is dispensed. Medication and pharmacy support includes providing the facility an available supply of contingency and emergency medications for immediate resident needs. Review of Closed Resident Record CR145's admission record indicated she was admitted [DATE]. Review of Closed Resident Record CR145's MDS assessment (MDS: Minimum Data Set assessment-a periodic assessment of resident care needs) 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.

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 provide documentation of medication regimen reviews (MRR) were completed at least monthly for two of three sampled resident records (Resident R4 and R20). Finding include: The facility Medication regimen review policy last reviewed 1/7/25, indicated that the drug regimen review of each resident is completed at least monthly by the consultant pharmacist and any irregularities are reported. Review of the clinical record indicated Resident R4 was admitted to the facility on [DATE], and readmitted [DATE]. Review of Resident R4's Minimum Data Set (MDS - a period assessment of care needs) dated 5/25/25, indicated diagnoses of depression, chronic pain due to trauma, and dementia (a loss of thinking, remembering, and reasoning skills.) Review of Resident R4's care plan indicated that the resident requires use of psychotropic medication and is at risk for adverse side effects. Review of Resident R4'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 policies, observations, and staff interviews, it was determined that the facility failed to properly store medications for one of four residents (Resident R34). Findings include: Review of Resident R34's admission record indicated she was admitted [DATE], with diagnosis that included anemia (a problem of not having enough healthy red blood cells or hemoglobin to carry oxygen to the body's tissues), adult failure to thrive, and malnutrition. Review of Resident R34's Minimum Data Set (MDS - a periodic assessment of care needs) dated 2/27/25, indicated the diagnoses were current. Review of Resident R34's physician order dated 1/8/25, instructed to apply two grams of 1% Voltaren Gel to back and bilateral arms topically every shift for pain. During an observation on 6/16/25, at 11:23 a.m., a cup of gel substance was located on Resident R34's bedside dresser. Resident R34 indicated the gel substance in the medicine cup was Voltaren gel (topical pain reliever for arthritis joint pain).…

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

Based on review of facility policy, facility documentation, clinical record review, and staff interview it was determined that the facility failed to protect residents from neglect for one of three residents reviewed (Resident R1). Findings include: Review of facility policy Prevention of Abuse and Response dated 7/30/24, indicated Neglect is the failure of the facility, its employees or service providers to provide goods and services to a resident necessary to avoid physical harm, pain, mental anguish, or emotional distress. Neglect occurs on an individual basis when a resident does not receive care in one or more areas. Review of the clinical record revealed Resident R1 was admitted to the facility 8/14/24. Review of the clinical record MDS (minimum data set - a periodic assessment of resident needs) indicated diagnosis of dementia with other behavioral disturbances and cerebral infraction. Review of facility submitted documentation dated 2/9/25, indicated Resident R1 was observed by staff outside of the facility (unattended without staff) by an employee entrance. Review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, resident clinical record, facility provided documents, resident and staff interviews, it was determined the facility failed to ensure resident safety and prevent an elopement (a situation in which a resident leaves the premises or a safe area without the facility's knowledge) and failed to complete a thorough investigation after an incident for one of seven sampled residents (Resident R1). Findings include: Based on a review of facility policy titled Elopement prevention guidelines last reviewed 7/22/24, indicated that the facility strives to promote resident safety and protect the rights and dignity of residents. The facility maintains a process to assess all residents for risk for elopement; implement prevention strategies for those identified as elopement risk, and follow a missing resident procedure. Review of Resident R1's admission record indicated he was admitted on [DATE]. Review of Resident R1's MDS assessment (MDS-Minimum Data Set assessment: periodic assessment of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of clinical records and staff interview, it was determined that the facility failed to document notification of changes in one of three residents reviewed (Resident R36). Findings include: Review the clinical record revealed that Resident R36 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of the Minimum Data Set (MDS- periodic assessment of care needs) dated 7/11/24, , included diagnosis of Diabetes Mellitus (condition that happens when your blood sugar is too high), and hypertension (condition where your pressure in your blood vessels is consistently elevated). Review of Resident R36's clinical record indicated check fingerstick glucose before dinner on Monday, Wednesday, and Friday please report if glucose >200. Review of Resident R36's clinical record MAR (medication administration record for July 2024 and May 2024 showed the following dates with above >200 glucose: July 8th and 17th. May 1st, 17th, and 24th. Additional review of the clinical records failed to show…

