Aspen Nursing And Rehab Center

Based on review of policies, clinical records, and investigation documents, as well as staff interviews, it was determined that the facility failed to ensure that residents were free from abuse for two of four residents reviewed (Residents 2, 3). Findings include: The facility's abuse policy, dated April 18, 2024, indicated that residents were not to be exposed to abuse, neglect, mistreatment and misappropriation. Neglect was defined as failure of the facility, its employees so service providers to provide goods and services necessary to avoid physical harm, mental anguish, emotional distress, or mental illness. Neglect was the unwillful act to neglect goods and services to a patient. Examples include failure to follow the care plan, failure to make accessible goods for resident, failure to reposition patient, medication errors, and call light response times. An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 2, dated October 8, 2024, revealed that the resident was understood and could understand others, 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.

Based on review of facility policies, resident interviews, observations, and staff interviews, it was determined that the facility failed to serve food items at appetizing temperatures. Findings include: The facility's policy regarding food temperatures, dated May 16, 2024, revealed that all hot items should be 135 Fahrenheit (F) or above. Cold products shall be 41 F or below. Foods failing to register these temperatures must be reheated/chilled until acceptable temperatures are reached. Observations of the lunch meal service on October 16, 2024, at 12:00 p.m. revealed that the last cart containing a test tray left the kitchen at 12:05 p.m. and arrived on the short hall at 12:07 p.m. Trays were passed to the residents and the last resident was served at 12:19 p.m. The test tray was removed from the cart at 12:20 p.m. and the temperature of the coffee was 110 F, the meat balls were 122 F, the pasta was 133 F, and the green beans were 80 F. The coffee, meatballs, pasta and green beans were lukewarm and not palatable. Interview with the Dietary Manager at the time of the observations…

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 policies, as well as observations and staff interviews, it was determined that the facility failed to ensure that food was served under sanitary conditions, failed to store food in accordance with professional standards of food service safety, and failure to ensure that dietary staff wore appropriate hair coverings in the kitchen. Findings include: The facility's policy regarding Food Preparation, Service and Sanitation, dated May 16, 2024, revealed that food and nutrition service employees were to prepare, distribute and serve food in a manner that complies with safe food handling practice by cleaning and sanitizing work surfaces and food-contact equipment between uses, following food code guidelines. Recommended storge practices include keeping all shelving and floors clean and dry at all times, wrap all food well to prevent freezer burn, and all opened and partially used foods shall be dated, labeled and sealed before being returned to a storage area. Food and nutrition services staff are to wear hair restraints so that hair does not contact food. Observations…

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 policies and clinical records, as well as observations and resident and staff interviews, it was determined that the facility failed to determine if residents were safe to self-administer medications for one of 29 residents reviewed (Resident 10). Findings include: The facility's medication administration policy, dated July 19, 2024, indicated that residents may self-administer their own medications only if the attending physician, in conjunction with the interdisciplinary care planning team, has determined that they have the decision-making capacity to do so safely. A admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 10, dated August 28, 2024, revealed that the resident was cognitively intact and required assistance from staff for daily care needs. Physician's orders for Resident 10, dated August 23, 2024, included an order for the resident to receive 20 grams(gm)/30 milliliter (ml) of Lactulose Encephalopathy Oral Solution (a medication used to treat constipation) 30 ml by mouth one time 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 observations and staff interviews, it was determined that the facility failed to provide a safe, clean, and homelike environment related to residents' wheelchairs for three of 29 residents reviewed (Residents 6, 33, 53). Findings include: The facility's policy for Homelike Environment, dated May 16, 2024, revealed that residents are provided with a safe, clean, comfortable and homelike environment. Observations of Resident 6's wheelchair on October 17, 2024, at 10:26 a.m. revealed that the vinyl material on both arm rests was torn. Observations of Resident 33's wheelchair on October 17, 2024, at 3:01 p.m. revealed that the vinyl material on both arm rests was cracked and torn. Observations of Resident 53's wheelchair on October 17, 2024, at 2:57 p.m. revealed that the vinyl material on the left arm rest was cracked and torn. Interview with the Maintenance Director on October 17, 2024, at 3:03 p.m. revealed that the wheelchair armrests for Residents 6, 33, and 53 were cracked and torn and peeling and that they should be replaced. 28 Pa. Code 201.29(j) Resident Rights. 28 Pa.…

