Squirrel Hill Wellness And Rehabilitation Center

Based on a review of facility policy, clinical records, incident investigations, and staff interviews, it was determined that the facility failed to report a misappropriation of resident property 12 of 14 residents (Resident R3, R4, R5, R6, R7, R8, R9, R10, R11, R12, R13, and R14).Findings include: Review of the facility policy Abuse, Neglect, & Exploitation dated 2/14/25, indicated the facility will report all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g., law enforcement when applicable) within specified timeframes:a. Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, orb. Not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury. Review of the Resident Assessment Instrument 3.0 User's Manual effective October 2025, indicated that a Brief Interview for Mental Status (BIMS) is a screening test that aids in detecting cognitive…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, incident investigations, and staff interviews, it was determined that the facility failed to implement policies and procedures to investigate misappropriation of resident property for 12 of 20 residents (Resident R3, R4, R5, R6, R7, R8, R9, R10, R11, R12, R13, and R14).Findings include: Review of the facility policy Abuse, Neglect, & Exploitation dated 2/14/25, A. An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur.B. Written procedures for investigations include:1. Identifying staff responsible for the investigation;2. Exercising caution in handling evidence that could be used in a criminal investigation (e.g., not tampering or destroying evidence);3. Investigating different types of alleged violations;4. Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the…

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

Based on a review of facility policy, observation, and staff interview, it was determined that the facility failed to ensure an environment free from the potential spread of infection for 27 of 41 residents (Resident R3, R4, R14, R15, R16, R17, R18, R19, R20, R21, R22, R23, R24, R25, R26, R27, R28, R29, R30, R31, R32, R33, R34, R35, R36, R37, R38).Findings include: Review of the facility policy, Isolation - Notices of Transmission-Based Precautions dated 6/1/25, indicated, Notices will be used to alert personnel and visitors of transmission-based precautions, while protecting the privacy of the resident. Review of the Pennsylvania Department of Health Respiratory Virus Outbreak Toolkit dated 11/24/25, indicated, The LTCF (long-term care facility) should encourage masking of HCP (health care personnel), residents, and visitors during any respiratory virus outbreak. Masks help to prevent the spread of illness. This provides protection for the wearer (if using a fitted N95 or KN95) and protection for others (some surgical and N95/KN95). When a resident is suspected or confirmed to have…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 provided documents and and staff interviews, it was determined that the facility failed to ensure residents' records are readily accessible to the State Survey Agency which caused a delay in the survey process for one of three residents (Resident R3).During an interview on 12/30/25, at approximately 1:30 p.m. the (former) Nursing Home Administrator was requested to provide the investigation documents related to the possible misappropriation of resident property for Resident R3.During an interview on 12/31/25, at approximately 11:30 a.m. the Director of Nursing was requested to provide the investigation documents related to the possible misappropriation of resident property for Resident R3.During a telephone interview on 1/2/26, at 1:05 p.m. the (former) Nursing Home Administrator was requested to provide the investigation documents related to the possible misappropriation of resident property for Resident R3.During an electronic communication on 1/5/26, at 10:43 a.m. the Director of Nursing was requested to provide the investigation documents related to…

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

Based on a review of facility policy, observations, and staff interviews, it was determined that the facility failed to provide information regarding how to file a grievance and information on the grievance official on two of three nursing units (Fourth Floor and Fifth Floor) and failed provide and make accessible grievance forms to residents and visitors on three of three nursing units (Fourth Floor, Fifth Floor, and Sixth Floor).Review of the facility policy, Resident and Family Grievances dated 2/14/25, indicated, Notices of resident's rights regarding grievances will be posted in prominent locations throughout the facility. During an observation of the Fourth Floor nursing unit on 12/5/25, at approximately 1:55 p.m. the grievance box was not easily observed. During an interview on 12/5/25, at approximately 2:00 p.m. Licensed Practical Nurse (LPN) Employee E1 and Nurse Aide (NA) Employee E2 were unable to state where the grievance box was located on the unit. During an interview and observation on 12/5/25, at 2:04 p.m. NA Employee E3 was able to show the surveyor where the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to notify a resident representative of a resident to resident abuse incident for one of four residents (Resident R1).Review of the Resident Assessment Instrument 3.0 User's Manual effective October 2025, indicated that a Brief Interview for Mental Status ( BIMS) is a screening test that aids in detecting cognitive impairment. The BIMS total score suggests the following distributions: 13-15: cognitively intact8-12: moderately impaired0-7: severe impairment Review of the facility policy, Abuse, Neglect, and Exploitation dated 2/14/25, indicated that it is the policy of the facility to provide protections for the health, welfare, and rights of each resident. Review of the clinical record indicated Resident R1 was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS - periodic assessment of resident care needs) dated 8/12/25, included diagnoses of heart failure (a progressive…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, nursing unit observations, and staff interviews, it was determined that the facility failed to provide a clean and homelike environment on one of four nursing units (Fourth Floor nursing unit).Findings include: Review of the facility policy, Safe and Homelike Environment dated 2/14/25, indicated, The facility will provide a safe, clean, comfortable, and homelike environment. During an observation of the Fourth Floor dining room/lounge on 12/5/25, at approximately 12:35 p.m. the sink was noted to have refuse in it, partially uses bottles of shampoo and lotion were on a shelf above the sink, and a drawer had a broken handle. In the drawer was one sock, a soiled Ziploc bag, and a soiled disposable cup lid. The sink in the dining room/lounge only had a handle for hot water. The outlet on the wall next to the television had no faceplate, allowing access to the wires. In the lounge was a resident reclining chair with one arm cushion missing, exposing the metal frame. A brown substance was dried to the side of the chair, multiple substances appeared to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to investigate a resident-to-resident abuse incident for one of four residents (Resident R1).Review of the Resident Assessment Instrument 3.0 User's Manual effective October 2025, indicated that a Brief Interview for Mental Status ( BIMS) is a screening test that aids in detecting cognitive impairment. The BIMS total score suggests the following distributions: 13-15: cognitively intact8-12: moderately impaired0-7: severe impairment Review of the facility policy, Abuse, Neglect, and Exploitation dated 2/14/25, indicated that an immediate investigation is warranted when suspicion of abuse, neglect, or exploitation, or reports of abuse, neglect, or exploitation occur. Review of the clinical record indicated Resident R1 was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS - periodic assessment of resident care needs) dated 8/12/25, included diagnoses of heart failure (a…

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

Based on review of facility policy, observations, resident and staff interviews, and review of the pest control documentation it was determined that the facility failed to maintain effective pest control programs so that the facility was free of pests in the Main Kitchen. Finding include: Review o the facility policy Pest Control Program dated 2/14/25, indicated it is the policy of this facility to maintain an effective pest control program that eradicates and contains common household pests and rodents. During an observation of the Main Kitchen on 5/20/25, at 8:42 a.m. mouse droppings and mouse traps were observed in the kitchen storage area. During an interview on 5/20/25, at 8:44 a.m. Assistant Kitchen Manager Employee E1 confirmed that there is a current concern with mice in the Main Kitchen. Assistant Kitchen Manager Employee E1 stated that morning she came in to throw tortilla shells away due to mice getting into the package. She keeps a detailed list of all food that needs to be discarded and replaced. During an observation in the Main Kitchen Dry Storage room it was noted…

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

Based on observation and staff interview, it was determined the facility failed to ensure the Department of Health most recent survey results were readily accessible to residents and visitors, for three of three locations (first floor lobby, nursing units fourth, and six floors). Findings Include: During an interview on 2/11/25, at 10:30 a.m., the Resident Group, four of four residents agreed that they were unaware of the location of the Department of Health survey results (Residents R5, R26 R28 and R52). During an observation on 2/12/25, at 9:20 a.m., signage in the lobby, fourth floor and sixth floor read survey results can be found on the 1st, 4th, and 6th floors (the public entry and resident care areas). During an observation on 2/12/25, at 9:20 a.m. in the lobby, no survey result book could be located. During an observation on 2/12/25, at 9:22 a.m. on the fourth floor, the survey result book was located behind empty folders and contained survey results from 2023. The prior survey date for this facility was on 2/12/24. During an observation on 2/12/25, at 9:24 a.m. on the sixth…