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

Based on review of facility policy, observations and staff interviews it was determined that the facility failed to provide a clean, safe, comfortable, and homelike environment for one of five resident rooms (Resident R55). Findings include: Review of the facility policy Resident Rights, last reviewed 7/22/24, indicated a resident has the right to a safe, clean comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. During an observation on 8/12/24 at 10:00 a.m. The wall area behind residents R55's headboard was noted to have pieces of drywall missing, large gouges, and denting. During an interview on 8/12/24, at 10:03 a.m. Licensed Practical Nurse Employee E3 confirmed the observation and stated that the facility has started to put protective sheets behind the headboards. 28 Pa Code: 201.18 (e)(1)(2) Management 28 Pa Code: 201.29 (a)(c)(d) Resident Rights

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policies, clinical records, and staff interviews, it was determined that the facility failed to develop and implement comprehensive care plans to meet care needs for two of four residents (Resident R9 and R15). Findings include: A review of facility policy Care Management reviewed 7/22/24, indicated the care plan will be developed consistent with each resident's rights and to meet the residents medical, nursing, and mental and psychosocial needs identified in the comprehensive assessment. Review of Resident R9's MDS (Minimum Data Set, periodic assessment of resident care needs) dated 7/25/24, indicates reentry to facility on 7/12/24, with the diagnosis of diagnoses of anemia (low iron in the blood) hypertension (high blood pressure) and Diabetes (high sugar in the blood) Review of physician orders 7/23/24, Indicates FreeStyle Libre 3 reader device (continuous glucose system receiver) check residents blood sugar before meals and at bedtime. Review of Resident R9's July 2024, medication…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, and staff interviews, it was determined that the facility failed to accurately monitor and provide comprehensive assessments of a pressure area for one of three resident (Resident R17). Findings include: The facility Wound management program dated 3/25/24, indicated that the facility is committed to providing a comprehensive wound management program to minimize the development of pressure injuries. A visual skin assessment is completed by the nurse. Results are documented in the skin observation tool. When the nurse observes a wound, he or she will assess the wound and document the findings. The following may be documented such as skin issues, type, length, width, depth, and wound stage. Review of Resident R17's admission record indicated she was admitted on [DATE], and readmitted on [DATE]. Review of Resident R17's MDS assessment (Minimum Data Set assessment: MDS -a periodic assessment of resident care needs) dated 4/26/24, indicated that she 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 facility policy review, observations, and staff interviews, it was determined that the facility failed to maintain sanitary conditions of respiratory equipment for one of three residents(Resident R49). Findings include: A review of the facility policy Respiratory Equipment last reviewed on 7/22/24, indicates to prevent the administration of oxygen or medication through contaminated equipment. Nebulizer sets will be changed weekly or as needed. After treatments units will be rinsed with hot tap water and allowed to dry. Set will be stored in clean plastic bags between treatments. Nebulizer sets will be marked with Resident's name, the date and initials when changed. A review of the admission record indicated Resident R49 was admitted to the facility on [DATE]. A review of R49's Minimum Data Set (MDS-periodic assessment of care needs) dated 7/6/24, included diagnoses of anemia (low iron in the blood), chronic obstructive pulmonary disease (COPD-makes it hard to breathe), and chronic kidney disease…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 one resident receiving hemodialysis (Resident R15). Findings include: A review of the facility policy Dialysis Services dated 7/22/24, indicated to ensure that residents who require dialysis receives such service, consist with professional standards of practice, the comprehensive person-centered care plan and the resident's goals and preferences. Communication between the dialysis staff and nursing staff provide continuity of care will be ongoing via dialysis assessment binder. A review of Resident R15's MDS dated [DATE], indicated reentry date of 4/9/24, with the diagnosis of hypertension (high blood pressure) end stage renal disease (last stage of kidney failure) and diabetes (high sugar in the blood) A review of Resident R15's physician…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 manufacturer's instructions, clinical record review, and staff interview it was determined that the facility failed to ensure that nursing staff have the specific competencies and skill sets necessary to provide care for a resident with a Free Style Libre 3 system (a new way for people with diabetes to check their sugar levels, without a finger stick test, using a sensor that can read changes in the liquid just underneath the skin) for two of two residents (Resident R9 and R15) Findings include: Review of the FreeStyle Libre 3 continuous glucose monitoring system updated 5/2023, indicated the following: . What to know before using the system. . Who should not use the system. . What you should know about wearing a sensor. . How to store the sensor kit. . How to store the unit. . When not to use the system. . What to know about the system. . What to know before applying the sensor. . When is sensor glucose different from blood glucose. . What to know about x rays. . When to remove the sensor. . What to…

