Heritage Care Center

Based on review of facility policy, resident and staff interview it was determined that the facility failed to follow up on resident grievances for eleven residents. Finding s include: Review of the facility policy dated 2/1/25, Skilled Nursing Facility Grievance Policy indicated: Purpose - To ensure all residents resident representatives and responsible parties in the skilled nursing facility have the right to voice concerns, file grievances, and receive a prompt, though, an impartial response without fear of retaliation. Acknowledgement the grievance official will acknowledge receipt of the grievance in 3 business days. A written decision will be issued within one week unless extenuating circumstances. Review of resident council minutes from July 2025 to October 2025 indicated residents had on-going concerns with using land line telephones in resident rooms and phone extensions for departments in the facility, as they were unable to get through. During a resident group interview on 11/17/25, at 2:00 approximately Residents indicated that they are unable to get in touch with the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident and staff interview identified that the facility failed to protect Resident R111 from potential burn accident/incident when providing a hot pack without a Physician order and monitoring the use /time placed and failed to provide adequate supervision for Resident R20 during med pass for one of two nursing units. During an observation on 11/18/25, at 8:25 a.m., Resident R111 asked the SA to go into her bedside stand drawer and get out the hot pack and place it on her left shoulder. The SA observed the disposable hot pack and told the resident that the nurse would be told. Resident R111 stated that the nurses always give me them. During a clinical record review Resident R111 was admitted to the facility on [DATE], with diagnoses which included a stoke causing left side hemiparesis. An MDS (Minimum Data Set- a periodic assessment of resident care needs) dated 9/8/25, indicated the diagnoses remained current. Review of Resident R111's current physician's orders did not include use of 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 resident clinical records, facility policy and staff interview it was determined the facility failed to provide consistent and complete communication with the dialysis center for two of three residents (Resident R6, and R24) and failed to have a physician order or care plan for location of dialysis treatment center for one of three residents (Resident R120).Findings include: Review of the facility policy End-Stage Renal Disease, Care of a Resident with dated 10/7/25, indicated residents with end-stage renal disease (ESRD) will be cared for according to currently recognized standards of care. The agreements between the facility and the ESRD facility will include how information will be exchanged between the facilities; and the resident's care plan will reflect the resident's needs related to ESRD and dialysis (a treatment that removes excess water, waste, and toxins from the blood when the kidneys are no longer functioning properly) care. The resident's comprehensive care plan will reflect the…

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

Based on review of facility documentation, cited deficiencies from previous surveys, review of plan of correction documentation, and staff interview, it was determined that the facility's Quality Assurance and Performance Improvement (QAPI) program failed to correct previously cited deficiencies. This has the potential to affect 105 of 105 residents.Finding include:Review of the facility policy Quality Assurance and Performance Improvement (QAPI) Program dated 10/7/25, indicated objectives of the QAPI program include providing a means to measure current and potential indicators for outcomes of care and quality of life; establish and implement performance improvement projects to correct identified negative or problematic indicators; reinforce and build upon effective systems and processes related to the delivery of quality care and services; and establish systems through which to monitor and evaluate corrective actions.Review of the facility's deficiencies and plan of corrections for the State Survey and Certification (Department of Health) survey ending 12/6/24, revealed 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 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 for three of three quarterly meetings (Quarter one, two, three of 2025).Findings include: Review of Quality Assurance and Performance Improvement (QAPI) sign in sheets and attendance records revealed only one QAPI meeting held in 2025, October 16, 2025. During an interview on 11/20/25, at 8:35 a.m. The Nursing Home Administrator confirmed the facility failed to conduct Quality Assessment and Assurance (QAA) meetings at least quarterly as required. 28 Pa Code: 201.18(e)(1)(2)(3)(4) Management

Based on observations and staff interviews, it was determined that the facility failed to ensure the dish machine was in proper working order in the Main Kitchen. Findings include: During an observation of the dish room on 11/17/25, at 10:00 a.m. the final rinse temperature indicated 140 degrees Fahrenheit. Dish washer temperature verification strip did not change color indicating not meeting the proper rinse temperature of 160 degrees Fahrenheit. During an interview on 11/17/25, at 10:15 a.m. Dietary Manager Employee E8 confirmed he was not aware that the dishwasher was inoperable and directed staff to use Styrofoam containers and cups. Dietary Manager Employee E8 stated Maintenance staff looked at the dish machine and it needed a new motor and would be down. During an interview on 11/18/25, at approximately 2:00 p.m. the Dietary Manager Employee E8 confirmed the facility failed to ensure the dish machine was in proper working order in the Main Kitchen. 28 Pa Code:201.14(a) Responsibility of Licensee

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, review of clinical records, observations and staff interview, it was determined that the facility failed to determine whether it was safe to self-administer medications for one of six residents (Resident R42).Based on review of facility policy, review of clinical records, observations and staff interview, it was determined that the facility failed to determine whether it was safe to self-administer medications for one of six residents (Resident R42). Findings include: Review of the facility policy Resident Self-Administration of Medications dated 10/7/25, indicated residents in the facility who wish to self-administer their medications may do so if the interdisciplinary team has determined that this practice is clinically appropriate. Assessments will include addressing the following and documenting in the care plan: storage of the medication, responsible party for storage of medication, documenting the administration of drugs, and location of where the drugs will be…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 resident and staff interviews, it was determined that the facility failed to assess and accommodate a resident's request for enabler rails (Resident R105).Findings include:Review of the facility policy Accommodation of Needs dated 10/7/25, indicated the facility's environment and staff behaviors are directed toward assisting the resident in maintaining and/or achieving safe independent functioning, dignity and well-being.Review of the admission record indicated Resident R13 admitted to the facility on [DATE].Revies of Resident R13's Minimum Data Set (MDS - a periodic assessment of care needs) dated 11/15/25, indicated the diagnoses of stroke (damage to the brain from an interruption of blood supply), hemiplegia (paralysis of one side of the body), and high blood pressure. Section C0500 indicated a Brief Interview for Mental Status (BIMS- is a screening test that aids in detecting cognitive impairment) score of 14 - cognitively intact. Section GG0170 - A. Roll…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 post complete and current contact information for the Adult Protective Services, State Long Term Care Ombudsman, and correct information for the Grievance Officer on two of two nursing units (Second and Third Floor nursing units). Findings include: During observations on 11/17/25, and 11/19/25, on the Second and Third Floor nursing units failed to reveal the contact information for Adult Protective Services, name and email of the State Long Term Care Ombudsman, and non - conflicting information for the Grievance Officer ( three grievance processes posted on the second floor and four posted on the third floor) with multiple grievance officers listed on each posting. During an interview on 11/19/25, at 3:16 p.m. Nursing Home Administrator was informed that the facility failed to post complete and current contact information Adult Protective Services, State Long Term Care Ombudsman, and correct information for the Grievance Officer on two of two nursing units. 28 Pa. Code 201.14(a)Responsibility 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 observation, resident and staff interview, it was determined that the facility failed to ensure all residents had access to a resident only telephone (Second and Third floor nursing units). Findings include: During an observation on 11/18/25, at 12:20 p.m. Resident R100 was at the nurse's station on the third floor and asked to use the facility phone. Resident R100 stated that they do not have a phone in their room and this is always the phone that they use to call their loved one. Resident R100 indicated that there is no other phone to use. During an interview on 11/19/25, at 12:43 p.m. with Maintenance Director Employee E11 confirmed that the facility does not have resident telephones for private use on the second and third floor nursing units. 28 Pa. Code 201.14 (a) Responsibility of licensee.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of clinical records and resident family and staff interviews it was determined that the facility failed to notify the residents responsible party of a change in a residents nursing care status (skilled nursing care with therapy to nursing care without therapy) for one of three residents Resident R119. Findings include: Review of the clinical record indicated Resident 119 Was admitted to the facility on [DATE]. Review of the admission information indicated a diagnosis of leukemia (cancer of the body's blood -forming tissues) unspecified not having reached remission, and antineoplastic chemotherapy induced pancytopenia (low levels of red blood cells, white blood cells, and platelets). Review of the clinical record indicated Resident was admitted for therapy and rehabilitation and completed therapy on 10/7/2025. Review of the clinical record for Resident R119 failed to include documentation showing Resident R119 responsible party/emergency contacts were notified in the discharge from therapy. During…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, observations, resident and staff interviews it was determined that the facility failed to maintain a homelike environment for three of nine residents (Resident R7, R24, and R46).Findings include: A review of the policy Homelike Environment dated 10/7/25, with a previous review date of 9/25/24, indicated Residents are provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible. The facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include a clean, sanitary and orderly environment. Review of Title 42 Code of Federal Regulations S483.10(i) Safe Environment. The resident has a right to a safe, clean, comfortable, and homelike environment, including but not limited to receiving treatment and supports for daily living safely. S483.10(i)(2) Housekeeping and maintenance services necessary to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of clinical record reviews and staff interviews, it was determined that the facility failed to initiate a thorough investigation for incident or accidents for one of three residents (Residents R20). Findings include: Review of clinical record indicated Resident R20 was admitted [DATE], with diagnoses which included Alzheimer's (progressive mental deterioration), adult failure to thrive and dementia (loss of cognitive functioning). A review of Resident R20's Minimum Data Set MDS-a periodic assessment of resident care needs), dated 11/9/25, indicated diagnoses remained current. Review of Resident R20 nurse progress notes dated 11/1/25 at 5:52 a.m., revealed that MD on rounds who was earlier informed of resident possibly ingesting nonprescribed meds. Review of Resident R20 incident investigation revealed no witness statements or statement from the nurse on R20's assignment. During an interview on 11/20/25, at 2:30 p.m. Regional Representative Employee E13 confirmed the facility did not conduct…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the Resident Assessment Instrument User's Manual and clinical records, and staff interview, it was determined that the facility failed to make certain that comprehensive Minimum Data Set assessments were accurate and fully completed for three of twelve residents (Resident R10, R69, and R84).Findings include: The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which gives instructions for completing Minimum Data Set Assessments (MDS - periodic assessment of 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, or it should be coded 1, and the BIMS assessment should be completed if the resident is at least sometimes understood. Section D: Mood, Question D0100 Should Resident Mood Interview Be Conducted? should be coded as 0 if the resident is rarely/never understood, and or it should be coded 1, and 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 and clinical records and staff interview, it was determined that the facility failed to update a care plan for one of six residents (Residents R105) to accurately reflect the current status of the resident.Findings include:Review of the facility policy Care Plans, Comprehensive Person-Centered dated 10/7/254, indicated the person-centered care plan describes services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being including services for each element of care.Review of Resident R105's admission record indicated she was admitted on [DATE].Review of Resident R105's Minimum Data Set (MDS- a periodic assessment of care needs) dated 9/5/25, indicated the diagnoses of hypertension, chronic obstructive pulmonary disease (COPD- a group of diseases that block airflow and make it hard to breathe), and obsessive compulsive disorder (OCD- mental health condition with unwanted, recurring thoughts and repetitive…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical record review, observation, and staff interview, it was determined that the facility failed to ensure that residents with an enteral feeding tube (G- Tube, a tube inserted in the stomach through the abdomen) received appropriate treatment and services to prevent potential complications for three of four residents (Residents R60, R99, and R117).Findings include: Review of facility policy Enteral Feedings - Safety Precautions 10/7/25, indicated preventing errors in administration staff should check the enteral nutrition label against the order before administration. Check the following information:-Resident name, identification, and room number.-Type of formula.-Date and time formula was prepared.-Route of delivery.-Access site.-Method (pump, gravity, syringe).-Rate of administration (milliliters/hour)-On the formula label document initials, date and time the formula was hung and initial that the label was checked against the order.Review of the admission 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy and documents, clinical records, and staff interviews, it was determined that the facility failed to provide prescribed parenteral fluids (the delivery of medication or nutrition into the body via routes that bypass the gastrointestinal tract) consistent with professional standards of practice for one of two residents (Resident R93).Findings include: Review of the facility policy Administration Set/Tubing Changes dated 10/7/25, indicated label tubing with date, time, and initials. Any tubing that is found not labeled must be changed and then labeled accordingly. Review of the clinical record indicated Resident R93admitted to the facility on [DATE]. Review of Resident R93's Minimum Data Set (MDS- a periodic assessment of care needs) dated 10/4/25, indicated the diagnoses of anemia (the blood doesn't have enough healthy red blood cells), high blood pressure, and peripheral vascular disease (a condition in which narrowed blood vessels reduce blood flow to the limbs). 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, clinical records, observations and staff interviews, it was determined that the facility failed to provide appropriate respiratory care and maintain oxygen equipment for five of eight sampled residents (Residents R35, R74, R99, R105, and R120).Findings include: Review of the facility policy Departmental (Respiratory Therapy) - Prevention of Infection last reviewed on 10/7/25, indicated that considerations related to oxygen administration include change the oxygen cannula and tubing every seven days or as needed. Keep the oxygen and tubing used as needed in a plastic bag when not in use. Considerations related to medication nebulizers/continuous aerosol include store the circuit in a plastic bag, marked with date and resident's name, between uses. Discard the administration set up every seven days. Review of Resident R35's admission record indicated she was admitted on [DATE]. Review of Resident R35's Minimum Data Set (MDS- a periodic assessment of care needs) dated 11/2/25,…