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

Based on review of facility policy, personnel in-service training records, and staff interview, it was determined that the facility failed to conduct at least 12 hours of in-service education, within 12 months of their hire date anniversary, for nurse aides as required for four of four nurse aides (Employee E1, E3, E4, and E5). Findings include: Review of the facility policy, Training Requirements most recently reviewed 10/20/24, indicated the facility will develop, implement, and maintain an effective training program for all new and existing staff. Review of facility provided documents and training records revealed the following: Nurse Aide (NA) Employee E1 had a hire date of 10/9/22. The facility provided education filed failed to have any dates or times provided on any documents within the file to confirm education occurred between 10/9/23, through 10/9/24. NA Employee E3 had a hire date of 10/11/04. The facility was unable to provide an education file or any other documentation that NA Employee E3 had completed any education from 10/11/23, through 10/11/24. NA Employee E4 had a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the facility policy and clinical records and staff interview, it was determined that the facility failed to provide the opportunity to formulate an advance directive (written instructions for when the individual is incapacitated) or conduct periodic review of instructions, for seven of the twenty-two residents reviewed (Resident R5, R11, R35, R41 R45, R52, and R55). Findings Include: A review of the facility policy Resident Rights Regarding Treatment and Advanced Directives last reviewed 10/20/24, indicated it's the policy of this facility to support and facilitate a resident's right to request, refuse and/or discontinue medical or surgical treatment and to formulate and advance directive. Decisions regarding advanced directives and treatment will be periodically reviewed as part of the comprehensive care planning process, the existing care instructions and whether the resident wishes to change or continue these instructions. Review of the Resident Assessment Instrument 3.0 User's Manual,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 in a timely manner, notice of Medicare non coverage (payment) for two of two residents (Resident R217 and R218). Findings include: Review of CMS guidelines, 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. The Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage, (SNF ABN) must be issued to Medicare Fee -for-Service (original Medicare) beneficiaries who are receiving care in a Skilled Nursing Facility (SNF) when: Medicare is expected to deny coverage and when the SNF wants to charge the beneficiary for the non-covered services. 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 policy review and observations and staff interviews it was determined that the facility failed to maintain a homelike environment throughout the facility (resident rooms, dining rooms and hallways) for three of three nursing units. (4th, 5th, and 6th floor nursing units) Findings include: A review of the facility policy Safe and Homelike Environment dated 10/20/24, indicated the facility will provide a safe, clean, comfortable, and homelike environment. During an observation of the facility on 2/14/25, at 9:30 a.m., the following was revealed: * Resident room [ROOM NUMBER] W (window) air condition/heating unit had broken vents and dusty debris and trash particles inside the unit. The wall next to the bathroom entrance had missing molding and holes around the night light. * Resident room [ROOM NUMBER] W air condition/heating unit had broken vents and dusty debris and trash particles inside the unit. * Resident room [ROOM NUMBER] W air condition/heating unit had broken vents and dusty debris and trash…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 the Resident Assessment Instrument User's Manual, clinical records, and staff interview, it was determined that the facility failed to make certain that comprehensive Minimum Data Set (MDS- periodic assessment of resident care needs) assessments were completed in the required time frame for seven of 25 residents (Resident R1, R23, R45, R49, R52, R57, and R58). Findings include: The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which provides instructions and guidelines for completing required MDS assessments, dated October 2024, indicated that an admission MDS assessment was to be completed no later than 14 days following admission (admission date plus 13 calendar days), and annual MDS assessment was to be completed no later than Assessment Reference Date (ARD). Resident R1 had an ARD of 11/13/24, with an MDS completion date of 11/28/24. Resident R23 had an ARD of 1/16/25, with an MDS completion due date of 1/31/25. Resident R45 had an admission date of 1/13/25, with an MDS completion due date of 1/27/25. Resident R49 had an ARD 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 the Resident Assessment Instrument User's Manual, clinical records, and staff interview, it was determined that the facility failed to make certain that quarterly Minimum Data Set assessments were completed within the required time frame for ten of 51 residents (Resident R12, R14, R20, R30, R34, R35, R41, R43, R44, and R55). Findings include: The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which provides instructions and guidelines for completing required Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2024, indicated that quarterly MDS assessments were to be completed no later than 14 days after the Assessment Reference Date (ARD). Resident R12 had an ARD of 12/12/24, with an MDS completion date of 1/3/25. Resident R14 had an ARD of 12/20/24, with an MDS completion date of 1/7/25. Resident R20 had an ARD of 11/14/24, with an MDS completion date of 11/30/24. Resident R30 had an ARD of 12/4/24, with an MDS completion date of 1/3/25. Resident R34 had an ARD of 11/28/24,…

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

Based on review of the Resident Assessment Instrument User's Manual and clinical records, and staff interview, it was determined that the facility failed to make certain that comprehensive Minimum Data Set assessments were accurate and fully completed for seven of ten residents (Resident R8, R10, R13, R29, R36, R40, and R54). Findings include: The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which gives instructions for completing Minimum Data Set Assessments (MDS - periodic assessment of care needs) dated October 2024, indicated that Section C: Cognitive Patterns, Question C0100 Should Brief Interview for Mental Status Be Conducted? (BIMS) should be coded as 0 if the resident is rarely/never understood, or it should be coded 1, and the BIMS assessment should be completed if the resident is at least sometimes understood. Section D: Mood, Question D0100 Should Resident Mood Interview Be Conducted? should be coded as 0 if the resident is rarely/never understood, and or it should be coded 1, and the assessment should be completed if the resident is at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of the facility policy, clinical record and staff interviews, it was determined that the facility failed to provide an ongoing program of activities to meet the interests of and support the physical, mental, and psychosocial well-being of each resident for eight of ten residents (Residents R5, R11, R26, R35, R41, R45, R52, and R55). Findings included: Review of the facility policy Resident Rights reviewed 10/20/24, indicated the resident has the right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility. Self-Determination - The resident has the right to, and the facility must promote and facilitate self-determination through support of resident choice, including but not limited to: The resident has a right to choose activities, schedules, health care and providers of health care services consistent with his or her interests, assessments and plan of care and other applicable provisions of this part. Review of the…

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

Based on staff interviews and review of facility provided documentation, it was determined the facility failed to provide a qualified professional to direct the activities program as required for two of 12 months (12/6/24 through 2/14/25). Findings include: Review of the Activities Director job description required Qualifications The activities program must be directed by a qualified professional who is a qualified therapeutic recreation specialist or an activities professional. During an interview on 2/13/25, at 1:30 p.m. the Nursing Home Administrator (NHA) and Director of Nursing (DON) confirmed the facility failed to provide a qualified professional to direct the activities program for two of 12 months (12/6/24 through 2/14/25). 28 Pa Code 201.18(b)(3) Management. 28 Pa Code 201.18(e)(6) Management

Based on facility policy review, review of Quality Assurance attendance records, and staff interview, it was determined that the facility failed to conduct Quality Assessment and Assurance (QAA) meetings at least quarterly with all the required committee members for three of four quarterly meetings (January 2024 through December 2024). Findings Include: The facility Quality Assurance and Performance Improvement (QAPI) Program policy dated 10/20/24, indicated that the facility shall develop, implement, and maintain an effective, comprehensive, data-driven QAPI program that focuses on indicators of the outcomes of care and quality of life and addresses all the care and unique services the facility provides. The QAA committee shall meet at least quarterly and as needed to coordinate and evaluate activities under the QAPI program. A review of the Quality assurance and performance improvement sign in sheets and attendance records indicated the facility had a first quarter meeting on 2/22/24. The facility failed to failed to provide evidence that the facility conducted a second third 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 facility policy, personnel in-service training records, and staff interview, it was determined that the facility failed to implement and maintain an effective training program for four of four nurse aides (Employee E1, E3, E4, and E5). Findings include: Review of the facility policy, Training Requirements most recently reviewed 10/20/24, indicated the facility will develop, implement, and maintain an effective training program for all new and existing staff. Review of facility provided documents and training records revealed the following: Nurse Aide (NA) Employee E1 had a hire date of 10/9/22. The facility provided education filed failed to have any dates or times provided on any documents within the file. NA Employee E3 had a hire date of 10/11/04. The facility was unable to provide an education file or any other documentation that NA Employee E3 had completed any education from 10/11/23, through 10/11/24. NA Employee E4 had a hire date of 10/11/05. The facility provided education filed revealed a 12-hour in-service packet, but no dates were present confirmed…

