John J Kane Regional Center-Ro

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy, clinical records, facility documents, and staff interviews, it was determined that the facility failed to permit a readmission to the facility after hospitalization and failed to demonstrate in the clinical record that the discharge was appropriate and necessary for one of three sampled closed resident records (Closed Resident Record CR1).Findings include: The facility Discharge and transfer policy dated 4/28/25, indicated that discharge criteria included to discharge as necessary to meet the resident's welfare and when the resident's welfare and physical needs cannot be met in the facility. The Facility assessment last updated 6/30/25, indicted that common diagnoses that residents in facility have are depression, impaired cognition and behaviors that need intervention. The assessment further indicated that staff are trained on specific areas that relate to psychiatric symptoms, provide interventions dealing with depression and anxiety. Review of Closed Resident Record CR1's admission…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 store, label. and date food and failed to monitor expiration dates of food products in the Main Kitchen which created the potential for food borne illness. Findings Include: Review of the facility policy Storing: Food and Equipment last reviewed 1/2/25, indicated that team members must store food in a manner that ensures quality, freshness, and safeguards against foodborne illness. All team members must follow food and temperature guidelines, labeling, use-by-dates, food storage chart, freezing, and leftover guidelines to ensure food and equipment criteria are met. Label food with name of product, date by which product should be used, and date thawed or frozen if applicable. Food should be discarded or used by the use-by-date. During an observation in the Main Kitchen Walk-in Cooler number one, on 4/7/25, at 9:35 a.m. the following was noted: · An opened bag of French fries, was not sealed, labeled, or dated. · A plastic bag containing bologna was 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.

Based on review of job descriptions, clinical records, and staff interviews, it was determined that the Nursing Home Administrator and Director of Nursing did not effectively manage the facility to make certain that necessary care and services were provided to residents requiring adequate supervision to prevent elopement. Findings include: Review of CFR §483.70 Administration. A facility must be administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Based on the findings in this report that identified the facility failed to maintain necessary supervision and person-centered care plan interventions that resulted in an elopement (resident exits to an unsupervised or unauthorized area without the facility's knowledge) for two residents. This failure created an immediate jeopardy situation for two of 21 residents who were identified as at risk for elopement (Residents R6, and R111). Facility failed to provide fundamental principal that applies…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 develop and implement a comprehensive care plan to meet care needs for four of four residents (Residents R7, R42, R66, and R219). Findings include: Review of facility policy Comprehensive Person-Centered Care Planning last reviewed on 1/2/25, indicated that the facility will comply with requirements related to comprehensive person-centered care planning. The services provided to or arrange for residents will meet professional standards of quality, are provided by qualified persons, and are culturally-competent and trauma-informed. Review of the clinical record indicated Resident R7 was admitted to the facility on [DATE]. Review of Resident R7's Minimum Data Set (MDS - a periodic assessment of care needs) dated 2/2/25, indicated diagnoses of high blood pressure, diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time), and muscle weakness. Review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical record review, observation, and staff interview, it was determined that the facility failed to ensure that residents with an enteral feeding tube (a tube inserted in the stomach through the abdomen) received appropriate treatment and services to prevent potential complications for three of four residents (Residents R35, R91, and R368). Findings include: Review of the facility policy Feeding: Feeding Tubes, dated 1/2/25, indicated that feeding and flush bags are labeled with the resident's name, date, time, and direction. The nurse confirms placement - G tubes - aspirate gastric contents using a 60 cc (cubic centimeter) piston syringe. Review of the facility policy Medication Administration through Gastrostomy Tube dated 1/2/25, indicated nurse pinches off the G tube by kinking and attaches the barrel of the piston syringe to tube. Checks for placement of the tube by following facility policy. Pours 30 milliliters of water into the syringe barrel to flush tube. 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, observations, staff interviews, and clinical record review, it was determined that the facility failed to provide appropriate respiratory care for three of seven residents (Residents R5, R102, and R368). Findings include: Review of facility policy Oxygen Guidelines dated 1/2/25, indicated oxygen is a medication and must be ordered by a practitioner. Set-ups (cannulas, face masks, respiratory delivery, humidification bottles) should be changed every 7 days and are labeled with date of change initialed by staff. Set-ups are stored in plastic bag when not in use to avoid contamination. Replace if contamination occurs. Review of Resident R5's Minimum Data Set (MDS - a periodic assessment of care needs) dated 2/27/25, indicated diagnoses of high blood pressure, hyperlipidemia (high levels of fat in the blood), and muscle weakness. Review of a physician order dated 2/26/25, indicated to administer O2 (oxygen) at 2L via NC (two liters per minute via nasal cannula - a lightweight tube…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, review of facility documentation, and staff interviews, it was determined that the facility failed to make certain that equipment was in safe operating condition for two of four crash carts and three of six Automated External Defibrillators (AED - a portable, electronic device designed to diagnose and treat life-threatening cardiac arrhythmias). Findings include: Review of facility policy Cardiopulmonary Resuscitation and Automated External Defibrillator: Basic Life Support dated [DATE], indicated the response team leader assures that staff members perform cardiopulmonary resuscitation (CPR-an emergency treatment that is done when someone's breathing or heartbeat has stopped) and utilizes the AED appropriately. The Material Manager Security assures that there is an adequate supply of disposable electrodes available. During an observation of the 2 East crash cart (a cart maintained with equipment used in cardiac emergencies) on [DATE], at 11:33 a.m. revealed a binder on the crash cart…