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

Based on observation, clinical record review, review of select manufacture's guidelines, and staff interview, it was determined that the facility failed to ensure a medication error rate below five percent (Resident R19).Findings include: The facility's medication error rate was 8% (percent) based on 25 medication opportunities with two medication errors. During a medication observation on 11/18/25, at 8:11 a.m. Licensed Practical Nurse (LPN) Employee E6 was preparing to administer Resident R19's morning dose of Lispro insulin. LPN Employee E6 verified the correct insulin and the correct dose; however, was not aware and did not prime the pen prior to drawing up the dose of 76 units.Further observation of LPN Employee E6's medication administration to Resident R19 failed to receive 17 gram Miralax (laxative medication used to treat occasional constipation or irregular bowel movements). Nurse had mixed the Miralax in with the liquid protein and water which resident refused. Nurse disposed of the mixture and did not repour the Miralax as ordered.Interview with the Director of 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 observation, review of facility policy, manufacturer recommendations, resident interviews, clinical records, and staff interview, it was determined that the facility failed to make certain that residents are free of significant medication errors for one of three residents observed (Resident R19). Findings include: Review of the facility policy Adverse Consequences and Medication Errors dated 10/7/25, indicated a medication error is defined as the preparation or administration of drugs or biological which is not in accordance with physician's orders, manufacturer's specifications, or accepted professional standards and principles of the professional providing services. Review of the manufacturer's guideline for Insulin Lispro KwikPen dated July 2023, indicated to prime the pen, select a dose of two units, hold the pen with the needle pointing upwards, gently tap the reservoir to remove air bubbles, press the injection button all the way in and check if insulin comes out of the needle tip. Then select 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, observations, and staff interviews, it was determined that the facility failed to store medications and biologicals properly for three of three medication carts (Second Floor East and South Medication carts and Third Floor South Medication cart) and two of two medication rooms (Second and Third Floor).Findings include: Review of the facility policy Storage of Medications last reviewed [DATE]/25, indicated that medications and biologicals are stored safely, securely, and properly. Medication storage areas are kept clean, well lit, and free of clutter. Observation on [DATE], at 8:02 a.m. of the Second Floor East Medication cart revealed pre-poured medications for the following residents' morning medication administration - Resident R25, Resident R42, Resident R32, and Resident R108. Further investigation of the Second Floor East Medication cart revealed the following medications opened and not labeled with a date as required:-Ipratropium solution (assists in making breathing…

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

Based on observation, and staff interview it was determined that the facility failed to properly approve the current menu cycle with the registered dietician as required for two of two nursing units (second and third floor nursing units).Findings include: During an observation on 11/17/25 and 11/18/25, on the Second and Third Nursing Floor unit's menus were posted (3 different weeks with a print date of 10/25) that failed to include a Registered Dietician acknowledgement that the weeks of the diet menu had been reviewed and approved. During an interview on 11/18/25, at the NHA (Nursing Home Administrator) was informed that the facility failed to properly approve the current menu cycle with the registered dietician. 28 Pa. Code 211.6(a)(b) Dietary services.

Based on facility policy, observation and resident and staff interview it was determined that the facility failed to provide special eating equipment and utensils for residents who need them and appropriate assistance to ensure that the resident can use the assistive devices when consuming meals and snacks for one of two residents (Resident R111).During an interview on 11/18/25, at 8:25 a.m., Resident R111 was attempting to eat her breakfast out of a foam container. Resident R111 stated that she is supposed to have a scoop plate so she can feed herself, but the dish machine has been broken, and the facility has been using foam.Review of Resident R111's current care plan indicated the use of a scoop dish for all meals. During an interview on 11/21/25, at 10:24 a.m., Therapy Manager Employee E15 stated that she cannot provide documentation for assessment for need of scoop plate as that was before WE Care took over however, the resident is still supposed to be getting it. She confirmed that the facility failed to provide proper special eating equipment for Resident R111.

Based on observation and staff interview it was determined that the facility failed to properly contain and dispose of garbage in outside dumpsters to prevent the potential for rodent and insect infestation. Findings include: During an observation and interview of the facility's outdoor trash compactor and dumpster on 11/17/25, at 10:15 a.m. with Dietary Manager (DM) E8 confirmed that there were trash and debris collecting in the disposal area, the dumpster lid was open and that the facility failed to properly contain and dispose of garbage in outside dumpster area to prevent potential rodent and insect infestation. 28 Pa. Code 201.18(b)(3) Management.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of facility policy, clinical record review, and staff interviews, it was determined that the facility failed to develop and implement discharge planning processes that focused on residents discharge goals for one out of three discharged residents sampled (Resident R1).Findings Include: Review of facility policy Transfer or Discharge, Preparing a Resident for, dated 9/5/25, previously reviewed 9/25/24, indicated residents will be prepared in advance for discharge. When a resident is scheduled for transfer or discharge, the business office will notify nursing services of the transfer or discharge so that appropriate procedures can be implemented. A post-discharge plan is developed for each resident prior to his or her transfer or discharge. The plan will be reviewed with the resident, and/or his or her family, at least twenty-four (24) hours before the resident's discharge or transfer from the facility. Nursing services is responsible for:- obtaining orders for discharge or transfer, as well as…

