Ivy Park Post Acute

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical record review and staff interview, it was determined that the facility failed to make certain that the necessary resident information was communicated to the receiving health care provider for two of six residents sampled with facility-initiated transfers (Residents R2, R13) and failed to notify the resident or resident's representative of the facility bed-hold policy (an agreement for the facility to hold a bed for an agreed upon rate during a hospitalization) for one of six resident hospital transfers (Resident R13), and failed to obtain a physician order for discharge for one of three residents ( Closed Record Residents R127). Findings include: Review of facility policy Transfer or Discharge last reviewed 5/20/25, indicated transfer and discharges must meet specific criteria and require resident/representative notification, orientation, and documentation in the medical record. Review of the clinical record indicated Resident R13 was admitted to the facility on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of policies and clinical records, observations and staff interviews, it was determined that the facility failed to develop comprehensive care plans that included specific and individualized interventions and/or goals to address the care needs of residents for three of five residents reviewed (Resident R4, R25, and R120). Findings include: Review of the facility policy Care Plans Comprehensive Person-centered last reviewed 5/20/25, indicated that a comprehensive, person-centered care plan that includes measurable objectives and time frames, to meet a resident's, physical, psychosocial and functional needs is developed and implemented for each resident. The comprehensive, person-centered care plan includes measurable objectives and timeframes, describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, including but not inclusive to: Services that would otherwise be provided for the above but are not…

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

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 follow physician orders for Blood Glucose levels for one of eight residents (Resident R50), failed to provide parameters of when to notify physicians of increased and decreased Capillary Blood Glucose (CBG) levels or notifying physician of results outside parameters ordered for five of eight residents (Residents R25, R34, R53, R75, and R120), failed to document appropriate interventions for a resident with hypoglycemia (low blood glucose) for one of eight residents (Resident R53), failed to provide therapeutic lab monitoring for one of three residents (Resident R58) and failed to ensure timely follow up physician appointments were scheduled for one out of three residents (Residents R111). Findings include: The facilities Nursing Care of the Older Adult with Diabetes Mellitus policy dated 5/20/25, indicated to provide overview of diabetes in the older adult, its symptoms and complications, and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical records, facility documents, resident interviews, and staff interviews, it was determined that the facility failed to make certain residents with behaviors triggering elopement risk were identified timely, failed to assess on an ongoing basis, and failed to provide care plan and physician orders for interventions regarding exit seeking behaviors for three of five residents (Resident R70, R104, and R120). Findings include: Review of facility policy Elopement Risk Assessment Policy dated 5/20/25, indicated all residents will have an elopement risk assessment completed upon admission, quarterly, and with a significant change in condition, such as increased confusion, agitation, or mobility changes. If a resident is identified as an elopement risk, the care plan will include individualized interventions to address safety and monitoring. Review of the Resident Assessment Instrument 3.0 User's Manual effective October 2024, indicated that a Brief Interview for Mental Status…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical record and staff interview it was determined that the facility failed to make certain consistent dialysis communication was maintained for two of three residents (Residents R2 and R21) and failed to maintain a current dialysis contract with dialysis vendor for two of three (Resident R2, and R61). Findings include: Review of the facility policy End-Stage Renal Disease (ESRD), Care of a Resident with dated 5/20/25, indicated agreements between this facility and the contracted ESRD facility include all aspects of how the resident ' s care will be managed, including: a. how the care plan will be developed and implemented; b. how information will be exchanged between the facilities; and c. responsibility for waste handling, sterilization and disinfection of equipment. Review of the admission record indicated Resident R2 was admitted to the facility on [DATE]. Review of Resident R2's Minimum Data Set (MDS - a periodic assessment of care needs) dated 5/12/25, indicated…

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

Based on review of personnel records and staff interview it was determined that the facility failed to complete annual performance evaluations for three of five nurse aides (NA Employee E17, E18 and E19). Findings include: Review of personnel files revealed that Nurse Aide Employee E17 last hire date was 9/27/17, last performance evaluation was completed 12/28/18-12/29/19. Review of personnel files revealed that Nurse Aide Employee E19 last hire date was 4/20/05 , last performance evaluation was completed 7/20/20-7/19/21 . Review of personnel files revealed that Nurse Aide Employee E18 last hire date was 3/27/23, there was no performance evaluations was completed in file. During an interview on 6/27/25, at 8:15 a.m. Human Resource Employee E16 confirmed that the facility does not have up to date performance appraisals completed on NA Employee E17, E18 and E19 as required. 28 Pa Code: 201.20 (a)(b)(c)(d) Staff development. 28 Pa Code: 201.14 (a) Responsibility of licensee.

Based on review of facility policy, observation and staff interview it was determined that the facility failed to properly contain and dispose of garbage in two of three outside dumpsters to prevent the potential for rodent and insect infestation (dumpster one and two). Findings include: Review of facility policy Dumpster Area dated 5/20/25 indicates area will be a clean, safe, and complaint waste disposal area that minimizes infection risks, deters pests, and adheres to Department of Health, Department of Environmental Protection, and local sanitation regulations. During an observation of the facility's outdoor trash receptacles on 6/23/25, at 10:30 a.m. Dietary Manager Employee E20 confirmed that the lid/cover was not closed on dumpster one and two and that there was liquid from the dumpster area collecting in the disposal area. 28 Pa. Code 201.18(b)(3) Management.

Based on review of facility policy, personnel records, and staff interview it was determined that the facility failed to ensure that three of five sampled Nurse Aides (NA) received a minimum of 12 hours of in-service education per year (NA Employees E17, E18 and E19). Review of faciliy policy In-Service Training-All Staff dated 5/20/25 indicated all staff must participate in initial orientation and annual in-service training. Review of facility nurse aide training records revealed that nurse aide Employees E17, E18 and E19 did not receive 12 hours of in-service training in the last year. The facility was unable to provide documented evidence that the above nurse aide employees had received a minimum of 12 hours of in-service training yearly. During an interview on 6/25/25 , at 1:15 p.m. Human Resource Employee E16 confirmed that the facility did not have evidence that NA Employee E17, E18 and E19 received the required 12 hours of yearly in-service training. 28 Pa. Code: 201.14(a) Responsibility of Licensee. 28 Pa. Code: 201.20(c) Staff Development.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, observations, and staff interviews, it was determined that the facility failed to ensure that care was provided in a manner which maintained resident dignity for one of four residents (Residents R120). Findings include: Review of facility policy Dignity dated 5/20/25, indicated each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. Review of Resident R120's clinical record indicated resident was admitted to the facility on [DATE]. Review of Resident R120's Minimum Data Set (MDS - periodic assessment of resident care needs) dated 5/8/25, indicated diagnoses of high blood pressure, diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time), and dementia (a group of symptoms that affects memory, thinking and interferes with daily life). Section M1200 Skin and Ulcer/Injury Treatments indicated pressure ulcer/injury…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 interview and observations, clinical record review, and staff interview it was determined that the facility failed to provide Activity of Daily Living (ADL) assistance for one of four residents (Resident R5). Findings include: The facility policy Activities of Daily Living (ADLs) dated 5/20/25, indicated a patient who is unable to carry out ADLs independently will receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene. Review of admission record indicated Resident R5 was admitted to the facility on [DATE]. Review of Resident R5's Minimum Data Set (MDS - a periodic assessment of care needs) dated 5/14/25, indicated the diagnoses of high blood pressure, heart failure (heart doesn't pump blood as well as it should), and coronary artery disease (damage or disease in the heart's major blood vessels). Section GG0130 Functional Abilities indicated resident was dependent for personal hygiene needs. Observation on 6/23/25, at 9:20…

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

Based on review of facility policy, observation, and staff interviews, it was determined that the facility failed to provide an ongoing program of activities to meet the interests of and support the physical, mental, and psychosocial well-being of each resident for one of three floors (Fourth floor). Findings include: Review of facility policy Activity Programs dated 5/20/25, indicated our activity program are staffed with personnel who have appropriate training and experience to meet the needs and interests of each resident. During a review of activity calendar on 6/25/25, at 10:30 a.m. the following activities were scheduled on the Fourth Floor: - 11:00 a.m. Moovin and Groovin - 2:30 p.m. Connect Four During an observation on 6/25/25, at 11:08 a.m. the Fourth-floor common room had nine residents in the room. Activity aide Employee E21 was sitting at a table with music playing. At 11 :14 a.m. Activity aide Employee E21 was sitting with her head resting on her hand, eating a lollipop and failed to interact with the group of residents at the activity. During an interview on 6/25/25,…