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

Based on observations and staff interview, it was determined that the facility failed to provide a dignified dining experience for one of three units observed (Three East) and failed to protect and value residents' private space for one of three units observed (Three East). Findings include: Review of the facility policy Resident Rights and Responsibilities dated 1/2/25, indicated that each resident have the right to be treated with dignity and respect. During a dining observation of the Three East dining room on 4/7/25, at 11:54 a.m. revealed that Resident R21 was being assisted with lunch by a staff member. Nurse Assistant (NA) Employee E7 was standing beside Resident R21 while feeding him his lunch. During an interview on 4/7/25, at 12:07 p.m. NA Employee E7 stated, I know we are supposed to sit down. During an interview on 4/7/25, at 3:00 p.m. the Director of Nursing confirmed the facility failed to provide a dignified dining experience for Resident R21. During an observation on Three East Unit on 4/7/25, at 12:11 p.m. Housekeeping Employee E26 was seen entering Resident R92's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, observations and staff interviews it was determined that the facility failed to provide a clean, safe, comfortable, and homelike environment for one of three resident areas (room [ROOM NUMBER]). Findings include: Review of the facility policy Resident Rights and Responsibilities dated 1/2/25, indicated Resident Rights are posted on each floor. Review of The Resident's [NAME] of Rights, indicated the resident has the right to a safe, clean comfortable and homelike environment, including but not limited to ensuring that the physical layout of the facility maximizes resident independence and is sanitary, orderly and comfortable. Observation on 4/7/25, 11:22 a.m. of unoccupied Resident room [ROOM NUMBER] revealed a large maintenance cart in the room. There were no beds or furniture in the room. Cart noted with handheld drills, scraping tools, caulk gun supplies, screws, wires and other maintenance tools. The lights above where the beds should be removed on both sides and wires…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 residents were free from neglect for two of four residents reviewed (Residents R35 and R68). Findings include: Review of facility policy Abuse - Resident and Reasonable Suspicion of a Crime dated 1/2/25, indicated neglect is the failure of the facility, the staff, or service providers to provide goods and services to a resident that are necessary to avoid or may result in physical harm, pain, mental anguish, or emotional distress. Review of the clinical record indicated Resident R35 was admitted to the facility on [DATE]. Review of Resident R35's Minimum Data Set (MDS - a periodic assessment of care needs) dated 3/17/25, indicated diagnoses of high blood pressure, dementia (a group of symptoms that affects memory, thinking and interferes with daily life), and diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time). MDS Section…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to notify the physician of decreased Capillary Blood Glucose (CBG) levels per physician orders and failed to implement the facility's hypoglycemia protocol for two of four residents (Residents R65 and R66). Findings include: Review of facility policy Hypoglycemia Protocol dated 1/2/25, indicated a CBG reading of less than 70 milligrams per deciliter (mg/dL) and symptomatic or a CBG of less than 60 mg/dL regardless of symptoms, hold all diabetic mediations and insulin until reviewed with physician, provide treatment, recheck CBG in 15 minutes, treat according to protocol, and notify physician. May repeat such administrations of this medication up to 2 times within 30 minutes time period in the event of an acute hypoglycemic episode. 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…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical record review, observations, and staff interviews, it was determined that the facility failed to ensure a resident with limited mobility receives appropriate services, equipment, and assistance to maintain or improve mobility for two of five residents (Residents R61 and R98). Findings include: Review of facility policy Contracture Management dated 1/2/25, indicated residents with limited ROM (range of motion) will receive appropriate treatment and services to increase and/or prevent further decrease in ROM. The nurse develops and coordinates an interdisciplinary person-centered plan of care that includes passive and/or active ROM exercises, splints, braces or other devices where applicable that will improve or maintain current ROM except where clinically contraindicated. Review of the admission record indicated Resident R61 was admitted to the facility on [DATE]. Review of Resident R61's Minimum Data Set (MDS- a periodic assessment of care needs) dated 2/27/25,…

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, observations, and staff interviews, it was determined that the facility failed to properly store medical supplies in one of three medication carts (Three East Med Cart), and one of three medication rooms (Three [NAME] medication room). Findings: Review of facility Medication Administration General Guidelines policy dated [DATE], indicated that facility will safely administer medications to residents as prescribed by the practitioner and in accordance with current standards of practice and regulatory requirements. The purpose is to provide direction to the licensed staff in the safe and effective administration of medication, including the storing and handling of medication. Check manufactures or pharmacy expiration dates, documentation of date open. During a medication cart review on [DATE], at 11:37 a.m. the following were observed: - Insulin Glargine Pen (used to treat diabetes - a metabolic disorder in which the body has high sugar levels for prolonged periods of time)…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 the review of clinical records, and staff interviews, it was determined that the facility failed to maintain and complete accurate, and appropriate documentation for two of eight residents (Resident R20, and R41). Findings include: Review of Title 