Crawford Care Center

Based on review of facility policies, clinical records, and staff interview, it was determined that the facility failed to follow physician's orders related to a medication gradual dose reduction (GDR-lowering a high-risk medication to determine if a person can function safely on a lower dose) and failed to administer pain medication timely resulting in a delay in treatment for two of 24 residents reviewed (Residents R3 and R5).Findings include:Facility policy entitled, Consulting Physician/Practitioner Orders dated 1/22/26, revealed .For consulting physician/practitioner orders received in writing or via fax, the nurse in a timely manner will:Call the attending physician to verify the order.Document the verification order by entering the order and the time, date, and signature on the physician order sheet.Follow facility procedures for verbal or telephone orders including: noting the order, submitting to pharmacy, and transcribing to medication or treatment administration record.Review of Resident R3's clinical record revealed an admission date of 7/26/24, with diagnoses 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 facility policy, facility documents, and facility meal schedule, observations, and resident and staff interviews, it was determined that the facility failed to ensure that alternate meals were served comparable to normal mealtime in accordance with resident preference and request for two of 24 residents (Residents R55 and R123).Findings include: Review of facility policy entitled Dining and Food Preferences dated 1/22/26, revealed The alternate meal and/or beverage selection will be provided in a timely manner. Review of facility meal schedule revealed that the scheduled time for lunch delivery starts at 11:00 a.m. and the last delivery is at 1:15 p.m. which identified that tray line would not be completed until 1:15 p.m. Observations on 4/27/26, and 4/28/26, revealed a sign on the dining services door indicating Alternate meals will be made at the end of tray line. Tray line does not stop! During an interview on 4/27/26, at approximately 12:45 p.m. Resident R55 stated, I have asked for an alternate meal, and it has taken over 30 minutes to get it, and it was only…

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

Based on review of facility policy, clinical records, observations, and staff interview, it was determined that the facility failed to provide appropriate urinary catheter (tubing inserted into the bladder to drain urine into a bag) care to help prevent urinary tract infections for one resident reviewed for catheter care (Resident R12).Findings include: Review of facility policy entitled Indwelling Catheter Use and Removal dated 1/22/26, revealed If an indwelling catheter is in use, the facility will provide appropriate care for the catheter in accordance with current professional standards of practice and resident care policies and procedures that include but are not limited to: Insertion, ongoing care and catheter removal protocols that adhere to professional standards of practice and infection prevention and control procedures. Review of Resident R12's clinical record revealed an admission date of 12/24/25, with diagnoses that include Parkinson's (a chronic and progressive movement disorder that causes shaking, slows a person's ability to move and worsens over time), drug induced…

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, review of facility policies and International Plumbing Code, and staff interviews it was determined that the facility failed to safely store food containers, and prepare, serve and store food in a safe and sanitary manner in the main kitchen; failed to prevent the potential for cross contamination (transfer of harmful substances or disease-causing organisms to food from unclean hands or objects) during food preparation; and failed to maintain safe storage of ice for residents for one of one ice machines located in the kitchen. Findings include: Review of the International Plumbing Code Chapter Eight dated 2018, revealed that devices that store ice and that discharge to the drainage system shall be provided with protection against backflow, flooding, fouling, contamination and stoppage of the drain; and when equipment discharges potable clear water waste (fit for human consumption) to the building drainage system, the discharge shall be through an indirect pipe by means of an air gap. A facility policy entitled Equipment dated 1/16/25, indicated that all…

