Southwestern Manor Nursing And Rehabilitation

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policies and documents, resident observations, resident and staff interviews, and resident care records, it was determined that the facility failed to have sufficient nursing staff to provide nursing and related services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of 22 of 47 residents (R1, R4, R5, R6, R7, R8, R9, R13, R14, R15, R16, R17, R18, R19, R20, R21, R22, R23, R24, R25, R26, and R27). Findings Include: Review of the facility policy Activity of Daily Living (ADLs), Supporting dated 1/30/24, indicated appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with hygiene, mobility, elimination (toileting), dining, and communication. Review of the facility policy Answering the Call Light dated 1/30/24, indicated the facility procedure is to ensure timely responses…

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

Based on review of facility documentation and staff interviews, it was determined that the facility failed to develop, implement, and maintain an effective training program, including additional training topics based on the resident population, outcome of the facility assessment, or non-common procedures for three of six staff members sampled (RN Employee E12, LPN Employee E15 and E16). Findings include: Review of the Facility Assessment dated 11/30/23, indicated the facility included under the section, Acuity - Frequency of Potentially High-Risk Treatments that surgical drains are a type of care provided. Within the subsequent section, Acuity - Care requirements the assessment indicated staff competencies were required. No further information was available describing what type of education would be provided. Review of physicians' orders dated from 6/1/23, through 5/31/24, revealed two residents had orders provided for the care of a Jackson Pratt drain (JP drain, a surgical suction drain that gently draws fluid from a wound to help the resident recover after surgery). Review of a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of nursing job descriptions, facility documents, clinical record, and staff interviews, it was determined that the facility failed to assure that licensed nurses displayed the appropriate competencies and skills sets to provide nursing services for one of two residents (Resident R11). Findings include: Review of the facility provided Registered Nurse (RN) job description titled, Staff Nurse (RN) indicated the RN nurse is responsible for competent administration of care and treatments according to physician orders and facility policy and procedure. Review of the facility provided Licensed Practical Nurse (LPN) job description titled, LPN Supervisor indicated the LPN must demonstrate knowledgeable of nursing and medical practices and procedures. Review of the Facility Assessment dated 11/30/23, indicated surgical drains as a type of care provided by the facility. Review of the [NAME] The Art and Science of Person-Centered Care, 9th edition dated 11/9/18, included in the steps for care for a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility documents, clinical record review, and staff interview, it was determined that the facility failed to provide the necessary services and failed to make certain appropriate treatment, and services for dementia were provided to one of four residents (Resident R2). Findings include: Review of the National Library of Medicine document, Sundowning in Dementia dated 12/27/16, defined sundowning as the emergence or worsening of neuropsychiatric symptoms (NPS) in the late afternoon or early evening. It represents a common manifestation among persons with dementia and is associated with several adverse outcomes (such as institutionalization, faster cognitive worsening, and greater caregiver burden). Review of the facility policy, Dementia - Clinical Protocol dated 11/30/23, indicated for the individual with confirmed dementia, the IDT (interdisciplinary care team will identify a resident-centered care plan to maximize remaining function and quality of life. Nursing assistants will receive initial…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 clinical record, physician records, documents, and staff interviews, it was determined that the facility failed to schedule ordered appointments and failed to provide transportation for one of three residents (Resident R11), which resulted in the actual harm of a delay in cancer treatment. Findings include: Review of the Resident Assessment Instrument 3.0 User's Manual effective October 2023, indicated that a Brief Interview for Mental Status (BIMS) is a screening test that aides in detecting cognitive impairment. The BIMS total score suggests the following distributions: 13-15: cognitively intact 8-12: moderately impaired 0-7: severe impairment Review of information provided by the U.S. National Institutes of Health; National Cancer Institute indicated a port (commonly referred to as a port-a-cath) is a device that is usually placed under the skin in the right side of the chest. It is attached to a catheter (a thin, flexible tube) that is threaded into a large vein above the right side 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, observation, and staff interview, it was determined that the facility failed to maintain infection control practices to prevent the potential of infection and/or reinfection occurring for one of four residents (Resident R1). Findings include: Review of the facility policy, Infection Prevention and Control Program dated 11/30/23, indicated the facility maintains an Infection Prevention and Control Program to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable dieases and infections. Review of the clinical record revealed Resident R1 was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS, periodic assessment of resident care needs) dated 5/20/24, included diagnoses of osteomyelitis (inflammation of bone or bone marrow, usually due to infection), peripheral vascular disease (PVD, circulatory condition in which narrowed blood vessels reduce blood flow to the limbs), and diabetes (a metabolic disorder…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of