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

Based on review of facility policy, personnel in-service training records, and staff interview, it was determined that the facility failed to provide training on Effective Communication for five of nine staff members (Employee E1, E3, E4, E7, and E8). Findings include: Review of the facility policy, Training Requirements most recently reviewed 10/20/24, indicated the facility will develop, implement, and maintain an effective training program for all new and existing staff. Training content includes, at a minimum: a. Effective communication for direct care staff. b. Resident rights and facility responsibility for caring of residents. c. Elements and goals of the facility's Quality Assurance and Performance Improvement program. d. Written standards, policies, and procedures for the facility's infection prevention and control program. e. Written standards, policies, and procedures for the facility's compliance and ethics program. f. Behavioral health. g. Dementia management and care of the cognitively impaired. h. Abuse, neglect, and exploitation prevention. i. Safety and emergency…

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

Based on review of facility policy, personnel in-service training records, and staff interview, it was determined that the facility failed to provide training on Resident Rights for six of nine staff members (Employee E1, E3, E4, E7, E8, and E9). Findings include: Review of the facility policy, Training Requirements most recently reviewed 10/20/24, indicated the facility will develop, implement, and maintain an effective training program for all new and existing staff. Training content includes, at a minimum: a. Effective communication for direct care staff. b. Resident rights and facility responsibility for caring of residents. c. Elements and goals of the facility's Quality Assurance and Performance Improvement program. d. Written standards, policies, and procedures for the facility's infection prevention and control program. e. Written standards, policies, and procedures for the facility's compliance and ethics program. f. Behavioral health. g. Dementia management and care of the cognitively impaired. h. Abuse, neglect, and exploitation prevention. i. Safety and emergency…

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

Based on review of facility policy, personnel in-service training records, and staff interview, it was determined that the facility failed to provide training on Abuse and Neglect Prevention for six of nine staff members (Employee E1, E3, E4, E7, E8, and E9). Findings include: Review of the facility policy, Training Requirements most recently reviewed 10/20/24, indicated the facility will develop, implement, and maintain an effective training program for all new and existing staff. Training content includes, at a minimum: a. Effective communication for direct care staff. b. Resident rights and facility responsibility for caring of residents. c. Elements and goals of the facility's Quality Assurance and Performance Improvement program. d. Written standards, policies, and procedures for the facility's infection prevention and control program. e. Written standards, policies, and procedures for the facility's compliance and ethics program. f. Behavioral health. g. Dementia management and care of the cognitively impaired. h. Abuse, neglect, and exploitation prevention. i. Safety 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 facility policy, personnel in-service training records, and staff interview, it was determined that the facility failed to provide training on the Quality Assurance and Performance Improvement (QAPI) program for six of nine staff members (Employee E1, E3, E4, E7, E8, and E9). Findings include: Review of the facility policy, Training Requirements most recently reviewed 10/20/24, indicated the facility will develop, implement, and maintain an effective training program for all new and existing staff. Training content includes, at a minimum: a. Effective communication for direct care staff. b. Resident rights and facility responsibility for caring of residents. c. Elements and goals of the facility's Quality Assurance and Performance Improvement program. d. Written standards, policies, and procedures for the facility's infection prevention and control program. e. Written standards, policies, and procedures for the facility's compliance and ethics program. f. Behavioral health. g. Dementia management and care of the cognitively impaired. h. Abuse, neglect, 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 facility policy, personnel in-service training records, and staff interview, it was determined that the facility failed to provide training on the Infection Prevention and Control program for six of nine staff members (Employee E1, E3, E4, E7, E8, and E9). Findings include: Review of the facility policy, Training Requirements most recently reviewed 10/20/24, indicated the facility will develop, implement, and maintain an effective training program for all new and existing staff. Training content includes, at a minimum: a. Effective communication for direct care staff. b. Resident rights and facility responsibility for caring of residents. c. Elements and goals of the facility's Quality Assurance and Performance Improvement program. d. Written standards, policies, and procedures for the facility's infection prevention and control program. e. Written standards, policies, and procedures for the facility's compliance and ethics program. f. Behavioral health. g. Dementia management and care of the cognitively impaired. h. Abuse, neglect, and exploitation prevention. i.…

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

Based on review of facility policy, personnel in-service training records, and staff interview, it was determined that the facility failed to provide training on behavioral health for seven of nine staff members (Employee E1, E3, E4, E6, E7, E8, and E9). Findings include: Review of the facility policy, Training Requirements most recently reviewed 10/20/24, indicated the facility will develop, implement, and maintain an effective training program for all new and existing staff. Training content includes, at a minimum: a. Effective communication for direct care staff. b. Resident rights and facility responsibility for caring of residents. c. Elements and goals of the facility's Quality Assurance and Performance Improvement program. d. Written standards, policies, and procedures for the facility's infection prevention and control program. e. Written standards, policies, and procedures for the facility's compliance and ethics program. f. Behavioral health. g. Dementia management and care of the cognitively impaired. h. Abuse, neglect, and exploitation prevention. i. Safety and emergency…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 policies and documentation, clinical record review and interviews with residents and staff, it was determined that the facility failed to honor a resident's right to smoke, for 4 of 10 residents reviewed (Residents R11, R19, R28, and R53). Findings include: A review of the facility Smoking Policy dated 10/20/24, indicated the facility follows a supervised smoking policy and smoking is permitted in designated areas. A review of the facility policy Smoke Free Facility dated 2/5/25, indicated that smoking is prohibited in all areas of the facility and facility grounds. A review of Resident R11's clinical record indicated the resident was admitted to the facility on [DATE] with diagnoses that included anxiety, depression, and hypertension (high blood pressure). The resident is alert and able to make needs known. A review of Resident R11's care plan dated 1/15/25, indicated the resident has history of smoking in the community and wishes to continue smoking. A 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.

Based on review of facility policy, facility documentation, resident group and staff interviews, it was determined the facility failed to provide Resident Council the opportunity for meetings for three of twelve months (September 2024, October 2024, and November 2024). Findings include: Review of the facility policy titled, Resident Council Meetings reviewed 10/20/24, states the council meets at least quarterly but no less than as determined by the group. The Activity Director/designee shall be designated to serve as the group liaison. The designated liaison shall be responsible for providing assistance with facilitating successful group meetings and responding to written requests from the group meetings. During Resident Group, with four alert and oriented residents and the Ombudsman on 2/11/25, at 10:30 a.m., Residents R5, R26 R28 and R52 indicated some months no meetings were arranged. The attendees reported that the activities department had organized the meetings until the activity director and one other activity staff member resigned. Council members reported, now there is only…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 resident and staff interviews, it was determined that the facility failed to provide and make accessible grievance forms to residents and visitors on one of two nursing units (fourth floor) and failed to make the grievance box accessible on one of two nursing units (fourth floor). Findings include: A review of the facility policy Resident and Family Grievance reviewed 10/20/24, indicated the facility utilizes a grievance form to identify concerns and for tracking. During an observation on 2/12/25, at 9:25 a.m. revealed the grievance box and forms were not accessible due to a trash bin placed in front of the grievance box on the fourth-floor nursing unit. During an observation on 2/12/25, at 9:25 a.m. revealed the grievance forms were not present on the fourth-floor nursing unit. During an interview on 2/12/25, at 9:25 a.m. The Director of Nursing confirmed the facility failed to provide and make accessible grievance forms to residents and visitors on one of two nursing units (fourth floor) and failed to make the grievance box…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 make certain allegations of abuse, neglect, exploitation, or mistreatment are thoroughly investigated for one of two residents reviewed. (Resident R46). Findings include: A review of the facility Abuse, Neglect, and Exploitation policy dated 10/20/24, indicated that the facility will provide complete and through documentation of the investigation. Identify and interviewing all involved persons, including the alleged victim, alleged perpetrator, witness and others who might have knowledge of the allegations. A review of Resident R46's admission record indicated the resident was admitted on [DATE]. Resident R46 was transferred to the hospital 2/3/25 for evaluation of a Deep Vein Thrombosis (blood clot). Review of the Resident Assessment Instrument 3.0 User's Manual effective October 2019 indicated that a Brief Interview for Mental Status (BIMS), is a screening test that aides in detecting…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, manufacturer's information, clinical record review, observations, and staff interview, it was determined the facility failed to provide to provide appropriate care and services to residents receiving tube feedings for one of two residents reviewed (Residents R20). Findings include: The facility policy entitled Care and Treatment of Feeding Tubes (delivery of food or medication via tube surgically inserted into stomach) dated 10/20/24, indicated the facility must utilize feeding tubes in accordance with current clinical standards of practice, with interventions to prevent complications to the extent possible. Review of the manufacturer's information, Glucerna 1.5 Cal dated 9/7/24, indicated, All medical foods, regardless of type of administration system, require careful handling because they can support microbial growth. NOTE: Failure to follow the increases the potential for microbial contamination and may reduce Hang product for up to 48 hours after initial connection when…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy and clinical records, and staff interview, it was determined that facility staff failed to maintain ongoing communication with the hemodialysis (a machine filters wastes, salts and fluid from your blood when your kidneys are no longer healthy enough to do this work adequately) center for one of two residents reviewed (Resident R18). Findings include: A review of the facility policy Hemodialysis reviewed 10/20/24, indicated residents ordered dialysis will have ongoing communication and collaboration with the dialysis facility regarding dialysis care and services. The licensed nurse will communicate via written format with a dialysis communication form. A review of the clinical record indicated Resident R18 was re-admitted to the facility on [DATE], with diagnoses that included end-stage renal disease (ESRD - the kidneys permanently fail to work) and low blood pressure. A review of the Minimum Data Set (MDS - periodic assessment of care needs) dated 2/2/25, indicated the…