42 Code of Federal Regulations (CFR) §483.709(i) Medical records. In accordance with accepted professional standards and practice, the facility must maintain medical records that are complete, accurately documented, readily accessible, and systematically organized. Review of the clinical record indicated Resident R20 was admitted to the facility on [DATE]. Review of Resident R20's Minimum Data Set (MDS) (assessment of a resident's abilities and care needs) dated 2/23/25, indicated diagnoses of high blood pressure, cerebrovascular accident (when blood flow to the brain is disrupted), and muscle weakness. Review of Facility Wound Summary Report provided on 4/7/25, Indicated that Resident R20 had a Stage three pressure injury (an ulcer that has burrowed past 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 facility policy, clinical record review, observation, and staff interview, it was determined that the facility failed to follow enhanced barrier precautions for one of four residents (Residents R91). Findings include: Review of the facility policy Precautions: Enhanced Barrier Precautions (EBP) dated 1/2/25, indicated EBP is an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities. Residents with EBP are indicated, use with the following high-contact resident care activities: Device care or use: central line, urinary catheter, feeding tube, and tracheostomy/ventilator care. Review of the admission record indicated Resident R91 admitted to the facility on [DATE]. Review of Resident R91's Minimum Data Set (MDS - a periodic assessment of care needs) dated 1/14/25, indicated the diagnoses of stroke (damage to the brain from an interruption of blood supply), difficulty swallowing,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility documents, and staff interview, it was determined that the facility failed to provide training on Quality Assurance and Performance Improvement (QAPI) for two of eight staff members (Employee E12, and E13). Findings include: Review of the Facility assessment dated [DATE], indicated that all personnel, including manager, staff (both employees and those who provide services under contract), and volunteers, as well as their education and/or training and any competencies related to resident care. During an interview on 4/9/25, at 1:19 p.m. Assistant Director of Nursing (ADON) Employee E14 stated that education is conducted by calendar year running January through December. Review of facility education documents for the year 2024 revealed the following concerns: Review of Registered Nurse (RN) Employee E12's facility provided information did not include training on QAPI education. Review of RN Employee E13's facility provided information did not include training on QAPI education. During…

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

Based on a review of facility policy, observation, and staff interview, it was determined that the facility failed to properly reheat food items in the unit pantries creating the potential for cross contamination and food-borne illness for two of three units (2 East Pantry and 3 East Pantry). Findings include: Review of the facility policy Reheating Food last reviewed on 1/2/25, indicates to assure residents receives food at a temperature that is safe and comfortable for the resident. To provide guidelines to staff to reheat food items when residents/resident representative requests food be warmed. 1. Retrieves thermometer in locked panty cupboard from nurse. 2. Cleans thermometer with alcohol prior to use. 3. Places food item to be warmed into microwave and sets at 30-second increments. 4. Removes food items and stirs 5. Places thermometer into center of food item until it stops registering. Safe food temperature is 140 degrees or less. a. Continues this process until food is at safe temperature. 6. Clean thermometer and returns to nurse for storage. Review of grievance log dated…

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

Based on facility policy review, facility documents, and staff interviews, it was determined that the facility failed to implement procedures to promote accurate accounting of controlled medications and ensure medication cart keys were provided to staff in accordance with professional standards during a shift to shift change on one out of six medication carts (3-West low hall ). Findings include: The facility Medications-narcotics, controlled substances policy last reviewed on 1/2/25, indicated that the medication key exchange included conducting a physical inventory of medications in the locked medication drawer every time medication keys are exchanged, the departing nurse reviewing the inventory form, the receiving nurse visualizing each medication in the drawer, the receiving nurse checking the narcotic disposition record, and both nurses signing the appropriate form. The facility Licensed Practical Nurse (LPN) job description last reviewed on 1/2/25, indicated that the LPN will ensure that medication and narcotics are completed accurately in accordance with established policies.…

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

Based on review of facility policies, observations, and staff interviews, it was determined that the facility failed to store medications securely in one out of six medications carts (3-West Low hall medication cart). Findings include: The facility Medication administration general guidelines policy last reviewed 1/2/25, indicated that all medications must be kept secured and in a locked environment. During observations on 2/3/25, at 12:13 p.m. observations of the 3-West unit found the 3-West low hall medication cart was observed unlocked. No registered nurse, licensed practical nurse or any other staff observed securing the cart. During observations on 2/3/25, at 12:17 p.m. observations of the 3-West unit found the 3-West low hall medication cart #1 observed unlocked. No registered nurse, licensed practical nurse or any other staff observed securing the cart. During an interview on 2/3/25, at 12:18 p.m. Assistant Director of Nursing (ADON) Employee E1 confirmed that the facility failed to store medications securely in one out of six medications carts as required. 28 Pa. Code…

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

