Wecare At Mt Lebanon Rehabilitation And Nrsg Ctr

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the facility policy, 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 advance directive instructions, for two of eight residents reviewed (Resident R13, and R85).Findings Include: A review of the facility policy Advance Directives last reviewed 1/22/25, indicated it's the policy of this facility that each resident has the right to formulate an Advance Directive. The interdisciplinary team will review annually with the resident his or her advance directives to ensure that such directives are still the wishes of the resident. Such reviews will be made during the annual assessment process and recorded in the medical record. Review of the Resident Assessment Instrument 3.0 User's Manual, effective October 2023, indicated that a Brief Interview for Mental Status (BIMS) is a screening test that aids 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.

Based on review of facility policy, observation, resident, and staff interviews, it was determined that the facility failed to provide a safe, clean, comfortable, and homelike environment for thirteen of twenty residents (R2, R10, R13, R77, R500, R501, R502, R503, R504, R505, R506, R507, R508, and 509) on two of two nursing units (ground floor G wing and first floor 1 wing).Findings included: Review of the facility policy Homelike Environment dated 1/22/25, indicated in part The facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include clean bed and bath linens that are in good condition. During an observation on 9/15/25, at approximately 10:55 a.m. of Resident R77's room revealed the bed linen to be extremely worn, with areas thin enough to make the blue mattress visible beneath it. During a group interview, on 9/15/25, at approximately 11:00 a.m., consensus from the group, Residents R500, R501, R502, R503, R504, R505, R506, R507, R508 and R509 verbalized…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 make certain, residents who voice grievances can do so without fear of discrimination or reprisal for ten of seventeen residents (R86, R500, R501, R502, R503, R504, R505, R506, R507, and R508) and failed to display written information on the grievance procedure and grievance official contact information in the building (main lobby, ground floor G wing and first floor 1 wing).Findings include: The resident has the right to voice grievances to the facility or other agency or entity that hears grievances without discrimination or reprisal and without fear of discrimination or reprisal. Such grievances include those with respect to care and treatment which has been furnished as well as that which has not been furnished, the behavior of staff and of other residents, and other concerns regarding their LTC facility stay.Notifying resident individually or through postings in prominent locations throughout the facility of the right to file grievances orally or in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy review, clinical record review, and staff interview, it was determined that the facility failed to ensure that the resident and/or their representative received written notice of the facility bed-hold policy at the time of transfer for two of four residents reviewed for hospitalization (Resident R5 and R12).Findings Include: Review of the facility policy Bed-Holds and Returns dated 1/22/25, indicated, All residents/ representatives are provided written information regarding the facility bed-hold policies, which address holding or reserving a resident's bed during periods of absence (hospitalizations or therapeutic leave). Residents are provided written information about these policies at least twice: Well in advance of any transfer (e.g. in the admission packet); and At the time of transfer (or, if the transfer was an emergency, within 24 hours). Review of the clinical record indicated Resident R5 was readmitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident R5'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.

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 ensure that MDS assessments accurately reflected the resident's status for five of twelve residents (Resident R2, R5, R53, R66, and R82).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 least sometimes understood. Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy and documents, clinical record review, resident, and staff interviews, it was determined that the facility failed to make certain that necessary care and services were provided for four of sixteen residents (Resident R5, R13, R71, and R97).Findings include: Review of facility policy Activities of Daily Living (ADL), Supporting reviewed 1/22/25, indicated resident will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. 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 2023, indicated that a BIMS…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 observations and resident and staff interviews, it was determined that the facility failed to follow physician's orders for five of eight residents (Resident R4, R5, R10, R37, and R77). Findings include: 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 resident care needs) dated 7/30/25, included diagnoses of anoxic brain injury (injury to the brain caused by a complete lack of oxygen) and chronic hepatitis (inflammation of the liver caused by viruses). Review of Resident R37's plan of care dated 4/27/25, indicated Resident R37 has a skin integrity impairment on the left lower extremity related to the history of abscess and non-healing wound. Included in the interventions for this care plan were to administer treatments as ordered. Review of a physician's order dated 8/18/25, indicated to cleanse Resident R37's left lower leg wounds with Dakins (disinfectant solution) 0.25. Apply…