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, and staff interview, it was determined that the facility failed to provide a written summary of the baseline care plan and order summary to the resident and/or representative for five of 13 residents reviewed (Residents R3, R18, R30, R64, and Closed Record CR110). Findings include: Review of facility policy entitled Baseline Care Plan dated 1/16/25, indicated A written summary of the baseline care plan shall be provided to the resident and representative . and This will be provided by completion of the comprehensive care plan. Review of Resident R3's clinical record revealed an admission date of 7/15/24, with diagnosis that included anxiety (a condition that causes a person to be nervous, uneasy, or worried about something or someone), and hypertension (high blood pressure). Resident R3's clinical record lacked evidence that a written summary of the baseline care plan and order summary was provided to Resident R3 and/or his/her representative. Review of Resident R18's clinical record revealed an admission date of 9/28/24, 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 policy and clinical records, observations, and staff interviews, it was determined that the facility failed to provide oxygen according to physician's orders and failed to promote cleanliness and help prevent the spread of infection for four of 25 residents reviewed for respiratory services (Residents R30, R44, R48, and R64). Findings include: A facility policy dated 1/16/25, entitled Oxygen Concentrator revealed the purpose of the policy is to establish responsibilities for the care and use of oxygen concentrators. An oxygen concentrator is a medical device that extracts oxygen from room air by filtering out or separating the nitrogen from the oxygen. The oxygen passes through a filter system and is then stored within the device for delivery based on the flow meter setting. Care of the Concentrator. Filters on concentrators to be cleaned weekly. The main body cabinet should be dusted when needed and can be wiped clean with a damp cloth and mild household cleaner if necessary. Change oxygen tubing and mask/cannula weekly and as needed. Change humidifier…

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 resident and staff interviews, it was determined that the facility failed to ensure that physician visits were conducted at least once every 60 days for three of three residents reviewed (R15, R19, and R26). Findings include: Interview on 4/15/25, at 1:35 p.m. with Resident R15 revealed that he/she had not seen their physician since his/her prior physician had stopped coming to the facility. He/she expressed that he/she has only seen the nurse practitioner. Interview on 4/15/25, at 2:00 p.m. with Resident R19 revealed that he/she has only seen a nurse practitioner since their last physician stopped coming to the facility, which was sometime last summer. Interview on 4/14/25, at 12:15 p.m. with Resident R26 revealed that he/she has not seen their physician since his/her prior physician stopped coming to the facility. He/she expressed that the last time they saw their physician was sometime last summer. He/she expressed that they have only seen the nurse practitioner. Interviews on 4/15/25, at 2:00 p.m. during resident council meeting revealed…

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 and staff interview, it was determined that the facility failed to ensure that waste was properly contained in dumpsters or compactors with lids or otherwise covered, and the garbage storage area was maintained in a sanitary condition to prevent the potential of harborage and feeding of pests for one of one garbage storage areas. Findings include: A facility policy entitled Disposal of Garbage and Refuse dated 1/16/25, indicated that refuse containers and dumpsters kept outside the facility shall be designed and constructed to have tightly fitting lids, doors, or cover; containers and dumpsters shall be kept covered when not being loaded; dumpsters shall be emptied according to the facility contract and garbage should not accumulate or be left outside the dumpster. Observation on 4/14/25, at 1:35 p.m. revealed four plastic rolling carts in proximity of the facility loading dock were overflowing with garbage bags. Three of the plastic carts contained clear unsealed garbage bags of cans with food remaining in a number the cans, and one…

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 ensure a physician's order and POLST (Pennsylvania Orders for Life-Sustaining Treatment) were identical to indicate the correct code status as Full Code (CPR/Attempt Resuscitation) or Do Not Resuscitate (DNR/Do Not Attempt Resuscitation-Allow Natural Death) for one of 18 residents reviewed (Resident R18). Findings include: Facility policy entitled, Communication of Code Status dated [DATE], indicated it is the policy of this facility to adhere to residents' rights to formulate advance directives. In accordance to these rights, this facility will implement procedures to communicate a resident's code status to those individuals who need to know this information. When an order is written pertaining to a resident's presence or absence of an Advance Directive, the directions will be clearly documented in designated sections of the medical record. Examples of directions to be documented include, but…