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

Based on observations and staff interview, it was determined that the facility failed to properly store food products and failed to maintain sanitary conditions which created the potential for cross contamination (Main Kitchen). Findings include: During an observation of the main designated kitchen on 8/18/25, at 10:30 a.m. the following was observed:- 1 container of mashed potatoes, no cover - 1 container of food thickener, no cover, not labelled, no date - Food Slicer: dried food, brown debris- Roucoup: dried food, debris - Steamer: food debris- bottom storage shelving of steam table: food debris- wall, ceiling beside clean side of dishwasher, brown debris During an interview on 8/18/25, Dietary Manager Employee E1 confirmed that the facility failed to properly store food products and maintain sanitary conditions in the main kitchen which created the potential for cross contamination. 28 Pa. Code: 201.18(b)(1) Management.28 Pa. Code: 211.6(c) Dietary services.28 Pa. Code: 201.14(a) Responsibility of licensee.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of resident clinical records and staff interview it was determined the facility failed to have active physician orders for dialysis for two of two residents (Resident R2 and R3).Findings include: Review of the clinical record indicated that 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 4/29/25, indicated with the diagnoses of end stage kidney disease (a condition where the kidney reaches advanced state of loss of function), diabetes mellitus (a chronic metabolic disease characterized by high blood sugar levels), and chronic kidney disease. Review of Resident R2's MDS Section O for Special Treatments and Procedures. J1 Dialysis indicated resident was receiving dialysis as a resident at the facility. Review of R2's physician order dated 7/31/25, indicated the resident has no active order for dialysis.Review of the clinical record indicated that Resident R3 was admitted to the facility on [DATE].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 resident clinical records and staff interview, it was determined that the facility failed to accurately assess pressure ulcers for two of seven residents (Resident R1 and R4).Findings include:Review of the clinical record indicated that Resident R1 was admitted to the facility on [DATE].Review of the Minimum Data Set (MDS - periodic assessment of care needs) dated 7/7/25, indicated that Resident R1 had diagnoses that included history of chronic obstructive pulmonary disease (a progressive lung disease that makes breathing increasingly difficult), hypertension and anxiety.Review of Resident R1 Wound Assessment report dated 8/15/25, resident has an unstageable pressure ulcer on right later half acquired 7/2/25.Review of a physician order dated 7/7/25, indicated to cleanse with wound cleanser, apply betadine to base of thewound, leave open to air, change Q Shift. Review of Resident R1's July TAR indicated the treatment was not documented as completed on 7/11/25, 7/12/25, 713/25, 7/16/25, 7/18/25,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 policies, observations and staff interviews, it was determined that the facility failed to properly store chemicals, properly label and date food products, properly store food products, monitor and maintain records of refrigeration/freezer temperature logs to make certain refrigeration/freezers function properly, maintain the cleanliness and sanitation of the Main Kitchen. (Main Kitchen). Findings include: A review of facility Food Storage: policy date 9/25/24, revealed that Food storage areas shall be maintained in a clean, safe and sanitary manner. Cold foods will be maintained at temperatures at 41 ° F (degrees Fahrenheit) or below. All foods stored in the walk in refrigeration and freezers will be stored above the floor on shelves. Leftovers will be labeled and dated. Soaps, detergents, cleaning compounds are stored in separate storage areas. The Dining Services Managers, [NAME] or designee will check refrigerators, freezers twice daily for proper temperature maintenance. 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 a review of facility policies,documents, observations and staff interviews it was determined that the facility failed to provide a dignified dining experience on 2/19/25, during the lunch meal service to four of seven residents. (Resident R1, R2, R3, and R4). Findings include: A review of facility Dignity policy dated 9/25/24, indicated that residents are treated with dignity and respect at all times. During a review of facility document Residents with staff feed printed on 2/19/25, it was revealed that Resident R1 and R2 required staff to feed the resident. During an observation on 2/19/25, at 12:35 pm it was revealed that Resident R1 was laying in bed being feed by a Nursing Assistant (NA) that was standing over her at the bedside. During an interview on 2/19/25, at 12:39 Registered Dietitian (RD) Employee E1 confirmed that the NA was standing over Resident R1 while she was feeding the resident which failed to provide a dignified dining experience for the resident. During an observation at of tray delivery on 2/19/25, it was observed that the trays arrived on the 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.

Based on a review of facility job descriptions and staff interviews it was determined that the facility failed to provide a qualified Food Service Director (FSD) to manage the daily operations of the Food Service Department for 99 days (11/22/24, through 2/18/25), Findings include: A review of the facility's Food Service Director job description date 9/25/24, revealed that the purpose of the FSD position is to plan, organize, develop and direct the overall operation of the Food Services department in accordance with established food service standards, policies, procedures and practices of the facility and requirements of current federal, state and local standards governing the facility and as may be directed by the Administrator to assure that quality nutritional services are provided as a daily basis and that the food services department is maintained in a clean, safe and sanitary manner. Education and Qualifications include: be a graduate of an accredited course in dietetic training approved by the American Dietetic Association or must be registered as a Food Service Director in…

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

Based on review of facility policy, observations, and staff interview, it was determined that the facility failed to properly store food products in the walk-in cooler and failed to maintain sanitary conditions which created the potential for cross contamination (Main Kitchen). Findings include: Review of facility policy Preventative Maintenance and weekly cleaning dated 9/25/24 indicates dietary manager or designer is responsible for checking all equipment listed on the weekly cleaning schedule to maintain a fully functioning hazard-free and clean environment in the kitchen. During an observation of the main designated kitchen on 12/2/24, at 8:50 a.m. the following was observed: -Two packages ground beef thawing on the 3rd shelf. -No dishwasher documentation for verification of temperature. During an observation of the main designated kitchen on 12/2/24, at 2:00 p.m. the following was observed: -Floor fan in dish room, brown debris. -Walls in dish room, food debris. -Ice machine, brown, slimy substance. During an interview on 12/2/24, at 2:30 p.m. Dietary Manager Employee E11…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 update a care plan for three of ten residents (Residents R4, R33, and R60) to accurately reflect the current status of the resident. Findings include: Review of the facility policy Care Plans, Comprehensive Person-Centered dated 9/25/24, indicated the person-centered care plan describes services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being including services for each element of care. Review of the admission record indicated Resident R33 was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS - a periodic assessment of care needs) dated 9/3/24, indicated the diagnoses of high blood pressure, seizure disorder (a person experiences abnormal behaviors, symptoms, and sensations, sometimes including loss of consciousness), and hypothyroidism (thyroid gland doesn't produce enough thyroid hormone).…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policies, observations, clinical record review, and staff interview, it was determined that the facility failed to provide appropriate respiratory care for three of four residents (Residents R19, R42, and R53). Findings include: Review of the facility policy Administering Medications through a Small Volume Nebulizer (a small machine that turns liquid medicine into a mist that can be inhaled) dated 9/25/24, indicated when equipment is completely dry, store in a plastic bag with the resident's name and the date on it. Review of the facility policy Respiratory Therapy-Prevention of Infections dated 9/25/24, indicated the purpose of this procedure is to guide prevention of infection associated with respiratory therapy tasks, equipment among residents. Change the oxygen nasal cannula (a tubing the provides oxygen to a resident through their nose) and tubing every seven days, or as needed. Review of the clinical record indicated that Resident R19 was admitted to the facility on [DATE].…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of resident clinical records, facility policy and staff interview it was determined the facility failed to provide consistent and complete communication with the dialysis center for two of two residents (Resident R63, and R86), and failed to have a care plan for monitoring of access site for one of two residents (Resident R86). Findings include: Review of the facility policy End-Stage Renal Disease, Care of a Resident with dated 9/25/24, indicated residents with end-stage renal disease (ESRD) will be cared for according to currently recognized standards of care. The agreements between the facility and the ESRD facility will include how information will be exchanged between the facilities; and the resident's care plan will reflect the resident's needs related to ESRD and dialysis (a treatment that removes excess water, waste, and toxins from the blood when the kidneys are no longer functioning properly) care. Review of the admission record indicated Resident R63 admitted to the facility on [DATE].…

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

Based on review of personnel files and staff interview it was determined that the facility failed to complete annual nurse aid employee evaluations for three of three sampled records (Nurse aide (NA) Employees E14, E15, and E16). Findings include: A request to review the annual performance evaluations for NA Employees E14, E15, and E16 revealed no documented evidence that the facility has completed annual performance appraisals as required. Review of NA Employee E14's personnel record indicated she was hired on 9/28/88. Review of NA Employee E15's personnel record indicated she was hired on 2/8/19. Review of NA Employee E16's personnel record indicated she was hired on 5/9/22. Interview with Human Resource Director Employee E17 on 12/6/24, at 11:59 a.m. indicated the company changed hands on 5/1/24, and the facility was unable to produce annual performance reviews for the NA Employees E14, E15, and E16. Interview on 12/6/24, at 3:00 p.m. the Nursing Home Administrator confirmed the facility failed to complete annual nurse aid employee evaluations as required. 28 Pa Code: 201.14 (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 review of facility policies, observations, and staff interviews, it was determined that the facility failed to properly store medications on four of four medications carts (2 West, 2 East, 3 East and 3 South Medication Cart) and for one of three residents (Resident R87). Findings include: A review of facility policy Medication Storage last reviewed 9/25/24, indicated the facility stores all drugs and biologicals in a safe, secure, and orderly manner. Drugs and biologicals are stored in the packaging, containers, or other dispensing systems in which they are received. The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. Drug containers that have missing, incomplete, improper, or incorrect labels are returned to the pharmacy for proper labeling before storing. Compartments containing drugs and biologicals are locked when not in use. During an observation on 12/2/24, at 8:52 a.m. of the Second Floor [NAME] Hall Medication Cart indicated the following medications were not stored properly in a bag 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 facility policy, observations, and staff interviews it was determined that the facility failed to provide adaptive feeding devices for three of three residents (Resident R6, R33, and R35). Findings include: Review of the facility policy Assisting the Resident with In-Room Meals dated 9/25/24, indicated check the tray before serving it to the resident to be sure that it is the correct diet ordered and that the food consistency is appropriate to the resident's ability to chew and swallow. Ensure that the necessary non-food items (i.e. silverware, napkin, special devices, straw, etc.) are on the tray. Report or replace missing items. Review of the admission record indicated Resident R6 admitted to the facility on [DATE]. Review of Resident R6's Minimum Data Set (MDS- a periodic assessment of care needs) dated 10/9/24, indicated diagnoses of high blood pressure, heart failure (heart doesn't pump blood as well as it should), and coronary artery disease (narrow arteries decreasing blood flow to heart). 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 observation and staff interview, it was determined the facility failed to provide a bed, a mattress and functional furniture in resident rooms on the first floor for 13 out of 13 rooms (First Floor). Findings include: Review of facility policy Homelike Environment dated 8/28/24, indicated that residents are provided with a safe, clean, comfortable, and homelike environment. Facility provides furniture, including a clean bed. During a tour on 12/6/24, at 1:00 p.m. revealed the following missing items in each room observed: room [ROOM NUMBER] - missing one bed and mattress. room [ROOM NUMBER] - missing one bed and mattress. room [ROOM NUMBER] - missing one bed and mattress. room [ROOM NUMBER] - missing one bed and mattress. room [ROOM NUMBER] - missing two beds and two mattresses. room [ROOM NUMBER] - missing one chair. room [ROOM NUMBER] - missing two beds, two mattresses and one chair. room [ROOM NUMBER] - missing two beds, two mattresses and one chair. room [ROOM NUMBER] - missing on bed and mattress.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 observations and staff interview, it was determined that that the facility failed to determine it was safe to self-administer medications for two of five residents (Resident R19 and R24). Findings include: Review of the facility policy Self-Administration of Medications dated 9/25/24, indicated residents have the right to self-administer medications if the interdisciplinary team has determined it's clinically appropriate and safe for the resident to do so. Review of Resident R19's admission record indicated that she was admitted on [DATE], with diagnoses that included schizoaffective disorder (a mental health condition that is marked by a mix of schizophrenia symptoms, such as hallucinations and delusions, and mood disorder symptoms, such as depression, mania and a milder form of mania called hypomania.), Bipolar disorder (a chronic mood disorder that causes intense shifts in mood, energy levels and behavior) and dementia (is the loss of cognitive functioning- thinking, remembering, 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, observations and staff interview it was determined that the facility failed to uphold privacy and dignity of resident information for one of three sampled resident (Resident R77). Findings Include: The facility Resident rights policy dated 9/25/24, indicated that Federal and state law guarantees certain basic rights to all residents of this facility. These rights include the resident's right to privacy and confidentiality. Review of Resident R77's admission record indicated she was originally admitted on [DATE], and readmitted on [DATE]. Review of Resident R77's MDS assessment (MDS-Minimum Data Set assessment: a periodic assessment of resident care needs) dated 11/6/24, indicated she had diagnoses that included dysphagia (difficulty swallowing), congestive heart failure (a progressive heart disease affecting pumping action of the heart muscles impacting circulation, swelling and shortness of breath), Alzheimer's dementia (a chronic or persistent disorder of the mental…