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

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 provide culturally competent, trauma care in accordance with professional standards of practice, accounting for the resident's past experiences and preferences in order to eliminate and/or mitigate triggers that may cause re-traumatization of the resident for three of eight residents (Resident R58, R20, and R30). Findings include: Review of the facility policy, Trauma Informed Care dated 10/20/24, indicated the facility will provide care and services which are delivered using approaches which are culturally-competent, account for experienced and preferences, ad address the needs of trauma survivors by minimizing triggers and/or retraumatization. The policy indicated trauma results from an event, series of events, or set of circumstances that is experienced by an individual ' s physically or emotionally harmful or life threatening and that has lasting adverse effects on the individual.…

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

Based on review of facility policy, personnel records, and staff interview it was determined that the facility failed to complete annual performance evaluations for one out of four nurse aides (NA Employee E3). Findings include: Review of nurse aide performance evaluations completed by the facility failed to include a performance evaluation for Nurse Aide Employee E3, with a hire date of 10/11/04. During an interview on 2/14/25, at approximately 2:00 p.m. the Nursing Home Administrator confirmed that the facility failed to complete annual performance evaluations for one of four nurse aides as required. 28 Pa Code: 201.20 (a)(b)(c)(d) Staff development. 28 Pa Code: 201.14 (a) Responsibility of licensee.

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 ensure the pharmacy completed a Medication Regime Review (MRR) at least monthly for two of five residents (Resident R5 and R56). Findings: Review of facility policy Medication Regimen Review reviewed 10/20/24, indicated the drug regimen of each resident is reviewed at least once a month by a licensed pharmacist. The Medication Regimen Review (MRR) is a thorough evaluation of the medication regimen of a resident, with the goal of promoting positive outcomes and minimizing adverse consequences and potential risks associated with medications. Review of the clinical record revealed Resident R5 was admitted to the facility on [DATE], with diagnoses that included dementia (group of symptoms affecting memory, thinking and social abilities), depression, and diabetes. Review of Minimum Data Set (MDS - a mandated assessment of a resident's abilities and care needs) dated 11/6/24, indicated the diagnoses…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policies and clinical records and staff interview, it was determined that the facility failed to make certain that medical records on each resident are complete and accurately documented for two of four residents (Residents R59 and R61) A review of the facility policy Documentation in the Clinical Record dated 10/20/24, indicated the resident's medical record shall be complete, accurate, and timely. During an interview on 2/13/25, at 1:00 p.m. the Director of Nursing revealed that clinical records shall be completed within 30 days of a resident discharge from the facility. A review of the clinical record on 2/13/25, indicated that Resident R59 was admitted to the facility on [DATE] and ceased to breathe on 12/2/24. A review of the Interdisciplinary Discharge Summary and Disposition of Medications forms dated 12/2/24, were not completed. A review of the clinical record on 2/13/25, indicated that Resident R61 was admitted to the facility 10/14/24, and discharged on 11/19/24. A review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of facility documents, information from the State Ombudsman Office and staff interviews it was determined that the facility failed to notify the State Ombudsman Office of resident transfers and discharges for two plus years ( 9/12/22 through 11/6/24) as required. Findings include: A request to review facility documents on 12/19/24, of the facility's compliance in notifying the State Ombudsman Office revealed that the facility failed to provide documented evidence of notifying the State Ombudsman Office of resident transfers and discharges for the time period of 9/12/22 through 11/6/24. A review of information on 8/1/24, provided by the State Ombudsman Office revealed that the facility failed to notify the State Ombudsman Office of transfers and discharges as required since 9/12/24 and an updated list received on 12/3/24 revealed that the facility as of 11/6/24 had started to notify, but was not providing complete information. During an interview on 12/19/24, at 12:55 p.m. the Nursing Home…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, resident interview and observations, clinical record review, and staff interview it was determined that the facility failed to provide Activity of Daily Living (ADL) assistance for one of five residents (Resident R1). Findings include: Review of the facility policy Resident Showers dated 10/2/23, indicated it is the practice of the facility to assist residents with bathing to maintain proper hygiene, stimulate circulation and help prevent skin issues. Review of admission record indicated Resident R1 was admitted to the facility on [DATE]. Review of Resident R1's Minimum Data Set (MDS- a periodic assessment of care needs) dated 7/13/24, indicated the diagnoses of chronic obstructive pulmonary disease (lung disease that block airflow and make it difficult to breath, severe morbid obesity, type 2 diabetes (condition in which the body has trouble controlling blood sugar and using it for energy, and bipolar disorder (episodes of mood swings ranging from depressive lows to manic…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, review of cited deficiencies from the facility's annual survey of 4/16/21, and staff interview, it was determined that the facility's Quality assurance and performance improvement (QAPI) program failed to correct previous cited deficiencies. This has the potential to effect all 104 residents of the facility. The findings include: The facility's deficiencies and plan of correction for the State Survey and Certification (Department of Health) survey ending April 18,2024, revealed that the facility developed plans of corrections that included quality assurance systems to ensure that the facility maintained compliance with cited nursing home regulations. The results of the current survey, ending May 7, 2024, identified a repeated deficiency related to not providing protection of abuse, resident rights and implementation of the policies and procedures to prohibit abuse for one of 104 residents resulting in physical harm. The facility QAPI Committee is responsible for the review and approval of facility policies, procedures and guidelines on 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical records, observation, and staff interview it was determined that the facility failed to uphold the privacy and dignity by not providing a privacy curtain for one of 25 residents reviewed (Resident 1), and one of two residents utilizing an indwelling urinary catheter (foley - a thin rubber tube inserted either through the urethra or suprapubic [abdomen] to allow for bladder drainage) (Resident R2) . Findings include: Review of the facility policy Promoting/Maintaining Resident Dignity last reviewed 10/2/23, indicated it is facility practice to protect and promote resident rights and treat each resident with respect and dignity as well as care for each resident in a manner and in an environment, that maintains or enhances resident ' s quality of life by recognizing each resident ' s individuality. Review of the facility policy Catheter Care, last reviewed 10/2/23, indicated the facility will ensure that residents with indwelling catheters receive appropriate catheter…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of policy, observation and staff interview, it was determined that the facility failed to properly maintain kitchen equipment in a sanitary condition creating the potential for cross contamination in the main kitchen of the facility (Main Kitchen). During an observation of the Main Kitchen on 2/5/24, at 10:30 a.m. the following was observed: -Flour bin, soiled outside, small bowl used as a scoop, stored directly in flour. -Sugar bin, soiled outside. -Floor soiled. -Knives hanging on a magnetic wall holder were visibly dirty. -Flying insects present in food preparation area. -Water pooling in meal lids in a cart next to tray line. -#2 refrigerator, a partially consumed 20-ounce bottle of soda. -(2) dented large cans of peaches. -Dishwasher room: dishes stored under table on clean side, face up. -Mouse droppings observed behind the ice maker and under the handwashing sink. During an observation of the Main Kitchen on 2/5/24, at 11:55 a.m. the Corporate Mobile Administrator was present 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 policies, clinical record review, observations, and staff interviews, it was determined the facility failed to implement measures to prevent the potential for cross contamination during a dressing change for two of two residents (Resident R18 and R9); failed to implement an infection control program that included a system of surveillance to identify possible communicable diseases or infections for 10 of 11 months (March 2023, April 2023, May 2023, June 2023, July, August 2023, September 2023, and October 2023, November 2023, and January 2024); and failed to conduct an assessment to identify where Legionella and other opportunistic waterborne pathogens could grow and spread, and implement measures to prevent growth. Findings include: Review of facility policy Infection Prevention and Control Program last reviewed 10/2/23, indicated the facility must have a system of surveillance is utilized for prevention, identifying, reporting, investigating, and controlling infections and communicable…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 the facility's infection control policies and procedures and staff interview, it was determined that the facility failed to implement an antibiotic stewardship program for nine of eleven months (May 2023, June 2023, August 2023, September 2023, and October 2023). Findings include: Review of facility policy Antibiotic Stewardship Program last reviewed 10/2/23, indicated it is the facility policy to optimize treatment of infections while reducing the adverse events associated with antibiotic use. It was indicated the facility must monitor antibiotic use on a monthly basis. Review of the facility's Infection Control surveillance for March 2023, through February 2024, failed to include documentation to indicate that antibiotic monitoring was completed for March 2023, April 2023, May 2023, June 2023, July 2023, August 2023, September 2023, October 2023, and November 2023. During an interview on 2/7/24, at 11:58 a.m. the Infection Preventionist Employee E41 confirmed that the facility was unable to locate and provide documentation to indicate that antibiotic monitoring…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy, observations, resident and staff interviews, and review of pest control documentation it was determined that the facility failed to maintain an effective pest control program so that the facility was free of pests in the Main Kitchen and on three of three nursing units (First Floor). Findings include: Review of the facility policy Pest Control Program dated 10/2/23, indicated it is the policy of this facility to maintain an effective pest control program that eradicates and contains common household pests and rodents. During an observation of the Main Kitchen on 2/5/24, at 9:20 a.m. mouse traps were observed in the kitchen storage area. During an interview on 2/5/24, at 9:20 a.m. Kitchen Manager Employee E29 confirmed that there is a current concern with mice in the Main Kitchen. During an interview on 2/5/24, at 10:02 a.m. Resident R11 stated, The mice are terrible. The traps aren't working. One of the girls screamed when she came in my room. She was afraid of the mouse. During 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, staff education records, and staff interviews, it was determined that the facility failed to conduct at least 12 hours of in-service education, within 12 months of their hire date anniversary, for nurse aides as required for five of five nurse aides (Employees E11, E12, E13, E14, and E15). Finding include: Review of the policy Inservice Training dated 10/2/23, indicated it is the policy of this facility to develop, implement, and maintain an effective training program for all new and existing staff, individuals providing services under a contractual arrangement, and volunteers, consistent with their expected roles. Review of Nurse Aide (NA) Employees E11, E12, E13, E14, and E15 education records with hire date greater than 12 months revealed the following: Nurse Aide (NA) Employee E12 had a hire date of 1/4/22, with 8.00 hours in-service education between 1/4/23, and 1/4/24. NA Employee E12 had a hire date of 11/12/13, with 0.00 hours in-service education between 11/12/22, and 11/12/23. NA Employee E13 had a hire date of 11/8/05, with 8.00 hours…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 facility policy, clinical records, and staff interviews it was determined that the facility failed to provide the opportunity to formulate an advance directive (written instructions such as a living will or durable power of attorney for health care for when the individual is incapacitated) for seven of the 12 residents reviewed (Resident R76, R93, R104, R106, R111, R265, R266). Findings Include: A review of the facility policy Advanced Directives reviewed 10/1/22 and 10/1/22, indicated the facility will comply with the requirements related to maintaining written policies and procedures regarding advance directives, including provisions to inform and provide written information to all adult residents concerning the right to accept or refuse medical or surgical treatment and formulate an advance directive. A review of the clinical record indicated Resident R76 was admitted to the facility on [DATE], with diagnoses that include diabetes, broken lower leg, and high blood pressure. A review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, observations, and staff interview, it was determined that the facility failed to maintain a clean, homelike environment for five of five nursing units (third, fourth, fifth, sixth, and seventh nursing units). Findings include: Review of the facility policy Safe and Homelike Environment last reviewed 10/1/22 and 10/2/23, indicated the facility will provide a safe, clean, comfortable, and homelike environment. Housekeeping and maintenance services will be provided as necessary to maintain a sanitary, orderly, and comfortable environment. The facility will provide and maintain bed and bath linens that are clean and in good condition. The facility will provide and maintain adequate and comfortable lighting levels in all areas. The facility will minimize odors by disposing of soiled linens promptly and reporting lingering odors and bathrooms needing cleaning to housekeeping department, and any furniture in disrepair to maintenance promptly. Review of the facility policy Resident…