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

Based on observations and staff interviews, it was determined that the facility failed to provide a safe environment for residents on two of two nursing units (Ground Floor and First Floor).Findings include: During an observation of the Ground Floor Soiled Utility Room on 9/14/25, at 2:03 p.m. the door was noted to be unsecured, with sharps containers and biohazardous waste containers accessible to residents. During an observation of the Ground Floor Soiled Utility/Trash Room on 9/14/25, at 2:03 p.m. the door was noted to be unsecured, with refuse and soiled linen accessible to residents. During an observation on 9/16/25, at approximately 1:00 p.m. a facility maintenance room on the Ground Floor was noted to be unsecured, with circuit breaker boxes accessible to residents. During an observation on 9/16/25, at approximately 1:00 p.m. a facility maintenance room on the First Floor was noted to be unsecured, with circuit breaker boxes accessible to residents. During an observation on 9/17/25, at 1:36 p.m. of the outdoor smoking area revealed a propane grill, with propane tank attached…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of resident and staff interviews, and grievance review, it was determined that the facility failed to have sufficient nursing staff to provide nursing and related services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for nineteen of twenty-four residents (Residents R5, R11, R13, R48, R62, R64, R71, R77, R79, R81, R500, R501, R502, R503, R504, R505, R506, R507, R508, and R509). Findings include: During an interview on 9/14/25, at 12:15 p.m. when asked if he felt the facility maintained sufficient staff to care for resident needs, Resident R11 stated, No! Review of the clinical record indicated Resident R5 was readmitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident R5's minimum data set (MDS, periodic assessment of resident care needs) dated 6/15/25, included diagnoses of cirrhosis (chronic damage leading to scarring and failure) of the liver and muscle wasting. Review of a physician order dated 9/9/25, indicated Cleanse…

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

Based on review of facility policy, observations, and staff interview, it was determined that the facility failed to make certain that medical supplies were properly stored and/or disposed of in two of two nursing units (Ground Floor and First Floor) and one of four medication carts (First Floor, high hall). Findings include:Review of the facility policy Storage of Medications dated 1/22/25, indicated the facility stores all drugs and biologicals in a safe, secure, and orderly manner. Unlocked medication carts are not left unattended. During an observation of the Ground Floor Soiled Utility Room on 9/14/25, at 2:03 p.m. a large box of vacutainer one-use holders (plastic sheath for blood-collecting tubes). During an observation of the First Floor Soiled Utility Room on 9/15/25, at 11:48 a.m. the following clean items were observed:-Blood-collecting sets.-Vacutainers, greater than 100.-Gauze-Aerobic blood culture bottle, with an expiration date of 7/26/25.-Anaerobic blood culture bottle, with an expiration date of 5/29/25.-Bandages, multiple boxes-Alcohol wipes-(2)Urine collection…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical records, and staff interview, it was determined that the facility failed to notify physicians of increased capillary blood glucose (CBG) levels for one of three residents (Resident R42). Findings include: Review of the facility policy Change in a Resident's Condition or Status dated 1/22/25, indicated, The nurse will notify the resident's Attending Physican or physician on call when there has been a specific instruction to notify the Physician of changes in the resident's condition. Review of the clinical record indicated Resident R42 was admitted to the facility on [DATE] and readmitted on [DATE]. Review of Resident R42's Minimum Data Set (MDS - a mandated assessment of a resident's abilities and care needs) dated 8/8/25, included diagnoses of high blood pressure and diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time). Review of a physician's orders dated 12/18/24, and reordered 7/15/25, indicated to inject Humalog…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of facility policy, clinical record review, observations, and staff interview it was determined that the facility failed to develop person-centered care plans for three of eight residents (Resident R14, R62, and R77). Findings include: Review of the facility policy, Care Plans, Comprehensive Person-Centered dated 1/22/25, indicated, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs is developed and implemented for each resident. Review of the facility policy, Smoking Policy - Residents dated 1/22/25, indicated, Electronic cigarettes are permitted in designated areas only. Residents who wish to use e-cigarettes are instructed on battery safety and tips to avoid battery explosions per FDA (United States Food and Drug Administration) recommendations. Instruction specific to e-cigarette safety is documented in the resident care plan. Review of Resident R14's admission record indicated she…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 observations, clinical record review, and staff interviews, it was determined that the facility failed to ensure that residents are free of significant medication errors for two of five residents reviewed (Resident R94 and R85). Findings include: Review of the United States Food and Drug package insert for levothyroxine sodium (synthetic thyroid hormone used to treat hypothyroidism, a condition where the thyroid gland does not produce enough T4) dated 12/2017, indicated: Administer once daily, preferably on an empty stomach, one-half to one hour before breakfast. Administer at least 4 hours before or after drugs that are known to interfere with absorption. Listed within the medications that interfere with levothyroxine absorption were: Proton-pump inhibitors - Gastric acidity is an essential requirement for adequate absorption of levothyroxine. Sucralfate, antacids and proton pump inhibitors may cause hypochlorhydria, affect intragastric pH, and reduce levothyroxine absorption. Review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical records, facility documents, and staff interview, it was determined that the facility failed to investigate incidents of possible abuse and neglect for one of two residents (Residents R1).Based on review of facility policy, clinical records, facility documents, and staff interview, it was determined that the facility failed to investigate incidents of possible abuse and neglect for one of two residents (Residents R1).Review of facility policy Abuse and Neglect - Clinical Protocol reviewed 1/22/25, indicated the nurse will assess the individual and document related findings. The facility defines abuse as the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain, or mental anguish. Abuse also included the deprivation by an individual of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Willful is defined as the individual must have acted deliberately,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 interviews, it was determined that the facility failed to properly secure the treatment cart for one of four carts observed (First floor Team #1 medication cart).Based on review of facility policy, observations, and staff interviews, it was determined that the facility failed to properly secure the treatment cart for one of four carts (First Floor Team #1 Medication Cart).Review of the facility policy Storage of Medications reviewed 1/22/25, indicated medications and biologicals are stored safely, securely, and properly. Drugs and biologicals used in the facility are stored in locked compartments. Only persons authorized to prepare and administer medications have access to locked medications.During an observation on 7/15/25, at 9:40 a.m. First floor Team #1 medication cart was observed in the hall by the nurse's station unlocked and unattended.During an interview on 7/15/25, at 9:45 a.m. Registered Nurse Employee E1 confirmed the first floor Team #1v medication cart was unattended and unlocked.During an interview on 7/15/25,…