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

Based on review of facility policy, personnel records and staff interview it was determined that the facility failed to complete annual performance evaluations for two of five nurse aide personnel records (Nurse aide Employee E8 and Nurse aide Employee E9). Findings include: The facility Certified nursing assistant position description last reviewed 7/22/24, indicated that the performance expectations are that the incumbent must be able to demonstrate the knowledge and skills necessary to provide care. Each employee is to be evaluated based on the standards set forth in the position description. Review of Nurse aide (NA) Employee E8's personnel record indicated she was hired to the facility on 2/4/19. The record indicated that the position description and the employee handbook were both signed on 2/4/19. Review of Nurse aide (NA) Employee E8's performance evaluation for the evaluation period of 3/14/23 to 1/26/24, did not indicate a review with the employee and was observed without a review date. Review of Nurse aide (NA) Employee E9's personnel record indicated she was hired to 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 clinical records, and staff interview it was determined that the facility failed to make certain residents receive appropriate treatment and services for highest practicable mental and psychosocial services for one of three residents (Resident R28). Findings include: Review of facility policy dated 7/11/24, Behavioral Health Services, Trauma Informed Care indicated: It is the goal of the facility to provide necessary behavioral health care and services to attain or maintain the highest practicable physical, mental and psychosocial well-being. Review of Resident R28's indicated was originally admitted on [DATE], and readmitted on [DATE]. Review of the MDS (minimum data set - a periodic assessment of resident needs) dated 4/30/24, with the following diagnosis adjustment disorder with depression (mental condition triggered by a serious event). Review of Resident R28's clinical record indicated the following: 7/4/24: nurses notes : alerted by Resident R28's roommate that resident demonstrating…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 medical supplies and biologicals in one of one medication rooms (third floor medication room) and one of three medication carts (yellow medication cart), properly secure medications in one of three medication carts (green hall medication cart) and failed to date open medications. Findings include: Review of the facility policy Medication Distribution System dated 7/22/24, indicate medications and biologicals are stored safely, securely, and properly. Orally administered medications are kept separate from medication administered by other routes. The facility's medication room is used to ensure an effective medication distribution by availability of a medication only refrigerator limiting access to only authorized personnel, kept clean, well-lit, and free of clutter. During an observation on 8/12/24, at 12:25 p.m. Licensed Practical Nurse (LPN) Employee E3 was completing a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, observations, and staff interviews, it was determined that the facility failed to implement infection control practices to prevent cross contamination during a dressing change for one of three residents (Resident R17) and failed to implement infection control practices during administration of eye drops on one of three residents. (Resident R261) Findings include: A review of the facility policy Dressing Change, Clean Technique, last reviewed 7/22/24 indicates to prevent contamination of wounds such as pressure ulcers procedure includes but not limit to: . Remove the soiled dressing, place in trash bags. . Remove your gloves, wash your hands, and apply new gloves. . Clean the wound with normal saline solution or prescribed cleanser. . Use a dry 4x4 to pat the tissue surrounding the wound dry. . Remove your gloves, wash your hands, and apply new gloves. Review of the facility policy Medication Administration and Charting Guidelines, last reviewed 7/22/24, indicate ophthalmic…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy and procedure review, clinical record review and staff interview it was determined the facility failed to provide care and service for pressure ulcers for one of three residents reviewed. (Resident 1) Findings include: Review of facility policy and procedure titled Wound Management Program, dated January 11, 2019, revealed The C.N.A. will observe resident's skin during care for signs and symptoms of skin breakdown and report concerns with skin integrity to nurse. Documenting findings in Point of Care Documentation. Review of Resident 1's diagnosis list revealed the resident was admitted to the facility on [DATE] with diagnosis of paraplegia (paralysis of the legs and lower body). Review of Resident 1's Braden Scale for Predicting Pressure Score Risk, dated February 15, 2024 revealed the resident to be at high risk for pressure ulcers. Review of Resident 1's Skin Observation tool dated February 16, 2024 revealed the resident was admitted with a Stage 4 pressure ulcer (full skin and tissue…

