Embassy Of Saxonburg

Based on review of the facility's job descriptions, observations, and staff interviews, it was determined that the facility failed to ensure the consistent services of a full-time Director of Nursing (40 or more hours a week) in the facility.Findings Include: Review of the facility provided Director of Nursing (DON) job description, signed and dated 12/22/25, indicated that the DON position purpose was, to plan, organize, develop, and direct the overall operation of the Nursing Service Department in accordance with current federal, stated, local standards, guidelines, and regulations that govern the facility, and as may be directed by the Administrator and the Medical Director, to ensure the highest level of quality care is maintained at all times. Job duties include assist the designated Infection Control Coordinator, monitor the planning, conducting, and scheduling of timely in-service training classes, ensure that a sufficient number of licensed practical and/or registered nurses and nurse aides are scheduled and working during all shifts. Information reported to the State…

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 properly store, label and date food items in the Main kitchen which created the potential for food borne illness.Findings include: Review of the facility policy Dating for Food Storage dated 3/16/26, and previously dated 1/21/26, indicated that when receiving foods from delivery, assure the foods are packaged with a shipping label. If the food item is removed from the original packaging/box from shipment, the item must have a date marked that it was received. In addition to labeling, dating items requires special attention. All foods that require time and temperature control should be labeled with the following: common name of food, date the food was made, use by date. If the food is not used within the days allowed to be held it must be discarded. Items that are being stored in the freezer must be labeled, dated, sealed in the same manner and may store for the period of time per guidelines. During a observation in the Main Kitchen in the walk-in freezer on 4/20/26, 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, personnel records and staff interviews, it was determined that the facility failed to complete annual performance evaluations for four of five nursing staff (Nurse Aide (NA) Employees E10, E11, E12, and E13).Findings include: Review of facility Employee Performance Evaluations policy dated 3/16/26, indicated all employees receive timely, fair, and consistent performance evaluations. After 90 days, performance evaluations are conducted annually. Review of NA Employee E10's personnel record indicated a hire date of 2/7/24. Last employee performance evaluation was dated 6/20/24. Review of NA Employee E11's personnel record indicated a hire date of 10/30/23. Last employee performance evaluation was dated 11/11/24. Review of NA Employee E12's personnel record indicated a hire date of 2/29/24. Last employee performance evaluation was dated 8/7/24. Review of NA Employee E13's personnel record indicated a hire date of 6/22/23. Last employee performance evaluation was dated 6/24/24. Review of personnel records did not include an annual performance…

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 a resident representative's concern, and staff interview, it was determined that the facility failed to ensure that residents have the right to communication and access to persons and services inside the facility. for one of two residents (Resident R64).Findings include: Review of a Resident Representative concern dated 3/17/26, stated that a bill was received on behalf of her mother (Resident R64) who was a resident at the facility. The Resident Representative had questions, and concerns with her bill, and stated: I called them and they don't answer their phone. I went in and spoke to a young girl, and I told her the problem and gave her my name and phone number, and nobody ever got back to me. If this is a legitimate bill, then why can't they explain why we owe this amount? During an interview on 4/22/26, at 2:49 p.m. the Nursing Home Administrator (NHA) stated that the Business Office Manager that would be able to explain the bill no longer worked at the facility, and that the NHA is now handling these concerns. However, the NHA was not made aware that the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical records, and staff interview, it was determined that the facility failed to provide documentation that residents or resident representatives were given the opportunity to formulate an advance directive (a written instruction such as a living will or durable power of attorney for health care for when the individual is incapacitated) for two of three residents reviewed (Resident R4 and R5).Findings include: Review of facility Residents' Rights Regarding Treatment and Advance Directives policy dated 3/16/26, indicated that the facility will support and facilitate a resident's right to request, refuse or discontinue medical or surgical treatment and to formulate advance directives. On admission, the facility will determine if the resident has executed an advance directive and if not, determine whether the resident would like to formulate an advance directive. The facility will provide the residents or resident representative information on formulating advanced directives.…