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 clinical records, as well as staff interviews, it was determined that the facility failed to notify the state ombudsman and/or the resident and resident's responsible party in writing regarding the reason for transfers/discharge to the hospital for five of 29 residents reviewed (Residents 8, 30, 36, 55, 102). Findings include: A nursing note for Resident 8, dated July 23, 2024, at 7:19 p.m., revealed that the resident was admitted to the hospital with kidney failure. There was no documented evidence that a written notice of Resident 8's transfer to the hospital was provided to the resident's responsible party regarding the reason for transfer. An annual MDS assessment for Resident 30, dated September 6, 2024, revealed that the resident was cognitively intact, required assistance with daily care needs, and had diagnosis that included heart failure, high blood pressure, and morbid obesity. A nursing note for Resident 30, dated May 31, 2024, at 8:40 p.m., revealed that the resident had a change in condition and was transferred to the local emergency room. There 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.

Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to provide a written notice of the facility's bed-hold policy to the resident and/or the resident's representative at the time of a transfer for five of 29 residents reviewed (Residents 8, 30, 36, 55, 102). Findings include: A nursing note for Resident 8, dated July 23, 2024, at 7:19 p.m., revealed that the resident was admitted to the hospital with kidney failure. There was no documented evidence that the resident and/or the responsible party was notified about the facility's bed-hold policy at the time of the above transfer to the hospital for Resident 8. An annual (MDS) assessment for Resident 30, dated September 6, 2024, revealed that the resident was cognitively intact, required assistance with daily care needs, and had diagnosis that included heart failure, high blood pressure, and morbid obesity. A nursing note for Resident 30, dated May 31, 2024, at 8:40 p.m., revealed that the resident had a change in condition and was transferred to the local 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 the Resident Assessment Instrument User's Manual and clinical records, as well as staff interviews, it was determined that the facility failed to complete accurate Minimum Data Set assessments for five of 29 residents reviewed (Residents 5, 8, 27, 46, 47). Findings include: The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which provides guidance and instructions for the completion of Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2024, indicated that the intent of Section N was to record the number of days, during the seven days of the assessment period, that any type of injection, insulin, and/or select medications were received by the resident. Section N0415F Antibiotic Medications and Section N0415I Antiplatelet Medications (medication used to prevent blood from clotting) was to be coded if the resident took the medication during the seven-day look-back period. Physician's orders for Resident 5, dated August 12, 2024, included an order for the resident to receive 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 clinical records, as well as family and staff interviews, it was determined that the facility failed to ensure that residents were provided with showers as scheduled for one of 29 residents reviewed (Resident 19). Findings include: An admission Minimum Data Set (MDS) assessment (a federally-mandated assessment of the resident's abilities and care needs) for Resident 19, dated September 10, 2024, revealed that the resident was cognitively intact and required moderate assistance from staff for personal care needs. Resident 19's care plan, dated September 6, 2024, revealed that the resident preferred showering two times per week on Wednesday and Sunday evening shift. Review of Resident 19's bathing records for September and October 2024 revealed that the resident received a bed bath on September 18, 2024, and a shower on October 9, 2024. There was no documented evidence to indicate that Resident 19 received a shower on the other scheduled days for September and October 2024. Interview with Resident 19's daughter on October 15, 2024, at 1:30 p.m. revealed 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.

Based on review of clinical records, as well as staff interviews, it was determined that the facility failed to ensure that physician's orders were followed for three of 29 residents reviewed (Residents 10, 37, 47). Findings include: The facility's policy regarding medication administration, dated May 16, 2024, revealed that medications are administered in accordance with prescriber orders, including any required time frame. An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 10, dated August 28, 2024, indicated that the resident was cognitively intact, required assistance from staff for daily care needs, and had diagnosis of gastro-esophageal reflux disease. Physician's orders for Resident 10, dated August 23, 2024, included an order for the resident to receive 1 gram (gm) of Sucralfate (a medication used to treat conditions of the digestive tract) one table by mouth before meals and at bedtime for gastric protection. Observations during medication administration on October 16, 2024, at 8:25 a.m. revealed that…

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

Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure the accountability of controlled medications (drugs with the potential to be abused) for three of 29 residents reviewed (Residents 5, 28, 30). Findings include: The facility's policy regarding Medication Administration, dated May 16, 2024, revealed that staff are required to document the administration of medication in the resident's medical record. An annual Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 5, dated August 14, 2024, revealed that the resident is cognitively impaired, required assistance from staff for daily care needs, and had diagnoses that include high blood pressure, dementia, and pain in left lower leg. Physician's orders for Resident 5, dated April 28, 2024, included an order for the resident to receive one 5/325 milligram (mg) tablet of Oxycodone/Acetaminophen (a controlled narcotic pain medication) orally every eight hours for pain. A review of the controlled drug…