Based on review of facility policy, observation, and staff interviews, it was determined that the facility failed to implement infection prevention and control monitoring policies for Respiratory Precautions for one of three residents (Resident R1), failed to prevent cross contamination by having dirty linens on the floor for one of eight residents (Resident R1), failed to maintain sanitary commodes in bathrooms for three of eight residents (Residents R2, R3, and R5), and failed to ensure floor mats were clean for four of eight residents (Residents R4, R6, R7, and R8). Findings include: Review of the CDC (Center for Disease Control) Fact Sheet Use Personal Protective Equipment (PPE) When Caring for Patients with Confirmed or Suspected Covid-19 indicated doffing - (taking off the gear) Remove gloves and gown. Healthcare Personnel may now exit patient room. Next, remove face shield or goggles and remove and discard respirator. Perform hand hygiene after removing the respirator and applying a new one. Review of the facility policy Cleaning and Preventative Maintenance, Resident Rooms…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, clinical record review and staff interview it was determined that the facility failed to follow a care plan and failed to develop a care plan for one of four residents (Resident R1). Findings include: Review of facility policy All Policy and Procedures : General Guidelines dated 1/3/24, indicated Staff must document all care and services provided to the resident. Documentation should - d. Include identification, evaluation, intervention, and attempts to made to implement and revise the plan of care to address the changing needs of the resident. Resident R1 was admitted to the facility on [DATE]. Review of Resident R1 clinical record MDS ( minimum data set - a periodic assessment of resident needs) dated 10/23/24, indicated diagnosis of unspecified dementia ( a general term for memory, language, problem -solving, and other thinking abilities that are sever enough to interfere with daily living) hypertension ( is when the pressure in your blood vessels is too high), 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, family and staff interview, it was determined that the facility failed to follow the physician order, with missed medication, resulting in a hospitalization for one of four residents (Resident R1). Findings include: Review of facility policy All Policy and Procedure: General Guideline dated 1/3/24, indicated Provide the necessary care and services to each resident to attain or maintain his or her practicable, physical mental, and psychosocial well-being in accordance with their comprehensive person centered care plan that is culturally -competent and trauma informed. Abide by rules and regulations and standards of practice. Ensure that resident obtains optimal improvement or does not deteriorate within the limits of a residents right to refuse treatment, goals of care, and within the limits of recognized pathology and the normal aging process. Review of facility policy Medication Administration General Guidelines dated 1/3/24, indicated It is the policy of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record reviews, observations and staff interviews, it was determined that the facility failed to prepare food in an appropriate consistency to meet the resident's needs for one of seven residents (Resident R1). Findings include: Review of the clinical record indicated Resident R1 was admitted to the facility on [DATE]. Review of Resident R1's MDS assessment (MDS-Minimum Data Set assessment: periodic assessment of resident care needs) dated 7/24/24, indicated diagnoses of muscle weakness, hemiplegia/hemiparesis following cerebral infarction and dysphagia (difficulty swallowing foods or liquids) . Physician orders for Resident R1, dated 11/8/23, included an order for the resident to receive a pureed diet with thin liquids. Review of reports submitted to the local state field office dated 10/13/24, at 8:45 a.m. revealed Resident R1 had an episode of coughing requiring suctioning after she ate a regular diet instead of pureed diet as ordered. A nurse's note for Resident R1, dated 10/13/24 at 8:57…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 date and store food products in a manner to prevent foodborne illness in the Main Kitchen. Findings include: Review of facility policy Food Storage dated 1/3/24, indicated foods products are labeled and dated with the receiving date. Never store chemicals with food and paper supplies. During an observation and interview in walk-in cooler number two in the Main Kitchen on 6/24/24, at 9:44 a.m. an opened gallon of iced tea, and an opened half- gallon container of lemonade had no date, and a plastic container of peaches, had no label or date. Food Service Director (FSD) Employee E18 confirmed that the facility failed to properly label and date opened food packages to prevent foodborne illness. During an observation and interview on 6/25/24, at 1:40 p.m. an opened bottled of iced tea was found in the chemical room in the Main Kitchen amongst the chemicals. FSD Employee E18 confirmed that the facility failed to properly segregate food and chemicals. 28 Pa. Code:…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, 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 out of four residents sampled with facility-initiated transfers (Residents R2, R41, R81, and R118). Findings include: Review of facility policy Transfer of Resident to Acute Facility dated 1/3/24, indicated the nurse documents in the electronic medical record notification of practitioner, notification of resident representative, and preparation of resident. The nurse sends the following information to the receiving facility: contact information of the practitioner responsible for the care of the resident, contact information for the resident representative, advance directive, all special instructions or precautions for ongoing care, comprehensive care plan goals, all other necessary information including but not limited to residents' overall status, discharge summary,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 three of four residents (Resident R2, R41, and R81). Findings include: Review of Title 42 Code of Federal Regulations §483.15(c)(5) Contents of the notice. The written notice specified in paragraph (c)(3) of this section must include the following: (i) The reason for transfer or discharge; (ii) The effective date of transfer or discharge; (iii) The location to which the resident is transferred or discharged ; (iv) A statement of the resident's appeal rights, including the name, address (mailing and email), and telephone number of the entity which receives such requests; and information on how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request; (v) The name, address (mailing and email) and telephone number of the Office 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 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 four resident hospital transfers (Resident R2, R41, R81, and R118). Findings Include: Review of facility policy Bed Hold Notice and Procedures dated 1/3/24, indicated written