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, review of clinical records, and staff interview, it was determined that the facility failed to notify the physician of a change in condition for one of three residents (Resident R1).Findings include:Review of facility policy Notification of Changes dated 3/16/26, and previously dated 1/21/26, indicated that the facility must inform the resident, consult with the resident's physician and/or notify the resident's family member or legal representative when there is a change requiring such notification. This may include a significant change in the resident's physical, mental or psychosocial. condition such as deterioration in health, and a transfer or discharge of the resident from the facility. Review of the clinical record revealed Resident R1 was admitted to the facility on [DATE]. Review of Resident R1's Minimum Data Set (MDS - a periodic assessment of care needs) dated 3/31/26, indicated diagnoses of high blood pressure, diabetes (a metabolic disorder in which the body has…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy and clinical records, and staff interview, it was determined that the facility failed to ensure that discharge documentation was on record for one of three closed resident records (Closed Resident Record R64).Findings include: Review of facility policy Transfer and discharge date d 3/16/26, and previously dated 1/21/26, indicated that for transfer to another provider, for any reason, the following information must be provided to the receiving provider: contact information of the practitioner who is responsible for the care of the resident; resident representative information, including contact information; advance directive information; and all other information necessary. Review of Closed Resident Record R64's admission record indicated she was admitted on [DATE]. Review of Closed Resident Record R64's MDS assessment (Minimum Data Set assessment: MDS -a periodic assessment of resident care needs) dated 8/24/25, indicated she had diagnoses that included hyperlipidemia (elevated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to make certain that the necessary resident information was communicated to the receiving health care provider for one of three residents sampled with facility-initiated transfers (Residents R1), and failed to provide a transfer notice to a representative of the Office of the Long-Term Care Ombudsman Division for one of three residents (Resident R1).Findings include: Review of facility policy Transfer and discharge date d 3/16/26, and previously dated 1/21/26, indicated that for transfer to another provider, for any reason, the following information must be provided to the receiving provider: contact information of the practitioner who is responsible for the care of the resident; resident representative information, including contact information; advance directive information; and all other information necessary to meet the resident's needs. Review of the clinical record revealed Resident…

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

Based on policy review, and staff interview, it was determined that the facility failed to ensure that the nutrition services provided met professional standards of quality for comprehensive care plan development for two of twelve months (March and April 2026).Findings Include: Review of the facility's policy Nutritional Management dated 3/1/26, and previously dated 1/21/26, indicated that monitoring of the resident's condition and care plan interventions will occur on an ongoing basis. Examples of monitoring include:Interviewing resident and/or resident representative to determine if their goals and preferences are being metDirectly observing the residentInterviewing the direct care staff to gain information about the resident, the interventions currently in place, what their responsibilities are for reporting on these interventions, and possible suggestions for changes if necessary During a telephonic interview on 4/22/26, at 12:46 p.m. Registered Dietitian (RD) Employee E7 confirmed that she has worked from home for the past two months, as she now works in Ohio and does not come…