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 review of facility policy, national accepted guidelines for Pressure Ulcers, and staff interview, it was determined that the facility failed to accurately assess pressure ulcers for two of five residents (Resident R4 and R94). Findings include: The facility policy Pressure ulcer/skin breakdown reviewed 5/20/25 indicated the nursing staff and practitioner will assess and document and individual's significant risk factors for developing pressure ulcers. The nurse shall describe and document the following: a. full assessment of pressure sore including location, stage, length, width, and depth and presence of extrudes or necrotic tissue b. pain assessment c. resident's mobility status d. current treatments e. all active diagnosis Review of the clinical record revealed that 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 5/28/25, indicated the diagnoses of coronary artery disease (reduced blood flow to the heart),…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy, review of clinical record, and staff interview, it was determined that the facility failed to provide appropriate foot care to two of five residents (Residents R117 and R120). Findings include: The facility's Podiatry Services Policy dated 5/20/25, indicated that podiatry services will be offered on a routine basis (e.g., every six to eight weeks) through a contracted provider. Nursing staff are responsible for coordinating visit schedules and obtaining consents. Review of the admission record indicated Resident R117 was admitted to the facility on [DATE]. Review of Resident R117's Minimum Data Set (MDS - a periodic assessment of care needs) dated 6/12/25, indicated diagnoses of high blood pressure, diabetes (a long-term condition in which the body has trouble controlling blood sugar and using it for energy), and dementia (a general term for loss of memory, language, problem solving and other thinking abilities that are severe enough to interfere with daily life). Review of Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of 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 four residents (Resident R125). Findings include: Review of the facility policy Trauma Informed Care and Culturally Competent Care last reviewed 5/20/25, indicated to guide staff in providing care that is culturally competent and trauma-informed in accordance with professional standards of practice. To address the needs of trauma survivors by minimizing triggers and/or re-traumatization. General guidelines that include but not inclusive to: Resident Care Planning develop individualized care plans that address past trauma in collaboration with the resident and family. Identify and decrease exposure to triggers that may re-traumatize the resident Review of the clinical record indicated Resident R125 was admitted to the facility on [DATE]. Review of Resident…

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

Based on review of facility policies, observations, and staff interviews, it was determined that the facility failed to store medications properly and securely in two of three medications carts (Third floor Low Cart, and Second floor Low Cart). Findings include: Review of the facility policy Medication Storage dated 5/20/25, indicated all drugs and biologicals will be stored in locked compartments. Certain medications or package types, such as multiple dose and ophthalmic (eye) solutions require an expiration date shorter than the manufacturer's expiration date to insure medication purity and potency. During an observation on 6/23/25, at 11:48 a.m. the Second floor Low Cart contained the following undated medications: -ipratropium nebulizer medication (used to treat respiratory conditions by relaxing muscles around the airways to make breathing easier - a drug delivery device used to administer medications in the form of a mist) three packages opened without a date as required. -Ellipta (a type of dry powder inhaler used for treating respiratory disease) one inhaler opened without a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy, observation, and staff interviews, it was determined that the facility failed to provide drinks in a form to meet individuals' needs in one of four residents (Resident R48). Findings include: Review of the facility policy Therapeutic Diets dated 5/20/25, indicated that therapeutic diets are prescribed by the attending physician to support the resident ' s treatment and plan of care and in accordance with his or her goals and preferences. A therapeutic diet must be prescribed by the resident's physician. Review of the clinical record revealed that Resident R48 was admitted to the facility on [DATE]. Review of Resident R48's Minimum Data Set (MDS - periodic assessment of resident care needs) dated 5/8/25, indicated diagnoses of high blood pressure, diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time), and dysphagia (difficulty swallowing). Section K Swallowing Nutritional Status K0520 C indicated mechanical altered diet and was check marked…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 records and staff interviews it was determined that the facility failed to ensure residents had the capacity to understand the terms of a binding arbitration agreement (A binding agreement by the parties to submit to arbitration all or certain disputes which have arisen or may arise between them in respect of a defined legal relationship, whether contractual or not.) for two of five residents (Resident R97 and Resident R104). Findings include: Review of the admission record indicated Resident R97 was admitted to the facility on [DATE]. Review of Resident R97's Binding Arbitration Agreement indicated that the resident signed the document on 4/4/25. Review of Resident R97's Minimum Data Set (MDS - a periodic assessment of care needs) dated 4/10/25, indicated the diagnoses of high blood pressure, dysphagia (difficulty swallowing), and dementia (a general term for loss of memory, language, problem solving and other thinking abilities that are severe enough to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy, clinical record review, observation, and staff interviews, it was determined that the facility failed to prevent cross contamination during a dressing change for one of three residents (Resident R120). Findings include: Review of the facility policy Wound Care dated 5/20/25, indicated the purpose of this procedure is to provide guidelines for the care of wounds to promote healing. Review of Resident R120's clinical record indicated resident was admitted to the facility on [DATE]. Review of Resident R120's Minimum Data Set (MDS - periodic assessment of resident care needs) dated 5/8/25, indicated diagnoses of high blood pressure, diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time), and dementia (a group of symptoms that affects memory, thinking and interferes with daily life). Section M1200 Skin and Ulcer/Injury Treatments indicated pressure ulcer/injury care. Review of Resident R120's physician orders dated 5/21/25, indicated to cleanse…