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

Based on review of facility policy, observations, and resident and staff interviews, it was determined that the facility failed to provide concern forms assessable to resident ' s and visitor ' s from a wheelchair on two of three nursing units (fifth, and sixth floor nursing unit), failed to have a grievance box and forms accessible on one of three nursing units (fourth floor) and failed to provide residents with the grievance official contact information (name, business address, email address, and business telephone number) on three of three nursing units (fourth, fifth, and sixth floor nursing units) Findings include: A review of the facility policy Grievance/Concern Resolution reviewed 10/1/22 and 10/2/23, indicated the facility utilizes a grievance form to identify concerns and track via a monthly log. During an observation on 2/8/24, at 8:42 a.m. revealed the grievance box and concern forms were not accessible due to two dining chairs placed in front of the grievance box and the grievance official information was not posted. During an observation on 2/8/24, at 8:44 a.m.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of clinical record reviews, resident interview and observations, and staff interviews, it was determined that the facility failed to provide Activity of Daily Living (ADL) assistance for 11 of 32 residents (Resident R12, R13, R22, R33, R37, R42, R54, R57, R80, R98, and R108) Findings Include: Review of the facility policy Activities of Daily Living (ADLs) dated 10/2/23, indicated that the facility will provide care and services for the following activities of daily living: -Bathing, dressing, grooming, and oral care. -Transfer and Ambulation. -Toileting. -Eating to include meals and snacks. -Using speech, language, or other functional communication systems. Review of Resident R37's admission record indicated he was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS - periodic assessment of care needs) dated 11/8/23, included diagnoses of dementia (a group of symptoms that affects memory, thinking and interferes with daily life), chronic obstructive pulmonary disease (COPD, a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical records, and staff interviews, it was determined that the facility failed to notify physicians of increased and decreased Capillary Blood Glucose (CBG) levels and failed to assess residents for hyperglycemia (high blood glucose) and hypoglycemia (low blood glucose), for five of eight residents reviewed (Residents R26, R59, R105, R111, and R265), and the facility failed to accurately assess one resident resulting in harm by hospitalization for hypoglycemia for one of five residents (Resident R59). 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,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 national accepted guidelines for pressure ulcers, and staff interview, it was determined that the facility failed to provide prescribed treatment and services related to the care of pressure ulcers for two of five residents (Resident R6 and R50). Findings include: Review of the facility policy, Pressure Injury Surveillance dated 10/2/23, indicated a system of surveillance is utilized for preventing, identifying, reporting, and investigating any new or worsened pressure injuries in the facility. Review of the facility policy, Wound Treatment Management dated 10/2/23, indicated wound treatments will be provided in accordance with physician orders, including the cleansing method, type of dressing, and frequency of dressing changes. Review of the clinical record indicated Resident R6 was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS - periodic assessment of care needs) dated 1/11/24, included the diagnoses of diabetes (a metabolic disorder in which the body has high sugar…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, resident interviews, clinical record review, and confidential staff interviews, it was determined that the facility failed to have sufficient nursing staff to provide nursing and related services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of four of four residents (Resident R15, R26, R105, and R109). Findings include: Review of the facility policy Medication Administration last reviewed 10/1/22 and 10/2/23, indicated medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manor to prevent contamination or infection. Review of the facility policy Nursing Services and Sufficient Staff last reviewed 10/1/22 and 10/2/23, indicated the facility will supply services by sufficient numbers of each of the following personnel types on a 24-hour basis to provide nursing care to all residents…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 the clinical records and staff interview, it was determined that the facility failed to provide documentation that medication regimen reviews were completed for three of five residents (Resident R82, R15, and R26). Findings include: During the survey, pharmacy completed medication regimen reviews were requested from the facility for Residents R82, R15, and R26. During an interview on 2/9/24, at 11:54 a.m. the Director of Nursing confirmed that the facility changed pharmacy providers, and was unable to produce any recommendations prior to December 2023. During an interview on 2/12/24, at approximately 1:00 p.m. the Nursing Home Administrator confirmed that the facility failed to provide documentation of medication regimen reviews for three of five residents. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.