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 and clinical records, as well as interviews with staff, it was determined that the facility failed to ensure that pharmacy recommendations related to drug irregularities were acted upon by a physician for two of 17 residents reviewed (Residents 7, 37). Findings include: Review of the facility's policy regarding the Role of the Consultant Pharmacist, dated May 16, 2024, revealed that the pharmacist will review the resident's medications and notify the physician of any irregularities. The physician will then make any necessary adjustments to the resident's medication. A quarterly Minimum Data Set (MDS) assessment (a federally-mandated assessment of a resident's abilities and care needs) for Resident 7, dated August 13, 2024, revealed that the resident was cognitively impaired and had diagnoses that included Alzheimer's disease. A progress note for Resident 7, dated April 19, 2024, revealed that a Medication Record Review (MRR) was completed by the pharmacist with medication changes recommended. There was no documented evidence in the clinical…

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 clinical records, as well as observations and staff interviews, it was determined that the facility failed to maintain a medication administration error rate that was less than five percent. Findings include: Observations during medication administration on October 16, 2024, revealed that two medication administration errors were made during 35 opportunities for error, resulting in a medication administration error rate of 5.71 percent. Physician's orders for Resident 10, dated August 23, 2024, included an order for the resident to receive 1 gram (gm) of Sucralfate (a medication used to treat conditions of the digestive tract) by mouth before meals and at bedtime for gastric protection. Observations during medication administration on October 16, 2024, at 8:25 a.m. revealed that Licensed Practical Nurse 5 prepared Resident 10's medications, which included 1 gm Sucralfate. Licensed Practical Nurse 5 administered 1 gm Sucralfate to Resident 10 at 8:30 a.m. after she had consumed her breakfast meal. Interview with Licensed Practical Nurse 5 on October 16, 2024, 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.

Based on review of facility policy and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that medications were properly labeled in one of two medication carts reviewed, and failed to label a multi-dose vial with the date it was opened in one of one medication room reviewed. Findings include: The facility's policy regarding storage and dating of medications and biologicals, dated May 16, 2024, indicated that the facility stores all medications and biologics in locked compartments under proper temperature, humidity and light controls. Medications dispensed by the pharmacy shall be labeled with the resident's name, medication name, dose, instructions and route of administration. When the original seal of a manufacturer's container or vial is initially broken, the container or vial will be dated. The manufacturer's instructions for Aplisol (an injectable medication used to detect exposure to the bacteria that causes tuberculosis), dated March, 2016, indicated that opened and in-use vials of Aplisol were to be discarded…

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

Based on review of job descriptions and the deficiencies cited during the current survey, it was determined that the Nursing Home Administrator (NHA) and the Director of Nursing (DON) failed to assume responsibility for effective management of the facility to ensure that the facility operated in compliance with state regulations and codes by not ensuring that mechanical lifts used to transfer residents were equipped with hanger bar latches without which the resident's health and safety are jeopardized for one of 29 residents reviewed (Resident 30). Findings include: The job description for the NHA, dated May 16, 2024, indicated that they must be knowledgeable of and demonstrate the ability to provide quality care by fostering a safe environment for residents and staff, providing emotional and psychological support for the residents within the facility, direct the day-to-day operation of the facility to ensure the highest degree of quality care is maintained at all times in accordance with current state and federal standards, and implement and enforce company policies and procedures…

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

Based on clinical record reviews and staff interviews, it was determined that the facility failed to ensure that clinical records were complete and accurately documented for one of 29 residents reviewed (Resident 102). Findings include: A quarterly MDS for Resident 102, dated July 31, 2024, indicated that the resident was cognitively intact, had a feeding tube (a tube surgically inserted into the stomach), and had pressure ulcers. A physician's order, dated October 9, 2024, included an order to empty and record drainage from Penrose drain (a tube surgically inserted to drain fluid from a wound) in the right hip every shift. A review of Resident 102's Medication Administration Review (MAR), dated October 2024, revealed that staff emptied the Penrose drain. A surgical note for Resident 102, dated October 8, 2024, revealed that the resident had surgery to clean out a pressure ulcer and the Penrose drain was sewn into the resident's pressure ulcer in the right hip and through the right buttock in order to create a tract for the wounds to heal. The Penrose drain would not be emptied,…