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

Based on a review of select facility policy and staff interview, it was determined the facility failed to designate a qualified individual(s) onsite, who is responsible for implementing programs and activities to prevent and control infections (7/1/24 to 9/30/24). Findings included: During a review of facilities Infection Control Committee meetings for the third quarter, the facility failed to provide signatures of attendees for July, August, and September 2024 infection control committee meeting. During an interview on 6/26/25, at 2:11 p.m. the Director of Nursing (DON) stated, Infection Preventionist (IP) Employee E5 was on leave of absence for the above months and was unable to provide an IP certificate who was completing the Infection Preventionist role during her leave of absence. During an interview on 6/26/25, at 2:40 p.m. the DON confirmed that the facility failed to designate a qualified individual(s) onsite, who is responsible for implementing programs and activities to prevent and control infections from 7/1/25, to 9/30/24. 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 review of facility policy, grievances and staff and resident interviews, it was determined that the facility failed to provide residents with access to their personal funds/petty cash for three of four residents (Residents R1, R2, R4). Findings include: Review of the facility policy Management of Residents' Personal Funds last reviewed on 11/1/24, indicated that the facility manages the personal funds of residents who request the facility to do so. Should the facility be appointed the resident's representative payee, and directly receive monthly benefits to which the resident is entitled, such funds are managed in accordance with established polices and federal/state requirements. Review of the Business Office Manager job description reviewed 11/1/24, indicated the BOM is responsible for the overall supervision and management of the business office staff and assists with managing resident trust fund. Review of the facility Resident Council minutes dated 12/5/24, indicated residents would like to know how to set up a trust fund account and how to get money taken out. Review…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical record review, and staff interviews, it was determined that the facility failed to ensure that a resident was free from neglect by not providing a two-person bed mobility assistance for one of four residents (Resident R1) resulting in a fall. Findings include: Review of facility policy Abuse Prohibition dated 9/30/24, indicated neglect is defined as the failure, indifference, or disregard of the Center, its employees, or service providers to provide care, comfort, safety, goods and services to a patient that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. This includes the failure to implement an effective communication system across all shifts for communicating necessary care and information between Center, patient, practitioners, and patient representatives. Review of facility policy Activities of Daily Living (ADLs) dated 9/30/24, indicated ADLs include bathing, dressing, grooming, transfer and ambulation, toileting, dining, and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to provide adequate supervision for bed mobility needs, resulting in an avoidable fall for one of four residents (Resident R1). Findings include: Review of facility policy Accidents/Incidents dated 9/30/24, indicated an accident is defined as any unexpected or unintentional incident which may result in injury or illness to a patient. Review of facility policy Activities of Daily Living (ADLs) dated 9/30/24, indicated ADLs include bathing, dressing, grooming, transfer and ambulation, toileting, dining, and communication. A patient who is unable to carry out ADLs will receive the necessary level of ADL assistance to maintain good nutrition, grooming, and personal and oral hygiene. Review of the clinical record indicated Resident R1 was admitted to the facility on [DATE]. Review of Resident R1's Minimum Data Set (MDS - a periodic assessment of care needs) dated 10/24/24, indicated diagnoses 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 record review, and staff interviews, it was determined that the facility failed to ensure the provision of consistent and timely physician services for one of four residents (Resident R1). Findings include: Review of facility policy Physician/Advanced Practice Practitioner (APP) Notification dated 9/30/24, indicated upon identification of a patient who has a change in condition, abnormal laboratory values, or abnormal diagnostics, a licensed nurse will report to physician/APP. If unable to contact attending physician/APP, the Medical Director will be contacted. Review of the clinical record indicated Resident R1 was admitted to the facility on [DATE]. Review of Resident R1's Minimum Data Set (MDS - a periodic assessment of care needs) dated 10/24/24, indicated diagnoses of high blood pressure, quadriplegia (paralysis of all four limbs), and Multiple Sclerosis (a disease that affects central nervous system). Review of a Resident Representative Concern dated 10/25/24,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, review of clinical documentation, staff interviews and review of facility reported events, it was determined the facility failed to ensure that physician orders were properly obtained, failed to identify pain or spasms to warrant medication, and failed to notify family for one of five residents (Resident R1). Findings: Review of facility policy Transcription of Orders dated 9/30/24, indicated orders from an authorized licensed independent practitioner are accepted by a Registered Nurse (RN) or Licensed Practical Nurse (LPN). A RN or LPN must review and verify accuracy and sign off orders. Review of facility policy Resident Rights under Federal Law dated 9/30/24, indicated that residents have the fundamental right to considerate care that safeguards their personal dignity along with respecting cultural, social, and spiritual values. Centers do not discriminate on the basis of race, color, religion, national origin, gender, disability or veteran status. The purpose is to treat…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, review of clinical documentation. observation and staff interview it was determined the facility failed to dispose and reconcile discontinued medication in a timely manner for one of two residents (Resident R1). Findings: Review of facility policy Disposal of Medication Waste dated [DATE], indicated medications will be disposed of in accordance with applicable federal, state, and local regulations for the disposal of chemical and potentially dangerous or hazardous pharmaceuticals. Medications for disposal include medications which are not taken with the patient upon discharge and discontinued, expired, or contaminated medications. Review of the clinical record indicated Resident R1 was admitted to the facility on [DATE]. Review of Resident R1's Minimum Data Set (MDS - a periodic assessment of care needs) dated [DATE], indicated diagnoses of aphasia (a language disorder that affects a person ' s ability to speak), depression, and cerebral infarction (necrotic tissue 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, review of clinical documentation, staff interviews and review of facility reported events, it was determined the facility failed to ensure that orders were properly obtained by a Physician, Physician Assistant, or Nurse Practitioner (NP) for one of five residents (Resident R1). Findings: Review of facility policy Transcription of Orders dated 9/30/24, indicated orders from an authorized licensed independent practitioner are accepted by a Registered Nurse (RN) or Licensed Practical Nurse (LPN). A RN or LPN must review and verify accuracy and sign off orders. Review of facility policy Resident Rights under Federal Law dated 9/30/24, indicated that residents have the fundamental right to considerate care that safeguards their personal dignity along with respecting cultural, social, and spiritual values. Centers do not discriminate on the basis of race, color, religion, national origin, gender, disability or veteran status. The purpose is to treat each resident with respect and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical records and interviews with staff it was determined that the facility failed to implement a safe and orderly discharge from the facility for one of three residents (Closed Record Resident R2). Findings include: Review of facility policy Discharge and Transfer dated 9/30/24, indicated Purpose -To provide guidance that meets federal and state regulations. To meet resident needs. To facilitate a safe transition to an alternate setting. Review of facility admit sheet indicated CR R2 was admitted to the faciltiy on 9/6/24. Review of MDS (minimum data set - a periodic assessment of resident needs) dated 9/14/24, indicated diagnosis of Conversion Disorder (a mental health condition issue that disrupts how your brain works) and Shortness of Breath. Review of CR R2 clinical record indicated the following: Discharge Planning - ongoing indicated home care/Personal Provider Name/ Address and phone number - returning to North Carolina, Physician phone number [PHONE NUMBER].…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 the facility failed to properly label and date food products, failed to properly monitor food temperatures, failed to maintain kitchen equipment and dry storage area in a clean sanitary condition, and failed to properly monitor food expiration dates in a manner to prevent foodborne illness in the Main Kitchen. Findings include: Review of the facility policy Food Handling last reviewed 5/7/24, indicated foods are stored, prepared, and served in a safe and sanitary manner to prevent bacterial contamination and possible spread of infection. Food thermometers are available to all employees who are responsible for checking the internal temperature and holding temperature of foods. Tray line holding food temperatures are taken and recorder on the production worksheets at the beginning of each meal service. Foods that are marked with the manufactures use by date that are properly stored can be used until that date as long as the product has not been combined with any other food or prepared in a way…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, resident council group interview, and resident and staff interviews, it was determined that the facility failed to have an ample linen supply at the staff's immediate use on two of three units (second floor and third floor). Findings include: Review of the facility Accommodation of Needs policy dated 5/7/24, indicated the resident/patient (hereinafter patient) has the right to a safe, clean, comfortable, and homelike environment including, but not limited to, receiving treatment and support for daily living safely. The Center must provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior including but not limited to clean bed and bath linens that are in good condition. During an interview 7/22/24, at 8:35 a.m. Resident R101 stated, There were no washcloths or towels last Thursday 7/18/24, the aide had to use paper towels to clean me up. During an interview 7/22/24, at 8:45 a.m. Resident R26 stated, Sometimes I have to wait for care as there are no washcloths or towels available.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to make certain that the necessary resident information was communicated to the receiving health care provider for four of five residents sampled with facility-initiated transfers (Residents R29, R39, R75, and R82). Findings include: Review of facility policy Discharge and Transfer dated 5/7/24, indicated transfer and discharge includes movement of a patient to a bed outside of the certified Center, whether that bed is in the same physical plant or not. Review of the clinical record indicated Resident R29 was admitted to the facility on [DATE]. Review of Resident R29's Minimum Data Set (MDS - a periodic assessment of care needs) dated 6/5/24, indicated diagnoses of high blood pressure, muscle weakness, and acute cholecystitis (inflammation of the gallbladder). Review of the clinical record indicated Resident R29 was transferred to hospital on 5/9/24 and returned to the facility on 5/19/24.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical record review, and staff interviews, it was determined that the facility failed to provide a transfer notice to a representative of the Office of the Long-Term Care Ombudsman Division for four of five residents (Residents R29, R39, R75, and R82). Findings include: Review of facility policy Discharge and Transfer dated 5/7/24, indicated copies of notices for emergency transfers must also be sent to the Ombudsman, but they may be sent when practicable, such as in a list of patients on a monthly basis or per state requirements. Review of the clinical record indicated Resident R29 was admitted to the facility on [DATE]. Review of Resident R29's Minimum Data Set (MDS - a periodic assessment of care needs) dated 6/5/24, indicated diagnoses of high blood pressure, muscle weakness, and acute cholecystitis (inflammation of the gallbladder). Review of the clinical record indicated Resident R29 was transferred to hospital on 5/9/24 and returned to the facility on 5/19/24. Review…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical record review, and staff interviews, it was determined that the facility failed to notify the resident or resident's representative of the facility bed-hold policy (an agreement for the facility to hold a bed for an agreed upon rate during a hospitalization) for four of five resident hospital transfers (Residents R29, R39, R75, and R82). Findings include: Review of facility policy Discharge and Transfer dated 5/7/24, indicated the Bed Hold Notice of Policy & Authorization form will be provided. Review of the clinical record indicated Resident R29 was admitted to the facility on [DATE]. Review of Resident R29's Minimum Data Set (MDS - a periodic assessment of care needs) dated 6/5/24, indicated diagnoses of high blood pressure, muscle weakness, and acute cholecystitis (inflammation of the gallbladder). Review of the clinical record indicated Resident R29 was transferred to hospital on 5/9/24 and returned to the facility on 5/19/24. Review of Resident R29's clinical…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, clinical record review, and staff interview, it was determined that the facility failed to ensure that a baseline care plan that included the minimum healthcare information necessary to properly care for a resident was developed and implemented within 48 hours of admission for 17 of 17 new admissions in the past 30 days. Findings include: A review of facility policy Person-Centered Care Plan last reviewed 5/7/24, indicated the center must develop and implement a baseline person-centered care plan within 48 hours of admission/readmission for each patient/resident that includes the instructions needed to provide effective and person-centered care that meets professional standards of quality care. A review of the facility's new admissions within the past 30 days failed to reveal baseline care plans in the clinical record. During an interview on 7/24/24, at 2:00 p.m. The Nursing Home Administrator stated, The baseline care plans are not being completed, they should be done on admission, however they are not being completed, and confirmed the facility…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on 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 (a machine that filters wastes, salts, and fluid from your blood when your kidneys are no longer healthy enough to do this work adequately) center for three of three residents (Residents R1, R27, and R41). Findings include: Review of facility policy Dialysis: Hemodialysis (HD) - Communication and Documentation dated 5/7/24, indicated Center staff will communicate with the certified dialysis facility regarding the ongoing assessment of the patient's condition by monitoring for complications before and after hemodialysis treatments received at a certified dialysis facility. To ensure ongoing communication and collaboration with the certified dialysis facility regarding hemodialysis (HD) patient care and services. Practice Standards: 1. Prior to a patient leaving the Center for HD, a licensed nurse will complete the top portion of…