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

Based on a review of facility policy, resident choice menu selections, resident interviews, it was determined that the facility failed to provide resident selected menu items for 14 of 20 residents (Resident R2, R5, R6, R7, R8, R9, R10, R12, R13, R14, R15, R16, R17, R19, and R20). Findings include: Review of the facility policy, Food and Nutrition Services dated 9/9/24, indicated Food and nutrition services staff will inspect food trays to ensure that the correct meal is provided to each resident, the food appears palatable and attractive, and it is served at a safe and appetizing temperature. If an incorrect meal is provided to a resident, or a meal does not appear palatable, nursing staff will report it to the food service manager so that a new food tray can be issued. During a dinner meal observation, on 4/16/21, at beginning at 4:52 p.m. the following was observed: Resident R2 had requested two ginger ale and two puddings on his meal ticket, did not receive either. Resident R5 received one chocolate cookie, rather than the two listed on the meal ticket. Resident R6 did not…

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

Based on review of facility policy and resident staff interviews, it was determined the facility failed to consistently provide snacks as desired by residents for of residents six of eight residents (Resident R2, R9, R11, R17, R19, and R20). Findings include: Review of facility policy titled Frequency of Meals dated 9/9/24 indicated, Evening snacks will be offered routinely to all residents. During an interview on 4/16/25, at 4:57 p.m. when asked if the facility provides evening snacks, Resident R20 responded, Sometimes. During an interview on 4/16/25, at 4:58 p.m. when asked if the facility provides evening snacks, Resident R9 responded, Once in a while. During an interview on 4/16/25, at 5:13 p.m. when asked if the facility provides evening snacks, Resident R2 responded, Hopefully, if they have some. During an interview on 4/16/25, at 5:29 p.m. when asked if the facility provides evening snacks, Resident R11 responded, No. Resident R11 continued on to say that she gets snacks once a month and that staff eat the snacks rather than provide them to the residents. During an interview…