facility policy, resident record review, resident interview, and staff interviews, it was determined the facility failed to protect the right of resident personal privacy and confidentiality of medical records for one of two residents (Resident R1). Findings Include: Review of facility policy titled Protected Health Information (PHI), Safeguarding Electronic last reviewed 11/30/23, informed this facility ensures the confidentiality, integrity and availability of all e-PHI created, maintained, received, or transmitted by our information system. Employees and staff have access to e-PHI only to the degree that such access is appropriate for their job requirements and responsibilities. Review of Resident R1's record indicated the resident was admitted to the facility on [DATE], and discharged on 2/8/24. Diagnoses included spinal stenosis (the space inside of the backbone is too small, causing pressure on the spinal cord and nerves), chronic obstructive pulmonary disease (COPD - a chronic…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 and resident and staff interviews, it was it was determined that the facility failed to correctly apply elastic ACE wraps for one of four residents (Resident R74) and failed to follow physician's orders for two of four residents (Resident R60, R74, and R89). Findings include: Review of Resident R60's admission record indicated he was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS, periodic assessment of resident care needs) dated 11/6/23, included diagnoses of abnormality of gain and mobility and atherosclerosis of native arteries of extremities, bilateral legs (narrowing of the arteries in both of the legs). Review of an active physician order dated 10/12/23, indicated Resident R60 should have ACE wraps applied to both legs, wrapped from toes to below the knee, on in the morning and off at the hour of sleep. During observations completed on 12/14/23, at 9:50 a.m., 11:30 a.m., 1:40 p.m., and 3:30 p.m. and on 12/15/23, at 9:00 a.m. and 11:45 a.m. all revealed 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, clinical record review, and staff interview, it was determined that the facility failed to consistently provide prescribed treatments for three of four residents (Resident R46, R49 and R63). Findings include: Review of the facility policy Pressure Ulcers/Skin Breakdown - Clinical Protocol last reviewed 11/30/23, indicated the nursing staff will assess and document an individual's significant risk factors for developing pressure ulcers. It also indicated that the nurse will describe and document: full assessment of pressure indicating location, stage, length, width and depth, presence of exudate (drainage) or necrotic (dying) tissue. Review of the clinical record indicated Resident R46 was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS - periodic assessment of care needs) dated 10/18/23, included the diagnoses of heart failure (a progressive heart disease that affects pumping action of the heart muscles) and lymphedema (the build-up of fluid in soft…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, resident record reviews, resident interviews and staff interviews, it was determined the facility failed to obtain physician orders for smoking and to ensure the medical care of each resident is supervised by a physician for eight of eight residents (Residents R2, R5, R31, R32, R55, R56, R70, and R199). Findings include: Review of facility policy titled Smoking Policy - Residents last reviewed 11/30/23, informed the facility shall establish and maintain safe resident smoking practices. The staff shall consult with the attending physician and the director of nursing services to determine if safety restrictions need to be placed on a resident's smoking privileges based on the safe smoking evaluation. Review of the facility's list of residents who smoke included Residents R2, R5, R31, R32, R55, R56, R67, R70 and R199. Review of Resident R2's record indicated the resident was admitted to the facility 9/6/18. Diagnoses included left side hemiplegia and hemiparesis…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 observations, facility documentation, resident and staff interviews, it was determined the facility failed to routinely offer evening snacks or provide snacks as requested for seven of seven residents (Resident R500, R501, R502, R503, R504, R505 and R506). Findings include: Review of facility policy titled Snacks/Hydration last reviewed 11/30/23, informed it is the [facility's] policy to provide the following: 1) Bulk snacks and beverages to be available for residents upon request located at each resident care area, 2) snacks to residents in which their individual plan of care specifies, and 3) offer all residents a bedtime snack. Food Service Department assembles bulk snack items and beverages and delivers them to resident care areas and to be offered as bedtime snack to each resident care areas. During a resident group meeting conducted on 12/12/23, at 1:30 p.m. Residents R500, R501, R502, R503, R504, R505, and R506 reported snacks are not given at bedtime, or even when they ask for a snack. Resident R501 reported buying their own…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 records, and staff interview, it was determined that the agency failed to maintain surveillance data and analysis for four of ten months (August, September, October, and November 2023) which caused six reportable infections not to be documented for five residents (Resident R5, R12, R23, R67, and R197). Findings include: Review of the facility policy Infection Prevention and Control Program dated 11/30/23, previously reviewed 10/31/22, indicated that surveillance tools are used for recognizing the occurrence of infections, recording their number and frequency, detecting outbreaks and epidemics, monitoring employee infection, monitoring adherence to infection prevention and control practices, and detecting unusual pathogens with infection control implications. Review of the clinical record indicated Resident R67 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of the Minimum Data Set (MDS, periodic assessment of resident care needs), dated…