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

Based on review of 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 two of three units (third floor medication room and fourth floor medication room). Findings include: Review of the facility policy Medication Administration dated 5/7/24, indicated the nurse shall place a date opened sticker on the medication if one is not provided by the dispensing pharmacy and enter the date opened. Review of the facility policy Medication Storage dated 5/7/24, indicate medications and biologicals are stored properly, following manufacturers or provider pharmacy recommendations, to keep their integrity and to support safe, effective drug administration. Any other foods such as employee lunches and activity department refreshments should not be stored in this refrigerator. The refrigerator should be kept clean and frost-free. Observation on 7/23/24, at 10:17 a.m. the third-floor medication room refrigerator contained one vial of tuberculin solution noted to be opened 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 facility policy, resident clinical records, and staff interview, it was determined the facility failed to ensure the coordination of hospice services with facility services to meet the needs of each resident for end of life care for two of two residents (Residents R31 and R97). Findings include: Review of facility policy Hospice dated 5/7/24, indicated each patient's written plan of care includes both the most recent hospice plan of care and a description of the services furnished by the Center attain or maintain the patient's highest practicable physical, mental, and psychosocial wellbeing. The Administrator will obtain a written agreement with each hospice that includes a communication process, including the method for documenting the communication between the Center and the hospice provider to ensure that the patient's needs are met 24 hours per day. Review of the clinical record indicated Resident R31 was admitted to the facility on [DATE]. Review of Resident R31's Minimum Data Set (MDS…

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

Based on review of facility policy, Quality Assurance attendance records, and staff interview, it was determined that the facility failed to conduct Quality Assessment and Assurance (QAA) meetings at least quarterly with all of the required committee members for three of three quarters (October 2023 through December 2023, January 2024 through March 2024, and April 2024 through June 2024). Findings include: Review of facility policy Center Quality Assurance Performance Improvement Process dated 5/7/24, indicated the QAA committee functions under the authority of the Administrator and the Governing Body and is composed of the Administrator, Director of Nursing, Medical Director, Infection Preventionist, consultant pharmacist, patient and/or family representatives, and three additional staff representatives. The QAA committee meets at least quarterly. During an interview on 7/26/24, at 8:15 a.m. the Nursing Home Administrator (NHA) stated that the facility was unable to locate any Quality Assurance and Performance Improvement sign-in sheets and attendance records for October 2023…

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

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 prevent cross contamination during a medication pass for two of six residents (Residents R46 and R98), and failed to follow enhanced barrier precautions (EBP) for eight of eight residents with tube feedings (R6, R28, R41, R53, R72, R73, R75, and R109), six of six residents with indwelling urinary catheters (R12, R38, R39, R75, R238, and R240), and two of two residents with indwelling dialysis catheters (R27 and R42). Findings include: Review of facility policy Medication Administration dated 5/7/24, indicated to administer oral medications in an organized, accurate, and safe manner. Pour the correct number of tablets or capsules into the medication cup, taking care to avoid touching any of the mediation unless wearing gloves. Review of the facility policy Enhanced Barrier Precautions (EBP) last reviewed 5/7/24, indicated in addition to Standard Precautions, EBP will be used…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy, clinical record review and staff interview, it was determined that the facility failed to make certain that an influenza and pneumococcal immunization was offered to four of five residents (Resident R53, R94, R106, and R112). Findings include: Review of the facility policy IC600 Influenza Immunization dated 5/7/24, indicated influenza immunization history will be obtained and documented upon admission for residents. Review of the facility policy OC601 Pneumococcal Vaccination dated 5/7/24, indicated the facility will provide the opportunity to receive the appropriate pneumococcal vaccine to all residents. Upon admission, obtain the pneumococcal vaccination history of all residents and document in the electronic record. Review of the admission Record indicated that Resident R53 was admitted to the facility on [DATE]. Review of Minimum Data Set (MDS-periodic assessment of care needs) dated 2/4/24, included diagnoses of a seizure disorder and high blood pressure. Section O0250 Influenza…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 in-service documentation, personnel records, and staff interviews it was determined that the facility failed to implement and maintain an effective training program for three out of five personnel records (Nurse Aide (NA) Employee E25, NA Employee E26, and NA Employee E27). Findings include: Review of facility policy In-service Training dated 5/7/24, indicated that the facility will provide in-service training for all personnel on a regularly scheduled basis. All mandatory in-service requirements must be completed annually as a condition of continued employment. Training topics include effective communication, resident rights, abuse, neglect, and exploitation, quality assurance and performance improvement (QAPI), infection control, compliance and ethics, and behavioral health. Review of NA Employee E25's personnel record indicated a date of hire on 4/13/05. Review of NA Employee E25's personnel file did not include annual in-service training on effective communication, resident rights, abuse, QAPI, infection control, compliance and ethics, and behavioral…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, review of facility documentation, resident and staff interviews it was determined that the facility failed to provide a dignified dining experience for meals for one of three units (4th Floor Nursing Unit). Findings include: Review of the facility policy FNS308 Meal Service dated 5/7/24, indicated meals are served accurately, timely, and at the appropriate temperature. It was indicated bases and dinner plates are heated for hot meals. The only exception to the use of disposable dishes are if the dishwasher is broken, or the resident is on suicide precautions. Review of the facility policy NSG270 Meal Service dated 5/7/24, indicated it is the policy of the facility to provide safe, sanitary, and dignified meals services which account for patient preference. Review of a grievance form dated 3/7/24, indicated meals are still coming up at times in Styrofoam containers/bowls. Plastic silverware is sent up, and at times no knife is provided. Review of a grievance form dated 7/11/24, indicated Styrofoam is still being used during meals. Review of the facility's food…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of clinical records, and staff interview it was determined that the facility failed to notify the resident's representative of a change in condition and transfer to the hospital for one of four resident records (Closed Resident Record CR241). Findings include: Review of facility policy Change in Condition: Notification of dated 5/7/24, indicated a Center must immediately notify the patient, consult with the patient's physician, and notify, consistent with their authority, the patient's representative, when there is a significant change in the patient's physical mental, or psychosocial status (that is, a deterioration in health, mental or psychosocial status in either life-threatening conditions on clinical complications), and when there is a decision to transfer of discharge the patient from the Center. Review of the clinical record indicated Closed Resident Record CR241 was admitted to the facility on [DATE]. Review of Closed Resident Record CR241's Minimum Data Set (MDS - a periodic assessment…

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

Based on review of facility policy, observation, and staff interview it was determined that the facility failed to maintain the confidentiality of residents' medical information on one of six medication carts (third floor low hall medication cart assignment two). Findings include: Review of facility policy Resident Rights dated 11/28/16, reviewed 5/7/24, indicates a resident has a right to personal privacy and confidentiality of their personal and medical records. During an observation on 7/24/24, at 9:11 a.m. Registered Nurse (RN) Employee E8 went into Resident R113's room to administer medications. RN Employee E8 left the computer screen open with resident information visible to anyone passing by in the hallway. During an interview on 7/24/24, at 9:19 a.m. RN Employee E8 confirmed the facility failed to provide privacy and confidentiality of resident health information on one of six medication carts (third floor low hall medication cart assignment two). 28 Pa. Code 201.29(j) Resident rights. 28 Pa. Code: 211.5(b) Clinical records.