Based on review of manufacturer ' s guidelines, observations, and staff interview, it was determined that the facility failed to make certain that medications and medication supplies were properly stored and/or disposed of in one of three medication rooms (Fifth-floor medication room). Findings include: Review of the facility policy Medication Storage dated 10/2/23, indicated the facility will ensure all medications housed on our premises will be stored in the pharmacy and/or medication rooms according to the manufacturer's recommendations. During an observation of the Fifth-floor medication room on 2/5/24, at 1:10 p.m. revealed the following -(5) DeClogger (g/j tube declogger tool) with an expiration date of 1/31/23 -(1) Needle with an expiration date 7/31/23. -(54) Syringes with an expiration date 5/1/23. -(87) Syringes with an expiration date 3/13/23. -(1) IV Administration set (tubing for infusing intravenous fluids) with an expiration date 5/15/23. -(74) Tuberculosis syringes with needle with an expiration date 7/11/21. -(51) Safety syringes with an expiration date 10/30/23.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 and documents, and staff interview, it was determined that the facility failed to provide training on Abuse, Neglect, and Exploitation for four of nine staff members (Employees E12, E6, E16, and E17). Findings include: Review of the policy Inservice Training dated 10/2/22, indicated it is the policy of this facility to develop, implement, and maintain an effective training program for all new and existing staff, individuals providing services under a contractual arrangement, and volunteers, consistent with their expected roles. Review of the Facility Assessment updated 12/28/23, indicated the training program content at a minimum included Abuse, Neglect, and Exploitation. Review of facility provided documents and training record for E12, E6, E16, and E17 revealed the following staff members did not have documented training on Abuse, Neglect, and Exploitation. Nurse Aide (NA) Employee E12 had a hire date of 1/12/13, failed to have Abuse, Neglect, and Exploitation in-service education between 11/12/22, and 11/12/23. Licensed Practical Nurse (LPN)…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 and documents, and staff interview, it was determined that the facility failed to provide training on Infection Control for four of nine staff members (Employees E12, E6, E16, and E17). Findings include: Review of the policy Inservice Training dated 10/2/23, indicated it is the policy of this facility to develop, implement, and maintain an effective training program for all new and existing staff, individuals providing services under a contractual arrangement, and volunteers, consistent with their expected roles. Review of the Facility Assessment updated 12/28/23, indicated the training program content at a minimum included Infection Control. Review of facility provided documents and training record for E12, E6, E16, and E17 revealed the following staff members did not have documented training on Infection Control. Nurse Aide (NA) Employee E12 had a hire date of 1/12/13, failed to have Infection Control in-service education between 11/12/22, and 11/12/23. Licensed Practical Nurse (LPN) Employee E6 had a hire date of 10/5/21, failed to have…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, investigation documentation, and staff interviews, it was determined that the facility failed to conduct a thorough investigation to rule out neglect and/or abuse for one of ten sampled residents (Resident R24). Findings include: Review of facility policy Abuse, Neglect, and Exploitation dated 10/1/22, last reviewed 10/2/23, indicated an immediate investigation is warranted when suspicion of abuse, neglect occurs. It was indicated all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegation must be identified and interviewed. A complete and thorough investigation must be documented. Review of the clinical record indicated that 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 9/13/23, indicated diagnoses hypertension (high blood pressure), anxiety disorder, and muscle weakness. Review…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, observations, and staff interviews, it was determined that the facility failed to ensure that residents receive proper treatment and assistive devices to maintain vision abilities for one of ten residents (Resident R31). Findings include: Review of Title 42 Code of Federal Regulations (CFR) §483.25(a) Vision and hearing states to ensure that residents receive proper treatment and assistive devices to maintain vision and hearing abilities. Review of the clinical record indicated that Resident R31 was admitted to the facility on [DATE]. Review of Resident R31's Admission/readmission Screen V2- V2 report dated 6/3/21, indicated the resident had blurred vision in his right eye and no deficits in his left. It was indicated he wears glasses. Review of the Minimum Data Set (MDS - a period assessment of care needs) dated 12/5/23, indicated diagnoses of hypertension (high blood pressure), coronary artery disease condition where the major blood vessels supplying the heart are narrowed),…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policies, clinical records, and staff interviews, it was determined that the facility failed to make certain that weight loss was identified and addressed and identify needs for increased nutrition for one of five residents (Resident R23). Findings include: Review of the facility job description for the Dietitian included to monitor residents for weight changes, nutrition support, and skin breakdown, and make recommendations as needed. Review of the facility policy, Weight Monitoring last reviewed 10/2/23, indicated that the facility will use a systemic approach to optimize a resident's nutritional status, to include identifying and assessing each resident's nutritonal status and risk factors, evaluate and analyze the assessment information, develop and consistently implement pertinent approaches and monitor the effectiveness of this and revise as necessary. Interventions will be identified, implemented and modified as appropriate, consistent with the resident's assessed needs,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, observations, and staff interview, it was determined the facility failed to provide to provide appropriate care and services to residents receiving tube feedings for one of two residents reviewed (Residents R47). Findings include: The facility policy entitled Care and Treatment of Feeding Tubes (delivery of food or medication via tube surgically inserted into stomach) dated 10/2/23, indicated the facility must utilize feeding tubes in accordance with current clinical standards of practice, with interventions to prevent complications to the extent possible. It was indicated the resident's plan of care will direct staff regarding proper positioning of residents consistent with resident's individual needs. Review of admission record indicated Resident R47 admitted to the facility on [DATE]. Review of Resident R47's Minimum Data Set (MDS- periodic assessment of care needs) dated 11/3/23, indicated diagnoses of cerebral palsy (a neurological condition that can present as issues 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 a review of clinical records, facility policy, and staff interview, it was determined that the facility failed to provide services to a resident with a substance use disorder for one of two residents (Resident R23). Findings include: Review of the SAMHSA (Substance Abuse and Mental Health Services Administration) publication, Opioid Overdose updated 2/1/24, indicated signs and symptoms of opioid overdose may be: -Face is extremely pale and/or feels clammy to the touch. -Limp body. -Pinpoint pupils. -Fingernails or lips have a purple or blue color -Vomiting or making gurgling noises -Difficulty to awaken or are unable to speak -Breathing or heartbeat slows or stops Review of the facility policy Provision of Quality of Care dated 10/2/23, indicated each resident will be provided care and services to attain or maintain his/her highest practicable physical, mental, and psychosocial well-being. Review of the clinical record indicated Resident R23 was admitted to the facility on [DATE]. Review of Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff interviews, it was determined that the facility failed to make certain a resident's medication regimen was free from potentially unnecessary medication for one of four sampled residents (Resident R31). Findings include: The facility Gradual Dose Reduction of Psychotropic Drugs policy dated 10/2/23, indicated residents who use psychotropic drugs receive gradual dose reductions and behavioral interventions unless clinically contraindicated, in an effort to discontinue these drugs. The facility Use of Psychotropic Medication policy dated 10/2/23, indicated resident are not given psychotropic drugs (any drug that affects brain activities associated with mental processes and behavior) unless the medication is necessary to treat a specific condition, as diagnosed and documented in the clinical record, and the medication is beneficial to the resident, as demonstrated by monitoring and documentation of the resident ' s response to the medication(s). Review of the clinical record…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy and clinical record, observation and staff interviews it was determined that the facility failed to make certain that residents are free from significant medication errors for one of four residents (Resident R70). Findings include: Review of Resident R70's Minimum Data Set (MDS-periodic review of care needs) dated 11/25/23, indicated the resident was admitted on [DATE], with diagnoses of high blood pressure, diabetes (a disease that occurs when your blood glucose, or blood sugar, is too high), and depression. Review of Resident R70's physician order dated 11/1/23, instructed the nurse to administer Humalog 100 unit/ml, subcutaneously (under the skin), before meals as per the following sliding scale: -If 0-300, inject 0 units -If 301-600, inject 5 units -If 601 or greater, call physician During an observation of Resident R70's medication administration on 2/8/24, at 9:52 a.m. LPN, Employee E24 confirmed Resident R70's Humalog was ordered for administration before meals. During…

