Little Sisters Of The Poor

Based on review of job descriptions, clinical records and staff interviews, it was determined that the Nursing Home Administrator (NHA) and the Director of Nursing (DON) failed to effectively manage the facility to prevent the elopements of a resident (Resident R1). Findings include: The job description for the Nursing Home Administrator dated 10/3/23, indicated the NHA collaborates with the Little Sisters of the Poor to coordinate, direct develop, and maintain various programs within all departments of the home. He or she will work together to ensure adherence to policies and procedures. NHA will direct and guide the performance of others. Knowledge of all relevant federal and state rules and regulations governing long-term care facilities and the ability to properly interpret these. The job description for the Director of Nursing dated 10/1/24, indicated the DON is responsible for the development and maintenance of nursing service objectives, standards of nursing practice, nursing policy and procedure manual. DON must have thorough knowledge of state and federal regulations 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.

Based on a review of facility policies, observations, and staff interviews, it was determined that the facility failed to properly date food items to ensure proper rotation, and failed to prevent possible cross-contamination while storing food service items, and failed to properly perform handwashing in the Main Kitchen. Findings include: A review of the facility policy Food Safety dated 11/4/24, and previously dated 11/6/23, indicated that the facility will provide safe and sanitary storage, handling, and consumption of all food that includes storage, preparations, distribution, and serving food in accordance with professional standards for food service safety. A review of the facility document Kitchen Porter/Dishwasher/Helper Job Description indicated that the employee must maintain high standards of sanitation, safety, proper storage and handling in accordance with Health Department, State, and Federal Codes. During an observation in the Dry Foods Storage Area of the Main Kitchen on 11/25/24, at 9:25 a.m. it was noted that none of the food items were dated at the time 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 observations and staff interview it was determined that the facility failed to have required postings for the Medicaid Fraud Control Unit for the facility. Findings include: Observations on the nursing care units on the First and Second Floor bulletin boards failed to include information for the Medicaid Fraud Control Unit throughout the survey from 11/25/24, through 11/27/24. During an observation and interview on 11/27/24, at 11:10 a.m. The Director of Nursing confirmed that the facility failed to post information about the Medicaid Fraud Control Unit. 28 Pa. Code: 201.14(a)Responsibility of licensee. 28 Pa. Code: 201.18e Management.

Based on observations, Group interview, and staff interview, it was determined that the facility failed to ensure that the Department of Health Survey Results were readily accessible to residents and visitors, and failed to post notice of the availability of the results on two of two Nursing Floors. (First Floor, and Second Floor) Findings Include: Observations on the nursing care units on the First and Second Floor bulletin boards failed to include information for the Department of Health Survey results throughout the survey from 11/25/24, through 11/27/24. During a group interview on 11/26/24, at 9:59 a.m. ten out of ten residents were unaware of the location where the survey results binder would be located and available to review. During an observation and interview on 11/27/24, at 11:10 a.m. The Director of Nursing was able to locate two Department of Health Survey Results Binders that were out of sight, as they were inside of desks on the First Floor and Second Floor, and confirmed that the facility failed to post notice of availability of these results on two of two Nursing…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, observations, interviews, and clinical record review, it was determined that the facility failed to provide appropriate respiratory care for four of seven residents (Residents R15, R25, R27, and R29). Findings include: Review of facility policy Oxygen Nasal Cannulas, Face Mask and Nebulizer Set Ups Protocol dated 11/6/23, last reviewed 11/4/24, indicated the nasal cannulas, face masks, and nebulizer set ups are changed routinely to decrease chance of infections. The date will be written on tape and applied to the tubing. Review of the clinical record indicated Resident R15 was admitted to the facility on [DATE]. Review of Resident R15's Minimum Data Set (MDS - a periodic assessment of care needs) dated 9/17/24, indicated diagnoses of high blood pressure, respiratory failure (a condition where the lungs cannot get enough oxygen into the blood), and shortness of breath. Review of a physician order dated 1/16/24, indicated to administer oxygen via nasal cannula (a lightweight…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 policy, clinical record review, and staff interview, it was determined that the facility failed to conduct ongoing accurate assessments to ensure that bedrails were used to meet resident needs and the risks associated with bedrail usage for five of five residents (Residents R17, R21, R27, R29, and R30). Findings include: Review of facility policy Bed Rail Use dated 11/6/23, last reviewed 11/4/24, indicated the resident's condition is reassessed at least annually or for a change in condition by Physical Therapy to determine the need for continuing use of half-length rails. Review of the clinical record indicated Resident R17 was admitted to the facility on [DATE]. Review of Resident R17's Minimum Data Set (MDS - a periodic assessment of care needs) dated 11/14/24, indicated diagnoses of depression (a constant feeling of sadness and loss of interest), need for assistance with personal care, and legal blindness. Review of a physician order dated 9/9/19, indicated top two…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, observations, and staff interviews, it was determined that the facility failed to properly monitor resident's personal refrigerators to ensure that food is properly stored and maintained for two of two residents (Residents R17 and R29), failed to implement Enhanced Barrier Precautions (EBP) for two of two residents (Residents R1 and R3), failed to provide a safe and sanitary environment to help prevent the potential for cross contamination for one of two medication rooms (First Floor Medication Room), and failed to implement infection control practices to prevent cross contamination during a dressing change for one of three residents (Resident R29). Findings include: Review of facility policy Food Safety dated 11/6/23, last reviewed 11/4/24, indicated staff will be appointed to check resident refrigerators for proper temperatures, food containment and quality, and disposal of items per facility policy. The Centers for Disease Control defines Enhanced Barrier Precautions as: an…