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

Based on observations and resident and staff interviews, it was determined that the facility failed to maintain an effective pest control program for one of two nursing units (Ground Floor nursing unit). Findings include: The facility PEST CONTROL POLICY dated 9/9/24, indicated that the facility will maintain an effective pest control program. During an interview on 4/13/25, at 11:08 a.m. Resident R1 stated that she often sees small ants and spiders in her room. Resident R1 stated that when the exterminator was in recently, her room was not treated. During an observation of Resident R2 ' s room on 4/13/25, at 11:35 a.m. there were ants observed on the floor below the PTAC unit (packaged terminal air conditioner, a self-contained heating and air conditioning system usually mounted through a wall). During an observation of the empty room G0004 on 4/13/25, at 11:38 a.m. the PTAC unit had been removed, leaving only the outer metal case. This case had grates to allow air flow through. Ants were visible in this room in the PTAC case. During an observation of Resident R3 ' s room on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility documents, clinical record review, and staff interview, it was determined that the facility failed to provide adequate supervision to prevent elopement one of four residents (Resident R1). Findings include: Review of the facility policy, Wandering and Elopements dated 9/9/24, indicated the facility will identify residents who are at risk of unsafe wandering. Review of the Resident Assessment Instrument 3.0 User's Manual, effective October 2023, indicated that a Brief Interview for Mental Status (BIMS) is a screening test that aides in detecting cognitive impairment. The BIMS total score suggests the following distributions: 13-15: cognitively intact 8-12: moderately impaired 0-7: severe impairment Review of Resident R1's admission record indicated he was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident R1's Minimum Data Set (MDS-periodic assessment of a resident's abilities and care needs) dated 9/19/24, included diagnoses of diabetes (a metabolic disorder in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility documents, clinical record review, and staff interview, it was determined that the facility failed to make certain residents with cognitive decline were reassessed for elopement, for one of four residents (Resident R1). Findings include: Review of the facility policy, Dementia - Clinical Protocol dated 9/9/24, indicated for the individual with confirmed dementia, the IDT (interdisciplinary care team will identify a resident-centered care plan to maximize remaining function and quality of life. Review of the Resident Assessment Instrument 3.0 User's Manual, effective October 2023, indicated that a Brief Interview for Mental Status (BIMS) is a screening test that aides in detecting cognitive impairment. The BIMS total score suggests the following distributions: 13-15: cognitively intact 8-12: moderately impaired 0-7: severe impairment Review of Resident R1's admission record indicated he was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident R1's Minimum Data Set…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, resident and staff interviews, it was determined that the facility failed to maintain a clean homelike environment for two of two nursing floors observed. (Ground and First Floor). Findings Include: During an observation on 10/31/24, from 8:06 a.m., through 10:00 a.m., the following was identified: Resident room [ROOM NUMBER] G- empty bathroom faucet was turned on to hot, from 8:06 a.m., though 8:26 a.m, the water ran continuously producing luke warm water to touch. There were holes in the wall in the bathroom. Resident R1 bathroom water was started at 8:12 a.m., and ran til 8:28 a.m., and was lukewarm to touch. Resident R1 stated that the water has to run and run for it to get hot. Holes were identified in the bathroom wall. room [ROOM NUMBER]G- empty bathroom faucet ran from 8:17 a.m., through 8:32 a.m, producing lukewarm water to touch. The HVAC unit was sitting off the wall with the outside plate to attach unit as the only barrier with several holes to the outside. Resident R2 and R3'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.

Based on review of facility policy, observations and staff interviews, it was determined that the facility failed to maintain infection control practices to prevent the potential for cross contamination during a dressing change. Findings include: Review of the facility policy Dry/Clean Dressings dated 4/9/24, indicated to clean the bedside stand before and after dressing change. Place the clean equipment on the clean field. Wash and dry hands thoroughly. Label tape or dressing with date, time, and initials. During an observation on 9/19/24, at 1:30 p.m. with Registered Nurse (RN) Employee E15 the following occurred during a dressing change: - a red biohazard bag was placed in the resident's regular garbage can - clean gloves donned, hands were not washed/sanitized prior - bedside table wiped but was not cleared of resident belongings - clean gloves donned again and hands were not washed/sanitized - personal scissors cleansed - items placed on bedside table (including a box of gloves, bag of cling gauze, and roll of tape) a clean barrier was not used - old bandage removed 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.

Based on review of facility documents and staff interview, it was determined that he facility failed to provide training on behavioral health for ten of ten staff members (Employees E1, E2, E3, E4, E5, E7, E8, E9, E10, E11). Findings include: Review of Nurse Aide (NA) Employee E1's facility provided information did not include training on behavioral health. Review of NA Employee E2's facility provided information did not include training on behavioral health. Review of NA Employee E3's facility provided information did not include training on behavioral health. Review of NA Employee E4's facility provided information did not include training on behavioral health. Review of NA Employee E5's facility provided information did not include training on behavioral health. Review of Activities Aide Employee E7's facility provided information did not include training on behavioral health. Review of Dietary Aide Employee E8's facility provided information did not include training on behavioral health. Review of Housekeeping Employee E9's facility provided information did not include training…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical records and staff interview, it was determined that the facility failed to provide the opportunity to formulate an advance directive (a written instruction such as a living will or durable power of attorney for health care for when the individual is incapacitated) for six of nine residents reviewed (Resident R27, R39, R42, R50, R55, and R67). Findings include: A review of the facility Advance Directives 12/29/23 and 4/9/24, indicated the resident has the right to formulate an advance directive, including the right to accept or refuse medial or surgical treatment. A review of the medical record indicated Resident R27 was re-admitted to the facility on [DATE], with diagnoses that included diabetes, depression, and anxiety. A review of the clinical record failed to reveal an advanced directive or documentation that Resident R27 was given the opportunity to formulate an Advanced Directive. A review of the medical record indicated Resident R39 was re-admitted to the…