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

Based on review of facility policy, observations and staff interview, it was determined that the facility failed to maintain call bell equipment for one of five residents (Resident R81). Findings include: The facility Call Lights: Accessibility and Timely Response policy dated 7/1/23, indicated the facility must adequately be equipped with a call light at reach resident's bedside to allow residents to call for assistance. It was indicated staff will report problems with a call light or call system immediately to the supervisor. During an interview on 2/5/24, at 12:25 p.m. Resident R81 stated she never had a call bell that worked. Resident R81 was observed pressing her call bell and the light above the room did not turn on. During an interview on 2/5/24, at 12:31 a.m. Licensed Practical Nurse (LPN), Employee E39 confirmed the light above the Resident R81's room was not working. During an interview on 2/6/24, at 10:14 a.m. Unit Manager, LPN Employee E40 confirmed that the facility failed to maintain call bell equipment for Resident R81 as required. 28 Pa. Code: 205.67(j) Electric…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 Centers for Medicare & Medicaid Services documents, facility policy, clinical record review, and staff interviews, it was determined that the facility failed to develop a comprehensive, person-centered care plan with all requirements, when a comprehensive care plan is being utilized in place of a baseline care plan for one of five residents (Resident R1). Findings include: Review of Centers for Medicare & Medicaid Services, HHS § 483.21 indicated that the facility may develop a comprehensive care plan in place of the baseline care plan if the comprehensive care plan is developed within 48 hours of the resident's admission and meets the requirements set forth (Comprehensive person-centered care plan for each resident, consistent with the resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified). Review of the facility policy Care Plans dated 10/2/23, previously reviewed 10/2/22, indicated the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical records and staff interview, it was determined the facility failed to develop and implement a comprehensive person-centered care plan to meet a resident's medical, nursing, mental and psychological needs for one of six residents (Resident R1). Findings include: Review of the facility policy Comprehensive Care Plan last reviewed 10/2/23, informed it is the policy of this facility to develop and implement a comprehensive person-centered care plan each resident, consistent with resident rights, that includes measurable objectives,and timeframes to meet a resident's medical, nursing, and mental and psychological needs that are identified in the resident's comprehensive assessment. All Care Assessment Areas (CAAs) triggered by the Minimum Data Set (MDS - a periodic assessment of needs) will be considered when developing the plan of care. The comprehensive care plan will describe, at a minimum, the services that are to be furnished to attain and maintain the resident's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical records and staff interviews, it was determined that facility staff failed to maintain ongoing communication with the dialysis center (an outpatient treatment center for those with chronic kidney failure) for four of six residents. (Residents R1, R2, R3 and R4). Findings include: Review of facility policy last reviewed on 10/2/23, titled Hemodialysis informed the facility will provide the necessary care and treatment, consistent with professional standards of practice, physician orders, the comprehensive person centered care plan, and the resident's goals and preferences, to meet the special medical, nursing, mental, and psychological needs of residents receiving hemodialysis (a machine that filters waste from the blood when the kidneys are no longer able). The facility will assure that each resident receives care and services for the provision of hemodialysis consistent with professional standards of practice. This will include the ongoing assessment of the…

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

Based on review of facility 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 Activity Director personnel file Employee E18, did not include information regarding the Activity Director having completed a state approved program to be qualified to oversee the Activity Program. During an interview on 2/28/23, at 12:30 p.m. Activities Employee E18 confirmed she was not qualified to oversee the Activity Program. 28 Pa. Code: 201.18(b)(3) Management

Based on a review of facility policies, observations, and staff interviews, it was determined that the facility failed to properly monitor food temperatures,and food expiration dates in the Main Kitchen and cleanliness of two of four nursing unit food pantries (4th floor and 7th floor pantries) creating the potential for food-borne illness. Findings include: A review of facility policy Food Storage, dated 10/1/22, indicated that ready-to-eat foods shall be marked with the date at the time of opening or preparation. Foods that require refrigeration shall be stored at 40° Farenheit (F) or lower. If there is any question about a product's storage or expiration, product shall be discarded. A review of the facility policy Food Temperatures dated 10/1/22, indicated that the temperature of food items on tray line shall be taken and recorded before the start of serving. During an observation in the Main Kitchen on 2/27/23, at 9:00 a.m., the walk-in cooler had a temperature of 62° F. The cooler contained four opened gallons of juice with no date, 10 cases of iced tea in gallon containers,…

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

Based on review of facility policy, observations and staff interview it was determined that the facility failed to make certain all residents had accessible access to a telephone to make a call with privacy on four of four nursing units (Fourth Floor, Fifth Floor, Sixth Floor, and Seventh floor). Findings include: Review of facility admission Notice Packet indicated that residents have the right to privacy with regard to accommodations, medical treatment, written and telephone communications, visits and meetings with family and other resident groups. Review of a resident representative's concern indicated that a resident had to wait over three weeks to get a phone installed in their room. During an interview on 3/2/23, at 9:30 a.m. Resident R77 had two land line phones in her room, and indicated that neither one has a cord to connect it to the phone outlet on the wall, and facility staff has never gotten a cord for these phones, and she has to use her roommates phone. During an interview on 3/2/23, at 12:05 p.m. the Nursing Home Administrator confirmed that R77's land line phone was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, and resident and staff interviews, and observations, it was determined that the facility failed to maintain sanitary conditions and a homelike environment on three of four resident floors (Fourth, Fifth and Sixth floors). Findings include: Review of the facility policy Safe Homelike Environment last reviewed 10/1/22, indicated in accordance with residents rights, the facility will provide a safe, clean, comfortable and homelike environment. Environment refers to any environment in the facility that is frequented by residents, including the residents rooms and bathrooms. During an observation on 3/1/23 at 12:10 p.m. Resident R61's mattress was noted to have large dark colored stain in the center of it, was sagging in the center where the buttocks would go, and the protective waterproof mattress layer was worn away in several areas around the center. During an interview on 3/1/23 at 12:20 p.m., upon inquiry, Unit Manager Employee E4 confirmed that he personally would not want to…

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

Based on review of the grievance policy, facility documents and staff interview it was determined that the facility failed to document, assign, resolve, and provide response to residents and/or their responsible parties regarding concerns for seven of seven grievances reviewed. Findings include: Review of the facility policy Grievance/Concern Resolution dated 10/21/22, indicated the facility strives to resolve resident and family concerns in a timely manner. Squirrel Hill utilizes a grievance form to identify concerns and track via a monthly log. During the facility's full health survey there was no monthly log provided. Review of the individual Concern/Grievance Forms related to delays/lack of care revealed the following: -Forms dated 2/2/23, 2/8/23, 2/13/23, 2/15/23, 2/16/23 & 2/20/23 failed to be assigned or provide a grievance resolution. During an interview on 3/3/23, at 3:07 p.m. the Director of Nursing confirmed that the facility failed to document, be assigned and be resolved for seven of seven grievances. 28 Pa. Code: 201. 29(1) Resident Rights 28 Pa. Code: 201. 18(e)(4)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy and clinical record review and resident, and staff interviews, it was determined that the facility failed to make certain that bathing, nail care, and assistance for activities of daily living were consistently provided for four of seven residents (Residents R61, R132, R357, R368). Findings include: Review of the facility policy Bath, Shower/Tub last reviewed 10/1/22, instructs facility staff to document the date and time the shower/tub bath was performed. Review of the facility policy Nail Care last reviewed 10/1/22, instructs facility staff to document completion of task when nail care is completed, or if the resident refuses. Review the clinical record indicated that Resident R61 was admitted to the facility on [DATE]. The Minimum Data Set (MDS-periodic assessment of care needs) dated 12/7/22, included diagnoses of Hypertension (high blood pressure), diabetes mellitus (disorder that results in dysfunction in processing sugars), and above the knee amputations of both 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 resident group interview and staff interview, it was determined that the facility failed to provide an ongoing program of activites based on the identified preferences/interests for eleven of eleven resident's to enhance the resident's quality of life. Findings include: During a review of Activities Calendar's for the dates October 2022- February 2023, all activities end at 3:30 p.m. During the Resident Council Group meeting on 2/28/23, at 2:00 p.m. the group consensus indicated that there are not enough activities, especially in the evening. During an interview on 3/1/23, at 2:15 p.m., the Activity Director E18 stated that activities end at 3:30 p.m. and the facility does not do activities in the evenings; the facility failed to provide activities to meet the needs of the residents. 28 Pa. Code: 201. 18(b)(3) Management 28 Pa. Code: 207.2(a) Administrators Responsibility