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

Based on a review of facility policy, resident interviews and staff interviews, it was determined the facility impeded residents' ability to meet or organize a resident or family group and failed to provide a designated staff person responsible for providing assistance and respond to written requests that result from group meetings for 10 of 11 months (1/23, 2/23, 3/23, 4/23, 5/23, 6/23, 7/23, 8/23, 9/23, and 10/23). Findings include: Review of facility policy titled Resident Council last reviewed 11/30/23, informed the facility supports the residents' rights to organize and participate in the resident council. The purpose of the resident council is to provide a forum for residents, families and resident representatives to have input in the operation of the facility, Council meetings are scheduled monthly or more frequently if requested by residents. During a resident group meeting conducted on 12/12/23, at 1:30 p.m. seven residents were in attendance. Resident R500, Resident R502, Resident R503, and Resident R504 voiced concerns that a resident council meeting had not been held in…

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

Based on review of facility policy, observations and staff interview, it was determined the facility failed to display the contact information (name, address, email address, and phone number) for the local State Survey Agency and a statement that the resident may file a complaint with the State Survey Agency concerning any suspected violation of state or federal nursing facility regulation on 3 of 3 resident information areas (Reception, 100 unit and 200 unit). Findings include: Review of facility policy titled Contact with External Agencies last reviewed 11/30/23, informed residents have unrestricted access to officials from outside agencies. Residents are not prohibited in any way from communicating with officials or agencies that are independent from or have oversight of the facility. These agencies/individuals include (but are not limited to): federal or state surveyors; federal or state health department employees; and/or any adult protection or advocacy agency employees or representatives. Contact information for resident advocacy agencies and services is posted in the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy and clinical record review and staff interview, it was determined the facility failed to notify the physician of a change in condition for one of four residents (Resident R59). Findings include: A review of the facility policy Change in a Resident's Condition or Status dated 11/30/23, indicated the nurse will notify the resident's physician when there has been a significant change in the resident's physical/emotional/mental condition. A review of the clinical record indicated Resident R59 was admitted to the facility on [DATE], with diagnoses that included right knee replacement, syncope (fainting caused by low blood pressure), mood disorder, and cognitive impairment. A review of the Minimum Data Set (MDS-periodic assessment of care needs) resident assessment dated [DATE], indicated the diagnoses remain current. A review of a nurse note dated 12/2/23, at 1:26 p.m., indicated resident R96 had been awake for over a day and combative and non-compliant with care and unable to follow simple…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 documentation and staff interview, it was determined the facility failed to issue the Skilled Nursing Facility Advanced Beneficiary Notice form published by the Centers for Medicare and Medicaid Services (SNF ABN CMS-10055) which provides information to residents/resident representatives so they can decide if they wish to continue skilled nursing services that may not be paid for by Medicare and assume financial responsibility for one of three residents (Resident R700). Findings include: A review of Resident R700's clinical record documented the resident was admitted to the facility on [DATE] and discharged [DATE]. A review of the SNF (Skilled Nursing Facility) Beneficiary Protection Notification Review form CMS-20052 (published by the Centers for Medicare and Medicaid Services and used to determine if nursing care facilities are in compliance with notifying residents/resident representatives of a termination/denial/resident discharge from Medicare Part A services) documented…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 observations and staff interviews, it was determined the facility failed to provide grievance forms for filing anonymous grievances on one of two units (100 unit). Findings include: During an observation on 12/11/23, at 11:35 a.m. the 100 unit grievance form receptacle did not contain grievance forms available to file an anonymous grievance. During an interview on 12/12/23, at 11:40 a.m. Unit Secretary Employee E5 confirmed confirmed the facility failed to make certain grievance forms for filing anonymous grievances were available to residents on the 100 unit. 28 Pa. Code: 201.18(e)(4) Management 28 Pa. Code: 201.29(i) Resident Rights