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

Based on review of facility policy and documentation, 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 five of five nurse aides (Employee E1, E2, E3, E4 and E5). Finding include: A review of the facility policy In-Service Training dated 4/9/24 and 12/29/23, indicated all staff (means all new and existing staff), are able to interact in a manner that enhances the resident's quality of life and quality of care and can demonstrate competency in the topic areas of the training. Review of the Facility Assessment dated 9/10/24, indicated that staff are trained on policies and procedures, consistent with their roles. This also includes determining if new or updated policies are needed, and ensuring they are developed or updated. Review of Nurse Aide (NA) Employee E1, E2, E3, E4 and E5's education records with hire date greater than 12 months revealed the following: NA Employee E1 had a hire date of 12/16/14, with 4 hours in-service training…

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

Based on review of facility policy, clinical records, and interviews with staff, it was determined that the facility failed to complete a Level II evaluation by a state Preadmission Screening and Resident Review (PASARR) representative to determine if the resident has a physical or mental condition, what specialized or rehabilitative services he or she needs, and whether placement in the facility is appropriate for one of three residents (Resident R15). Findings include: A review of the facility policy titled Policy Interpretation and Implementation dated April 9, 2024, revealed that it was the responsibility of the facility to assure that all residents admitted to the facility receive a screening (Level I) and referral for Level II in accordance with State and Federal Regulations. Review of Resident R15's clinical record indicated the PASARR form for this resident was accurately completed and revealed the resident needed a Level II evaluation. The resident had a diagnosis of Schizophrenia and bi-polar disorder. During an interview with Social Services Employee E6, at 1:34 p. m., on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, 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 two of seven residents reviewed (Residents R39, and R78). Findings include: The Centers for Disease Control defines diabetes as: Diabetes Mellitus is a chronic (long-lasting) health condition that affects how your body turns food into energy. Most of the food you eat is broken down into sugar (also called glucose) and released into your bloodstream. When your blood sugar goes up, it signals your pancreas to release insulin. Insulin acts like a key to let the blood sugar into your body's cells for use as energy. If you have diabetes, your body either doesn't make enough insulin or can't use the insulin it makes as well as it should. When there isn't enough insulin or cells stop responding to insulin,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 interview, it was determined that the facility failed to provide adequate supervision due to documentation for the bed mobility needs for one of five residents (Resident R8), which resulted in a roll out of bed. Findings include: Review of the Resident Assessment Instrument (RAI) 3.0 User's Manual effective October 2019, indicated that bed mobility is defined as how resident moves to and from lying position, turns side or side, and positions body while in bed or alternate sleep furniture. The RAI further indicated that How a resident turns from side to side, in the bed, during incontinence care, is a component of Bed Mobility and should not be considered as part of Toileting. Review of American Congress of Rehabilitation Medicine - Caregiver Guide and Instructions for Safe Bed Mobility published 4/28/17, indicated bed mobility refers to activities such as scooting in bed, rolling, side-lying to sitting, and sitting to lying down. Resident R8 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 observations and staff interviews, it was determined that the facility failed to properly dispose of expired and/or opened medical supplies in one of two medication rooms (First floor). Findings include: During an observation of the facility medication room on [DATE], at 1:15 p.m. of the facility medication room, the following was observed: -19 Medline triple pack povidone iodine swabsticks with expiration date of 3/2024. -16 Curad oil emulsion dressing with expiration date of [DATE]. -16 Dynarex DynaSorb super absorbent dressing with expiration dates of [DATE]. -25 Brava strip paste coloplast with an expiration dates of [DATE],[DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. -One I Medical Devices IM41000 small bore extension set 7 with an expiration date of [DATE]. During an interview on [DATE], at 10:11 a.m. the Nursing Home Administrator confirmed the facility failed to properly dispose of expired and/or opened medical supplies in one of one medication rooms. 28 Pa. Code: 211.10(c)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of facility policy, clinical records, and staff interview, it was determined the facility failed to ensure the right to retain personal possessions for one of three residents (Resident R1). Findings include: A review of the facility policy Personal Property dated 4/9/24, stated the resident has the right to retain and use personal possessions, including some furnishings, and appropriate clothing, as space permits, unless to do so would infringe upon the rights or health and safety of other residents. Review of the clinical record indicated that Resident R1 was originally admitted to the facility on [DATE], with a readmission date of 2/6/24. Review of the Minimum Data Set (MDS, periodic assessment of resident care needs) dated 6/5/24, included diagnoses of anxiety and depression. Review of Resident R1's care plan, most recently updated on , included goals and interventions for a psychosocial wellbeing problem. Review of a psychotherapy progress note dated 10/4/23, indicated that Resident R1…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 financial documents, interviews with vendors and staff, it was determined that the facility failed to pay bills in a timely manner for services without which the residents' health and safety are potentially impacted. Findings include: 28 PA Code Commonwealth of Pennsylvania Long Term Care Licensure Regulations, subsection 201.14(g), dated July 1, 2023, indicated that a facility owner shall pay in a timely manner bills incurred in the operation of a facility that are not in dispute and that are for services without which the residents' health and safety are jeopardized. Review of facility provided Accounts Payable Ledger on 1/30/24, at 8:45 a.m., indicated Vendor 1 with an outstanding balance of $2,707.31 for services from October 2023, and prior. Interview with Nursing Home Administrator on 1/30/24, at 10:12 a.m., indicated that the facility utilizes the company for equipment such as oxygen concentrator's and specialty beds for residents requiring them. The NHA indicated that she does not review the ledger as the Consultants pay the bills and that the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews, it