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy and clinical records, observations and staff interview it was determined that the facility failed to administer medications with a medication error rate that was less than five percent for two of three residents (Resident's R99 and R147). Findings include: Two medication errors occurred during 26 observed opportunities, which resulted in a 7% medication error rate. Review of the facility policy Administering Medications last updated 10/1/22, indicated medications must be administered in accordance with the orders, including any required time frame. Review of R99's Minimum Data Set (periodic review of care needs) indicated she was admitted on [DATE], and her current diagnosis included obesity, pancreatitis (inflammation of the pancreas gland) and depression. Review of Resident R99's physician order dated 6/15/21 instructed the nurse to give sucralfate (coats stomach and treats acid reflux) 10 milliliters before meals and at bedtime. Review of Resident R147's MDS dated [DATE],…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, manufacturer recommendations, observations, and staff interviews, it was determined that the facility failed to properly store biologicals and medications in two of three medication rooms (4th and 5th floors) and two of four medication carts (4th Floor South and 6th Floor North medication cart.) Findings include: Review of the facility policy Medication Storage dated [DATE], states medications will be stored in the pharmacy and /or medication rooms according to the manufacturer ' s recommendations. Manufacturer's recommendations of Tubersol (Tuberculin Purified Protein Derivative) instruct a vial of Tubersol which has been entered and in use for 30 days should be discarded. Manufacturer guidelines for Lispro Insulin indicate that once accessed or no longer refrigerated, the insulin pens should be dated and used within 28 days. Manufacturer guidelines for Spriva Respimat (a respiratory inhaler) indicate that three months after insertion of cartridge, throw away the Spriva…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, staff interviews and manufacturer guidelines, the facility failed to perform glucometer control testing on four of six nursing units (4th floor South and North Units and 5th floor South and North units.) Manufacturer guidelines for the Assure Platinum Blood Glucose meter (a machine used to check the blood sugar levels of residents) indicate that the meter should be tested when using a new bottle of test strips. During an observation on 2/27/23, at 2:05 p.m. of the glucometer control testing logs for the 4th floor, the South Hall was noted to have no tests performed for the month of January 2023 and only two tests performed during the 26-day review period in February 2023. The North Hall logs was noted to have no tests performed for the month of January 2023, and three tests performed during the 26-day review period in February 2023. During an interview at that time, Licensed Practical Nurse Employee E5 reported that the control tests should have been performed daily, and confirmed that the logs were incomplete for January and February. During an observation 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.

Based on a Resident Group meeting and individual resident and staff interviews, it was determined that the facility failed to provide care in an environment, which promotes each resident's quality of life by failing to respond timely to residents' request for assistance for receiving telephone calls for three of three residents (Resident R17, R73 and R145) and provide prompt assistance to meet residents care needs for two of five residents who require incontinence care (Residents R10 and R73) Findings included: During an interview with Resident R365 on 2/27/23, at 11:22 a.m., it was stated that she activated her call bell at 6:00 a.m. and staff responded by shutting off her call light and telling her that she will have to wait. She then rang call bell again at 6:30 a.m. and staff responded by shutting off the call light again and telling her they will be back after shift change. Call light was activated again at 7:20 a.m., and staff responded by shutting off her light and telling her she will have to wait because trays (breakfast) are coming. Resident R 365 stated that she had…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy and clinical records, and resident and staff interviews it was determined that the facility failed to prevent the misappropriation of resident property for four of six resident (Residents R108, R130, R106 and R99) Findings include: Review of the facility policy Abuse and Neglect Prevention updated 10/1/22, indicated the misappropriation of resident property is defined as the deliberate misplacement, exploitation, or wrongful, temporary or permanent use of a residents personal belongings or money without a residents consent. Review of the facility policy Resident Personal Food Storage and Handling indicated a separate refrigerator specifically intended for resident food storage will be maintained by the facility. All prepared perishable food or beverages brought in by residents, family or visitors for resident use will be labeled with the residents name and date the item was stored. All food and beverages must be labeled and dated with the residents name and date otherwise it…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy and clinical records and staff interview, it was determined that the facility failed to report an incident of alleged verbal abuse as required to the State Agency for one of three residents (Resident R72). Findings include: A review of the facility policy Abuse and Neglect Prevention dated May 10/1/22 indicated the Administrator or the Director of Nursing will ensure that all alleged or suspected violations involving abuse are investigated and reported immediately to the Pennsylvania Department of Health. A review of the clinical record face sheet indicated that Resident R72 was admitted to the facility on [DATE], with diagnoses that included seizures, stroke, diabetes, and asthma. A review of the MDS (minimum data set - resident assessment and care screening) dated 12/12/22, indicated the diagnoses remain current and Resident R72 is cognitively intact. A review of a Grievance/Concern Form dated 1/24/23, indicated Resident R72 approached nursing for ice. The nurse responded,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 interviews, it was determined that the facility failed to ensure that a comprehensive resident care plan was implemented related to communication needs for one of two residents (Resident R 98). Findings include: Review of clinical record indicated Resident R98 was admitted to the facility on [DATE], with diagnoses that included diabetes (a disease that results in too much sugar in the blood), tracheostomy (an incision in the windpipe made to relieve an obstruction in breathing), and kidney failure. A review of Minimum Data Set (MDS- periodic review of resident needs) dated 2/8/23, indicated that the above diagnoses remain current. During an interview on 2/28/23, at 1:11 pm, Resident R98 was mouthing words, with no sound being emitted from her mouth. Resident used gestures to try to convey what she wanted to communicate; however, little could be understood. Resident was asked if she would like a pen and paper to communicate, she shook her head no.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, resident interviews, and staff interviews it was determined that the facility failed to follow physician orders as required for one of three residents (Resident R365) and failed to ensure qualified and appropriately trained staff were providing direct care to residents for one of one Resident (Resident R132). The Nursing Home Reform Act, adopted by Congress as part of the Omnibus Budget Reconciliation Act of 1987 (OBRA '87), mandated training and evaluation standards for nurse aides who work in nursing facilities. Each state is responsible for following the terms of this federal law. The facility Job description for Certified Nursing Assistant dated 10/1/22 in accordance with current federal, state, and local standards governing the facility and lists job duties including Personal Care Functions: Assist residents with bath functions (i.e., bed bathtub or shower bath, etc.) as directed. Findings include: A review of the clinical record revelaed that Resident R132 was admitted to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of clinical records, and staff interviews, it was determined that the facility failed to provide necessary treatment and services to promote healing of pressure injuries for two of five residents (Residents R361 and R369). Findings include: Review of clinical record revealed that Resident R361 was admitted on [DATE], with diagnoses that include Chronic Obstructive Pulmonary Disease (COPD- lung disease that blocks airflow and makes it difficult to breathe), hypertension (high blood pressure), and congestive heart failure (a chronic condition in which the heart does not pump blood as well as it should). A review of the Minimum Data Set assessment (MDS-a periodic assessment of resident care needs) dated 2/24/23, indicated the diagnoses remain current. Review of clinical record for Resident R361 revealed an order written on 2/18/23, to apply zinc ointment and foam dressing to left buttock in the morning. Review of Treatment Administration Records (TAR) from February 20223, revealed that Resident R361…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy and clinical record and staff and resident interviews, it was determined that the facility failed to make certain that residents are free of significant medication errors for one of four residents (Resident R72) Findings include: A review of the facility policy Administering Medications dated 10/1/22, indicated it is policy to safely administer medications to residents as prescribed by the practitioner and in accordance with current standards of practice. A review of Resident R72's Minimum Data Set (periodic review of care needs) dated 12/12/22, indicated the resident was admitted on [DATE], and current diagnosis include seizures, diabetes, high blood pressure, and asthma. The resident is cognitively intact. A review of Resident R72's physician orders dated 1/17/23, indicated to give Dilaudid (a narcotic that treats pain) 4 Milligrams (MG) by mouth every four hours as needed. A review of Resident R72's Individual Narcotic Inventory Form dated 1/12/23, for Dilaudid 4 MG…

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