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of facility policy, resident record, observation, resident interview and staff interview, it was determined the facility failed to provide necessary services to maintain good grooming and personal hygiene for thirteen of 43 residents (Resident R28, R22, R40, R29, R46, R201, R200, R250, R50, R81, R1, R90 and R15). Findings include: Based on review of facility policy titled Activities of Daily Living (ADLs) last reviewed 11/30/23, informed residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. Review of Resident R28's clinical record indicated she was admitted on [DATE]. Review of the Minimum Data Set (MDS, periodic assessment of resident care needs) dated 11/16/23, included the diagnoses of diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time) and muscle wasting. During an observation on 12/12/23, at 9:18 a.m. Resident R28…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, staff record review and staff interview it was determined the facility failed to have a qualified Activities Director to oversee the activities department for all 101 current residents in the facility. Findings include: Based on a review of facility policy titled Activity Program last reviewed 11/30/23, informed our activity programs are staffed with personnel who have appropriate training and experience to meet the needs and interests of each resident. Our activities programs are under the direct supervision of a qualified professional who is a qualified therapeutic recreational specialist or an activities professional who is licensed or registered, if applicable, by the state in which practicing: AND is eligible for certification as a therapeutic recreational specialist or as an activities professional by a recognized accrediting body; OR has two years of experience in a social or recreational program within the last 5 years; OR is a qualified occupational therapist or occupational therapy assistant; OR has completed a training course approved…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, review of facility policy, and staff interview, it was determined that the facility failed to ensure that the resident's attending physician addressed pharmacy recommendations for one of five residents reviewed (Resident R36). Findings include: Review of the facility policy Medication Regimen Review, dated 11/30/23, indicated the consultant pharmacist performs a medication regimen review and provides a written report to the physician for any irregularity. The physician documents in the medical record in a timely manner that the irregularity has been reviewed and what action was taken to address it. Review of the clinical record indicated Resident R36 was admitted to the facility on [DATE], with diagnoses that included dementia and insomnia. Review of the MDS (Minimum data set- resident assessment and care screening) dated 10/27/23, indicated the diagnoses remain current. Review of Resident R36's clinical record revealed that the facility's pharmacist made recommendations to the…

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

Based on review of facility documents and staff interview it was determined that the facility failed to complete the Facility Assessment annually. Findings include: A review of the Facility Assessment Tool, dated 10/31/22, through, 10/31/23, revealed the facility did not complete the template to indicate accurate information on: For the sections titled Function Care Requirements instructions for completing the template indicated to address in the description: -Types of care required. -Services required. -Staff/Personnel required. -Staff competencies required. -Physical plant environment required - such as campus buildings and physical structures. -Medical and non-medical equipment required (including vehicles). -Health information technology resources required - such as systems for electronically managing patient records and electronically sharing information with other organizations. -Policies and procedures required in the provision of care to meet current professional standards. A description of this section with this information was not included in the Facility Assessment, 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.