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

Based on review of facility policy, newly hired personnel records and staff interviews it was determined that the facility failed to properly screen an employment by completing a state background check prior to hire for one out of five personnel records (Registered Nurse Employee E2). Findings include: The facility Abuse, Neglect, Exploitation and Misappropriation Prevention policy dated 9/25/24, indicated that the resident have the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. Conduct employee background checks and not knowing employ or otherwise engage any individuals who has been found guilty of abuse or neglect and a disciplinary action in effect against his or her professional license by a state licensure body. The facility Background Screening Investigations policy dated 9/25/24, indicated that facility conducts employment background screening checks, reference checks, and criminal conviction investigation checks on all applicants. Background and criminal checks are completed prior to employment. Review of Registered Nurse (RN)…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 make certain that the necessary resident information was communicated to the receiving health care provider for two out of four residents sampled with facility-initiated transfers (Residents R48 and R53). The findings include: Review of policy Transfer or Discharge Documentation dated 9/25/24, indicated when a resident is transferred or discharged , details of the transfer or discharge will be documented in the medical record and appropriate information will be communicated to the receiving health care facility or provider. Review of Resident R48's clinical record indicated the resident was admitted to the facility on [DATE]. Review of Resident R48's MDS (Minimum Data Set, periodic assessment of resident care needs) dated 11/22/24, indicated diagnoses of cancer (a disease that occurs when cells in the body grow and spread uncontrollably), diabetes (a metabolic disorder in which the body has high sugar levels 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of clinical record review and interview with staff, it was determined that the facility failed to provide discharge planning that focuses on the resident's discharge goals and preparation of resident to be active partners in the discharge planning process that focuses on the resident's discharge planning and process for one of three residents (CR1). Findings include: Review of Closed Resident Record CR1's admission record indicated CR1 was admitted [DATE]. Review of CR1's Minimum Data Set (MDS-a periodic assessment of care needs) dated 9/3/24, indicated diagnoses of necrotizing fasciitis (rare but serious bacterial infection that causes the death of soft tissue in the body), heart disease, and diabetes mellitus. Review of CR1's progress notes dated 9/12/24, indicated resident left facility with brother, resident left with belongings, medication, medication list, and discharge instruction, nurse educated resident on wound care and follow up appointments. Review of CR1's progress notes 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 clinical records, resident and staff interview it was determined that the facility failed to assess a CGM (continuous glucose monitoring device), obtain physician orders for care and management of and failed to have a care plan for care and management of the device for one of three residents (Resident R309). Findings include: Interview with the Nursing Home Administrator on 12/6/24, at 10:48 a.m. indicated the facility did not have a policy for CGM. Review of the admission record indicated Resident R309 admitted to the facility on [DATE]. Review of Resident R309's Minimum Data Set (MDS- a periodic assessment of care needs) dated 11/26/24, indicated the diagnoses of knee replacement, high blood pressure, and diabetes (a long-term condition in which the body has trouble controlling blood sugar and using it for energy). Review of Resident R309's current physician orders and care plan failed to include the CGM for care and management of. Interview with Resident R309 on 12/2/24, at 12:09 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, observation, and interviews with staff, it was determined that the facility failed to make certain residents were 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 two of three residents (Resident R4, R35). Findings include: Review of the facility Pressure Ulcers/ Skin Breakdown-Clinical Protocol last reviewed 9/25/24, indicated the nursing staff and practitioner will assess and document an individual's significant risk factors for developing pressure ulcers. The nurse shall describe and document a full assessment of pressure sore including location, stage, length, width, and depth, and presence of exudates or necrotic tissue. The physician will order pertinent wound treatments, including pressure reduction surfaces, wound cleansing and debridement approaches, dressing, and application of topical…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy, clinical record review, and interview, the facility failed to ensure that appropriate treatment and services were provided for one of four residents (Resident R11) with an indwelling urinary catheter. Findings include: Review of facility policy Catheter Care, Urinary dated 9/25/24, indicated to be sure the catheter tubing and drainage bag are kept off the floor and provide privacy. Review of the clinical record indicated Resident R11 was admitted to the facility on [DATE]. Review of Resident R11's Minimum Data Set (MDS - a periodic assessment of care needs) dated 11/7/24, indicated diagnoses of stroke, Non-Alzheimer's Dementia (dementia caused by other diseases with symptoms forgetfulness, limited social skills, and impaired thinking abilities that interfere with daily functioning), and obstructive uropathy (a condition in which flow of urine is blocked). Review of Resident R11's physician orders dated 8/15/24, indicated Foley catheter 16 French (the measure of the outer diameter of a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical record review, observation, and staff interview, it was determined that the facility failed to ensure that residents with an enteral feeding tube (a tube inserted in the stomach through the abdomen) received appropriate treatment and services to prevent potential complications for one of four residents (Residents R22). Findings include: Review of facility policy Enteral Tube Feeding via Continuous Pump dated 9/25/24, indicated the purpose of this procedure is to provide a guideline for the use of a pump for enteral feedings. Check the enteral nutrition label before administration. Refrigerate formulas that have been reconstituted in advance and discard within 24 hours. Discard formulas kept at room temperature within four hours. Review of Resident R22's clinical record indicated the resident was admitted to the facility on [DATE]. Review of Resident R22's Minimum Data Set (MDS - a periodic assessment of care needs) dated 11/6/24, indicated diagnoses of coronary artery…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, resident record review, and staff interviews, it was determined that the facility failed to provide a trauma survivor with trauma informed care to eliminate or mitigate triggers that may cause re-traumatization of the resident for one of three residents (Resident R89). Findings include: Review of facility policy Trauma Informed Care and Culturally Competent Care dated 9/25/24, indicated that trauma-informed care is an approach to delivering care that involves understanding, recognizing, and responding to the effects of all types of trauma. A trauma-informed approach to care delivery recognizes the widespread impact and signs and symptoms of trauma in residents, and incorporates knowledge about trauma into care plans, policies, procedures, and practices to avoid re-traumatization. A guide to address the needs of trauma survivors by minimizing triggers and re-traumatization. Review of the clinical record indicated Resident R89 was admitted to the facility on [DATE]. 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 clinical record review, facility policy review, and staff interviews, it was determined that the facility failed to ensure Medication Regimen Reviews (MRR) were completed by the facility after the consultant pharmacist recommendations were made for two out of six months (July 2024 and September 2024). Findings include: The facility policy Medication Regimen Review reviewed 9/25/24, indicated that a drug regimen of each resident is reviewed at least once a month by a licensed pharmacist and includes a review of the resident ' s medical chart. Written communication is sent to the attending physician and Director of Nursing. Facility staff shall act upon all recommendations according to procedures for addressing MRR reviews. Review of Resident R53's admission record indicated she was admitted to the facility on [DATE]. Review of Resident R53's MDS assessment (Minimum Data Set assessment: MDS -a periodic assessment of resident care needs) dated 11/13/24, indicated the diagnoses of heart failure (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 observation, clinical record review, review of select manufacture's guidelines, and staff interview, it was determined that the facility failed to ensure a medication error rate below five percent (Resident R96, and R80). Findings include: The facility's medication error rate was 7.69% (percent) based on 26 medication opportunities with two medication errors. Observation of a medication administration pass on 12/2/24, at 9:26 a.m. revealed Registered Nurse (RN), Employee 1, failed to administer Resident R96's 17 gram Miralax (laxative medication used to treat occasional constipation or irregular bowel movements) in the morning as ordered. The Miralax was unavailable in the medication cart, and RN Employee E1 indicated he will return to administer Resident R96's Miralax. Review of the resident's clinical record on 12/2/24, at 12:29 p.m. indicated the Miralax was not administered because it was out of stock. Observation of a medication administration pass on 12/2/24, at 9:32 a.m. revealed RN Employee E1, failed to administer Resident R80's 4% topical Lidocaine patch 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 facility meal delivery times, observations and staff interview, it was determined that the facility failed to deliver meals in a timely manner for one of two meal observations (Third floor). Findings include: The facility Cart delivery document indicated the following meal delivery times for the Third floor: 328 hallway/3-South meal cart will arrive at 12:10 p.m. 301 hallway/3-East meal cart will arrive at 12:14 p.m. 316 hallway/3-West meal cart will arrive at 12:17 p.m. During dining/meal observations on 12/2/24, the following was observed: at 12:37 p.m. the first lunch cart arrived for the Third floor 328 hallway/3-South. Lunch included caesar salad, roast turkey, tater tots, sherbet, coffee, and juice. at 12:41 p.m. the second lunch cart arrived for the Third floor 301 hallway/3-East. at 1:09 p.m. the third lunch cart arrived for the Third floor 316 hallway/3-West and main dining/common area. During an interview on 12/2/24, at 1:39 p.m. the Nursing Home Administrator (NHA) confirmed that the facility failed to deliver meals in a timely manner for residents on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policies and clinical records and staff interview, it was determined that the facility failed to make certain that medical records on each resident are complete and accurately documented for one of three residents (Resident R53). Findings: Review of policy Medication and Treatment Orders date 9/25/24, indicated that orders for treatments will be consistent with principles of safe and effective order writing. The signing of orders shall be by signature. Review of Resident R53's admission record indicated she was admitted to the facility on [DATE]. Review of Resident R53's MDS assessment (Minimum Data Set assessment: MDS -a periodic assessment of resident care needs) dated 11/13/24, indicated the diagnoses of heart failure (a progressive heart disease that affects pumping action of the heart muscles), high blood pressure, and depression. Review of Resident R53's physician orders indicated to cleanse right posterior thigh with normal saline solution (a mixture of sodium chloride 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 documents, resident clinical record and staff interviews it was determined that the facility failed to ensure a representative signed a binding arbitration agreement on the behalf of a resident lacking capacity to understand the agreement terms for one of three sampled residents (Resident R96). Findings include: The facility Alternative dispute resolution agreement form last reviewed 9/25/24, indicated that the resident, or the resident's authorized representative, has read this agreement in its entirety and understand the language in which it is written. A review of the Resident Assessment Instrument 3.0 User's Manual effective October 2019, indicated that a Brief Interview for Mental Status (BIMS, a screening test that aides in detecting cognitive impairment). The BIMS total score suggests the following distributions: 13-15: cognitively intact 8-12: moderately cognitive impaired 0-7: severe cognitive impairment Review of Resident R96's admission record indicated he was originally…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 implement infection prevention and control monitoring policies for enhanced barrier precautions (EBP- a type of isolation requiring gloves, gowns, and possible face shield to be worn with care) for two of three residents (Resident R16 and R48), and failed to adhere to proper handwashing prior to insulin administratioin for one of two residents (Resident R16). Findings: A review of the facility policy Diabetic Care last reviewed 9/25/24, indicated the first step in the procedure to administering insulin is to wash hands. A review of the facility policy Enhanced Barrier Precautions last reviewed 9/25/24, indicated standard precautions apply to the care of all residents regardless of suspected or confirmed infection or colonization status. Staff are trained prior to caring for residents on EBP. Signs are posted in the door or wall outside the resident room 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.