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, review of facility policies and documents, and staff interviews, it was determined that the facility failed to provide housekeeping services necessary to maintain a clean environment for one of one resident equipment observed (Resident R64). Findings include: Review of facility policy entitled Housekeeping In-Service dated 1/16/25, indicated Dust Mop: The entire floor needs to be dust mopped . and Damp mop: The most important area of a patient's room to disinfect the floor. Review of resident R64's clinical record revealed an admission date of 8/23/24, with diagnoses that included chronic obstructive pulmonary disease (condition when your lungs do not have adequate air flow), anxiety (a condition that causes a person to be nervous, uneasy, or worried about something or someone), and hypertension (high blood pressure). Observations on 4/14/25, at 12:25 p.m., 1:55 p.m., and 2:50 p.m. revealed that upon entering Resident R64's room and walking across the floor, a sticky sound was heard with each step. Further observations of Resident R64's room revealed a large…

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, and staff interview, it was determined that the facility failed to develop a respiratory care plan for two of 25 residents reviewed (Residents R30 and R64). Findings include: Review of facility policy entitled Comprehensive Care Plans dated 1/16/25, indicated The comprehensive care plan will describe . The services that are to be furnished to attain or maintain the residents highest practicable physical, mental, and psychosocial well-being, and The comprehensive care plan will be reviewed and revised . Review of Resident R30's clinical record revealed an admission date of 12/4/24, with diagnoses that included anxiety (a condition that causes a person to be nervous, uneasy, or worried about something or someone), obstructive sleep apnea (a condition when a person repeatedly stops and starts breathing when they are sleeping), and hypertension (high blood pressure). Review of Resident R30's physician's orders revealed an order dated 1/31/25, for oxygen 2 lpm (liters per minute) via nasal cannula (oxygen tubing that has prongs…

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, observations and staff interviews it was determined that the facility failed to follow the plan of care for one of 25 residents reviewed (Resident R48). Findings include: Resident R48's clinical record revealed an admission date of 7/02/18, with diagnoses including polyosteoarthritis (a form of arthritis that affects multiple joints at the same time), dementia, and dizziness. A care plan entitled Safety/Fall Risk included an intervention dated 8/06/24, to place his/her bed against the wall. Observations on 4/14/25, at 3:05 p.m. and 4/15/25, at 9:52 a.m. revealed Resident R48's bed was positioned with a bedside table between the bed and the wall, and the bed was not placed against the wall as care planned. During an interview on 4/15/25, at 10:20 a.m. Licensed Practical Nurse Employee E5 confirmed that Resident R48's bed was not positioned against the wall. 28 Pa. Code 211.12(d)(5) Nursing services

Based on review of facility policy and manufacturer's guidelines, observations and staff interviews, it was determined that the facility failed to appropriately discard outdated medications for one of three medication carts reviewed and one of two medication rooms reviewed (500 and 100 hall medication carts and 500/600 medication room). Findings include: Review of facility policy entitled Multi-Dose Vials dated 1/16/25, indicated Multi-dose vials will be labeled with date open. Medications will be discarded . Insulin is 28 days from date open. Review of manufacturer's guidelines revealed that an open pen of Lispro Insulin must be used within 28 days after opening or be discarded. Review of manufacturer's guidelines revealed that an open pen of Lantus/Basaglar Insulin must be used within 28 days after opening or be discarded, even if the vial still contains insulin. Review of manufacturer's guidelines revealed that an open vial of Tubersol (solution to test for tuberculosis) should be discarded within 30 days after opening. Observation of drug storage on 4/14/25, at 12:40 p.m. of the…