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

Based on review of facility policy, facility documents and staff interviews, it was determined that the facility failed to provide Communication training to four of seven direct care facility staff reviewed (Employees E1, E10, E12 and E14). Finding include: Review of the facility policy Nursing Education, Mandatory Training and Competency Evaluation dated 11/4/24, and previously dated 11/6/23, indicated that the facility will establish, implement and maintain written policies and procedures for verification of appropriate educational preparation and competency, to include certification and/or licensure in good standing, upon hire and on an ongoing basis while employed. Proficiency in skills and techniques necessary to care for residents' needs includes competencies in areas such as communication and personal skills, personal care skills, mental health and social service needs, basic restorative services and resident rights. During an interview on 11/26/24, at 1:45 p.m. Human Resources Director Employee E15 stated that education is conducted by calendar year running January through…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 provide training on resident protection from abuse and neglect for two of seven staff members (Employees E11, and E13). Findings include: Review of the facility policy Nursing Education, Mandatory Training and Competency Evaluation dated 11/4/24, and previously dated 11/6/23, indicated that the facility will establish, implement and maintain written policies and procedures for verification of appropriate educational preparation and competency, to include certification and/or licensure in good standing, upon hire and on an ongoing basis while employed. Review of the facility policy Abuse dated 11/4/24, and previously dated 11/6/23, indicated that all staff shall be trained during orientation and on an on-going basis on issues related to reporting of resident abuse, neglect or mistreatment. During an interview on 11/26/24, at 1:45 p.m. Human Resources Director Employee E15 stated that education is conducted by calendar year running January through December. 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.