Based on review of activity calendars, resident group interview, observations, and staff interviews, it was determined that the facility failed to meet the activity needs for two of two nursing units (First and Second Floor) Findings include: During the resident group meeting on 2/11/23, at 1:00 a.m., revealed that three out of three residents agreed that there is not much to do, most evening activites do not occur, and there is not a way to go on any outings outside of the facility. During a review of the resident council meeting minutes for the last six months showed that the residents wished for more things to do. During a review of the facility provided activity calendar for 2/10/23, the 6:00 p.m. activity was to be a movie. During an observation of the activity room on the second floor from 6:00 p.m., through 7:30 p.m., revealed that no one was in the activity room and the television was off. During a review of the facility provided activity calendar for 2/11/23, the 2:00 p.m. activity was to be a craft (unspecified) and the 6:30 p.m. activity was to be a card game of UNO.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 federal code, facility documentation and staff interview, it was determined that the facility failed to ensure that the Activities Department had a qualified director to oversee the activities program. The findings include: Review of the United States Code of Federal Regulations (CFR), §483.24(c)(2) indicted the activities program must be directed by a qualified professional. Review of facility documentation and an interview indicated that the facility has not had an Activity Director employed since 8/8/22. During an interview on 2/11/23, at 4:00 p.m., the Nursing Home Administrator confirmed she is filling in until the faiclity can hire an Activity Director. During an interview on 2/12/23, at 1:45 p.m., Nursing Home Administrator confirmed that the facility did not employ an Activity Director to oversee the Activites Department. 28 Pa. Code: 201.18(b)(3) Management.

Based on review of facility policy, observation, and staff interview, it was determined that the facility failed to store drugs and biological properly on one of two medication rooms (100 Unit) and one of two medication carts (F Hall Cart). Findings include: Review of a facility policy entitled Medication Storage, dated 10/31/22, indicated that the facility stores all drugs and biologicals in a safe, secure, and orderly manner including Drugs and biologicals used in the facility are stored in locked compartments under proper temperature, light and humidity controls. Drug containers that have missing, incomplete, improper, or incorrect labels are returned to the pharmacy for proper labeling before storing. Discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed. Manufacturer recommendations for pneumococcal vaccine indicate that the biological should be refrigerated between 36-46 degrees Fahrenheit and is only stable at temperatures up to 77 degrees Fahrenheit for up to 4 days. Manufacturer guidelines for Lantus, Humalog,…