was determined that the facility failed to ensure that residents were provided a written notice of his or her rights and services provided, as well as all rules and regulations governing resident conduct and responsibilities during their stay in the facility prior to or upon admission for 13 of 13 residents (R4, R5, R6, R2, R7, R8, R9, R3, R10, R11, R12, and R13). Findings include: Review of the facility provided admission Packet included: application for admission, personal information, legal representation, choice of funeral home, income information, provision of services, charges and billing, Medicare/Medicaid programs, personal finances, transfers, bed holds, resident responsibilities, personal properly, notice of privacy practices, authorization of treatment, grievance procedures, and the facility arbitration agreement. Review of residents admitted to the facility between 10/16/23, through 12/6/23, revealed the following: During an interview on 12/8/23, 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 review of facility policy, clinical records and staff interview, it was determined that the facility failed to document notification of emergency contacts of emergent hospital transports for two of five residents (Resident R1 and R2). Findings include: Review of the facility policy, Notification of Change of Condition: Responsible Party/Guardian last reviewed 3/21/23, indicated the responsible party or guardian is to be notified of changes in condition or occurrences to ensure that the resident's responsible party or guardian is notified of changes and /or occurrences and action and pertinent information are documented. Review of the clinical record revealed that Resident R1 was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS - periodic assessment of care needs) dated 9/21/23, included diagnoses dementia (a group of symptoms that affects memory, thinking and interferes with daily life) and diabetes (a metabolic disorder in which the body has high sugar levels for prolonged…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 completed in the required time frame for 14 of 20 newly admitted residents. 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 2019, indicated that an admission MDS assessment was to be completed no later than 14 days following admission. Review of the facility policy MDS/RAI/Care Planning dated 3/21/23, indicated residents will have a comprehensive assessment completed by day 14 of a stay. Resident R15 had an admission date of 2/10/23, with an MDS completion date of 3/6/23. Resident R16 had an admission date of 2/10/23, with an MDS completion date of 3/7/23. Resident R17 had an admission date of 2/10/23, with an MDS completion date 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 and clinical records, and staff interview, it was determined that the facility failed to make certain that comprehensive Minimum Data Set assessments were completed accurately for eleven of 20 newly admitted residents (R14, R16, R18, R20, R21, R22, R23, R25, R26, R28, and R29). 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 2018, and updated October 2019, 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…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 admission documents and staff interview, it was determined that the facility failed to ensure resident rights to make informed decisions and choices about important aspects of residents' health, safety and welfare by making certain residents understand the conditions of a binding arbitration agreement and failed to ensure the agreement is explained to the resident and his or her representative in a form and manner that he or she understands, three of seven residents (Resident R14, R30, and R31). Findings include: Review of the facility's admission packet contained the document Voluntary Arbitration Agreement, indicated In arbitration, a neutral third party chosen by the Parties issues a final, binding decision. When Parties agree to arbitrate, they waive their right to a trial by jury and the possibility of an appeal. Review of Resident R14's admission record indicated the resident was admitted to the facility on [DATE]. Review of the Social Services Initial Assessment completed on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the facility's admission agreement and staff interviews, it was determined that the facility failed to ensure a neutral and fair arbitration process by ensuring both the resident or his or her representative, and the facility agree on the selection of a neutral arbitrator. Findings include: Review of facility's admission Agreement packet, which contained the document Voluntary Arbitration Agreement, indicated that Accordingly, any dispute arising out of relating to the provision of services by the Facility to [NAME] Resident, Resident ' s admission to the Facility, Resident ' s contracts with the Facility or the subject matter thereof, any breach of contract, including any dispute regarding the execution, validity or scope of this Arbitration Agreement or any of its clauses, will be resolved through arbitration administered by [name of arbitrator services company which the facility utilizes] and conducted pursuant to the [arbitrator] Rules of Procedure for Arbitration. The facility'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 clinical record review and staff interview, it was determined the facility failed to provide nutritional services by enteral feeding as ordered by the physician for one of two residents reviewed (Residents R3). Findings include: The facility policy entitled Feeding Tubes (delivery of food or medication via tube surgically inserted into stomach) dated 3/21/23, indicated that enteral feedings may be prescribed for residents who are physically unable to take food by mouth in amounts that will support adequate nutrition. Review of admission record indicated Resident R3 admitted to the facility on [DATE]. Review of Resident R3's Minimum Data Set (MDS- periodic assessment of care needs) dated 11/18/23, indicated diagnoses of dysphagia (difficulty swallowing) following a stroke and diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time). Review of a physician order dated 11/16/23, discontinued on 11/18/23, at 2:30 p.m., indicated that Resident R3 was to receive…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 provide the opportunity to formulate an advance directive (a written instruction such as a living will or durable power of attorney for health care for when the individual is incapacitated) for seven of seven residents reviewed (Resident R9, R15, R48, R52, R68, R76, and R90). Findings include: A review of the facility policy Advanced Directive last reviewed [DATE], indicated the facility has policies and procedures which allow the withholding of CPR measures from individual residents who have advance directive stating they do not want to be resuscitated. A review of the medical record indicated Resident R9 was re-admitted to the facility on [DATE], with diagnoses that included anxiety, high blood pressure, and obesity. A review of the clinical record failed to reveal an advanced directive or documentation that Resident R9 was given the opportunity to formulate an Advanced Directive. A review…