notice of the bed hold policy will be provided to the resident or legal representative upon admission, upon hospital transfer, or at day two or three when resident is admitted to the hospital, and upon therapeutic leave of absences lasting over 24 hours. Review of the clinical record indicated Resident R2 was admitted to the facility on [DATE]. Review of Resident R2's MDS (Minimum Data Set, periodic assessment of resident care needs) dated 5/21/24, indicated diagnoses of heart failure (a progressive heart disease that affects…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of clinical record review, and staff interview, it was determined that the facility failed to ensure that a resident and a resident's representative was provided a summary of their completed baseline care plan for three of six residents (Resident R41, R71, and R82). Findings include: Review of Resident R41's clinical record indicated the resident was admitted to the facility on [DATE]. Review of Resident R41's MDS (Minimum Data Set, periodic assessment of resident care needs) dated 3/9/24, indicated diagnoses of heart failure (a progressive heart disease that affects pumping action of the heart muscles), hypertension (high blood pressure in the arteries), and depression. Review of Resident R41's clinical record failed to produce documentation that a resident and resident representative was provided with a summary of the baseline care plan. Review of Resident R71's clinical record indicated the resident was admitted to the facility on [DATE]. Review of Resident R71's MDS dated [DATE], indicated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, 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 three of three residents (Resident R83, R88, and R99). Findings include: Review of facility policy Behavior Management and Trauma Informed Care dated 1/3/24, indicated that the facility provides behavioral health care services, according to comprehensive assessment and person-centered plan of care to residents who are diagnosed with post-traumatic stress disorder (PTSD- a disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event). The Interdisciplinary Team will identify and address through resident/resident representative interview, triggers that can lead to expressions or indicators of distress. Review of the clinical record indicated Resident R83 was admitted to the facility on [DATE]. Review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to obtain a diagnosis for hospice services for four of four residents (Residents R70, R71, R81, and R98) and failed to have a completed hospice communication binder for one of four residents (Resident R71). Findings include: Review of facility policy Hospice Services dated 1/3/24, indicated any level of care above routine requires approval and authorization from the attending physician that he or she concurs that the resident's condition warrants a greater level of care. The attending physician writes an order for hospice services when resident/family agrees to hospice services and is eligible for the service. Review of the clinical record revealed that Resident R70 was admitted to the facility on [DATE]. Review of Resident 70's MDS (Minimum Data Set, periodic assessment of resident care needs) dated 4/14/24, indicated diagnoses of stroke, dysphagia (difficulty swallowing), and muscle…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility documents, facility policy, clinical records, and staff interviews, it was determined that the facility failed to implement written policies and procedures to ensure a complete and thorough investigation of an incident involving the potential for neglect for one of three residents (Resident R52) involving a choking incident. Findings include: Review of facility policy Abuse - Resident and Reasonable Suspicion of a Crime dated 1/3/24, indicated neglect is the failure of the facility, the staff, or service providers to provide goods and services to a resident that are necessary to avoid or may result in physical harm, pain, mental anguish, or emotional distress. Neglect may be the result of a pattern of failures or may be the result of one or more failures involving one resident and one staff person. The House Supervisor or Administrator/Designee interviews and obtains written statements from complaining party and witnesses using a facility form. Review of the clinical record indicated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility documents, facility policy, clinical records, and staff interview, it was determined that the facility failed to conduct a thorough investigation of a choking incident to rule out neglect for one of three residents (Resident R52). Findings include: Review of facility policy Abuse - Resident and Reasonable Suspicion of a Crime dated 1/3/24, indicated neglect is the failure of the facility, the staff, or service providers to provide goods and services to a resident that are necessary to avoid or may result in physical harm, pain, mental anguish, or emotional distress. Neglect may be the result of a pattern of failures or may be the result of one or more failures involving one resident and one staff person. The House Supervisor or Administrator/Designee interviews and obtains written statements from complaining party and witnesses using a facility form. Review of the clinical record indicated Resident R52 was admitted to the facility on [DATE]. Review of Resident R52's Minimum Data Set…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 notify the physician of increased and decreased Capillary Blood Glucose (CBG) levels, failed to assess a resident for hyperglycemia (high blood glucose) and hypoglycemia (low blood glucose) for one of three residents (Resident R73), and failed to obtain physician orders for one of ten residents (Resident R369). Findings include: Review of facility Emergency Care Guidelines: Hypoglycemia Protocol dated 1/3/24, indicated a CBG reading of less than 70 milligrams per deciliter (mg/dL) and symptomatic or a CBG of less than 60 mg/dL regardless of symptoms, hold all diabetic mediations and insulin until reviewed with physician, provide treatment, recheck CBG in 15 minutes, treat according to protocol, and notify physician. May repeat such administrations of this medication up to 2 times within 30 minutes time period in the event of an acute hypoglycemic episode. The Centers for Disease Control…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review facility polices, observations, clinical records, and staff interviews it was determined that the facility failed to make certain that appropriate treatments and services were provided for the use of a urinary catheter as required for two of four residents (Resident R2 and R82). Findings include: Review of facility Catheter, Urinary -Bladder Irrigation: Continuous and Intermittent policy dated 1/3/24, indicated to safely provide care and treatment for bladder infections, inflammation, spasms and irritation as prescribed by the practitioner. Open solutions are discarded after twenty-four hours. Review of facility Catheter care and Drainage Bag policy dated 1/3/24, indicated to promote hygiene, monitor urinary output and minimize the growth and transmission of pathogens for residents with indwelling urinary catheters. Drainage bags are to be covered by a dignity bag. Review of the clinical record indicated Resident R2 was admitted to the facility on [DATE]. Review of Resident R2's MDS (Minimum Data…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy review, clinical record review, observation, and staff interviews, it was determined that the facility failed to provide colostomy care and services consistent with professional standards of practice for one of three residents reviewed (Resident R41). Findings include: Review of facility policy Colostomy and Ileostomy Care dated 1/3/24, indicated residents who require special services like ostomy (a stoma is surgically created opening from an area inside the body to the outside) care receive such care consistent with professional standards of practice. Staff to notify practitioner when there are changes to the stoma or skin. Review of the admission record indicated Resident R41 was admitted to the facility on [DATE]. Review of Resident R41's MDS (Minimum Data Set, periodic assessment of resident care needs) dated 3/29/24, indicated diagnoses of heart failure (a progressive heart disease that affects pumping action of the heart muscles), hypertension (high blood pressure in the arteries),…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, clinical record review, and staff interviews, it was determined that the facility failed to follow Enhanced Barrier Precautions (EBP) for two of four residents (Residents R1 and R65) and failed to track active infections for one out of three residents (R369). Findings include: Review of facility policy Precautions: Enhanced Barrier Precautions dated 1/3/24, indicated Enhanced Barrier Precautions are established for residents during high-contact care activities for residents with chronic wounds or indwelling medical devices. EBP is an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care. Indwelling medical devices include central lines, urinary catheters, feeding tubes, tracheostomies. High-contact resident care activities include dressing, bathing/showering, transferring when anticipating close physical contact for long duration of time, providing…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, security footage, facility documents, and staff interviews, it was determined that the facility failed to provide adequate supervision resulting in an elopement (resident exits to an unsupervised or unauthorized area without the facility's knowledge) for one out of four sampled residents (Resident R1). This deficiency is cited as past non-compliance. Finding include: The facility Elopement: missing resident policy dated 12/30/21, indicated that it is the policy of the facility to provide each resident with receive adequate monitoring and interventions to maintain safety. When a resident is unaccounted for all staff will report any suspected unplanned resident absence to the Supervisor or charge nurse. Review of Resident R1's admission record indicated he was admitted on [DATE]. Review of Resident R1's MDS assessment (Minimum Data Set assessment: MDS -a periodic assessment of resident care needs) dated 2/19/24, indicated that Resident R1 had diagnoses that…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy, clinical record review, and interview, the facility failed to ensure that appropriate treatment and services were provided for six of six residents with an indwelling urinary catheter (Residents R1, R2, R3, R4, R5, and R6). Findings include: Review of facility policy Catheter Care and Drainage Bags dated 1/3/24, indicated the facility will safely and appropriately provide hygiene, monitor urinary output, and minimize the growth and transmission of pathogens for residents with indwelling urinary catheters (tube in bladder to drain urine), and the drainage bags are to be covered with a dignity bag. Review of the Centers for Disease Control guidance Guidelines for Prevention of Catheter-Associated Urinary Tract Infections updated 6/6/19, indicated to keep the collecting bag below the level of the bladder at all times. Review of facility policy Catheter Urinary: Removal dated 1/3/24, indicated physician orders discontinuation of catheter and any follow up treatments when condition is…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 prescribed medication for Resident R1. Findings include: Review of facility policy Notification of Change in Residents Condition and Treatment Changes, last reviewed 1/3/24, indicate it is the policy of the [NAME] J. [NAME] Regional Centers to fully inform residents or responsible parties when applicable, in language that he or she can understand of his or hers health status including significant changes in condition or treatment. Review of Resident R1's clinical record indicate an admission date of 6/29/23, with the diagnosis of acute respiratory failure (not enough oxygen in the body), muscle weakness, dysphagia (difficult swallowing). Review of Resident R1's medication administration record (MAR) indicate orders 2/19/24 -2/21/24, azithromycin 500 milligram tablet, 1 tablet hour of sleep for 3 days diagnosis cough, pneumonia. MAR indicates resident received.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, resident record, investigation documents and staff interview, it was determined that the facility failed to report an allegation of neglect within 24-hours for one of six sampled residents (Resident R1). Findings include: The facility Abuse-Resident and reasonable suspicion of a crime dated 2/7/23, last reviewed 1/3/24, indicated that neglect is the failure of the facility, staff or service providers, to provide goods and services to a resident that are necessary to avoid or may result in physical harm, pain, mental anguish or emotional distress. Alleged violations, whether or not confirmed, must be reported to the Administrator, Pennsylvania Department of Health, the Area Agency on Aging, Compliance Officer, and to the Executive Director. Timing of the report involving no serious bodily injury shall be reported no later than 24-hours. Review of Resident R1's admission record indicated he was admitted on [DATE], and Resident R1'S diagnoses