Based on observations, and staff interview, it was determined that the facility failed to maintain a clean homelike environment for two of three units (second floor shower room and fourth floor nursing unit). Findings include: Review of facility policy Accommodation of Needs dated 5/7/24, indicated the resident/patient has the right to a safe, clean, comfortable, and homelike environment including, but not limited to, receiving treatment and support for daily living safely. Review of the facility policy Cleaning and Disinfecting dated 5/7/24, indicated leaning and disinfecting of frequent touched items and surfaces, resident care items, and the environment, will be conducted routinely and based on risk of infection involved. For durable medical equipment such as feeding pumps, staff shall store used/dirty equipment in soiled utility rooms. Central Supply or designees shall be responsible for terminal cleaning/disinfection in designated locations. During an observation on 7/22/24, at 8:49 a.m. Resident R57's tube feeding pole and floor surrounding the pole were observed dirty with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical records, facility documents, and staff interview, it was determined that the facility failed to fully investigate injuries of unknown origin for one of four residents reviewed (Resident R125). Findings include: A review of the facility's Abuse, Neglect, and Exploitation policy dated 5/7/24, indicated immediately upon receiving information concerning a report of suspected or alleged abuse, mistreatment, or neglect the Administrator or designee will initiate a thorough investigation within 24 hours, ensure that documentation of witnessed interviews is included. Review of the clinical record revealed that Resident R125 was admitted to the facility on [DATE], with diagnosis that included high blood pressure, adjustment disorder with anxiety, and muscle weakness. A review of Resident R125's progress note dated 6/5/24, entered by Licensed Practical Nurse (LPN) Employee E32, stated the resident was heard getting up with her canes and walking in the hall, ran to resident and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policies, clinical records, and staff interviews, it was determined that the facility failed to develop comprehensive care plans to meet resident care needs for one of four residents (Residents R19). Findings include: Review of facility policy Person-Centered Care Plan last reviewed on 5/7/24, indicate a comprehensive, individualized care plan will be developed within seven days after completion of the comprehensive assessment (admission, annual, or significant change in status and review and revise the care plan after each assessment. The care plan includes measurable objectives and timetables to meet a patient's medical, nursing, nutrition, and mental and psychosocial needs that are identified in the comprehensive assessments. Review of Resident R19's admission record indicated admission to the facility on [DATE]. Review of the MDS (a periodic assessment of care needs) dated 5/4/24, included diagnoses of heart failure (heart can't pump blood the way it should), hypertension (high…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 interview and staff interviews it was determined that the facility failed to provide Activity of Daily Living (ADL) assistance for two of seven residents (Residents R82 and R100). Findings include: Review of facility policy Activities of Daily Living (ADLs) dated 5/7/24, indicated the facility must provide the necessary care and services to ensure that a patient ' s ADL abilities are maintained or improved and do not diminish unless circumstances of the patient ' s clinical condition demonstrate that a change was unavoidable. ADL ' s include hygiene, bathing, dressings, grooming, and oral care. Review of admission record indicated female Resident R82 was admitted to the facility on [DATE] Review of Resident R82's Minimum Data Set (MDS - a periodic assessment of care needs) dated 5/5/24, indicated the diagnoses of high blood pressure, coronary artery disease (damage or disease in the heart's major blood vessels), and cerebral infarction (necrotic tissue…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, observations, and staff interviews, it was determined that the facility failed to ensure that residents receive proper treatment and assistive devices to maintain hearing abilities for one of eight residents (Resident R57). Findings include: Review of the clinical record indicated that Resident R57 was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS - a period assessment of care needs) dated 2/15/24, indicated diagnoses of hypertension (high blood pressure), muscle weakness, and diabetes (a chronic, disease characterized by elevated levels of blood glucose (or blood sugar). Review of Resident R57's Audiology visit summary dated 3/6/24, indicated the patient was referred by the facility for decreased hearing. It was indicated the resident had excessive ear wax in both ears. Recommendations included to refer for ear wax removal in both ears, follow facility protocol for wax removal, debrox (medication used to treat earwax buildup) and ear canal flush 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 clinical record review and staff interviews, it was determined that the facility failed to properly monitor weight and nutrition status by failing to obtain weights for one of three residents (Resident R12) and failed to provide necessary services for one of three residents reviewed (Resident R106). Findings include: Review of facility policy Weights and Heights dated 5/7/24, indicated patients are weighed upon admission and/or re-admission, then weekly for four weeks and monthly thereafter. Additional weights may be obtained at the discretion of the interdisciplinary care team. Hospital weight will not service as admission or re-admission weight. Review of facility policy NSG270 Meal Service dated 5/7/24, indicated that person-centered meal service includes the delivery of a safe, sanitary, and comfortable environment for meals. It was indicated if a resident requires assistance with eating, do not deliver the tray until assistance can be provided. Staff will provide assistance during meal services 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 records, facility policy, and staff interview, it was determined that the facility failed to obtain physician orders for maintenance flushing of a enteral-tube for one of four residents (Resident R41), failed to obtain orders for enteral-tube displacement for one of four residents (Resident R53), failed to label tube feeding flush kit with dates on 2 of 8 residents (R28 and R41), and failed to label tube feeding formula and water flush on one of eight residents (R53). Review of the facility policy Enteral Management dated 5/7/24, indicate to provide safe and effective management of enteral tubes (a tube that is placed directly into the stomach through an abdominal wall incision for administration of food, fluids, and medications). Review of the facility policy Enteral Feeding: Administration by Pump dated 5/7/24, indicate to verify order. Order includes, but is not limited to frequency of water flushes. Evaluate tube and site for damage, leakage, or irritation. If tube is damaged,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, interviews, and clinical record review, it was determined that the facility failed to provide appropriate respiratory care for two of four residents (Residents R94 and R106). Findings include: Review of facility policy Procedure: Oxygen: Nasal Cannula dated 5/7/24, indicated if a humidifier is used it must be labeled with the date. It was indicated the flow rate of oxygen must be set to the prescribed order. Review of the clinical record indicated Resident R94 was admitted to the facility on [DATE], with diagnoses of muscle weakness, high blood pressure, and Chronic Pulmonary Disease (COPD-a chronic inflammatory lung disease that causes obstructed airflow from the lungs). Review of Resident R94's Minimum Data Set (MDS - a periodic assessment of care needs dated 7/16/24, indicated the diagnoses were current. Review of Resident R94's care plan dated 1/14/22, indicated to administer oxygen as per physician order. Review of Resident R94's physician order dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, personnel records and staff interview it was determined that the facility failed to complete annual performance evaluations for two out of five nurse aide personnel records (Nurse Aide (NA) Employee E25 and NA Employee E26). Findings include: Review of facility policy Performance Appraisal dated 5/7/24, indicated managers will meet with their regular full-time, regular part-time, and regular casual employees at least annually to conduct a performance appraisal or have a performance based conversation. Review of NA Employee E25's personnel record indicated she was hired to the facility on 4/13/05. Review of NA Employee E26's personnel record indicated she was hired to the facility on [DATE]. Review of personnel records did not include an annual performance evaluation based on the date of hire for NA Employee E25 and NA Employee E26. During an interview on 7/26/24, at 9:55 a.m. Scheduler Employee E18 confirmed that the facility failed to complete annual performance evaluations…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 records and facility policy review, and staff interview, it was determined that the facility failed to ensure that a resident who displayed mental or psychosocial adjustment difficulties received appropriate treatment and services to correct the problem for one of three residents (Resident R84). Findings include: Review of the facility OPS416 Person-Centered Care Plan dated 5/7/24, indicated a comprehensive person-centered care plan must be developed for each patient and must describe the services that are to be furnished. The care plan must be customized to each individual resident's preferences and needs. Review of the facility policy NSG206 Behaviors: Management of Symptoms dated 5/7/24, indicated residents exhibiting behavioral symptoms will be individually evaluated to determine the behavior. Behaviors and interventions will be addressed in the care plan. The facility will ensure necessary