Based on a review of facility policies, documents, menus, observations, and resident family and staff interviews it was determined that the facility failed to follow resident food preferences for six of 12 residents (Resident R1, R4, R5, R10, R11, and Resident R12.) Findings include: A review of facility Resident Food Preferences policy, last reviewed 9/25/24, indicated individual food preferences will be assessed upon admission and communicated to the interdisciplinary team. Review of Resident R4's grievance submitted on 8/12/24, indicated he continues to be provided pork items to eat on his tray. It was indicated the Assistant Director of Social Services witnesses the pork bacon on Resident R4's tray along with his meal ticket that states in large red capital letters NO PORK. Review of Resident R5's grievance submitted on 8/12/24, indicated her meal ticket does not match what she is receiving and coffee does not arrive with meal. During an observation conducted for tray accuracy on 8/16/24, for the breakfast and lunch meals it was revealed that the facility failed to provide 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 a review of facility policy, observations, and staff interviews it was determined that the facility failed to make certain that residents are served food products that meet their dietary needs for one of eight residents (Resident R7). Findings include: A review of facility Therapeutic Diets policy last reviewed 9/25/24, indicated that diets will be determined in accordance with the resident's informed choices, preferences, treatment goals, and wishes. Review of the facility undated Therapeutic Diet Descriptions indicated an easy to chew ground diet consistency is a transition to the regular consistency and is appropriate for residents with mild to moderate dysphagia (difficulty swallowing). The meats are ground and served with a sauce or gravy. Vegetables are cooked until very tender/soft. Difficult to chew fruits, stringy fruits, fresh vegetables, corn, seeds, nuts, coconut, dried fruits, crispy and fried potatoes, dry/tough/crusty breads are avoided. During an observation and interview on 8/16/24, at 10:16 a.m. Resident R1 breakfast meal ticket indicated an easy to chew…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility documents, facility policy, clinical records, and staff interviews, it was determined that the facility failed to implement written policies and procedures to conduct a thorough investigation of an incident to rule out neglect for one of two residents (Resident R1) involving a fall sustained while receiving care. Findings include: Review of facility policy Abuse and Neglect- Clinical Protocol, review date undetermined, indicated that neglect is defined as the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. Review of the facility policy Abuse, Neglect, Exploitation or Misappropriation- Reporting and Investigating, review date undetermined, indicated that All reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation or resident property are reported to local, state and federal agencies (as…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility documents, facility policy, clinical records, and staff interviews, it was determined that the facility failed to conduct a thorough investigation of an incident to rule out neglect for one of two residents (Resident R1) involving a fall sustained while receiving care. Findings include: Review of facility policy Abuse and Neglect- Clinical Protocol, review date undetermined, indicated that neglect is defined as the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. Review of the facility policy Abuse, Neglect, Exploitation or Misappropriation- Reporting and Investigating, review date undetermined, indicated that All reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation or resident property are reported to local, state and federal agencies (as required by current regulation) 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 a review of Resident Assessment Instrument (RAI) User's Manual, clinical records, and staff interviews, it was determined that the facility failed to ensure that MDS assessments accurately reflected the resident's status for one of two residents (Resident R1). Findings include: The Resident Assessment Instrument (RAI) User's Manual, which gives instructions for completing Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs),dated October 2023, indicated the following instructions: -Observation (Look-Back, Assessment) Period is the time period over which the resident's condition or status is captured by the MDS assessment. Most MDS items themselves require an observation period, such as 7 or 14 days, depending on the item. Since a day begins at 12:00 a.m. and ends at 11:59 p.m., the observation period must also cover this time period. A standard 7-day look-back period counts back from and includes the Assessment Reference Date (ARD+6 previous days). -Section…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, resident interview, and staff interviews, it was determined that the facility failed to document and/or institute interventions for a fall for one of two residents (Residents R1). Findings include: Review of the facility job description for Certified Nursing Assistant, indicated that the purpose of the job position is to provide each resident with routine daily nursing care and services in accordance with the resident's assessment and care plan and as may be directed by your supervisor in accordance with the requirements of the policies and procedures of this facility in accordance with current federal, state, and local standards governing the facility. Job duties include assisting with lifting, turning, moving, positioning, and transporting residents into and out of beds, chairs, bathtubs, wheelchairs, lifts, etc. Review of Resident R1's admission record indicated she was admitted to the facility on [DATE]. Review of Resident R1's Minimum Data Set (MDS) assessment (mandated…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 ensure that the physician order indicated a catheter size for a urinary catheter (insertion of a tube into the bladder to remove urine) for one of two residents (Residents R2). Findings include: Review of facility policy Indwelling Catheter Insertion, review date undetermined, indicated that a physician's order should be present, and that the size of the catheter and the amount of sterile water sued to inflate the balloon should be documented. Review of admission record indicated that Resident R2 was admitted on [DATE]. Review of Resident R2's Minimum Data Set Assessment (MDS, periodic assessment of resident care needs) dated 6/30/24, indicated diagnoses of obstructive uropathy (restriction in the flow of urine), difficulty swallowing, and pain. Section H - Bladder and Bowel indicated the utilization of an indwelling catheter. Review of Resident R2 's physician order dated 6/27/24, indicated…