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

Based on review of facility policies and clinical records, and staff interviews, it was determined that the facility failed to ensure the resident and/or resident representative was offered the opportunity to participate in the development, review, and/or revision of their person-centered care plan for three of three residents reviewed (Residents R1, R2, and R3). Findings include: Facility policy entitled Care Planning - Interdisciplinary Team, dated 1/18/24, indicated the interdisciplinary team is responsible for the development of resident care plans. Resident care plans are developed according to the timeframes and criteria established by 483.21. The resident, the resident's family and/or resident's legal representative/guardian or surrogate are encouraged to participate in the development of and revisions to the resident's care plan. Facility policy entitled Quarterly Assessments and Care Plan, dated 1/18/24, indicated Quarterly MDS assessments are conducted to track the resident's status between comprehensive assessments to ensure critical indicators of gradual change in 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 a review of facility policy, facility written menus, observations, and staff interviews, it was determined that the facility failed to follow their planned menu. Findings include: Facility policy entitled, Menus dated 1/18/24, revealed Menus will be planned in advance to meet the nutritional needs of the residents/patients in accordance with established national guidelines. Menus will be developed to meet the criteria through the use of an approved menu planning guide. Menus will be served as written, unless a substitution is provided in response to preference, unavailability of an item, or a special meal. A menu substitution log will be maintained on file. Facility menus revealed a meal consisting of smothered chicken thigh, whole kernel corn, oven browned potatoes, cornbread, sliced pears and coffee or hot tea was to be provided for the residents' lunch meal on 12/30/24. Observations of the 400-unit meal service on 12/30/24, at 1:15 p.m. revealed five residents received mashed potatoes instead of oven browned potatoes. During an interview on 12/30/24, at 1:17 p.m. the…

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

Based on a review of facility policy, facility meal schedules, observations, and staff interviews, it was determined the facility failed to follow their schedule for frequency of resident meals. Findings include: A facility policy entitled, Meal Distribution, dated 1/18/24, revealed meals are transported to the dining locations in a manner that ensures proper temperature maintenance, protects against contamination, and are delivered in a timely and accurate manner. Facility posting entitled, Tray Service Schedule noted: Lunch: 11:00 a.m. - 11:45 a.m. - Main Dining Room, 11:45 a.m. - 500 Hall, 11:55 a.m. - 600 Hall, 12:05 p.m. - 100 Hall, 12:15 p.m. - 300 Hall, 12:25 p.m. - 400 Hall. Observations on 12/30/24, at 12:25 p.m., 12:35 p.m., and 12:50 p.m. of the dining rooms for the 300 and 400 units revealed residents sitting in their wheelchairs and dining room chairs awaiting their lunch meal (both units are located in a secured dementia unit). At 12:57 p.m. (42 minutes beyond the scheduled service) the meal cart for the 300-unit dining room arrived with resident meals, followed by 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 policies and clinical records, and staff interview, it was determined that the facility failed to develop a comprehensive care plan for one of one residents reviewed regarding an elopement (Resident R30). Findings include: Facility policy entitled, Care Plans, Comprehensive Person-Centered revised March 2022, included: the comprehensive, person-centered care plan includes measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs is developed and implemented for each resident; care plan interventions are chosen only after data gathering, proper sequencing of events, careful consideration of the relation ship between the resident's problem areas and their causes, and relevant to clinical decision making. Resident R30's clinical record revealed an admission date of 1/12/24, with diagnoses that included dementia, weakness, unsteady on feet, abnormalities of gait and mobility, and repeated falls. Resident R30's clinical record revealed 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 clinical records, and staff interview, it was determined that the facility failed to thoroughly investigate an elopement (unauthorized leave from a safe area) for one of one residents reviewed for elopements (Resident R30). Findings include: A facility policy entitled, Wandering and Elopements revised March 2019, revealed that when the resident returns to the facility, the Director of Nursing or charge nurse shall: examine the resident for injuries; contact the attending physician and report findings and conditions of the resident; notify the resident's legal representative; complete and file an incident report; and document relevant information in the resident's medical record. Resident R30's clinical record revealed an admission date of 1/12/24, with diagnoses that included dementia, weakness, unsteady on feet, abnormalities of gait and mobility, and repeated falls. The most recent Quarterly Minimum Data Set (federally mandated process that assesses the clinical needs and functional capabilities of residents in nursing…