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

Based on resident and staff interviews, it was determined that the facility failed to routinely offer bedtime snacks for seven of seven residents (Resident R3, R26, R57, R59, R 500, R 501, and R 502). Findings include: During a resident group interview on 12/11/23, at 11:10 a.m., the residents indicated that that they do not receive bedtime snacks. Residents stated that there are snacks available in the vending machine but that it is expensive. During an interview on 12/12/23, at 9:37 a.m., Dietary Manager Employee E1 stated that dietary provides a bin of snacks daily to the nursing units at approximately 8:30 p.m., and that nursing is responsible for offering and passing the snacks. During an observation on 12/12/23, at 10:05 a.m., of the First floor and Second floor Pantry, bins of snacks were available and in large supply. During an interview on 2/12/23, at 1:15 p.m. Resident R3 stated she does not consistently receive a snack at bedtime but that she would like to have one. I only got a snack about five times in the past month. During an interview on 2/12/23, at 1:18 p.m.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, observations, and staff interview, it was determined that the facility failed to maintain a sanitary environment and store foods in accordance with professional standards for food service safety for one of two nursing units (100 Unit.) Findings include: The facility policy Foods Brought by Family/Visitors dated 10/31/22, states food or beverage brought in to consume later will be labeled, sealed in containers and containers will be labeled with the resident ' s name, the item, and a use by date. During an observation on 2/10/23 at 5:10 p.m. of the 100-unit pantry revealed the following: Five packets of thick-n-easy (a drink thickening agent) in drawer dated best by 7/9/22. In the upper cabinet, an opened bag of cheese crackers, unlabeled or dated, and a loaf of bread with a best by date of [DATE]. In the refrigerator was a container marked pork with no date. A container marked chicken with no date. Two styrofoam bowls of cake with no dates. A container with shrimp in it with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident and staff interviews, it was determined that the facility failed to ensure all residents were granted privacy in opening their mail for one of three residents in resident council (Resident R900), and for one of four residents reviewed (Resident R51). Findings include: The facility policy Resident Rights dated 2/17/21, and 10/31/22, states that residents have the right to communicate in person and by mail, email, and telephone with privacy. During the resident council meeting on 2/11/23, at 11:10 a.m. Resident R900 reported that the facility has previously opened his mail from the credit union without his permission. A review of the clinical record revealed that Resident R51 was admitted to the facility on [DATE]. The Minimum Data Set (MDS - a periodic assessment of care needs) dated 12/26/22, indicated the diagnoses of heart failure (a progressive heart disease affecting pumping action of the heart muscles impacting circulation, swelling and shortness of breath), high blood pressure, 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.