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

Based on review of facility policies, observations and staff interview it was determined that the facility failed to store all drugs and biologicals in a safe, secure, and orderly manner for one of two nursing units (Second floor). Findings include: Review of the facility policy Storage of Medications review date undetermined, indicated that only persons authorized to prepare and administer medications have access to locked medications. Compartments (including, but not limited to drawers, cabinets, rooms, refrigerators, carts, and boxes) containing drugs and biologicals are locked when not in use. Unlocked medication carts are not left unattended. During an observation and interview on 8/15/24, at 11:44 a.m. the door to the Second Floor medication room was propped open, and contained a treatment cart containing medications that was unlocked. Assistance Director of Nursing Employee E8 Employee confirmed that the facility failed to store all drugs and biologicals in a safe, and secure manner for one of two nursing units (Second Floor). 28 Pa Code: 211.9 (a) Pharmacy services. 28 Pa…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 resident and staff interviews it was determined that that the facility failed to provide the residents a dignified dining experience for the breakfast and lunch meals on 7/26/24. (Breakfast and lunch meals) Findings include: A review of facility Frequency of Meals policy last review date undetermined, revealed that the facility serves three meals at times comparable to meal times of the community or in accordance with the resident's needs, preferences and requests. A review of the facility's meal cart delivery schedule revealed that meal carts for the breakfast meal are delivered to the nursing units beginning at 7:17 am and finishing at 7:57 am. The third floor south nursing unit delivery time is 7:42 am for the breakfast meal. Meal carts for the lunch meal are delivered to the nursing units beginning at 11:48 am and finishing at 12:17 pm. the third floor south nursing unit delivery time is 12:10 pm for the lunch meal During an observation of breakfast meal service on 7/26/24, it was identified that the meal delivery cart…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 standardized recipes, observations and staff interviews it was determined that the facility failed to provide alternate menu selections of equal or greater nutrient value for the chef salad alternate selection. Findings include: During a review of the facility Chef Salad standardized recipe it was revealed that a Chef Salad consisted of one cup of salad greens consisting of lettuce, salad greens, red cabbage, shredded carrots, and radishes. the salad greens are placed on a serving plate and topped with two slices of cucumbers, a green pepper ring, two ounces of turkey, one once of ham, one ounce of swiss cheese and two hard cooked egg wedges. Served with salad dressing of choice. During an observation of the preparation of alternative meal selection Chef Salad on 7/26/24, at 12:00 pm it was revealed that the salad was prepared by placing a handful of tossed salad mix into a cereal size bowl. On top of the salad mix was turkey, ham, American cheese that was not portioned to make certain that the correct portion was served, 2 hard cooked egg wedges, diced…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, documents, menus, observations, and resident family and staff interviews it was determined that the facility failed to follow resident food preferences for seven of eight residents (Resident R1, R2, R3, R4, R5. R6. and R8), to make certain all alternative menu selections offered on the Always Available menu are available (food supply Main Kitchen) , and provide an easy process for alternative menu selections be made by the resident or resident representative for the breakfast and lunch meals on 7/26/24. (Breakfast and lunch meals 7/26/24). Findings include: A review of facility Food Preference policy, last review date was undetermined, indicated that resident food preferences will be obtained upon admission to the facility. During an observation conducted for tray accuracy on 7/26/24, for the breakfast and lunch meals it was revealed that the facility failed to provide the residents with their food preferences as follows: Breakfast Meal: * Resident R2 requested two pancakes and received a waffle, and the facility failed to provide Fruit Berry…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, documents, observations and staff interviews it was determined that the facility failed to provide two of two meals on 7/26/24, [NAME] timely manner. (Breakfast and Lunch meal service 7/26/24) Findings include: A review of facility Frequency of Meals policy last review date undetermined, revealed that the facility serves three meals at times comparable to meal times of the community or in accordance with the resident's needs, preferences and requests. A review of the facility's meal cart delivery schedule revealed that meal carts for the breakfast meal are delivered to the nursing units beginning at 7:17 am and finishing at 7:57 am. The third floor south nursing unit delivery time is 7:42 am for the breakfast meal. Meal carts for the lunch meal are delivered to the nursing units beginning at 11:48 am and finishing at 12:17 pm. the third floor south nursing unit delivery time is 12:10 pm for the lunch meal During an observation of breakfast meal service on 7/26/24, it 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 a review of facility policies, documents and staff interviews it was determined that the facility failed to resolve five of 12 grievances from the time period of 4/1/24 through 7/18/24 (4/1/24, 4/28/24, 5/19/24, 6/12/24, and 7/1/24). Findings include: A review of facility WeCare Heritage Care Center (HCC) Grievance Policy and Procedure, last day reviewed undetermined, revealed that the facility investigates and resolves all grievances within a five day period. A review of the facility's grievance log indicated that grievances logged on 4/1/28, 4/28/24, 5/19/24, 6/12/24 and 7/1/24 failed to be resolved. During an interview on 7/26/24, at 11:00 am the Nursing Home Administrator confirmed that facility failed to resolve grievances dated 4/1/24, 4/28/24, 5/18/24, 6/12/24 and 7/1/24 as required. PA Code: 201.18(e)(4) Management

Based on a review of facility documents it was determined that the facility failed to assess, analyze and sustain improvements (Plan of Correction (POC) in deficient practices cited for abbreviated surveys completed on 5/22/24 and 6/16/24. ( POC for survey completed on 5/22/24 and 6/16/24) Findings include: A review of the facitlty's Quality Assurance Process Improvement (QAPI) committee meeting minutes for 5/24, 6/24, and 7/24 revealed no evidence that the facility assessed and analyzed the improvements for a citation issued on 5/22/24 for failure to provide meals in a timely manner and a citation issued on 6/16/24, for failure to provide alternate meal selections of equal or greater nutrition value and appeal. The POC developed by the facility to correct deficient practice cited on 5/22/24, included that the facility reviewed the cart delivery schedule and made certain that the delivery times were accurate and appropriate. Discrepancies to the delivery schedule were to be reported to Dietary Management. The facility audited the improvement process three times per week for two…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, documents and staff interviews it was determined that the facility failed to permit Resident R9 to return to the facility as required. (Resident R9) Findings include: A review of facility Discharging a Resident Without a Physician's Approval policy last review was undetermined indicated that residents that discharge from the facility against medical advice (AMA) follow a protocol of obtaining a physician's order for all discharges unless the resident or representative is discharging the resident himself AMA. The resident is to be educated on the consequences of discharging AMA and presented with a form that indicates his understanding of the consequences and potential hazards. A review of Resident R9's face sheet indicated that the resident was admitted to the facility on [DATE], with the diagnosis of heart failure, high blood pressure, history of leukemia and dementia. A review of facility documents indicated on 7/4/24, the resident and his son notified the nurse on 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 a review of facility documents and staff interviews it was determined that the facility failed to provide proper supervision to a resident (Resident R9) which resulted in the residents's elopement. (Resident R9) Findings include: A review of Resident R9's face sheet indicated that the resident was admitted to the facility on [DATE], with the diagnosis of heart failure, high blood pressure, history of leukemia and dementia. A review of facility documents indicated on 7/4/24, the resident and his son notified the nurse on the resident's nursing unit that they were going down stairs for some fresh air. A review of a statement from Receptionist Employee E3 indicated that she opened the door for the resident and his son to go outside because she thought they were going outside to walk in the parking lot. At approximately 8:00 pm the nurse entered the resident's room and discovered that he had not returned. The Assistant Director of Nursing was notified due to the facility not knowing the resident's where…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, observations and staff interviews it was determined that the facility failed to make certain that residents are served food products that meet their dietary needs for one of eight residents (Resident R7). Findings include: A review of facility Food and Nutrition Services policy last review date undetermined, indicated that the facility provides meal that meet the resident's nutritional and special dietary needs. During an observation on 7/26/24, at 8:45 am it was revealed that Resident R7's meal ticket indicated that the resident was to receive nectar thickened liquids. The tray card indicated the resident was receiving nectar thick orange juice and hot tea. The tray card also indicated regular consistency 2% milk which resulted resulted in the resident receiving this product. During an interview on 7/26/24, at 8:45 am Nursing Assistant Employee E3 confirmed that Resident R7's special dietary need included nectar thick liquids and she was served regular consistency 2% milk in error due to the tray card inaccuracy. Pa Code: 211.6(b) Dietary…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, Resident Council Minutes, and resident and staff interviews it was determined that the facility failed to provide a nourishing evening snacks to all residents. (all residents) Findings include: A review of facility Food and Nutrition Services policy dated 5/24, indicated that residents are provided a nourishing snack 24 hours a day. During resident interviews Resident R1, R2 and R3 voiced concerns regarding evening snacks not being available. A review of Resident Council Minutes dated 4/18/24, revealed that the residents voiced concerns regarding the number of dietary staff and how it is negatively impacting the dietary services offered to the residents. During an interview on 6/21/24, at 10:00 a.m. Food Service Director (FSD) Employee E1 confirmed that due to the dietary department being under staffed the department changed how evening snacks are delivered to the residents. The dietary department assemblies the snacks and delivers them to the nursing units before trayline for the dinner meal service begins. FSD Employee E1 confirmed that the…

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

Based on a review of facility policy, documents, and resident and staff interviews, it was determined that the facility failed to provide Facility Sponsored Group activities during the evening hours during the week and on weekends for six of six months. (1/24, 2/24, 3/24, 4/24, 5/24, and 6/24) Findings include: A review of facility Activities policy reviewed on 3/1/24, and 5/1/24, indicated that the facility provides activites to residents based on their comprehensive assessment, care plan, and preferences. Facility Sponsored Group, individual, independent activities are designed to meet the interests of each resident. A review of facility activities calendars for the time period of 1/24, through 6/24, provided no evidence that the facility provides Facility Sponsored Group activities during the evening hours during the week and on weekends. Facility Sponsored activities end daily between 3:30 pm and 4:30 pm. During an interview on 6/21/24, at 11:45 am Resident R2 confirmed that activities in the evening consist of a group of residents that started a card club, and working jigsaw…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, three week Spring/Summer 2018 cycle menu, and staff interviews it was determined that the facility failed to provide the residents an alternative menu selection for the lunch and dinner meals that was of equal or greater nutrient value and appeal for the three week menu cycle. (Week One, Week Two, and Week Three) Findings include: A review of the facility Food Services policy dated 3/1/24, and 5/1/24, indicated that each resident is provided with a nourishing, palatable, well balanced diet that meets the resident's daily nutritional needs taking into consideration the preferences of each resident. During a review of the facility's three week Spring/Summer 2018 cycle menu it was revealed that the facility failed to offer an alternative menu selection of equal nutrient value and appeal for the lunch and dinner meals. During an interview on 6/21/24, at 9:55 a.m. Food Service Director Employee E1 confirmed that the facility utilizes a Spring/Summer three week cycle menu dated with an implementation date of 2018. The three week cycle menu failed to…