Based on review of facility policy, facility documents, and staff interview, it was determined that the facility failed to provide training on Quality Assurance and Performance Improvement (QAPI) for seven of seven staff members (Employee E1, E9, E10, E11, E12, E13, and E14). Findings include: Review of the facility policy Nursing Education, Mandatory Training and Competency Evaluation dated 11/4/24, and previously dated 11/6/23, indicated that the facility will establish, implement and maintain written policies and procedures for verification of appropriate educational preparation and competency, to include certification and/or licensure in good standing, upon hire and on an ongoing basis while employed. During an interview on 11/26/24, at 1:45 p.m. Human Resources Director Employee E15 stated that education is conducted by calendar year running January through December. Review of facility education documents for the year 2023 revealed the following concerns: Review of Registered Nurse (RN) Employee E1's facility provided information did not include training on QAPI education.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 provide training on Infection Control for five of seven staff members (Employees E1, E9, E10, E12, and E14). Findings include: Review of the facility policy Nursing Education, Mandatory Training and Competency Evaluation dated 11/4/24, and previously dated 11/6/23, indicated that the facility will establish, implement and maintain written policies and procedures for verification of appropriate educational preparation and competency, to include certification and/or licensure in good standing, upon hire and on an ongoing basis while employed. Review of the facility policy Infection Control dated 11/4/24, and previously dated 11/6/23, indicated that initial orientation for new employees covers infection control, universal precautions, and hand washing. This information is reviewed yearly. During an interview on 11/26/24, at 1:45 p.m. Human Resources Director Employee E15 stated that education is conducted by calendar year running January through December. Review of…

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

Based on review of facility policy, facility documents, and staff interview, it was determined that the facility failed to provide training on Compliance and Ethics for two of seven staff members (Employees E11, and E13). Findings include: Review of the facility policy Nursing Education, Mandatory Training and Competency Evaluation dated 11/4/24, and previously dated 11/6/23, indicated that the facility will establish, implement and maintain written policies and procedures for verification of appropriate educational preparation and competency, to include certification and/or licensure in good standing, upon hire and on an ongoing basis while employed. During an interview on 11/26/24, at 1:45 p.m. Human Resources Director Employee E15 stated that education is conducted by calendar year running January through December. Review of facility education documents for the year 2023 revealed the following concerns: Review of Nurse Aide (NA) Employee E11's facility provided information did not include training on Compliance and Ethics education. Review of NA Employee E13's facility provided…

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

Based on review of facility documents, and staff interviews it was determined that the facility failed to ensure that all nurse aide staff received a minimum of twelve hours of in-service education training each year for five out of five Nurse Aide Employees (Employee E9, E10, E11, E12, and E13) Findings include: Review of the facility policy Nursing Education, Mandatory Training and Competency Evaluation dated 11/4/24, and previously dated 11/6/23, indicated that the facility will establish, implement and maintain written policies and procedures for verification of appropriate educational preparation and competency, to include certification and/or licensure in good standing, upon hire and on an ongoing basis while employed. During an interview on 11/26/24, at 1:45 p.m. Human Resources Director Employee E15 stated that education is conducted by calendar year running January through December. Review of facility education documents for the year 2023 revealed the following concerns: Review of Nurse Aide (NA) Employee E9's facility provided information indicated that she had 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.