Based on facility policy, facility documents, and staff interviews, it was determined that the facility failed to provide the Notice of Medicare Non-Coverage in a timely manner, for one of three residents (Resident R52). Findings include: Review of Centers for Medicare & Medicaid Services (CMS), Form Instructions for the Notice of Medicare Non-Coverage (NOMNC) CMS-10123, (a notice that informs the recipient when care receive from skilled nursing facility is ending and how you can contact a Quality Improvement Organization (QIO) to appeal) dated 1/1/20, indicated that A Medicare provider or health plan must deliver a completed copy of the Notice of Medicare Non-Coverage (NOMNC) to beneficiaries/enrollees receiving covered skilled nursing, home health (including psychiatric home health), comprehensive outpatient rehabilitation facility, and hospice services. The NOMNC must be delivered at least two calendar days before Medicare covered services end or the second to last day of service if care is not being provided daily. Review of the facility provided NOMNC form indicated that the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and staff interview it was determined that the facility failed to provide a homelike environment for one of four resident room hallways (2nd floor 207 hallway) Findings include: During an observation on 2/10/23, from 4:50 through 5:30 p.m., the following was noted: -paint scuffs along both side of the hallway at wheelchair level -missing paint along the handrails on both sides of the hallway -the tile floor outside and between room [ROOM NUMBER]-213 is cracked and uneven in the middle of the hallway. During an interview on 2/10/23, at 5:45 p.m., Licensed Practical Nurse Employee E4, confirmed the above findings. 28 Pa. Code 207.2(a) Administrators responsibility.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy, facility provided documentation and resident and staff interviews, the facility failed to ensure residents were free from misappropriation of funds for one of two residents reviewed (Resident R51). Findings include: Review of the facility Resident Abuse and Neglect Prevention Program dated 2/17/21, defines misappropriation of resident property as the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent. Examples include but are not limited to: stealing, cashing checks without permission. A review of the clinical record revealed that Resident R51 was admitted to the facility on [DATE]. The Minimum Data Set (MDS - a periodic assessment of care needs) dated 12/26/22, indicated the diagnoses of heart failure (a progressive heart disease affecting pumping action of the heart muscles impacting circulation, swelling and shortness of breath), high blood pressure, and depression. During an interview on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, national accepted guidelines for Pressure Ulcers, and staff interview, it was determined that the facility failed to prevent the development and accurately assess pressure ulcers for two of five residents (Resident R2 and Resident R56). Findings include: The facility policy entitled Pressure Ulcers/Skin Breakdown - Clinical Protocol last reviewed 10/31/22, indicated the nursing staff will assess and document an individual's significant risk factors for developing pressure ulcers. It also indicated that the nurse will describe and document: full assessment of pressure indicating location, stage, length, width and depth, presence of exudate (drainage) or necrotic (dying) tissue. The National Pressure Ulcer Advisory Panel (NPUAP) defines Moisture Associated Skin Damage (MASD) as inflammation and erosion of the skin caused by prolonged exposure to moisture and its contents, including, urine, stool, perspiration, wound exudate, mucus or saliva; occurs in the perineum (area between…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 clinical record review, review of facility provided documents, review of facility diet manual and staff interview, it was determined that the facility failed to provide the appropriate diet to meet the needs for one of eight residents reviewed. (Resident R11). Findings include: Review of the facility approved diet manual indicated a Mechanical Soft Meat and Mechanical Soft Ground Meat diet contain foods of an appropriate consistency of foods that have been altered in which can be more easily chewed and managed by a person with dysphagia. Review of the clinical record indicated Resident R11 was admitted to the facility 10/26/10. Review of the Minimum Data Set (MDS - periodic assessment of care needs)dated 8/8/22, included diagnoses of cerebral palsy (condition of impaired muscle conditions), aphasia (language disorder affecting the ability to communicate), and dysphagia (difficulty swallowing), Review of a physician order dated 11/14/21, indicated Resident R11 was to receive a regular mechanical soft diet with thin liquids, puree fruits, to be fed in an upright position with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of hospice contracts, clinical record review and staff interviews, it was determined that the facility failed to ensure that the facility received the required information from and communicated with the contracted hospice provider for one of two residents receiving hospice services (Resident R92) Findings include: An agreement between the facility and a hospice provider (provider of end-of-life services), dated 12/30/15, revealed that the hospice will designate an interdisciplinary group and ensure services as furnished in accordance with the Hospice plan of care. The Hospice shall furnish the facility with a copy of the plan of care and that hospice shall maintain the Hospice Plan of Care, including services provided by the hospice staff, in a separate section in the nursing facility clinical record and ensure it contains the following information: Election of Hospice Care Form, MDS assessments, physician certification of terminal illness form, Election Statement, Hospice Interdisciplinary…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 a pneumococcal immunization was offered to two of seven residents (R45 and R90). Findings include: The facility policy Pneumococcal Vaccine dated 10/31/22, indicated Residents will be assessed for eligibility to receive the pneumococcal vaccine series, and when indicated, will be offered the vaccine series within thirty (30) days of admission to the facility unless medically contraindicated or the resident has already been vaccinated. Review of the Centers for Disease Control (CDC) document, Pneumococcal Vaccination: Summary of Who and When to Vaccinate last reviewed 1/24/22, indicated that CDC recommends pneumococcal vaccination for all adults 65 years or older, and for adults 19 through [AGE] years old who have certain chronic medical conditions or other risk factors. Included in this list were: alcoholism, chronic liver disease, chronic lung disease, chronic renal failure,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 and staff interviews it was determined that the facility failed to provide handrails in a safe and functional environment for residents use in corridors in one four resident room hallways (2nd floor 207 hallway) Findings include: During an observation on 2/10/23, from 4:45 p.m. through 5:30 p.m. the handrail outside of room [ROOM NUMBER] was separated at the connector adjoining the wall and the handrail outside of room [ROOM NUMBER] was uneven. During an interview on 2/10/23, at 5:45 p.m Licensed Practical Nurse Employee E4, confirmed the above finding. 28 Pa. Code 205.9(a) Corridors.