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

Based on review of resident council minutes and interviews with residents and staff the facility failed to offer residents the opportunity to vote for five of thirteen residents. Findings include: Review of resident council minutes for seven months (February to September 2023) failed to include information of the facility asking residents to vote. During a resident group on 9/28/23, at 10:45 a.m. Residents indicated that they were not offered the opportunity to vote, in the May 2023 election. Five of thirteen residents indicated that they were interested in voting. During an interview on 9/29/23, at 2:07 p.m. Nursing Home Administrator confirmed that the facility could not provide documentation showing that the residents were asked prior to the May 2023 election if they wanted to vote and that the facility failed to offer residents the opportunity to vote. 28 Pa. Code 201.1(i)Resident rights.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of clinical records and staff interview it was determined that the facility failed to develop comprehensive care plans for one of twelve residents reviewed (Resident R33). Findings include: Review of Resident R33 clinical record was re-admitted on [DATE]. Review of Resident R33 MDS (minimum data set - a brief periodic assessment of resident needs) dated 7/24/23, indicated that Resident R33 had diagnosis of congestive heart failure ( when your heart can't pump blood well enough to your body), and arthritis ( swelling and tenderness of one or more joints). Review of Resident R33 clinical record, listed care plans as cancelled, with no active care plans in place. Review of the MDS Section B0200. Hearing indicates Resident R33 has minimal difficulty hearing - difficulty in certain environments. Review of Resident R33 hospital record dated 4/13/23, indicated that resident has an impacted cerumen, right ear (causes symptoms such as hearing loss). During an interview on 9/27/23, at 10:17 a.m. 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 facility policy, clinical record review, job description review, observation, and staff interview, it was determined the facility failed to provide care and services to meet the accepted standards of practice for one of four residents (Resident R100). Review of the facility Licensed Practical Nurse (LPN) job description indicated that it is the responsibility of the LPN to provide care, based on physical, psycho/social, safety, and related criteria, appropriate to the residents served in his/her assigned area. It was indicated the LPN must maintain a current knowledge of federal, state, and other regulations applicable to job. Review of Resident R100's Minimum Data Set (MDS-periodic review of care needs) dated 9/20/23, indicated the resident was admitted on [DATE]. Review of Resident R100's diagnoses dated 9/20/23, indicated a diagnosis of low blood pressure, depression, and hypothyroidism (occurs when the thyroid gland can't make enough thyroid hormone to keep the body running normally). 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 a review of facility documents, clinical record review and staff interview it was determined that the facility failed to provide hearing assistive devices, treatment and services to one of two residents reviewed (Resident R33). Findings include: Federal regulations states: §483.25(a) Vision and hearing To ensure that residents receive proper treatment and assistive devices to maintain vision and hearing abilities, the facility must, if necessary, assist the resident- Review of clinical record indicated Resident R33 was admitted to the facility on [DATE]. Review of Resident R33 MDS (minimum data set - a brief periodic assessment of resident needs) dated 7/24/23, indicated that Resident R33 had diagnosis of congestive heart failure (when your heart can't pump blood well enough to your body), and arthritis (swelling and tenderness of one or more joints). Review of the MDS Section B0200. Hearing indicates Resident R33 has minimal difficulty hearing - difficulty in certain environments. Review of Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy and clinical record, observation and staff interviews it was determined that the facility failed to administer medications with a medication error rate that was less than five percent for two of four residents (Resident R20). Findings include: Two medication errors occurred during 26 observed opportunities, which resulted in a 7.69% medication error rate. Review of Resident R20's Minimum Data Set (MDS-periodic review of care needs) dated 7/15/23, indicated the resident was admitted on [DATE], and diagnosis included depression, chronic pain, and schizophrenia (combination of mood disorder, depression and delusions). Review of Resident R20's physician order dated 7/11/23, instructed the nurse to give one tablet of Senna (stool softener to prevent constipation) one time a day for bowel regularity. During an observation of Resident R20's medication administration on 9/27/23, at 9:26 a.m. Licensed Practical Nurse (LPN), Employee E7 had Resident R20's morning medications signed off…

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

Based on review of facility policies, observations, and staff interviews, it was determined that the facility failed to maintain and implement updated COVID-19 polices based on national standards and perform hand hygiene for one of four residents (Resident R49). Findings include: Review of the facility Hand Hygiene policy dated 6/9/20, last reviewed 6/23, indicated hand hygiene must be performed before and after resident contact and before and after performing any procedure. Review of the facility COVID-19, Coronavirus Prevention and Response dated 6/6/23, indicated residents are tested on admission Day 1, then if negative, test again 3 Day, then again on Day 5. It was indicated resident who become symptomatic will be tested. Review of the facility COVID-19 Contingency Staffing policy dated 6/6/23, indicated If staffing were to fall below the state required 2.7 hours of staffing per resident per day, the community would notify the Pennsylvania Department of Health, document the reason for inability to maintain 2.7 requirement. The facility policy failed to reflect the updated…

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