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, activity documentation, resident council group interview, and resident and staff interviews, it was determined that the facility failed to provide an ongoing program of activities to meet the interests and support the physical, mental, and psychosocial well-being of each resident for one of three residents (Resident R15) and failed to have sufficient activity staff. Findings include: Review of facility policy Activity last reviewed 3/16/26, indicated the facility will provide an ongoing program to support residents in their choice of activities on their comprehensive assessment, care plan, and preference. Facility-sponsored group, individual, and independent activities will be designed to meet the interests of each resident as well as support their physical, metal, and psychosocial well-being. Activities will encourage both independence and interaction within the community. During a review of the facility's April 2026 activity calendar the following was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical record review, facility provided documents, and staff interviews, it was determined the facility failed to maintain an environment free of potential accident hazards and provide safe bed mobility for one of two residents (Resident R32), and that the facility failed to ensure leg rests were applied to a resident's wheelchair prior to moving resident for one of two residents (Resident R53). Findings include: Review of facility policy Accidents and Supervision last reviewed 3/16/26, indicated the resident environment will remain free of accident hazards as is possible. Each resident will receive adequate supervision and assistive devices to prevent accidents. Review of Resident R32's admission record indicated she was admitted on [DATE]. Review of Resident R32's MDS assessment (Minimum Data Set assessment: MDS -a periodic assessment of resident care needs) dated 4/15/26, indicated she had diagnoses that included anxiety disorder (a medical condition creating a sense of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to ensure that a resident with an enteral feeding tube (a tube inserted in the stomach through the abdomen) received appropriate treatment and services to prevent potential complications for one of two residents (Residents R10). Findings include: Review of the facility policy Enteral Nutrition dated 3/1/26, and previously dated 1/21/26, indicated that the dietitian, with input from the physician, nurse, and resident/representative, will determine the calorie, protein, nutrient and fluid needs and evaluate whether the resident's current intake is adequate to meet those nutritional needs; identify the appropriate enteral nutrition to be administered and give direction regarding the need for additional fluids to be administrated. The physician will be involved in the decision regarding the use of enteral feeding, and document the reason for the decision. The dietitian is responsible 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical records, staff interview, and observations, it was determined that the facility failed to provide appropriate respiratory care for two of two residents (R14 and R44).Findings Include: Review of facility policy Oxygen Administration dated 3/16/26, indicated oxygen is administered to residents who need it, consistent with professional standards of practice, the comprehensive person-centered care plans, and the residents' goals and preferences. Change oxygen tubing weekly and as needed. Change humidifier bottles when empty. Keep delivery system in plastic bag when not in use. Review of facility policy Comprehensive Care Plans dated 3/16/26, indicated the facility will develop and implement a comprehensive person-centered care plan for each resident. Review of the clinical record indicated Resident R14 was admitted to the facility on [DATE], with diagnoses of heart failure (a progressive heart disease that affects pumping action of the heart muscles), respiratory failure,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical records, and staff and resident interviews it was determined that the facility failed to meet residents pain needs for one of three residents reviewed (Resident R7).Findings Include: Review of the facility policy Pain Management dated 3/16/26, indicated the facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. Based upon the evaluation, the facility in collaboration with the attending physician/prescriber, otherhealth care professionals and the resident and/or the resident's representative will develop, implement, monitor and revise as necessary interventions to prevent or manage each individual resident's pain beginning at admission. Review of the clinical record revealed Resident R7 was admitted to the facility on [DATE], with diagnoses of low back pain, anxiety, and chronic pain. Review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical records, and staff interview it was determined that the facility failed to provide trauma survivors with trauma informed care to eliminate or mitigate triggers that may cause re-traumatization of the resident for one of two residents (Resident R43).Findings include: Review of facility policy Trauma Informed Care dated 6/3/1/26, and previously dated indicated that the facility will identify triggers which may re-traumatize residents with a history of trauma. Trigger-specific interventions will identify ways to decrease the resident's exposure to triggers which retraumatize the resident, as well as identify ways to mitigate or decrease the effect of the trigger on the residents, and will be added to the resident's care plan. Review of the clinical record indicated Resident R43 was admitted to the facility on [DATE]. Review of Resident R43 MDS (minimum data set - a periodic assessment of care needs), dated 3/18/26, indicated diagnosis of PTSD (a mental health condition…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, resident clinical records, and staff interviews, it was determined that the facility failed to ensure a resident received appropriate behavioral health management to maintain the highest practicable well-being for one of four sampled residents (Resident R50).Findings include: Review of the facility policy Behavioral Health Services dated 3/16/26, indicated the facility will ensure all residents receive necessary behavioral health services to assist them in reaching and maintain their highest level of mental and psychosocial functioning. The facility will ensure the necessary behavioral health care services are person-centered and reflect the resident's goal for care, while maximizing the resident's dignity, autonomy, privacy, socialization, independence, choice, and safety. Review of the admission record indicated Resident R50 admitted to the facility on [DATE]. Review of Resident R50's care plan dated 3/6/23, indicated to monitor, document, and report as needed adverse…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy review, clinical record review, and staff interviews, it was determined that the facility failed to provide evidence that the licensed pharmacist's medication regimen was reviewed and acted upon timely for one of five sampled residents (Resident R8).Findings include: The facility Medication reconciliation policy last reviewed on 3/16/26, indicated that monthly reconciliation processes included providing pharmacy consultation access to all medications areas and records for completion of pharmacy services activities. Respond to any medication irregularities reported by pharmacy consultant. Review of Resident R8's admission record indicated he was admitted on [DATE]. Review of Resident R8's MDS assessment (Minimum Data Set assessment: MDS -a periodic assessment of resident care needs) dated 4/8/26, indicated he had diagnoses that included hypertension (a condition impacting blood circulation through the heart related to poor pressure), diabetes (metabolic disorder impacting organ function…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, observations, and staff interviews, it was determined that the facility failed to properly store medical supplies in one of one medication storage rooms (Main Storage Room), and failed to store one of six residents' medications securely (Resident R45). Findings: Review of facility Medication Storage policy dated [DATE], indicated that medication and biologicals are stored safely, securely, and properly following manufacturer's recommendations or those of the supplier. Review of the admission record indicated Resident R45 admitted to the facility on [DATE], with diagnoses of adult failure to thrive, urinary tract infection, and anxiety. Review of Resident R45's MDS dated [DATE], revealed the diagnoses were current. Review of Resident R45's physician order dated [DATE], indicated to apply 1% Fungicure External Solution to fingernails topically two times a day for fungal for four weeks. During an observation on [DATE], at 10:07 a.m. Resident R45's bottle of Fungicure External…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy, clinical record review, observation, and staff interviews, it was determined that the facility failed to prevent cross contamination and implement appropriate transmission-based precautions for one of three residents (Residents R3).Findings Include: Review of the facility policy Enhanced Barrier Precautions (EBP) last reviewed 3/16/26, indicated Enhanced Barrier precautions are an infection control intervention designed to reduce transmission of multidrug resistant organisms (MDRO) that employs targeted gown and gloves use during high contact resident care activities. An order for enhanced barrier precautions will be obtained for residents with wounds. Gloves and gowns are made available immediately near or outside the resident's room. Review of the facility policy Clean Dressing Change last reviewed 3/16/26, indicated it is the facility policy to provide wound care in a manner to decrease potential for infection and/or cross contamination. After removing existing dressing, remove…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, review of facility documentation, and staff interviews, it was determined that the facility failed to make certain that equipment was in safe operating condition for one of one of the facilities crash cart (a cart that contains supplies in the event of an emergency), (Main Nursing Unit).Findings include: During a review of facility provided documentation labeled Embassy of Saxonburg, indicated the emergency cart is to be checked by the night shift Registered Nurse (RN) Supervisor daily. Check expiration dates and replace missed items. During a review of facility provided documentation labeled Embassy of Saxonburg revealed missing signatures on the following dates: [DATE] were missing [DATE], [DATE], and [DATE] signatures.February 2026 were missing [DATE], [DATE], and [DATE] signatures.[DATE] were missing [DATE], [DATE], [DATE], and [DATE] signatures. During an observation of the facilities crash cart, located at the Main Nurses Station, on [DATE], at 9:40 a.m. revealed the 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 facility policy, resident observations, resident and staff interviews, it was determined that the facility failed to have sufficient nursing staff to provide nursing and related services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for six residents (Residents R2, R3, R9, R10, R11, and R12).Findings include: Review of the facility policy Sufficient Nursing Staffing Policy dated 1/15/26, indicated it is the policy of this facility to maintain staffing practices that are consistent with federal regulations, state law, and professional standards of practice, while supporting safe and effective care. During an interview on 3/12/26, at 10:01 a.m. Resident R2 indicated the facility is understaffed. We are not showered. reason given; they (staff) just don't do it. Yesterday resident went to the doctor's office and did not give shower prior to going, didn't have wound on buttocks dressed, letting resident sit on buttocks for day. Resident tries to get staff to get resident out of bed, they won't do it. Once resident is put…