behavioral health services are person-centered and reflect the patient's goal of care, while…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of clinical records and staff interview, it was determined that the facility failed to ensure a resident with dementia receives the appropriate treatment and services to attain or maintain his highest practicable physical, mental, and psychosocial well-being for one of four residents reviewed (Resident R106). Findings include: Review of the facility OPS416 Person-Centered Care Plan dated 5/7/24, indicated a comprehensive person-centered care plan must be developed for each patient and must describe the services that are to be furnished. The care plan must be customized to each individual resident's preferences and needs. Review of Resident R106's clinical record indicated the resident was admitted to the facility on [DATE], with diagnoses that included Alzheimer's disease, (a form of dementia which causes a gradual decline in memory, thinking and reasoning skills), depression, and anxiety. A Minimum Data Set Assessment (MDS, a form completed at specific intervals to determine care needs) dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of clinical records, and staff interview it was determined that the facility failed to ensure that a resident's laboratory test results were received for one of seven residents (Resident R75). Findings include: Review of facility policy Cultures/Culture Reports dated 5/7/24, indicated the facility that resident culture results will be communicated promptly to the attending physician or advanced practice provider to ensure that all infections are promptly and properly identified through accurate evaluation of culture results for patient care. Practice standards include: Report all culture results promptly to physician and document the results of culture, notification and response of attending physician. Review of the clinical record indicated Resident R75 was admitted to the facility on [DATE]. Review of Resident R75's MDS (Minimum Data Set, periodic assessment of resident care needs) dated 1/10/24, indicated diagnoses of high blood pressure, atrial fibrillation (disease of the heart characterized…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, clinical records, observations, and staff interviews, it was determined that the facility failed to provide food in a form to meet individuals needs who are ordered easy to chew diet textures for one of five residents (Resident R45). Findings include: Review of facility policy Meal Service dated 5/7/24, indicated that person-centered meal service includes the delivery of a safe, sanitary, and comfortable environment for meals while accommodates patient preference and personal choice. Meal service may occur in dining rooms, patient room, and other suitable locations that promote a homelike environment. The purpose is to provide safe, sanitary, and dignified meal services which account for patient preference. When assisting residents, assure the correct meal is served to the patient. Review of the clinical record indicated Resident R45 was admitted to the facility on [DATE]. Review of Resident R45's Minimum Data Set (MDS - a periodic assessment of care needs) dated 7/12/24, 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy, clinical record review and staff interview, it was determined that the facility failed to provide accurate and timely documentation related to offering the COVID-19 vaccine and providing education for two of five residents reviewed for immunizations (Resident R53 and R106). Findings include: Review of the Centers for Disease Control (CDC) Staying Up to Date with COVID-19 Vaccines dated 7/3/24, indicated the CDC recommends the 2023-2024 updated COVID-19 vaccines-Pfizer-BioNTech, Moderna, or Novavax-to protect against serious illness from COVID-19. People aged 65 years and older who received 1 dose of any updated 2023-2024 COVID-19 vaccine (Pfizer-BioNTech, Moderna or Novavax) should receive 1 additional dose of an updated COVID-19 vaccine at least 4 months after the previous updated dose. Review of the admission Record indicated that Resident R53 was admitted to the facility on [DATE]. Review of Minimum Data Set (MDS-periodic assessment of care needs) dated 2/4/24, included diagnoses 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, personnel files and staff interview it was determined that the facility failed to conduct the minimum 12 hours of nurse aide (NA) training per year for two of five NA personnel files (NA Employee E25 and E27) and failed to complete annual training on dementia management for one of five NA personnel files (NA Employee E25) and abuse prevention for two out of five NA personnel files were completed (NA Employee E25 and NA Employee E26). Findings include: Review of facility policy In-service Training dated 5/7/24, indicated that the facility will provide in-service training for all personnel on a regularly scheduled basis. All mandatory in-service requirements must be completed annually as a condition of continued employment. Training topics include dementia management and resident abuse prevention. The facility will ensure continuing competence for no less than 12 hours per year. Review of NA Employee E25's personnel record indicated she was hired to the facility on 4/13/05.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 and facility record review, facility submitted documents and staff interview, it was determined that the facility failed to make certain residents were provided appropriate treatment and services for one of forty seven residents (Resident R1). Findings include: Review of the facility policy Post Mortem Care dated [DATE], indicated When funeral home transport arrives: Verify the identification of the funeral home personnel. Verify identity of patient (i.e. identification bracelet or tag) in the presence of the funeral home personnel. Review of clinical record revealed Resident R1 was originally admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS-periodic assessment of resident care needs) dated [DATE], included diagnosis of dementia (a group of thinking and social symptoms that interferes with daily functioning), anxiety disorder (mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one daily's life), and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical record review, and staff interview it was determined that the facility failed to provide a trauma survivor with trauma centered care for one of two residents (Resident R3). Findings include: Review of facility policy Trauma Informed Care dated 5/7/24, indicated the following: Centers will provide care and services, which in addition to meeting professional standards, are delivered using approaches, which are culturally competent, account for experiences and preferences and address the needs of trauma survivors by minimizing triggers and or re-traumatization. Review of clinical record indicated Resident R3 was admitted to the facility on [DATE]. Review of Resident R3 admit sheet indicated the following diagnosis PTSD (Post Traumatic Stress Disorder - a disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event) , anxiety disorder ( a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility documentation, and staff interviews it was determined that the facility failed to have enough staff to supervise and prevent incidents for one of forty-seven residents. Findings include: Review of facility submitted information dated [DATE], indicated that on [DATE], at 5:17 a.m. Resident R1 was asleep in her bed when her Resident R2 expired. When the funeral home transportation showed up to pick up the expired resident, directed to the resident room and Resident R1 was secured onto cot under sheet, and transported out of the facility. Residents to follow identification bands put in place. Review of facility documentation Daily Staffing Sheet for [DATE], 11pm to 7/730 am indicated that there was 1 RN on duty on the unit with 2 nurse aides. Further review of the Daily Staffing Sheet indicated the two other units had 2 nurses with 1 unit having 3 nurse aides. During interview on [DATE], with staff who worked on [DATE], indicated that all 3 staff members were working at the time of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical record, facility documentation and staff interview it was determined that the facility failed to make certain medications were administered as ordered by physician for one of four residents reviewed (Resident R3). Findings include: Review of facility policy Medication Errors dated 5/7/24, indicated Medication Error means the observed or identified preparation or administration of medications or biologicals which is not in accordance with the prescriber's order; manufactures specifications (not recommendations) regarding the preparation and administration of the medication or biological; or accepted professional standards and principals which apply to professionals providing services. Types of errors include; medication omission. Review of clinical record indicated Resident R3 was admitted to the facility on [DATE]. Review of Resident R3 admit sheet indicated the following diagnosis PTSD (Post Traumatic Stress Disorder - a disorder in which a person has 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 facility documents, observations, and staff interview, it was determined that the facility failed to have appropriate personal protective equipment (PPE) to prevent cross-contamination for two of two residents in Covid-19 isolation (respiratory infection Resident R1 and R2) and two of two residents in other isolation precautions (Resident R3 and R4) and failed to clean consistently to prevent infectious spread from items or environment to residents and or staff on three of three units (2nd, 3rd, and 4th floors). Findings include: Review of the facility Infection Control Policies and Procedures Cleaning and Disinfecting last reviewed 8/8/23, indicated cleaning and disinfecting of frequently touched items and surfaces, resident care items and the environment, including common areas of the center, will be conducted routinely and based on risk of infection involved. Review of the facility Infection Control Policies and Procedures Covid-19 last reviewed 8/8/23, indicated Special droplet and contact…