Based on review of facility policy, facility documents and staff interviews, it was determined that the facility failed to provide training on Behavioral Health for three of seven staff members (Employees E1, E10, and E14). Findings include: Review of the facility policy Nursing Education, Mandatory Training and Competency Evaluation dated 11/4/24, and previously dated 11/6/23, indicated that the facility will establish, implement and maintain written policies and procedures for verification of appropriate educational preparation and competency, to include certification and/or licensure in good standing, upon hire and on an ongoing basis while employed. During an interview on 11/26/24, at 1:45 p.m. Human Resources Director Employee E15 stated that education is conducted by calendar year running January through December. Review of facility education documents for the year 2023 revealed the following concerns: Review of Registered Nurse (RN) Employee E1's facility provided information did not include training on Behavioral Health education. Review of Nurse Aide (NA) Employee E10's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of facility policy, observations, and resident and staff interviews, it was determined that the facility failed to provide care in a manner and environment that promotes and maintains quality of life by failing to allow a resident to smoke at requested times for one of three residents reviewed (Resident R17). Findings include: Review of facility policy Residents' [NAME] of Rights dated 11/6/23, last reviewed 11/4/24, indicated the Resident has the right to a dignified existence that will provide and maintain a supportive environment to promote self-esteem and personal dignity and to ensure that the Resident and civil rights are respected and protected. Review of facility policy Smoking dated 11/6/23, last reviewed 11/4/24, indicated residents who are determined by assessment that they are in need of supervision while smoking will be provided supervised smoking breaks in the appropriate designated smoking area. Resident may be supervised by a facility employee, family member and/or volunteer 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 observations, resident, and staff interviews, it was determined that the facility failed to determine the ability to self-administer medications for one of three residents (Residents R24). Findings include: Review of the facility policy Medication Administration dated 11/6/23, last reviewed on 11/4/24, indicated remain with resident to ensure that medication is swallowed. Review of the admission record indicated Resident R24 was admitted to the facility on [DATE]. Review of Resident R24's Minimum Data Set (MDS - a periodic assessment of care needs) dated 11/7/24, indicated the diagnoses of hypertension (high blood pressure), hyponatremia (low sodium in the blood), and hyperlipidemia (high fat in the blood). Review of Resident R24's physician orders failed to include medication self-administration. Review of Resident R24's care plan failed to include interventions for medication self-administration. Review of Resident R24's clinical record indicated the absence of a Self-Administration of Medication…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, and staff interview, it was determined that the facility failed to maintain a safe homelike environment in one of four nursing units (St. [NAME]). Findings include: During an observation of resident room [ROOM NUMBER] on 11/25/24, at 1:01 p.m. it was noted that the door handle was missing, and an exposed, sharp piece of metal was sticking out from the mount where the handle would be placed. During an interview on 11/27/24, at 11:17 a.m. the Director of Nursing (DON) confirmed that the handle was missing from the door of resident room [ROOM NUMBER] and an exposed, sharp piece of a metal was sticking out from the mount where the handle would be placed. During an interview on 11/27/24, at 11:17 a.m. the DON confirmed that the facility failed to maintain a safe homelike environment in one of four nursing units (St. [NAME]). 28 Pa. Code: 201.18(b)(3)(e)(1) Management. 28 Pa. Code 201.29(j) Resident rights. 28 Pa. Code 207.2(2) Administrator's Responsibility.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, resident grievances for 12 months, and resident and staff interviews, it was determined that the facility failed to ensure resident grievances were addressed timely for one of two grievances reviewed. Findings include: Review of facility policy Grievance dated 11/6/23, last reviewed 11/4/24, indicated the Home will ensure prompt resolution to all grievances, keeping the Resident and Resident Representative informed throughout the investigation and resolution process. Review of the clinical record indicated Resident R15 was admitted to the facility on [DATE]. Review of Resident R15's Minimum Data Set (MDS - a periodic assessment of care needs) dated 9/17/24, indicated diagnoses of high blood pressure, respiratory failure (a condition where the lungs cannot get enough oxygen into the blood), and shortness of breath. Review of a facility Grievance or Complaint Form indicated Resident R15 filed a grievance on 7/8/24. There was no documentation available that 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 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 two residents with facility-initiated transfers (Resident R17 and R35). Findings include: Review of the clinical record indicated Resident R17 was admitted to the facility on [DATE]. Review of Resident R17's Minimum Data Set (MDS - a periodic assessment of care needs) dated 11/14/24, indicated diagnoses of depression (a constant feeling of sadness and loss of interest), need for assistance with personal care, and legal blindness. Review of Resident R17's clinical record revealed that the resident was transferred to the hospital on [DATE]. Review of Resident R17's clinical record revealed no documented evidence that the facility had communicated specific information to the receiving health care provider for the residents transferred and expected to return, which included the resident's care plan…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, and staff interview, it was determined that the facility failed to notify the resident/resident representative and/or the representative of the Office of the State Long-Term Care Ombudsman of resident transfers, in writing, to include to include the following: the reason for the transfer or discharge, date of transfer, location of transfer, statement of the resident's appeal rights, and name, address (mailing and email), and telephone number of the Office of the State Long-Term Care Ombudsman for two of two resident records reviewed (Resident R17 and R35) Findings Include: Review of the clinical record indicated Resident R17 was admitted to the facility on [DATE]. Review of Resident R17's Minimum Data Set (MDS - a periodic assessment of care needs) dated 11/14/24, indicated diagnoses of depression (a constant feeling of sadness and loss of interest), need for assistance with personal care, and legal blindness. Review of Resident R17's clinical record revealed that the resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical records, 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 two of two resident hospital transfers (Resident R17, and R35). Findings Include: Review of the facility policy Bed Hold and Return dated 11/4/24, and previously dated 11/6/23, indicated that the facility will provide the resident and resident representative a written notice which specifies the duration of the bed-hold policy at the time of transfer for hospitalization or therapeutic leave. Review of the clinical record indicated Resident R17 was admitted to the facility on [DATE]. Review of Resident R17's Minimum Data Set (MDS - a periodic assessment of care needs) dated 11/14/24, indicated diagnoses of depression (a constant feeling of sadness and loss of interest), need for assistance with personal care, 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 interviews, it was determined that the facility failed to make certain that residents were provided appropriate treatment and care by failing to implement the facility's hypoglycemia (low blood sugar) protocol, failing to document appropriate hypoglycemia interventions, failing to notify the physician of a resident's refusal of weekly weights, and failing to follow physicians orders for one of five residents reviewed (Resident R21). 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…