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 plans of correction for previous surveys, and the results of the current survey, it was determined that the facility's Quality Assurance Performance Improvement (QAPI) committee failed to correct quality deficiencies and ensure that plans to improve the delivery of care and services effectively addressed recurring deficiencies. Findings include: The facility's deficiencies and plan of corrections for an annual survey ending December 7, 2023, revealed that the facility developed plans of correction that included quality assurance systems to ensure that the facility maintained compliance with cited nursing home regulations. The results of the current survey, ending October 18, 2024, identified repeated deficiencies regarding accurate completion of Minimum Data Set (MDS) assessments (mandated assessments of residents' abilities and care needs); quality of care; accidents and hazards; pharmacy services; medication storage; food procurement-storing, preparing and serving food under sanitary conditions; complete and accurate medical records; and following…

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 policies, as well as observations and staff interviews, it was determined that the facility failed to ensure that proper infection control practices were followed while providing medications for one of 29 residents reviewed (Resident 19). Findings include: The facility's medication administration policy, dated May 16, 2024, indicated that only persons licensed or permitted by the state to prepare, administer and document the administration of medications may do so and that staff will follow established facility infection control procedures (e.g. handwashing, aseptic technique, gloves, isolation precautions, etc.) for the administration of medications, as applicable. An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 19, dated September 9, 2024, indicated that the resident was alert, could understand, and required assistance from staff for her daily care needs. Observations on October 16, 2024, at 8:15 a.m. during medication pass revealed that Licensed Practical Nurse 5 was preparing…

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

Based on clinical record reviews and staff interviews, it was determined that the facility failed to follow recommendations from the optometrist for follow-up appointments for five of seven residents (Residents 2, 3, 4, 6, 7). Findings include: An optometrist (a healthcare provider who specializes in caring for your eyes) note for Resident 2, dated March 27, 2023, revealed that the resident presented for a diabetic eye exam, and the patient was receiving care pursuant to an order from the primary care physician. Upon the primary care physician's review of the most current consult note and plan of care, should the primary care physician not agree with the medical necessity of both the care and plan of care, the optometrist was to be notified immediately, and that the resident was to return in six to nine months for a dilated fundus exam (a diagnostic procedure that uses eye drops to dilate or enlarge the pupil in order to obtain a better view of the fundus, the inside, back surface of the eye). There was no documented evidence that the optometrist's recommendation for Resident 2 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 clinical record reviews and resident and staff interviews, it was determined that the facility failed to support and accommodate a resident's choices and preferences for one of four residents reviewed (Resident 3). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 3, dated November 2, 2023, revealed that the resident was cognitively intact, required assistance from staff for his daily care needs, and had diagnoses that included traumatic brain injury. Interview with Resident 3 on January 24, 2024, at 12:00 p.m. revealed that he fights with the Nursing Home Administrator often because she does not permit him to make his own decisions. He stated that she encourages his sister-in-law to make his decisions and that he does not always agree with the decisions. He stated he just wants to be able to make his own decisions without his sister-in-law having a say. He confirmed that his sister-in-law is his power of attorney, but he does not feel she needs to make decisions for him as he is…

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

Based on review of facility policy and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that the physician was notified of a resident's change in condition for one of 22 residents reviewed (Resident 4). Findings include: The facility's policy for refusal of care, dated September 28, 2023, indicated that the attending physician must be notified of refusal of treatment in a time frame determined by the resident's condition and potential serious consequences of the refusal. The facility's bowel protocol includes for the daylight nurse to administer Milk of Magnesia after nine shifts of no bowel movement, and if ineffective, the evening shift nurse is to administer a suppository. If the suppository is ineffective, the nurse the next morning is to administer a Fleets enema. If the Fleets enema and all other interventions are ineffective, the registered nurse is to assess the resident and call the physician. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 4, dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the Resident Assessment Instrument User's Manual and clinical records, as well as staff interviews, it was determined that the facility failed to complete accurate Minimum Data Set assessments for three of 22 residents reviewed (Residents 5, 11, 40). Findings include: The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which gives instructions for completing Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2019, revealed that Section B0700 (make self understood) should be coded with either usually understood, sometimes understood, or rarely/never understood, and Section B0800 (ability to understand other) should be coded with either usually understands, sometimes understands, or rarely/never understands. Section C0100 (should brief interview for mental status be conducted) should be completed if the resident is at least sometimes understood verbally, in writing, or using another method. Section D…