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

Based on a review of facility policies, observations, and staff interviews, it was determined that the facility failed to properly monitor food expiration dates in the Main Kitchen creating the potential for food-borne illness (Main kitchen). Findings include: Review of facility policy FNS505 Dry Storage, dated 5/1/23, indicates products stored in the dry storage areas are maintained in a safe and sanitary manner. During an observation conducted on 8/7/23, at 9:30 a.m., of the bread storage area in the Main Kitchen, revealed 3 loaves of whole wheat bread with Use by date of 8/2/23, with one loaf observed that was covered in a green mold-like substance. Items were immediately discard by Dietary Director (DD) Employee E1. During interview conducted while above observation was made on 8/7/23, at 9:30 a.m., Dietary Director (DD) Employee E1 confirmed the above observation as accurate, and that the facility failed to monitor food expiration dates in the Main Kitchen creating the potential for food-borne illness. 28 Pa. Code 201.14(a) Responsibility of licensee

Based on facility policy, documents submitted by the facility, and staff interview it was determined that the governing body of the facility failed to ensure consistent appointment of an administrator licensed by the state for three out of seven days (8/4/23, 8/5/23, and 8/6/23). Findings include: The facility Adherence to the code of conduct policy dated 4/4/22, indicated that all directors, officers, employees must comply with applicable legal requirements, standards, policies, and procedures. The code of conduct is a standard derived from policies and procedures as well as relevant federal and state laws. Review of an electronic notification dated 8/4/23, indicated the Previous NHA Employee E13 notified the local State filed office that she was no longer the Administrator and Administrator in Training (AIT) Employee E3 would be supervising the facility. During an entrance interview on 8/7/23, at 9:04 a.m. Administrator in Training (AIT) Employee E3 and the Director of Nursing (DON) were present and no NHA was present. During an interview on 8/7/23, at 12:47 p.m. the Nursing Home…

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

Based on review of facility policy, facility documents and staff interview it was determined that the facility failed to complete the Facility Assessment annually (January 2022 to August 2023). Findings include: The facility Facility assessment policy dated 3/1/22, indicated that the facility will conduct and document a facility-wide assessment. The facility will review and update the assessment annually and when there is a substantial modification. Review of the facility assessment found it last reviewed and dated November 30, 2021. The facility assessment did not indicate an annual review had occurred for 2022 or 2023. During an interview on 8/9/23, at 11:27 a.m. the Nursing Home Administrator (NHA) confirmed that the facility failed to complete the Facility Assessment annually as required. 28 Pa. Code 201.18(b)(3)(e)(2) Management.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, and staff interview, it was determined that the facility failed to maintain a clean homelike environment for three of three units (second and fourth floor's solariums, third floor shower rooms and solarium) and seven of nine resident rooms observed (Residents R31, R41, R71, R72, R81, R94, and R270). Findings Include: Review of facility policy Accommodation of Needs dated 2/1/23, indicated the resident has a right to a safe, clean, comfortable, and homelike environment including, but not limited to, receiving treatment and support for daily living safely. Observation of the second floor nursing unit, on 8/7/23, at 8:45 a. m. revealed debris on the hallway floors, solarium floors, and tables appeared sticky with food debris (dirt, crumbs, tissues). Review of admission record indicated Resident R270 admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS- a periodic assessment of care needs) dated 7/25/23, indicated the diagnoses of high blood pressure, seizure disorder…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 of resident areas and nursing units, and staff interviews it was determined that the facility failed to make certain anonymous grievance forms are readily accessible for resident use throughout the facility for three of three nursing units (Second floor, Third floor, and Fourth floor). Findings include: The facility Grievance/concern policy dated 7/19/23, indicated that the resident has the right to voice grievances to the center or other agencies that hear grievances without discrimination or reprisal. A description of the procedure voicing grievances/concerns will be on each unit and include the right to file grievances in writing, the right to file grievances anonymously. During a tour on 8/7/23, at 2:15 p.m. the Third floor nursing unit and resident solarium/common area was observed without grievance forms for resident usage. During a tour on 8/8/23, at 10:30 a.m. the Third floor nursing unit and resident solarium/common area was observed without grievance forms for resident usage. During a tour on 8/9/23, at 1:25 p.m. the Third…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based review of facility provided documents and clinical records, observations and staff interviews, it was determined that the facility failed to develop and implement comprehensive care plans for two of 16 residents (Resident R40 and R41). Findings include: Review of the facility policy Person Centered Care Plan dated 10/24/22, indicated the Center must develop and implement a person centered care plan for each resident that includes the instructions needed to provide effective and person centered care that meet professional standards of quality care. The interdisciplinary team and resident or patient representative will establish goals and expected outcomes of care, the type, amount, frequency, and duration of care and any other factors related to the effectiveness of the plan of care. Review of admission record indicated Resident R40 was readmitted to the facility on [DATE]. Review of Minimum Data Set (MDS - a periodic assessment of care needs) dated 7/4/23, indicated the diagnoses of end stage renal disease…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, resident interview and observations, clinical record review, and staff interview it was determined that the facility failed to provide Activity of Daily Living (ADL) assistance for six of 16 residents (Residents R40, R25 R48, R60, R71 and R97). Findings include: The facility policy Activities of Daily Living (ADLs) dated 5/1/23, last reviewed 8/8/23, indicated a patient who is unable to carry out ADLs will receive the necessary level of ADL assistance to maintain good nutrition, grooming, and personal and oral hygiene. Review of admission record indicated Resident R40 was readmitted to the facility on [DATE]. Review of Minimum Data Set (MDS - a periodic assessment of care needs) dated 7/4/23, indicated the diagnoses of end stage renal disease (ESRD, an inability of the kidneys to filter the blood), high blood pressure, and muscle wasting and weakness. During an interview on 8/7/23, at 9:32 a.m. Resident R40 stated that he does not get sufficient assistance to the restroom.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy review, observations, and staff interviews, it was determined that the facility failed to maintain sanitary conditions of respiratory equipment for four of seven residents reviewed (Resident R41, R69, R83, and R271). Findings include: Review of the facility policy Oxygen: Nasal Cannula dated 6/15/22, last reviewed on 8/8/23, indicated the nasal cannula (light weight tube in the nose to provide oxygen) labeled with date of initial set-up and to replace disposable set-up every seven days. Date and store cannula in treatment bag when not in use. Review of admission record indicated Resident R41 admitted to the facility on [DATE]. Review of Minimum Data Set (MDS - a periodic assessment of care needs) dated 7/13/23, indicated the diagnoses of anemia (the blood doesn ' t have enough healthy red blood cells), heart failure (heart doesn ' t pump blood as well as it should), and high blood pressure. Review of Resident R41's physician order dated 6/27/23, indicated one liter via nasal cannula at…

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

Based on review of facility policy, Nursing staff personnel records, nurse training documentation and staff interview, it was determined that the facility failed to ensure that nursing staff received annual in-service education for six out of ten nursing personnel (Nurse Aide (NA) Employee E14, Nurse Aide Employee E15, Nurse Aide Employee E16, Nurse Aide Employee E17, Licensed Practical Nurse (LPN) Employee E21, and Licensed Practical Nurse (LPN) Employee E22). Findings include: The facility In-service training policy dated 7/1/22, indicated that the facility will provide in-service training for all personnel. All mandatory in-service requirements must be completed annually as a condition of continued employment. Training topics include residents rights, abuse, neglect and exploitation, behavioral health, infection control, compliance and ethics, effective communication, and dementia management. Review of NA Employee E14's personnel record indicated she was hired to the facility on 2/20/97. Review of NA Employee E14's personnel record did not include annual in-services on infection…