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

Based on review of facility policies, observations, and staff interviews it was determined that the facility failed to properly store medical supplies and biologicals in one of two medication rooms. Findings include: Review of the facility policy Medication Storage in the Facility dated 11/6/23, last reviewed on 11/4/24, indicated all medications are maintained within the temperature ranges noted in the United States Pharmacopeia (USP and by the Centers for Disease Control (CDC). Refrigerated 36 degrees Fahrenheit to 46 degrees Fahrenheit with a thermometer to allow temperature monitoring. During an observation on 11/26/24, at 9:00 a.m. the first-floor medication room refrigerator temperature log was not completed the following dates: 11/11/24. 11/19/24. 11/21/24. During an interview on 11/26/24, at 9:07 a.m. Registered Nurse (RN) Employee E6 confirmed the above observations and that the facility failed to properly store medical supplies and biologicals in one of two medication rooms. 28 Pa. Code: 211.9(a)(1)(k) Pharmacy services. 28 Pa. Code: 211.10(c) Resident care policies. 28…

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

Based on a review of facility policy, facility's planned cycle menus, observations, and interviews with staff, it was determined that the facility failed to develop therapeutic menu extensions to ensure a pre-planned nutritionally adequate menu was developed for four of four weeks of their cycle menu. Findings include: Review of the facility's policy Menu Planning, dated 11/3/23, indicated that nutritional needs of individuals will be provided in accordance with the established national standards adjusted for age, gender, activity level and disability, through nourishing, well balanced diets. Regular and therapeutic menus will be written by the facility's food and nutrition professional, in accordance with the facility's approved diet manual. Review of facility's policy Therapeutic Diets, dated 11/3/23, indicated that the facility will provide a therapeutic diet that is individualized to meet the clinical needs and desires of the patient/resident to achieve outcomes/goals of care. Available therapeutic menus should coincide with the therapeutic diets on the facility's menu…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, national and state guidance, clinical record review, observations, and staff interviews, it was determined the facility failed to establish COVID policies updated to national standards, accurately track COVID positive residents, and implement the proper precautions before they can spread to other persons in the facility for one of three residents (Resident R32). Findings include: Review of the CDC COVID-19 Testing: What You Need to Know guidelines dated 9/25/23, indicated if a resident's displays symptoms they should be tested immediately. If a resident does not have symptoms but have been exposed to COVID-19, it was indicated to wait at least 5 full days after your exposure before taking a test. If you are only going to take a single test, a Polymerase Chain Reaction (PCR) test will provide a more reliable negative test result. It was indicated if you use an antigen test, a positive result is reliable, but a negative test is not always accurate. If your antigen test is negative, take…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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) for one out of three residents (Resident R42). 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 bloodstream. Over time, that can cause serious health problems, such as heart 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 a review of Resident Assessment Instrument (RAI) User's Manual, clinical records, and staff interviews, it was determined that the facility failed to ensure that MDS assessments accurately reflected the resident's status for two of twelve residents (Resident R26 and R43). Findings include: The Resident Assessment Instrument (RAI) User's Manual, which gives instructions for completing Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2023, indicated the following instructions: -Section K0510: Nutritional Approaches, check all of the nutritional approaches that were performed in the last 7 days; K0510C, mechanically altered diet - require change in texture of food or fluid (e.g. puree food, thickened liquids). Review of clinical record revealed that Resident R26 was admitted to the facility 7/5/21. Review of Resident R26's MDS assessment dated [DATE], indicated diagnoses high blood pressure, renal insufficiencies, and dysphagia (a condition…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical records, and staff interview it was determined that the facility failed to provide interventions to treat abnormal glucose readings via a Capillary Blood Glucose (CBG) level and provide treatment as ordered for one out of three residents (Resident R42). 