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

Based on staff interviews and review of employee files it was determined that the facility failed to employ a qualified Food Service Director to manage the daily operations of the Dietary Department for three out of three months (January 2026 through March 2026).Findings include: During an interview on 3/12/26 at 9:57 a.m. Kitchen Manager, Employee E21 had been employed as the Kitchen Manager since she started at the facility on 1/28/26, and that she was not a Certified Dietary Manager. A review of Kitchen Manager, Employee E21 employee file revealed a hire date of 1/21/26. The Kitchen Manager was a Nurse Aide. During an interview on 7/21/24, at 1:40 p.m., the Interim Nursing Home Administrator (NHA), Employee E12 and Director of Nursing (DON) confirmed that the facility failed to provide documented evidence that Kitchen Manger, Employee E21 met the qualifications for the position of Food Service Director. Pa Code: 201.18(e)(6) Management.

Based on a review of a job description, facility and clinical records, and staff interviews, it was determined that the Nursing Home Administrator (NHA) did not effectively manage the facility to make certain that residents were free from abuse and failed to make certain the facility implemented its abuse policies, creating an immediate jeopardy situation.Findings include: The job description for the NHA specified the primary purpose of the job position is to direct the day-to-day functions of the facility in accordance with current federal, state, and local standards, guidelines, and regulations that govern long-term care facilities to assure that the highest degree of quality care can be provided to our residents at all times. Based on the findings in this report that identified that the facility failed to effectively manage the facility to make certain that residents were free from abuse and failed to make certain the facility implemented its abuse policies, resulting an immediate jeopardy situation. The facility failed to provide fundamental principal that apply to treatment and…

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

Based on review of facility documents and staff interview, it was determined that the facility failed to accurately complete the Facility Assessment. Findings include: A review of the Facility Assessment, dated 3/26/25 revealed the facility did not complete the template to indicate accurate information on:-In the section titled, List of Key Personnel were the previous Nursing Home Administrator, the previous Director of Nursing, and the previous Assistant Director of Nursing.-In the section titled Census indicated time period of 2025 year to date.-In the section titled Information about our residents has not been reviewed since 3/26/25. During an interview on 3/14/26, at approximately 1:00 p.m. the Interim Nursing Home Administrator Employee E12 confirmed that the facility failed to accurately complete the Facility Assessment and that all the information about our residents was from last time employee worked at facility.28 Pa. Code 201.18(b)(3)(e)(2) Management.