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 clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that care plans were updated to reflect changes in residents' care needs for two of 22 residents reviewed (Residents 2, 35). Findings include: An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 2, dated September 1, 2023, indicated that the resident was cognitively impaired, needed limited assistance with transfers and ambulation, and had no fall history. A nurses note, dated September 24, 2023, at 4:45 a.m. revealed that Resident 2's alarm was sounding, and the licensed practical nurse found the resident on the floor in front of the recliner. The intervention for the fall was for anti-skid tape to be placed on the floor in front of the resident's recliner. Observations on December 6, 2023, at 12:28 p.m. revealed that there was anti-skid tape on the floor bedside Resident 2's bed. There was no anti-skid tape observed in front of resident's recliner. An administrator's note,…

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 clinical records, as well as staff interviews, it was determined that the facility failed to ensure that nursing assessments were completed, and the physician was notified of a resident's change in condition for one of 22 residents reviewed (Resident 4). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 4, dated October 18, 2023, revealed that the resident was cognitively intact, was independent for personal hygiene needs, had an indwelling catheter, had a pressure ulcer (injuries to skin and underlying tissue resulting from prolonged pressure), and had diagnosis that included paraplegia (paralysis of legs and lower body). The facility's bowel protocol includes for the daylight nurse to administer Milk of Magnesia after nine shifts of no bowel movement, and if ineffective, the evening shift nurse is to administer a suppository. If the suppository is ineffective, the nurse the next morning is to administer a Fleets enema. If the Fleets enema and all other…

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 clinical records and staff interviews, it was determined that the facility failed to ensure that treatments for pressure ulcers were provided as ordered by the physician for two of 22 residents reviewed (Residents 4, 22). Findings include: The facility's policy regarding dressing and wound documentation, dated September 28, 2023, indicated that wound care/dressings and refusals should be documented on the resident's medical record, treatment sheet or designated wound form. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 4, dated October 18, 2023, revealed that the resident was cognitively intact, was independent for personal hygiene needs, had an indwelling catheter, had a pressure ulcer (injuries to skin and underlying tissue resulting from prolonged pressure), and had diagnoses that included paraplegia (paralysis of legs and lower body). Physician's orders for Resident 4, dated September 22, 2023; October 23, 2023; and October 24, 2023, included an order for the resident's right gluteal…

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 clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that physician-ordered contracture management services were provided as care planned for one of 22 residents reviewed (Resident 11). Findings include: An annual Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 11, dated August 30, 2023, revealed that the resident was usually able to make herself understood and was usually able to understand others, was dependent on staff for her daily care needs, and had diagnoses that included dementia. Current physician's orders for Resident 11 included an order for the resident to have bilateral (both sides) PRAFO (provides support to keep the ankle aligned to treat muscle weakness) foot/ankle boots applied when getting out of bed and removed when returning to bed, leaving on for six to eight hours or to the resident's tolerance. A care plan for Resident 11, dated September 30, 2022, revealed that the resident had a self-care deficit caused by…

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

Based on clinical record reviews, observations, and staff interviews, it was determined that the facility failed to ensure that each resident received assistance devices to prevent accidents for two of 22 residents reviewed (Residents 20, 34). Findings include: An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 20, dated October 23, 2023, revealed that the resident was cognitively impaired, was dependent on staff for daily care needs including transfers and locomotion, and had diagnoses that included dementia. Observations of Resident 20 on December 4, 2023, at 12:20 p.m. revealed that the resident was pulled in her wheelchair from the hallway to the dining area by the speech therapist. The wheelchair had no footrests on it to prevent the resident from dragging her feet. An interview with the speech therapist at that time revealed that the resident should have had footrests on her chair but did not, so she pulled the resident so she could observe her feet. A quarterly MDS assessment for Resident 34, dated…

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

Based on review of clinical records, as well as staff interviews, it was determined that the facility failed to maintain accountability for controlled medications (drugs with the potential to be abused) for one of 22 residents reviewed (Resident 5). Findings include: A significant change Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 5, dated September 29, 2023, indicated that the resident was usually understood and could usually understand others, required extensive assistance for personal hygiene needs, was taking pain medication as needed, and had diagnoses that included dementia. Physician's orders for Resident 5, dated April 28, 2023, included an order for the resident to receive 5/325 milligrams (mg) of Oxycodone-Acetaminophen (a controlled pain medication) every eight hours as needed for pain. Review of the controlled drug record (a form that accounts for each tablet/pill/dose of a controlled drug) for Resident 5 for September, October, and November 2023 indicated that a dose of Oxycodone-Acetaminophen 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.