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

Based on observations, review of facility records, and staff interviews, it was determined that the Nursing Home Administrator (NHA) and the Director of Nursing (DON) did not effectively manage the facility to make certain that proper infection control procedures were followed to protect residents from cross-contamination, infections, viruses and disease in the facility. Findings include: The job description for the NHA revealed that the purpose of this position is to establish and maintain systems that are effective and efficient to operate the facility in a manner to safety meet resident needs in compliance with federal, state, and local requirements. The job description for the DON revealed that the purpose of this position is to provide nursing management, set resident care standards for all direct care providers and provide complete supervision and management for the nursing department. Based on the findings in this report that identified that the facility failed to consistently maintain an infection prevention and control program to mitigate or potentially control the spread…

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, review of clinical records and facility documents, and staff interviews, it was determined that the facility failed to ensure the Infection Preventionist (IP) performed the duties of the position to adequately implement an infection control program to detect and prevent the spread of COVID-19. Findings include: The job description for the IP revealed that the purpose of this position is to implement, coordinate, and ensure that the facility's infection prevention and control program is effective and in compliance with all state and federal regulations. Pennsylvania Department of Health COVID-19 Infection Control and Outbreak Response Toolkit for Long-Term Care Version 1.1 dated February 2024, and expanded from infection prevention and control guidance from the Centers for Disease Control and Prevention (CDC) for nursing homes and Long-Term Care Facilities. During the Outbreak: COVID-19 Outbreak Management and Control Measures included: 1.Identify and Isolate First Case. a. Isolate with transmission-based precautions (TBP) on COVID-19 Care Unit in accordance…

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 facility policy, and resident and staff interviews, it was determined that the facility failed to allow residents the right to make choices about aspects of his or her life in the facility that are significant to the resident for one of 22 residents reviewed (Resident R22). Findings include: A facility policy entitled, Discharge Summary and Plan, revised 10/2022, indicated when a resident's discharge is anticipated, a post-discharge plan is developed to assist the resident with discharge, every resident is evaluated for his/her discharge needs and has an individualized post-discharge plan, and includes: where the resident plans to reside; arrangements that have been made for follow-up care and services; description of the resident's stated discharge goals; degree of caregiver/support person availability, capacity and capability to perform required care; how the interdisciplinary team will support the resident in the transition to post-discharge care; what factors may make the resident vulnerable to preventable readmission; and how those…

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 documentation and staff interview, it was determined that the facility failed to issue the Notice of Medicare Non-Coverage liability and/or appeal notice, and Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN form - provides information to residents so they can decide if they wish to continue skilled services that may not be paid for by Medicare and assume financial responsibility) to the resident, or the resident's representative, following the end of Medicare covered services for two of two residents reviewed who remained in the facility for long-term care (Residents R6, R52) and one resident who was discharged from the facility (Closed Record Resident CR190). Findings include: Resident R6's clinical record revealed an admission date of 1/25/24, with diagnoses including broken vertebrae, colon cancer, repeated falls, and bacterial skin infection of the left toe. Review of an admission Minimum Data Set (MDS- standardized assessment tool that measures health status in…

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

Based on review of facility policy and clinical records, and staff interview, it was determined that the facility failed to provide a written summary of the baseline care plan and order summary to the resident and/or representative for eight of 22 residents reviewed (Residents R30, R14, R81, R3, R41, R69, R74, and R83). Findings include: A facility policy entitled, Care Plans - Baseline dated 2/12/24, revealed The resident and/or representative are provided a written summary of the baseline care plan (in a language that the resident/representative can understand) that includes, but is not limited to the following: a. The stated goals and objectives of the resident; b. A summary of the resident's medications and dietary instructions; c. Any services and treatments to be administered by the facility and personnel acting on behalf of the facility; and d. Any updated information based on the details of the comprehensive care plan, as necessary. Resident R30's clinical record revealed an admission date of 3/29/24, with diagnoses that included heart failure (a condition where the heart…