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

Based on observation, review of Centers for Disease Control(CDC) guidelines for Legionella Control, the facility's infection control tracking log for water management and staff interviews it was determined that the facility failed to ensure the consistent implementation of infection control procedures designed to prevent the spread of infection or cross-contamination during medication administration by using handwashing, alcohol-based hand sanitizer, or wearing gloves while preparing resident medications. The facility failed to maintain a comprehensive program for water management to monitor the the potential development and spread of Legionella within the facility. Findings include: Review of the facility policy Medication Administration reviewed 3/22/22 and 3/21/23, indicated medications are administered in accordance with good nursing principles and practices. All drugs, devices, and related materials will be administered by nursing in accordance with federal and state laws. Review of the facility policy Hand Hygiene/Handwashing reviewed 3/22/23 and 3/21/23, indicated effective…

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

Based on observations, and resident and staff interviews, it was determined that the facility failed to maintain a clean, homelike environment on one of two nursing units ( First Floor nursing unit) and for six of 30 residents of the ground floor nursing units (Residents R13, R65, R60, R87, R33 and R32). The facility failed to provide residents with a personal laundry. Findings include: During an observation on 10/1723, at 9:30 a.m. , the laminate on the first floor in the main hall by the elevator was lifted which could be a tripping hazard. During an interview on 10/20/23, at 10:25 a.m., Regional Clinical Consultant Employee E21 confirmed that the facility failed to maintain a safe homelike environment. During an observation on 10/20/23, from 9:53 a.m., through 10:18 a.m., the following was observed: Residents R13 and R65's toilet was leaking onto the floor. Resident R65 stated she had told the unit manager but no one was around to fix it. Resident R60's privacy curtain was falling down blocking her vision of the hall. Resident R87's baseboard near the bathroom was cracked and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical records, facility incident reports, facility submitted documentation, and staff interviews it was determined that the facility failed to report elopements for two of three residents (Resident R23 and R67) and failed to investigate and report an incident when a resident swallowed a potentially poisoned substance (Resident R67). Findings include: Review of the facility policy Accidents and Incidents-Investigating and Reporting, last reviewed on 3/21/23, with a previous review date of 3/22/22, indicated that all accidents and incidents are to be reported. Any incident/accident regardless of how minor, must be reported to the immediate supervisor. A witness statement(s) should be completed. Review of the facility policy Elopement last reviewed on 3/21/23, with a previous review date of 3/21/22, indicated that cognitively impaired residents at risk for elopement will be appropriately monitored to reduce the potential for an injury. In the event of an electronic 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.