Based on review of policies, as well as observations and staff interviews, it was determined that the facility failed to ensure that medications were properly secured in the medication cart. Findings include: The facility's policy regarding the security of the medication cart, dated September 28, 2023, indicated that the nurse was to secure the medication cart during the medication pass to prevent unauthorized entry and the medication cart was to be securely locked at all times when out of the nurse's view. Observations on December 4, 2023, at 3:56 p.m. revealed that a medication cart (east cart) in the hallway was unattended by staff members and was unlocked. Interview with Licensed Practical Nurse 3 on December 4, 2023, at 3:58 p.m. confirmed that her medication cart was unsecured and should have been locked. Interview with the Director of Nursing on December 4, 2023, at 4:00 p.m. confirmed that the medication cart should have been locked when unattended. 28 Pa. Code 211.9(a)(1) Pharmacy services. 28 Pa. Code 211.12(d)(5) Nursing services.

Based on review of facility policies, as well as observations and staff interviews, it was determined that the facility failed to store and prepare food in accordance with professional standards for food service safety by failing to properly label and date refrigerated and frozen foods. Findings include: The facility's policy regarding food storage, dated September 28, 2023, revealed that leftover food was to be stored in covered containers or wrapped carefully and securely. Each item was to be clearly labeled and dated before being refrigerated or frozen. Observations in the kitchen's walk-in refrigerator on December 4, 2023, at 10:02 a.m. revealed an unopened package of cheese that was not in the original container and not dated, and an opened bag of cheese that was not sealed, opened to air, and not dated. Observations in the kitchen's walk-in freezer on December 4, 2023, at 10:04 a.m. revealed a bag of frozen chicken opened to air and not sealed. Observations in the reach-in freezer on December 4, 2023, at 10:07 a.m. revealed unopened packages of frozen pancakes and French toast…

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 clinical records, as well as resident and staff interviews, it was determined that the facility failed to maintain clinical records that were complete and accurately documented for two of 22 residents reviewed (Residents 18, 42). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 18, dated September 22, 2023, revealed that the resident was cognitively intact, required extensive assistance of staff for personal hygiene needs, had an indwelling urinary catheter (a tube placed and held in the bladder to drain urine), and had diagnoses that included neurogenic bladder (problem in which a person lacks bladder control due to a brain, spinal cord, or nerve condition). Physician's orders for Resident 18, dated August 10, 2022, included an order for the resident's urinary catheter to be changed once a month with an 18 French/10 cc balloon (size of indwelling catheter). Review of the October and November 2023 Treatment Administration Record (TAR) for Resident 18 revealed that there…

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 plans of correction and the results of the current survey, it was determined that the facility's Quality Assurance Performance Improvement (QAPI) committee failed to correct quality deficiencies and ensure that plans to improve the delivery of care and services effectively addressed recurring deficiencies. Findings include: The facility's deficiencies and plans of corrections for State Survey and Certification (Department of Health) surveys ending March, 10, 2023; December 29, 2022; and December 12, 2022, revealed that the facility developed plans of correction that included quality assurance systems to ensure that the facility maintained compliance with cited nursing home regulations. The results of the current survey, ending December 7, 2023, identified repeated deficiencies related to physician notification; quality of care; proper storage and labeling of medications; food procurement, storing, preparing and serving food under sanitary conditions; and resident records. The facility's plan of correction for a deficiency regarding physician…

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 policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that proper infection control practices were followed while providing catheter care for one of 22 residents reviewed (Resident 22). Findings include: The facility's policy regarding catheter care, dated September 28, 2023, indicated that the catheter tubing and drainage bag were to be kept off the floor to prevent catheter-associated urinary tract infections. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 22, dated November 8, 2023, revealed that the resident was alert and oriented, and had diagnoses that included neuromuscular dysfunction of the bladder (a condition that results in the bladder not filling or emptying correctly). The resident's care plan, dated September 19, 2023, indicated the use of an indwelling catheter. Physician's orders for Resident 22, dated November 16, 2023, included an order for the resident to receive Keflex (an antibiotic) for a…

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