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, and staff interview, it was determined that the facility failed to review and revise comprehensive care plans to reflect the current care and services for nine of 22 residents reviewed (Residents R40, R14, R30, R37, R81, R41, R43, R74, and R83). Findings include: A facility policy entitled, Care Plans, comprehensive Person-Centered, dated 2/12/24, indicated that the interdisciplinary team reviews and updates the care plan: when there has been a significant change in the resident's condition; when the desired outcome is not met; when the resident has been readmitted to the facility from a hospital stay; and at least quarterly (every three months) in conjunction with the required quarterly MDS (Minimum Data Set- standardized assessment tool that measures health status in nursing home residents). Resident R81's clinical record revealed an admission date of 1/21/24, with diagnoses that included vitamin D deficiency, major depressive disorder, and pneumonia. Resident R81's care plan revealed a target date of 2/21/24, indicating…

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, and staff interview, it was determined that the facility failed to provide a clinical rationale for the continued use of a PRN (as needed) psychotropic (affecting the mind) medication beyond 14-days and failed to provide evidence that non-pharmacological interventions (interventions attempted to calm a resident other than medication) were attempted prior to the administration of a PRN psychotropic medication for four of 22 residents reviewed (Residents R81, R41, R43, and R2). Findings include: A facility policy entitled Psychotropic Medication Use dated 2/12/24, revealed that Non-pharmacological approaches are used (unless contraindicated) to minimize the need for medications, permit the lowest possible dose, and allow for discontinuation of medications when possible For psychotropic medications that are NOT antipsychotics: If the prescriber or attending physician believes it is appropriate to extend the PRN order beyond 14 days, he or she will document the rationale for extending the use and include the duration of the PRN…

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 prevent the opportunity for potential unauthorized access of medications for one of five medication carts (Primrose Lane- memory care unit), failed to label a multi-dose insulin pen (medication to treat elevated blood sugar levels) with the date it was opened in one of five medication carts (Maple Lane), and failed to ensure that medications subject to abuse were stored in separately locked, permanently affixed compartment in one of three medication refrigerators (Blue Unit). Findings include: Review of the facility policy entitled Administering Medications dated 2/12/24, indicated that the medication cart must be kept closed and locked when out of the nurse's view. Review of the facility policy entitled Medication Labeling and Storage dated 2/12/24, indicated that multi-dose vials/containers are dated when opened and discarded within 28 days unless the manufacturer specifies a shorter or longer date. Review of the facility policy entitled Controlled Substances 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 facility policy, facility records, and staff interview, it was determined that the facility failed to provide evidence of a Quality Assurance and Performance Improvement (QAPI) Committee meeting for one of four quarterly QAPI Committee meetings reviewed occurring in 2023 and 2024 (First Quarter of 2024). Findings include: Review of facility policy entitled, Quality Assurance and Performance Improvement (QAPI) Program dated 2/27/2023 stated, The committee meets monthly to review reports, evaluate data and monitor QAPI-related activities and make adjustments to the plans. Review of the QAPI Committee Attendance Records revealed no evidence of a quarterly meeting for the First Quarter of 2024. During an interview on 5/01/24, at 11:30 a.m. the Nursing Home Administrator confirmed that there was no evidence of a QAPI Committee meeting regarding the First Quarter meetings of 2024. 28 Pa. Code 201.18(b)(3) Management 28 Pa. Code 201.18(e)(1) Management