included quadriplegia (paralysis of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy and clinical record review, and staff interview, it was determined that the facility failed to follow physician orders for medication administration for one of eight residents reviewed (Resident R1). Findings include: A review of the facility's policy, Medication Administration General Guidelines, dated 1/4/23 indicated that medications will be safely administered as prescribed by the practitioner and in accordance with current standards of practice and regulatory requirements. A review of the clinical record revealed Resident R1 was admitted to the facility on [DATE], with diagnoses that included, stroke, hemiplegia (paralysis on one side), and high blood pressure. A review of the Minimum Data Set - Resident Assessment and Care Screening (MDS) dated [DATE], indicated the diagnoses remained current and the resident is alert with periods of confusion. A review of a physician order dated 12/6/23, indicated to give Hydralazine (medication that lowers blood pressure) 10 mg (milligrams) one…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy and clinical records, and staff interview, it was determined that the facility failed to make certain medications were administered as ordered by the physician for one of eight residents (Resident R1). Findings include: A review of the facility policy Medication Administration General Guidelines dated 1/4/23, indicated to administer medications as prescribed by the practitioner and in accordance with current standards of practice and regulatory requirements. A review of the clinical record indicated that Resident R1 was admitted to the facility on [DATE], with diagnoses that included anxiety disorder, and insomnia. A review of the Minimum Data Set (MDS - periodic assessment of resident care needs) dated 9/20/23, indicated the diagnoses remain current and the resident is alert and oriented with periods of confusion, and able to make needs known. A review of a physician order dated 10/13/23, indicated to give Temazepam (a controlled substance sedative to treat insomnia) 15 mg…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, resident fund account statements and staff interview it was determined that the facility failed to provide proper accounting of resident funds and prevent commingling of funds for four out of six closed resident records (Closed Resident Records CR125, CR127, CR128, and Closed Resident Record CR173). Findings include: The facility Resident funds authorization form last reviewed 1/4/23, indicated that upon death of a resident, the facility will follow regulatory guidelines with respect to closing out of the resident fund account. Closed Resident Record CR125's admission record indicated she was admitted on [DATE]. Closed Resident Record CR125's MDS assessment (Minimum Data Set assessment: MDS -a periodic assessment of resident care needs) dated 4/26/22, indicated she had diagnoses that included dementia (a condition characterized by memory loss and progressive or persistent loss of intellectual functioning), chronic kidney disease(a loss of kidney function…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, resident fund account statements and staff interview it was determined that the facility failed to convey resident funds and closed accounts upon discharge or death in a timely manner for four out of eight closed resident records (Closed Resident Records CR125, CR127, CR128, and Closed Resident Record CR173). Findings include: The facility Personal Property policy dated [DATE], indicated to review the accounts of the deceased or discharged and pay the amounts of the difference between any payment made within 30 days. The facility Resident funds authorization form last reviewed [DATE], indicated that upon death of a resident, the facility will follow regulatory guidelines with respect to closing out of the resident fund account. Closed Resident Record CR125's admission record indicated she was admitted on [DATE]. Closed Resident Record CR125's MDS assessment (Minimum Data Set assessment: MDS -a periodic assessment of resident care needs) dated [DATE],…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical records, observations, and staff interviews, it was determined that the facility failed to provide timely treatment and services, consistent with professional standards of practice, to prevent pressure sore development for three of eight residents (Resident R19, R29 and R1), and promote healing, and prevent worsening of pressure injuries. The facility failed to promote healing and provide treatment according to the physician orders for one of eight residents (Resident R70). Findings include: Review of the facility policy Wound Care-Pressure Ulcer/Injury Prevention, last reviewed on [DATE], with a previous review date of [DATE], indicated that the facility is to ensure resident ' s receive care to prevent pressure ulcers/injuries, residents do not develop pressure ulcers unless the clinical condition demonstrates that they were unavoidable and resident ' s with pressure ulcers receive necessary treatment and services to promote healing, prevent infection and prevent…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the financial and clinical records, staff and resident interview, it was revealed that the facility failed afford a resident and/or their legal representative the right to manage his own financial affairs for one of six sampled residents (Resident R70). Findings include: The facility Resident rights and responsibilities policy last reviewed on 7/1/23, indicated that the purpose of the guideline is for staff to respect resident's individuality and value the resident's input . All activities and interactions assist the resident in maintaining and enhancing self-esteem and self-worth. Review of Resident R70's admission record indicated he was admitted on [DATE], and Resident R70 diagnoses included quadriplegia (paralysis of all four limbs), neuromuscular dysfunction of the bladder (muscle and nerve concerns impacting bladder control), and peripheral vascular disease (PVD- a narrowing of the blood vessels in the legs). Review of Resident R70's MDS assessment (Minimum Data Set assessment: MDS - a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policies, clinical records, Emergency Department notes and staff interviews, it was determined that the facility failed to develop and implement a comprehensive care plan to meet care needs for one of two residents (Resident R111) related to PTSD (post traumatic stress disorder). Findings include: Review of the facility policy Comprehensive Person-Centered Care Planning last reviewed on 1/4/23, with a previous review