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

Based on a review of facility policies, observations and staff interviews it was determined that the facility failed to provide a safe, functional environment for residents, staff and visitors on two of two nursing units (Second Floor Nursing Unit and Third Floor Nursing Unit) Findings include: A review of facility Housekeeping policy dated 5/1/24, indicated that all employees keep hallways clean, orderly and free of obstruction. All tools and materials are to be secured and out of the way of traffic. Aisles are provided for exits, fire extinguishers and work areas and are free of clutter and debris. During an observation on 6/21/24 at 9:10 a.m. it was revealed that the facility stored a housekeeping cart that blocked the path to the fire extinguisher on the third floor nursing unit. During an observation on 6/21/24, at 9:20 a.m. it was revealed that the facility stored a wheelchair in front of the fire extinguisher completely blocking immediate access to the fire extinguisher in the event of an emergency. During an observation on 6/21/24, at 9:30 a.m. it was revealed that the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility documents, and staff interviews, it was determined that the facility failed to have sufficient dietary staff to perform essential kitchen duties in the Main Kitchen. Findings include: Review of Facility assessment dated [DATE], indicated that individual preferences are met related to diet in conjunction with the medical needs of the resident, Appropriate consistencies are offered in line with physician orders and speech therapy recommendations. The facility employs a dietitian as well as staff that interacts with the residents daily to obtain preferences, Meal preparations are made with an attempt to meet food preferences of the individual. Review of the facility's Cart Delivery Schedule: indicated the following: 2 East is to receive lunch at 11:56 a.m. 3 South is to receive lunch at 12:10 p.m. 3 [NAME] is to receive breakfast at 7:57 a.m., lunch at 12:17 p.m., and dinner at dinner at 5:32 p.m. And that all times are within +/- 5 minutes. Review of a resident representative concern…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 resident and staff interview, it was determined that the facility failed to follow physician orders for medication and treatment administration for four of four residents reviewed (Resident R1, R2, R4, and R5). Findings include: Review of facility policy Medication Administration and Charting Guidelines last reviewed October 2023, indicated to chart after administering medication. There are only three acceptable reasons for not administering a medication or treatment: resident is out on pass, medication is held due to medical reason, and refusal by the resident. The resident's MAR (medication administration record) is initialed by the person administering a medication; or, if utilizing an eMAR (electronic) the medication is clicked as administered. Review of facility policy Wound Dressing Change last reviewed October 2023, indicated to document procedure including any significant findings in the resident's record after performing a wound dressing…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 resident interviews, staff interviews, clinical record review, and grievance review, it was determined that the facility failed to have sufficient nursing staff to provide nursing and related services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of ten of 17 residents reviewed (Resident R1, R2, R3, R4, R6, R7, R8, R9, R11, and R12). Findings include: Review of facility policy Activities of Daily Living (ADL) last reviewed October 2023, indicated showers and/or baths are offered and provided as indicated. Review of facility policy Bath: Tub last reviewed October 2023, indicated baths are given according to a pre-determined schedule and as needed. Document bath and personal care on ADL flow sheet. Review of facility policy Call Lights last reviewed October 2023, indicated staff are to respond to call lights and communication devices promptly and in person whenever possible. Review of a greivance dated 5/19/24, Resident R1 stated that she pressed her call…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 resident interviews, and staff interviews, it was determined that the facility failed to serve food products at palatable temperatures for three weeks. Findings include: Review of a resident representative concern dated 5/8/24, indicated that They have been sending the meals up on Styrofoam plates and plastic utensils. During an interview on 5/22/24, at 9:45 a.m., Food Service Director (FSD) Employee E1 stated that she had 22 staff members working in the kitchen, however once the facility was bought by a different company, she lost a lot of staff and is now down to eight staff members since 5/1/24. FSD Employee E1 stated that they are using a lot of Styrofoam as There is no one to do dishes. FSD Employee E1 confirmed that food has been served cold as it has been served in Styrofoam. During an interview on 5/22/24, at 10:45 a.m. Resident R10 confirmed that she has been receiving food in Styrofoam and added I hate Styrofoam. During an interview on 5/22/24, at 10:49 a.m. Resident R11 stated that food is served in Styrofoam and its cold. During an interview on 5/22/24, at 10:52…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 documents, and staff interviews, it was determined that the facility failed to provide food in a form to meet individuals' needs in one of four residents ordered nectar thickened liquids (liquids that are thickened to ease with swallowing difficulties), and one in 20 residents ordered easy to chew diet textures. Findings include: Review of Facility assessment dated [DATE], indicated that individual preferences are met related to diet in conjunction with the medical needs of the resident, Appropriate consistencies are offered in line with physician orders and speech therapy recommendations. Review of a resident representative concern dated 5/8/24, indicated that Many patients have swallowing issues and are not given the appropriate diets which is increasing aspiration (when food or liquids enter a person's airway and eventually the lungs by accident) risks. Review of a resident representative concern dated 5/20/24, indicated that a resident Gets moist meals because of his dysphagia (difficulty…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, resident interviews, and staff interviews, it was determined that the facility failed to provide menu selections according to the resident's preference for three weeks. Findings include: Review of Facility assessment dated [DATE], indicated that individual preferences are met related to diet in conjunction with the medical needs of the resident. Meal preparations are made with an attempt to meet food preferences of the individual. Review of a resident representative concern dated 5/8/24, indicated that They used to get a weekly menu where they would circle what they wanted. They have not gotten a menu in a week. Residents are served food they did not want. During an interview on 5/22/24, at 9:45 a.m., Food Service Director (FSD) Employee E1 stated that she had 22 staff members working in the kitchen, however once the facility was bought by a different company, she lost a lot of staff and is now down to eight staff members. FSD Employee E1 also stated that she used to pass…

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

Based on review of facility documents, meal delivery observations, resident interviews, and staff interviews it was determined that the facility failed to ensure that meals were served at regularly scheduled times for three weeks. Findings include: Review of the facility's Cart Delivery Schedule: indicated the following: 2 East is to receive lunch at 11:56 a.m. 3 South is to receive lunch at 12:10 p.m. 3 [NAME] is to receive breakfast at 7:57 a.m., lunch at 12:17 p.m., and dinner at dinner at 5:32 p.m. And that all times are within +/- 5 minutes. Review of a resident representative concern dated 5/13/24, indicated that Breakfast is coming after 9:00 a.m., lunch after 2:00 p.m., and dinner at 6:00 p.m. During an interview on 5/22/24, at 9:45 a.m., Food Service Director (FSD) Employee E1 stated that she had 22 staff members working in the kitchen, however once the facility was bought by a different company on 5/1/24, she lost a lot of staff and is now down to eight staff members. FSD Employee E1 stated that food has been served consistently late. During an interview on 5/22/24, 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, and interviews with staff, it was determined that the facility failed to ensure that a resident was free of a significant medication error for one of four residents (Resident R4). Findings include: Review of facility policy Medication Administration and Charting Guidelines last reviewed October 2023, indicated to chart after administering medication. There are only three acceptable reasons for not administering a medication or treatment: resident is out on pass, medication is held due to medical reason, and refusal by the resident. The resident's MAR (medication administration record) is initialed by the person administering a medication; or, if utilizing an eMAR (electronic) the medication is clicked as administered. Review of the clinical record indicated Resident R4 was admitted to the facility on [DATE]. Review of Resident R4's Minimum Data Set (MDS - a periodic assessment of care needs) dated 5/15/24, indicated diagnoses of 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.