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 bloodstream. Over time, that can cause…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 a review of facility policy, clinical record review and staff interview, it was determined that the facility failed to timely assess the nutritional status and develop an individualized care plan after an unplanned weight loss for one resident (Resident R14), and failed to timely assess the nutritional status of one resident (Resident R26). Findings include: Review of facility policy MDS, Completion/Error Corrections, dated 11/6/23, indicates the Minimum Data Set (MDS) will be completed for each resident within fourteen (14) days of admission, annually, quarterly, and whenever a significant change occurs in the resident's condition. Review of facility policy Hydration and Nutrition, dated 11/6/23, indicates the nutrition and hydration status of each resident is maintained as close to optimal levels as possible. The dietary plan of care and progress note is written at least every ninety (90) days. Review of facility policy Medical Nutritional Therapy Documentation, dated 11/6/23, indicates 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 review of facility policy, observations, resident records and staff interview it was determined that the facility failed to accurately monitor the intake of a enteral feed for one out two residents (Resident R1). Findings include: The facility Tube Feeding policy reviewed on 11/6/23, indicated physician specifies the type of solution, amount, and frequency and feedings are initiated and monitored by a licensed nurse. It stated the purpose is to supply nutrition and hydration to residents unable to take liquid or mouth by normal means. The facility Documentation in Medical Record policy dated 11/6/23, indicated each resident's medical record shall contain an accurate representation of the actual experience of the resident and include enough information to provide a picture of the resident's progress through complete, accurate, and timely documentation. Review of Resident R1's admission record indicated she was admitted on [DATE], with diagnoses that included dysphagia (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 clinical record review and staff interviews, it was determined the Director of Nursing failed to follow accepted standards of nursing practice. Findings include: 28 PA Code Commonwealth of Pennsylvania Long Term Care Licensure Regulations, subsection 211.12(d)(5), dated July 1, 2023, indicated general supervision, guidance and assistance for a resident in implementing the resident's personal health program to assure that preventive measures, treatments, medications, diet and other health services prescribed are properly carried out and recorded. Review of the job description titled Director of Nursing (DON) dated 9/1/14, indicated the DON is responsible for the standards of nursing practice. It was indicated the DON assures that nursing documentation is informative, descriptive of care rendered and that is compliant with federal and state regulations. The facility Change in Resident Condition or Status policy dated 11/6/23, stated if the resident has a change in condition the resident's physician must…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 pneumococcal vaccinations were administered in a timely fashion for one of five residents (Resident R34). Findings include: Review of the facility policy dated 11/6/23, indicated the facility follows the most up to date administration schedules for pneumococcal vaccines. Residents who have had Prevnar 13 should have a Prevnar 23 at least one year later. After at least five years elapse since the first Prevnar 23, she is given one more dose of Prevnar 23. Review of the admission Record indicated that Resident R34 was admitted to the facility on [DATE]. Review of R34's Minimum Data Set (MDS-periodic assessment of care needs) dated 11/16/23, included diagnoses of high blood pressure, peripheral vascular disease (a condition in which narrowed blood vessels reduce blood flow to the limbs), and renal insufficiency (condition where the kidneys lose the ability to remove waste and balance…

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