Based on review of facility documents and clinical records, and staff and family interviews, it was determined that the facility failed to fully inform and discuss the change of treatments for the medical management of a resident's clinical status and/or discuss alternate treatment options preferred by the resident's representative in advance of these changes for one of five residents reviewed for pharmacy recommendations (Resident R38). Findings include: The facility's admission packet provided to residents/representatives on admission revealed: all residents have the right to equal access to quality care regardless of diagnosis, severity of condition, or payment source; have to right to be fully informed of your medical condition in a language you can understand, and to participate in your person-centered care planning and treatment; and the right to refuse and/or discontinue medications and treatments (but this could be harmful to your health). Resident R38's clinical record revealed an admission date of 10/26/17, with diagnoses including secondary hyperaldosteronism…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of clinical records and facility documentation, and staff interview, it was determined that the facility failed to complete the Minimum Data Set (MDS-periodic assessment of resident care needs) to accurately reflect the resident's status at the time of the assessment for two of 22 residents reviewed (Residents R14 and R57). Findings include: Resident R14's clinical record revealed an admission date of 3/27/24, with diagnoses that included end stage renal disease (a diseases where the kidneys no longer work to meet the body's needs), hypokalemia (low potassium levels), and hypertension (high blood pressure). Resident R14's clinical record revealed that dialysis was ordered on 3/27/24, and Resident R14 received dialysis treatments on 3/30/24, and 4/2/24. The five day MDS dated [DATE], Section O0100 J. Special Treatments, Procedures, and Programs category, dialysis was marked No indicating Resident R14 was not receiving dialysis treatments. Resident R57's clinical record revealed an admission date…

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

Based on review of facility policy and clinical records, and staff interview, it was determined that the facility failed to develop comprehensive care plans for two of 22 residents reviewed (Residents R14 and R64 ). Findings include: Review of facility policy entitled Care Plans, Comprehensive Person Centered dated 2/12/24, indicated The comprehensive person centered care plan is developed within seven days of the completion of the required MDS assessment, and no more than 21 days after admission. Review of Resident R14's clinical record revealed an admission date of 3/27/24, with diagnoses that included end stage renal disease (a diseases where the kidneys no longer work to meet the body's needs), hypokalemia (low potassium levels), and hypertension (high blood pressure). Review of Resident R14's physician orders revealed an order for dialysis every Tuesday and Saturday. Further review of Resident R14's person centered plans of care revealed only a plan of care for nutrition. Review of Resident R64' clinical record revealed an admission date of 4/10/24, with a diagnoses 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 observations, review of clinical records and facility policy and staff interviews, it was determined that the facility failed to promote cleanliness and help prevent the spread of infection regarding respiratory care equipment according to physician's orders for two of two residents reviewed for respiratory care (Residents R43 and R69) Finding include: Review of facility policy entitled Oxygen Administration dated 2/12/24, indicated tubing is to be changed weekly and dated, and filters on concentrators to be cleaned weekly with tubing change. Review of Resident R43's clinical record revealed an admission date of 11/21/17, with diagnoses that included dementia (a disease that affects short term memory and the ability to think logically), chronic obstructive pulmonary disease (COPD-a disease that obstructs air flow from the lungs), and peripheral vascular disease (a disease where your veins have trouble sending blood from your limbs back to your heart). Review of Resident R43's physician orders revealed an order dated 11/1/23, for oxygen at two liters per minute as needed.…

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 contract, clinical record, and staff interview, it was determined that the facility failed to maintain records relating to dialysis communication for one of one residents reviewed for dialysis (Resident R14). Findings include: Review of dialysis contract dated 2/12/24, indicated Designated Resident Information, Facility shall ensure that all appropriate medical, social, administrative, and other information accompany all designated residents at the time of transfer to center. This information shall include . appropriate medical records . treatments being provided to designated resident, including medications and any changes in the patient's condition, change of medication, diet, or fluid intake . any other information that will facilitate the adequate coordination of care as reasonably determined by center. Review of facility's dialysis communication form entitled Dialysis/Observation Communication Form revealed that the top section was to be completed by the facility, which included treatments being provided to the resident, including medications and any…

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 requirements according to the Affordable Care Act (ACA), review of Payroll Based Journal (PBJ) Staffing Data Reports and staff interview, it was determined that the facility failed to electronically submit direct care staffing information for one of the last four quarters (Quarter Four of 2023). Findings include: Review of Section 6106 of the ACA requires facilities to electronically submit direct care staffing information (including agency and contract staff) based on payroll and other auditable data to the Centers for Medicare and Medicaid Services (CMS). Submission must be received by the end of the 45th calendar day (11:59 p.m. Eastern Standard Time) after the last day of each fiscal quarter to be considered timely. First quarter reporting includes data from October 1st through December 31st and is due by February 14th. Second quarter reporting includes data from January 1st through March 31st and is due by May 15th. Third quarter reporting includes data from April 1st through June 30th and is due by August 14th. Fourth quarter reporting includes July 1st…