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

Based on review of facility policy, personnel records and staff interview it was determined that the facility failed to complete annual performance evaluations for four out of five nurse aide personnel records (Nurse Aide (NA) Employee E14, Nurse Aide Employee E15, Nurse Aide Employee E16, and Nurse Aide Employee E17). Findings include: The facility Human resource: performance appraisal policy dated 7/1/22, indicated that managers will meet with regular full-time, regular part-time, and regular casual employees at least annually to conduct a performance appraisal. Review of NA Employee E14's personnel record indicated she was hired to the facility on 2/20/97. Review of NA Employee E15's personnel record indicated she was hired to the facility on 4/12/22. Review of NA Employee E16's personnel record indicated she was hired to the facility on 5/9/11. Review of NA Employee E17's personnel record indicated she was hired to the facility on 4/22/13. Review of personnel records did not include an annual performance evaluations based on the date of hire for NA Employee E14, NA Employee E15,…

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

Based on policy review, record review, observation, documentation and review of Centers for Disease Control (CDC) guidelines for Legionella (bacteria that causes disease found in contaminated water) control, and staff interviews it was determined that the facility failed to maintain a clean environment, failed to handle soiled linens properly, and failed to maintain a comprehensive program for water management to monitor the potential development and spread of Legionella and failed to implement control measures for Legionella within the facility for seven of twelve months (January, February, March, April, May, June, July 2023). Findings Include: A review of facility policy Infection Control dated 8/8/23, previously dated 8/30/22, indicated the facility will maintain a safe, sanitary environment for residents. Review of the facility policy Water Management dated 8/8/23, previously dated 8/30/22. indicated the facility will utilize water management practices to reduce the risk of growth and spread of Legionella and other opportunistic pathogens in building water systems. Core Elements…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 infection control documentation and staff interview, it was determined that the facility failed to have one or more individuals serving as the Infection Preventionist, for three of twelve months (September, October, and November 2022). Review of the Pennsylvania Department of Health notice PAHAN #626, dated 2/15/22, PAHAN #663, dated 10/4/22, PAHAN #694, dated 5/11/23, indicated long-term care facilities should Assign one or more individuals with training in IPC (infection preventions and control) to provide on-site management of the IPC program. This should be a full-time role for at least one person in facilities that have more than 100 residents . Review of the QAPI (Quality Assurance and Performance Improvement) committee meeting sign-in sheets indicated that the Director of Nursing had the role of Infection Preventionist from September through November 2022. During an interview on 8/11/23, at 1:13 p.m. the Nursing Home Administrator confirmed that the facility's Infection Preventionist did not begin in that role until December 2022, and confirmed the facility…

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

Based on review of facility policy, personnel records and staff interview it was determined that the facility failed to complete annual training on dementia management and resident abuse prevention for four out of five nurse aide personnel records (Nurse Aide (NA) Employee E14, Nurse Aide Employee E15, Nurse Aide Employee E16, and Nurse Aide Employee E17). Findings include: The facility In-service training policy dated 7/1/22, indicated that the facility will provide in-service training for all personnel. All mandatory in-service requirements must be completed annually as a condition of continued employment. Training topics include residents rights, abuse, neglect and exploitation and dementia management. Review of NA Employee E14's personnel record indicated she was hired to the facility on 2/20/97. Review of NA Employee E15's personnel record indicated she was hired to the facility on 4/12/22. Review of NA Employee E16's personnel record indicated she was hired to the facility on 5/9/11. Review of NA Employee E17's personnel record indicated she was hired to the facility on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policies, observations, resident and staff interviews, it was determined that the facility failed to determine the ability to self-administer medications for one of eight residents (Resident R27). Findings include: Review of the facility's policy NSG309 Medications: Self-Administration dated 3/1/22, indicated patients who request to self-administer medications will be evaluated for safe and clinically appropriate capability based on the patient's functionality and health condition. If it is determined that the patient is able to self-administer: a physician/advanced practice provider (APP) order is required; Self-administration and medication self-storage must be care planned; when applicable, patient must be provided with a secure, locked area to maintain medications; patient must be instructed in self-administration; Evaluation of capability must be performed initially, quarterly, and with any significant change in condition. Review of the admission record indicated Resident R27 was…

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

Based on review of facility policy, 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 (Cook Employee E12). Findings include: The facility Abuse prohibition policy dated 10/24/22, indicated that the facility will implement an abuse prohibition program by screening potential hires, training employees, and identifying possible incidents. The facility will screen potential employees for a history of abuse, neglect, or mistreating residents, including attempting to obtain information. Review of [NAME] Employee E12's personnel record indicated he was hired 4/17/23. Review of [NAME] Employee E12's did not include a State background check prior to his date of hire. During an interview on 8/8/23, at 2:58 p.m. the Nursing Home Administrator (NHA) confirmed that the facility failed to properly screen [NAME] Employee E12 by completing a State background check prior to hire as required. 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical records, and staff interview it was determined that the facility failed to notify a physician of abnormal glucose readings via a Capillary Blood Glucose (CBG) level as per order, and failed to provide as needed medications for constipation for two of five residents (Resident R29 and R40). Findings include: The Centers for Disease Control defines diabetes as: Diabetes Mellitus is a chronic (long-lasting) health condition that affects how your body turns food into energy. Most of the food you eat is broken down into sugar (also called glucose) and released into your bloodstream. When your blood sugar goes up, it signals your pancreas to release insulin. Insulin acts like a key to let the blood sugar into your body's cells for use as energy. If you have diabetes, your body either doesn't make enough insulin or can't use the insulin it makes as well as it should. When there isn't enough insulin or cells stop responding to insulin, too much blood sugar stays in your…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy review, clinical record review, resident, and staff interviews, it was determined that the facility failed to provide colostomy care and services consistent with professional standards of practice for two of three residents reviewed (Resident R72 and R317). Findings include: Review of facility policy Colostomy and Ileostomy Care dated 6/1/21, last reviewed 8/8/23, indicated to Gather supplies: pouching system (may be disposable or reusable, drainable or closed-ended, and one-piece or two-piece). Document: Date and time pouching system changed or emptied, the type and size of appliance used, and the appearance of the stoma (any opening in the body) and peristomal skin (skin around the stoma). Review of the admission record indicated Resident R72 was admitted to the facility on [DATE]. Review of Resident R72's MDS dated [DATE], indicated the diagnoses of CAD, heart failure, and high blood pressure. Section H indicated a colostomy (a surgical process that diverts bowel through an artificial…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, clinical record review, resident and staff interviews, 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 for 18 of 32 residents. (Resident R4, R13, R20, R25, R33, R40, R48, R53, R60, R71, R89, R96, R97, R109, R217, R300, R301, and R302) and for two of five confidential group residents. Findings Include: Review of facility policy Nursing Scheduling and Timekeeping Process dated 8/8/23, previously reviewed 8/30/22, indicated the facility will staff according to budgeted staffing levels and adjust schedules based on census. Budgeting and adjusted staffing levels are based on a combination of census, acuity levels, and regulatory requirements. During an interview on 8/7/23, at 9:32 a.m. Resident R40 stated that he does not get sufficient assistance to the restroom. When asked, Resident R40 confirmed that he has soiled himself due 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 records and staff interviews, it was determined that the facility failed to schedule ordered appointments for one of two residents (Resident R93). Findings include: Review of the clinical record indicated that Resident R93 was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS - periodic assessment of resident care needs) dated 6/1/23, indicated that these diagnoses of diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time), coronary artery disease (damage or disease in the heart's major blood vessels), acquired absence of right leg below knee, and pain in left knee. During an interview on 8/8/23, at 10:33 a.m. Resident R93 stated, I had a doctor appointment a while ago. they forgot to put in for transportation and they had it set and ready to go. and it was not setup. Review of an After Visit Summary from the hospital outpatient Department of Physical Medicine and Rehabilitation dated on 4/13/23, at 9:51 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 documents, resident clinical record and staff interview 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 four sampled residents (Resident R53). Findings include: The facility Resident rights under federal law policy dated 2/1/23, indicated that the facility residents have the fundamental right to considerate care that safeguards their personal dignity along with respecting cultural, social and spiritual values. When a resident is found by her physician to be medically incapable of understanding these rights, the resident's representative will be informed of these rights and will acknowledge by a signature when receiving a copy of the rights. Review of Resident R53's admission record indicated she was admitted on [DATE], with diagnoses that included dementia (a condition characterized by memory loss and progressive or persistent loss 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.