Based on resident interviews, review of clinical records and staff interview, it was determined that the facility failed to obtain physician orders for outside dental/oral services for two of three residents (Resident R1 and R33) and failed to provide foot care according to professional standards of practice for one of two residents (Resident R62). Findings include: During an interview on 10/17/23, at 8:22 a.m., Resident R1 stated that he had asked staff to have the doctor to see him because he felt like there was something lodged in his right upper gum and had told the nurse but no one came to see him. During an interview on 10/17/23, at 8:38 a.m., Registered Nurse Employee E45 stated that the Physician does not come in until tomorrow, but she would have him seen. Review of the clinical record indicated that on 10/18/23, the Physician and/or Nurse Practitioner had not seen resident to follow up for his gum issue. Review of the clinical record indicated that on 10/19/23, an order had been obtained for Resident R1 to have an xray of his mouth which was unable to be obtained as 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, observations, clinical records, facility incident reports, facility submitted documentation, and staff interviews it was determined that the facility failed to provide necessary supervision and maintain an environment free from potential accident hazards on one of two nursing units (Ground Floor) with unlocked accessible personal laundry area and unlocked unattended therapy rooms, failed to prevent actual elopements for two of three residents (Residents R23 and R67) and failed to make certain potentially poisonous substances were not accessible to confused residents for one of three residents (Resident R67). Findings include: Review of the facility policy Accidents and Incidents-Investigating and Reporting, last reviewed on 3/21/23, with a previous review date of 3/22/22, indicated that the facility makes all attempts to keep all residents in the facility safe from accidents. All accidents and incidents are to be reported. Any incident/accident regardless of how minor, must be…

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

Based on review of facility policies, observations, and staff interviews, it was determined that the facility failed to properly and securely store medications in two of four medication carts ( Front hall and Back Hall first floor medication carts), failed to secure narcotics on one of two medication carts (Front Hall medication cart, first floor). Findings include: Review of the facility policy Storage of Medications last reviewed on 3/21/23, with a previous review date of 3/22/22, indicated that medications are stored in a safe, secure and orderly manner in accordance with federal and state regulations and facility policies. Compartments containing medications are locked when not in use. All controlled drugs are stored under double-lock and key. During an observation on 10/17/23, at 7:55 a.m., the medication cart for the First Floor Back Hall was left unsecured. During an interview on 10/17/23, at 8:02 a.m., Licensed Practical Nurse (LPN) Employee E77 confirmed that the facility failed to properly secure medications. During an observation on 10/17/23, at 8:03 a.m., the medication…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical records and staff interview, it was determined that the facility failed to update a care plan for two of seven residents (Resident R68, and R90) to accurately reflect the current status of the resident. Findings include: Review of the facility policy MDS/RAI/Care Planning reviewed 3/22/22 and 3/21/23, indicated the residents will have a comprehensive assessment completed by day 14 of stay and a comprehensive care plan completed and reviewed within seven days of the completion of the MDS. The resident will then be assessed at least quarterly, and care plan reviewed by the interdisciplinary team. Review of the facility policy Smoking Policy, reviewed 3/22/22 and 3/21/23, indicated upon admission residents who smoke will be reviewed for safety. Review of a clinical record indicated Resident R68 was admitted to the facility on [DATE], with diagnoses that included diabetes, high blood pressure, and tobacco use. Review of Resident R68's MDS dated [DATE], 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.

Based on facility policy observation, clinical record review and staff interview, it was determined that the facility failed to provide treatment and services to prevent further decrease in range of motion for one of three residents (Resident R62). Findings include: Review of the facility policy Splint/Brace Management last reviewed on 3/21/23, with a previous review date of 3/21/22, indicated that residents will be assessed to determine a splint/brace device program to attain, maintain and prevent decline in joint mobility. During an observation on 10/18/23, at 10:00 a.m., Resident R62 had her right hand clenched with long sharp nails indenting her palm, Resident was able to open hand to a c position, she stated that her hand hurt. Resident R62's left hand was able to open except the thumb was beginning to contract. Review of the current Physician orders for Resident R62 did not include the placement or use of hand splint(s). During an interview on 10/18/23, at 10:39 a.m., Registered Nurse Employee E45 confirmed that Resident R62 had not been assessed for hand splints and had 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.

Based on review of facility records and staff interview, it was determined that the facility failed to ensure the designated Infection Preventionist was qualified with specialized training in infection prevention and control. Findings include: Review of the individual identified as the facility Infection Control (I/C) Preventionist Employee E88 personnel file, documentation did not include indication of the specialized training required to be in the position. Employee E88 had been indicated as the I/C Preventionist since August 2023. During an interview on 10/19/23, at 9:43 a.m., the Infection Control Preventionist Employee E88 confirmed that she had not completed specialized training required. 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 211.10(d) Resident care policies. 28 Pa. Code 211.12(d)(1)(5) Nursing services