Based on a review of facility admission information packet, resident records, and staff interviews, it was determined that the facility failed to provide advanced (48 hours) written notification of changes in the covered services provided to the residents for all payment sources for three of four residents (Resident R1, R2 and R3), Findings include: A review of facility admission Information packet section N: Discharge Planning indicated that each resident's case is reviewed on a regular basis to determine if their medical needs continue to warrant the services provided by the facility. Discharge or transfer to a lesser level may occur when it has be determined that such services are no longer necessary. Residents and family members are notified in advance of the changes in provided services. During a review of facility documents it was determined that the facility failed to provide advanced written notice to Resident R1, R2 and R3 of the determination for the necessity of covered services as provided by the facility. During an interview on 2/7/24, at 10:25 am Registered Nurse Case…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 policies, review of medical records, and insurance provider reviewer and staff interviews it was determined that the facility failed to properly implement a facility initiated discharge for one of 10 residents (Resident R1) Findings include: A review of facility Admission, Transfer Discharge - Resident Discharge policy last reviewed October 2023, indicated that the purpose is to promote continuity of care and prepare the resident for discharge. A review of facility face sheet (admission record) for Resident R1 revealed that the resident was admitted to the facility on [DATE] with the diagnosis of total right knee replacement, diabetes, and asthma. A review of Resident R1's progress notes dated 1/11/24, at 14:54 revealed that Social Worker Employee E1 wrote a note indicating the she attempted to meet with Resident R1 to inquire about discharge plans as insurance coverage ends today (1/11/24), During an interview on 2/7/24, at 10:25 am Registered Nurse (RN) Case Manager Employee E2…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 policies, documents, resident records and staff interviews it was determined that the facility failed to properly provide written motivation of discharge from the facility for one of 10 residents (Resident R1), Findings include: A review of facility Admission, Transfer Discharge - Resident Discharge policy last reviewed October 2023, indicated that the purpose is to promote continuity of care and prepare the resident for discharge. A review of facility admission Information packet section N: Discharge Planning indicated that each resident's case is reviewed on a regular basis to determine if their medical needs continue to warrant the services provided by the facility. Discharge or transfer to a lesser level may occur when it has be determined that such services are no longer necessary. Residents and family members are notified in advance of the changes in provided services. A review of facility face sheet (admission record) for Resident R1 revealed that the resident was admitted to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of facility policies, documents, resident medical records and staff interviews it was determined that the facility failed to implement a safe and orderly discharge from the facility for one of 10 residents (Resident R1) Findings include: A review of facility Admission, Transfer Discharge - Resident Discharge policy last reviewed October 2023, indicated that the purpose is to promote continuity of care and prepare the resident for discharge. A review of facility face sheet (admission record) for Resident R1 revealed that the resident was admitted to the facility on [DATE] with the diagnosis of total right knee replacement, diabetes, and asthma. A review of Resident R1's progress notes dated 1/11/24, at 14:54 revealed that Social Worker (SW) Employee E1 wrote a note indicating the she attempted to meet with Resident R1 to inquire about discharge plans as insurance coverage ends today (1/11/24), A review of emails revealed the following: * an email dated 1/11/24 at 11:50 am to Real Time Census…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 label and date food products, maintain equipment in a sanitary manner and maintain the appropriate chemical strength for the sanitizing solution in the Main Kitchen. (Main Kitchen) Findings include: A review of facility policy Food and Nutrition Refrigeration and Storage lasted reviewed on 10/26/23, indicated all opened food items are stored in properly covered containers. Each container is labeled with the content and date. The facility maintains a first in first out (FIFO) method of stock rotation. Prepared foods are labeled and dated. A review of facility policy Food and Nutrition Sanitation lasted reviewed on 10/26/23, indicated that the Dietary Team is to keep equipment and the department clean. A review of facility policy Food and Nutrition Dishwashing lasted reviewed on 10/26/23, indicated that manual ware washing is conducted using a three compartment sink system to wash, rinse and sanitize. A quaternary sanitizer is used in the third sink 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 a review of facility policies, observations and staff interviews, it was determined that the facility failed to properly dispose of refuse, properly store soiled linen, and maintain the outdoor refuse area in a clean and sanitary manner to prevent the potential for rodent and insect infestation in the outdoor refuse area. (Outdoor Refuse Area) Findings include: A review of the facility's policy Food and Nutrition Garbage and Refuse lasted reviewed on 10/26/23, indicated that dumpster lids are to remain closed at all times. During an observation on 12/4/23, at 8:50 a.m. the following was observed: * the lid to the recycle dumpster was bent and prevented the lid from closing properly. the recycle bin contained cardboard boxes, a bag of metal cans and a pastry box with a donut. * the area surrounding the outdoor refuse area contained leaves, pine needles and pine cones. There was a pile of leaves, pine needles and pine cones behind the compactor, * there were five bins of soiled linen that were covered with only a clear plastic bag. During an interview on 12/4/23, at 8:50 a.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, observation, and staff interviews, it was determined that the facility failed to use PPE (Personal Protective Equipment) appropriately which created the potential for the cross-contamination and the spread of diseases and infections on one of three nursing units (Second floor nursing). Findings include: Review of facility policy Routine Testing For Covid 19, last reviewed 10/26/23, indicated health care personnel (HCP) who enter the room of a patient with suspected or confirmed Covid-19 infection should adhere to Standard Precautions and use a NIOSH (National Institute for Occupational Safety and Health) approved particulate respirator with N95 filters or higher, gown, gloves, and eye protection. PPE not intended for shift use (all red zone) should be doffed (taken off) prior to exiting a Covid infectious resident's room as indicated. Review of facility line listing for Covid outbreak positive infections indicated the facility experienced positive residents and staff from…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, documents and clinical records and staff interviews, it was determined that the facility failed to make certain a resident was free from abuse and neglect for one of three residents reviewed (Resident R6). Findings include: The facility's policy Abuse Neglect Exploitation General Policy last reviewed 3/28/22, and 10/26/23, indicated the goal is to prevent and prohibit all types of abuse, neglect, misappropriation of resident property, and exploitation that achieves but is not limited to identifying, correcting and intervening in situations in which abuse, neglect, exploitation, and/or misappropriation of resident property is more likely to occur. Willful is defined as - the individual must have acted deliberately, not that the individual intended to inflict harm. The facility will employ trained and qualified registered, licensed, and certified staff on each shift in sufficient numbers to meet the needs of the residents, and assure that staff assigned have knowledge 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.

Based on review of facility policy, resident record, investigation documents and staff interview, it was determined that the facility failed to report an incident of neglect for one of three sampled residents (Resident R113). Findings include: The facility Safety-abuse neglect exploitation general policy dated 5/1/22, last reviewed 10/26/23, indicated that the facility shall report all alleged violations to the state agency. If the event does not result in serious bodily injury, the staff member must report the suspicion no later than 24 hours after forming the suspicion. Review of Resident R113's admission record dated 8/25/23, indicated that Resident R113 was admitted with diagnoses that included dysphagia (difficulty swallowing), brain disorder, cerebrovascular disease, a history of alcohol abuse, Non-traumatic Subarachnoid Hemorrhage (an incident involving bleeding in the area between the brain and the tissue covering the brain causing pain and cognitive decline), and paraplegia. Review of Resident R113's MDS assessment (MDS-Minimum Data Set Assessment: a periodic assessment of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of facility policy and clinical records and staff interviews it was determined that the facility failed to make certain that resident assessments were accurate for four of four residents (Resident R22, R30, R121 and R7). 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 2019, 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 is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, documents, and staff interviews, it was determined that the facility failed to follow a physician order, and failed to coordinate a diagnostic imaging procedure for one of seven residents (Resident R17), and the facility failed to transcribe and follow a physician order for one of seven residents with skin impairment (Resident R121). Review of Resident R17's admission record indicated he was admitted on [DATE], with diagnoses that included osteomyelitis (bone infection), muscle wasting, morbid obesity and chronic heart failure (heart muscle doesn't pump blood as well as it should). Review of Resident R17's MDS assessment (Minimum Data Set assessment- a periodic assessment of resident care needs) dated 11/7/23 indicated that these diagnoses current upon review. Review of physician's orders dated 8/31/23 indicated Maxillofacial CT (computed tomography) with contrast dx: right parotid gland swelling. Facility provided documentation indicated the following: CT scan ordered 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policies, observations, clinical record, communication documents and staff interview it was determined that the the facility failed to coordinate care and acquire a physician's order to modify the route of medication administration for one of six residents receiving medications via a G-tube (Resident R113), and failed to adminster enteral feedings as per pharmacy standards for one of six sampled residents (Resident R30). Findings include: The facility Quality of care-tube feeding management policy dated 8/2023, indicated that it is important that any decision regarding the use of a feeding tube be based on the resident's clinical condition and wishes. A decision to use a feeding tube has a major impact on a residents and his or her quality of life. Use of a feeding tube should not be used unless there is a valid, clinical rationale. The interdisciplinary team is responsible for assuring the ongoing review, evaluation and decision-making regarding the continuation of all treatments. It…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of manufacturer's recommendations, observation, clinical record and staff interview, it was determined that the facility failed to make certain that residents are free of significant medication errors for one of four residents (Resident R82). Findings include: Review of manufacturers guidelines for Insulin Lispro (a short acting, manmade version of human insulin) indicated to prime the Pen before each injection. Priming the Pen means removing the air from the needle and cartridge that may collect during normal use and ensures that the Pen is working correctly. If the Pen is no primed before each injection, the resident may get too much or too little insulin. Review of admission record indicated Resident R82 admitted to the facility on [DATE]. Review of Resident R82's Minimum Data Set (MDS - a periodic assessment of care needs) dated 11/20/23, indicated the diagnoses of diabetes (too much sugar in the blood), stroke, and Covid - 19. Review of Resident R82's physician order dated 12/4/23, indicated…

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

Based on a review of the facility's three week cycle menu and staff interviews it was determined that the Registered Dietitian (RD) failed to approve the menu prior to implementation for three of three cycle menu weeks (Week one, Week two and Week three). Findings include: During a review of the facility's three week cycle menu titled Spring/Summer 2018 it was revealed that the facility failed to provide documented evidence that the menus had been approved by the RD prior to the implementation of the menus. During an interview on 12/5/23, at 11:00 a.m. the Food Service Manager Employee E4 revealed that the facility implemented the current Spring/Summer 2018 three week cycle menu in 2018. The facility has made modifications and revisions to the menu since implementation. The facility failed to provide documented evidence that the RD has approved the three week cycle menu prior to implementation and with each modification or revision. During an interview on 12/5/23, at 11:00 a.m. the Food Service Manager Employee E4 confirmed that the RD failed to sign and date the Spring/Summer 2018…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, review of facility documents, and interviews with staff and residents, it was determined that the facility failed to serve food that was following resident preference and selections on meal tickets for three of eight residents (Residents R45, R51, and R83). Findings include: Review of admission record indicated Resident R45 was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS- a periodic assessment of care needs) dated 9/9/23, indicated the diagnoses of anemia (the blood doesn't have enough healthy red blood cells), high blood pressure, and heart failure (heart doesn ' t pump blood as well as it should). Observation on 12/4/23, at 12:08 p.m. Resident R45 was sitting out of bed in her chair and was eating yellow cake with chocolate icing. Main dish noted on bedside table was a slow cooked barbecue pulled pork sandwich and tater tots. The bowl containing coleslaw was consumed. Interview on 12/4/23, at 12:09 p.m. Resident R45 indicated she doesn't eat pork and that'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 policy, observation and staff interview, it was determined that the facility failed to properly maintain kitchen equipment and floors in a sanitary condition creating the potential for cross contamination in the main kitchen of the facility. Findings include: Review of facility Kitchen Sanitation policy dated 1/06/22, indicated that the dietary department will ensure the proper procedures will be followed when cleaning equipment following each use and that special cleaning assignments will be completed as assigned. Review of facility Sanitation-Refrigerator/Storage policy dated March 2022, indicated the dietary department will ensure that all storage areas are maintained, well lit, and clean. Review of facility Dietary Infection Control policy dated March 2022, indicated food will be protected from contamination and spoilage by proper covering, storage, and dating. Storage of perishable and nonperishable supplies is in accordance with local health regulation. All foods will be clearly…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, facility documents and staff interview it was determined the facility failed to ensure that residents were free from any significant medication errors for two of five residents. (Resident R1 and R2). Findings include: Review of facility policy Medication Administration General Guidelines dated March 2022, indicated accepted standards of practice will be followed. Verify medication order on Medication Administration Record (MAR) with medication label for: Right resident, right drug, right does, right route, right time, any special instructions, and expiration date. The policy further indicated that nurses administer medications to one resident at a time. Nurse who pours medications must be same nurse administering medication. Review of the admission record indicated Resident R1 was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS - a periodic assessment of care needs) dated 8/2/23, indicated the diagnoses of stroke (damage 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.