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 planned written menus, observations, and resident and staff interviews, it was determined the facility failed to provide each resident with a nourishing, well-balanced diet that meets his/her daily nutritional needs for one of one meal observed (lunch meal 4/01/24) and three of three meals reviewed (lunch, dinner meal 4/01/24 and breakfast meal 4/02/24). Findings include: Review of a facility policy entitled, Resident Food Preferences, dated 2/12/24, revealed Individual food preferences will be assessed upon admission and communicated to the interdisciplinary team. Modifications to diet will only be ordered with the resident's or representative's consent. The food services department will offer a variety of foods at each scheduled meal, as well as access to nourishing snacks throughout the day and night. Review of the facility menu for cycle week 3 for the lunch meal on 4/01/24, revealed Chicken Pot Pie w/Biscuit, Alternate- Hamburger on a Bun-Lettuce & Tomato-Ketchup-Pickle Spear, Tossed Salad w/Dressing, Broccoli Florets, Tater Tots-Ketchup…

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, review of clinical records, and resident and staff interviews, it was determined that the facility failed to provide a bath/shower as resident preference for four of 26 residents reviewed (Residents R1, R4, R5, R6). Findings include: No policy was provided on baths/showers. Resident's R1's clinical record revealed an admission date of 9/03/21, with diagnoses that included polyosteoarthritis (joint pain and stiffness), dysuria (discomfort, pain, or burning when urinating), hypothyroidism (a condition when the thyroid gland doesn't produce enough thyroid hormone), and presence of artificial eye. During an interview with Resident R1 on 4/01/24, at 1:25 p.m. he/she indicated their bath/shower was scheduled for Wednesday and Saturday evenings, but he/she has not received the scheduled bath/shower in at least the past 10 days. Resident R1 verbalized, I told several people that I would like my bath on the dayshift, due to more reliable staff work those hours. It all depends on who and how many are working if you get a bath or not. Resident was observed with greasy…

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 and resident interviews, it was determined that the facility failed to follow physician orders for three of six residents reviewed (Residents R1, R2, and R3). Findings include: Resident's R1's clinical record revealed an admission date of 9/03/21, with diagnoses that included polyosteoarthritis (joint pain and stiffness), dysuria (discomfort, pain, or burning when urinating), hypothyroidism (a condition when the thyroid gland doesn't produce enough thyroid hormone), and presence of artificial eye. Review of Resident R1's Medication Administration Record (MAR) revealed a physician order with start date of 2/25/22, Levothyroxine Sodium 100 micrograms (mcg) give one tablet by mouth one time a day for hypothyroidism. Resident R1's MAR further revealed for the month of March 2024 that his/her Levothyroxine Sodium 100 mcg was not administered per physician order on 3/03/24, 3/04/24, 3/06/24, 3/09/24, 3/11/24, 3/12/24, and 3/13/24. During an interview on 4/01/24, at 1:25 p.m. Resident R1 indicated he/she has not received his/her medication for…

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 resident and staff interview, it was determined that the facility failed to promote and facilitate resident self-determination through support of resident choice and make choices about aspects of his or her life in the facility that are significant to the resident for 11 of 11 residents reviewed for availability of food preferences (Residents R1-R11). Findings include: Review of Resident Council Meeting minutes dated 2/06/24, revealed: -resident concerns from two resident council members about having soup available daily. Review of the Results of the Investigation indicated that soup is offered on the current menus cycle, and one resident in the facility can receive soup for lunch and dinner per resident and family request. The Resolution lacked how the facility addressed the concerns how they directly related to the residents voicing the concerns and indicated that Resident is pleased with outcome but failed to indicate what the outcome was as it related to the residents voicing their concerns. -resident concerns from one resident council…

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.