date of 1/3/22, indicated that the facility will comply with requirements related to comprehensive person-centered care planning. The services provided to or arrange for residents will meet professional standards of quality and will be provided by qualified persons and are trauma-informed. Practitioner's orders, progress notes which include treatment plans will be part of the whole resident comprehensive person-centered care plan. Review of the clinical record indicated that Resident R111 was admitted to the facility on [DATE] with diagnoses which included a stroke,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical records, and staff interviews, it was determined that the facility failed to ensure that a resident receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan when the facility failed to notify the physician of a pacemaker device malfunction allowing for the potential for one of two residents (Resident R84) to have had a cardiac event with not providing monitoring of her heart rate via the pacemaker device or physical assessment during the pacemaker monitoring device malfunction time of three days (3/3/23 through 3/6/23). Findings included: Review of the facility policy Pacemaker/Defibrillator last reviewed on 1/4/23, with previous review date of 1/3/22, indicated that the facility will follow the cardiologist and manufacturers recommendations and the Safe Medical Device Act and obtain detailed information about each device, report any malfunctions of the devices and assure the device is checked.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 observation, clinical record review, and staff interview, it was determined that the facility failed to prove appropriate respiratory care for one of five residents (Residents R101). Findings include: Review of the facility's policy Oxygen Guidelines dated 1/4/23, and previously dated 1/3/22, indicated that the cannulas, face masks, and humidification bottles should be changed at least every seven days and are labeled with date of change initialed by staff. Review of the clinical record indicated that Resident R101 was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS - periodic assessment of care needs) dated 5/18/23, indicated diagnoses of chronic obstructive pulmonary disease (COPD, a group of progressive lung disorders characterized by increasing breathlessness), heart failure (a progressive heart disease that affects pumping action of the heart muscles), and hypertension (high blood pressure in the arteries). Review of physician's orders…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 timely annual resident rights, communication and infection control competencies for two out of five nurse aide personnel records (Nurse aide Employee E1 and Nurse aide Employee E2). Findings include: The facility Nursing Assistant job description dated 1/29/07, and last reviewed 1/4/23, indicated that the nurse aide provides each assigned resident with routine individualized nursing care in accordance with current applicable Federal, state, and local standards, guidelines and regulations. The facility assessment dated [DATE], indicated that staff competencies are necessary to provide the level and types of care needed for the resident population. Annual mandatory education consist of test to determine competency. Education is formal and informal and includes resident rights, abuse, infection control, dementia, psychosocial needs and customer service. Review of Nurse aide Employee E1's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, personnel files and staff interviews it was determined that the facility failed to complete annual performance evaluation based on date of hire for one out of five nurse aide personnel records (Nurse Aide Employee E3). Findings include: The facility Nursing Assistant job description dated 1/29/07, and last reviewed 1/4/23, indicated that the nurse aide provides each assigned resident with routine individualized nursing care in accordance with current applicable Federal, state, and local standards, guidelines and regulations. The facility assessment dated [DATE], indicated that staff competencies are necessary to provide the level and types of care needed for the resident population. Annual evaluations identify opportunities for staff development. Review of Nurse aide Employee E3's personnel record indicated she was hired on 4/4/16. Review of Nurse aide Employee E3's personnel record did not include an annual performance evaluation. During an interview on 7/27/23, at 10:53 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.

Based on review of manufacturer directions, observations and staff interviews, it was determined that the facility failed to implement measures to prevent the potential for cross contamination due to not cleaning the of two hydrocollator units for use on residents requiring moist heat for treatment. Findings include: During an observation on 7/28/23, at 10:17 a.m., of the two hydrocollator units of the therapy department, documentation did not include that the staff emptied cleaned and changed the water of the two hydrocollator's to prevent the potential for cross contamination. During an interview on 7/28/23, at 10:17 a.m., Physical Therapy Aide Employee E14 confirmed that the facility failed to follow the manufacture's directions for cleaning and refilling the two hydrocollator units of the therapy department and implement measures to prevent the potential cross contamination. 28 Pa. Code: 201.14(a) Responsibility of licensee. 28 Pa. Code: 207.2(a) Administrator's responsibility. 28 Pa. Code: 211.10(c)(d) Resident care policies.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, personnel files and staff interview it was determined that the facility failed to complete annual training on dementia management for two out of five nurse aide personnel files (Nurse aide Employee E1 and Nurse Aide Employee E2). Findings include: The facility Nursing Assistant job description dated 1/29/07, and last reviewed 1/4/23, indicated that the nurse aide provides each assigned resident with routine individualized nursing care in accordance with current applicable Federal, state, and local standards, guidelines and regulations. The facility assessment dated [DATE], indicated that staff competencies are necessary to provide the level and types of care needed for the resident population. Annual mandatory education consist of test to determine competency. Education is formal and informal and includes resident rights, abuse, infection control, dementia, psychosocial needs and customer service. Review of Nurse aide Employee E1's personnel record indicated she was hired 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.