Based on review of facility documents and staff interviews it was determined that the facility failed to put forth a good faith effort to correct the deficient practice cited during the survey of 3/14/26, by failing to provide adequate staffing to meet the needs of the resident, providing qualifying coursework for the Dietary Manager, provide on sight oversight of daily dietary operations, training the Human Resources Director (Staff member responsible for hiring of qualified staff) to the qualifications of a Dietary Manager, hiring a qualified Dietary Manager to fill a vacant position, and making certain that the Facility Assessment documents are current and accurate as required. (Staffing, training, employment process, and Facility Assessment) Findings include: During an interview on 4/29/26 at 9:30 am the Director of Nursing confirmed that the facility had failed to correct meeting the needs of the residents by failing to provide showers to the residents. A review of Resident Electronic Treatment Records (ETAR) for April 2026, confirmed that the facility failed to meet 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 the review of facility policy,, clinical records, and staff interviews, it was determined that the facility failed to ensure a physician completed the initial visits for three of four residents (Resident R5, R7, and R8).Findings include: Review of the facility's Physician Visits and Physician Delegation policy dated 6/1/24, last reviewed 1/21/26, indicated a physician assistant (PA), Nurse Practitioner (NP), and Clinical Nurse Specialist (CNS), may not perform initial comprehensive visits. Review of the clinical record indicated Resident R5 was admitted to the facility on [DATE], with diagnoses of anxiety, depression, and lung cancer. Review of Resident R5's late entry note entered on 3/1/26, effective 2/25/26, revealed an initial visit was completed by Certified Registered Nurse Practitioner, Employee E20 for the resident's admission. The facility failed to ensure a physician completed the initial visit. Review of the clinical record indicated Resident R7 was admitted to the facility on [DATE], and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on the review of clinical records and staff interview, it was determined that the facility failed to appropriately and timely document progress note in the clinical record for four of four residents (Residents R5, R6, R7, and R8).Findings include: Review of the clinical record indicated Resident R5 was admitted to the facility on [DATE], with diagnoses of anxiety, depression, and lung cancer. Review of Resident R5's late entry note entered on 3/1/26, effective 2/25/26, a total of four days later, revealed an initial visit was completed for the resident's admission. The facility failed to timely document in the resident's clinical record. Review of the clinical record indicated Resident R6 was admitted to the facility on [DATE], with diagnoses of dementia, tremor, and history of falling. Review of Resident R6's late entry note entered on 3/13/26, effective 3/5/26, a total of eight days later, revealed the resident was seen for a right shoulder injection. The facility failed to timely document in the…

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

Based on review of facility education documents, and staff interview, it was determined that the facility failed to provide training on effective communication for five of five staff members (Registered Nurse (RN) Employee E15, and Nurse Aides (NA) Employee E8, NA E16, NA E17 and, NA E18).Findings include: Review of facility provided employee listing of hires prior to 3/13/25, indicated the following employees were hired on the following dates:RN Employee E15 - hire date of 5/15/24.NA Employee E8 - hire date of 10/30/23.NA Employee E16 - hire date of 2/29/24.NA Employee E17 - hire date of 9/10/24.NA Employee E18 - hire date of 12/4/24. Review of facility provided documents and training records for RN Employee E15, and NA's Employee E8, NA E16, NA E17 and, NA E18, failed to include education on effective communication as required. Interview on 3/14/26, at 1:00 p.m. the Interim Nursing Home Administrator Employee E12 confirmed that the facility failed to provide training on effective communication for five of five staff members (Registered Nurse (RN) Employee E15, and Nurse Aides (NA)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical records, observation, and interviews with staff, it was determined that the facility failed to make certain residents were provided necessary treatment and services, consistent with professional standards of practice, for a pressure ulcer (PU/PIs- injuries to skin and underlying tissue resulting from prolonged pressure on the skin) for one of four residents (Resident R2).Findings include: Review of facility's policy, Pressure Injury Prevention and Management dated 1/8/25, last reviewed 1/21/26, indicated the facility is to provide treatment and services to heal the pressure ulcer/injury. Interventions for preventions will be implemented for all residents who have ap reassure injury. Interventions will be documented in the care plan and communicated to all relevant staff. Review of the clinical record revealed that Resident R2 was admitted to the facility on [DATE], with diagnoses with abnormal posture, paraplegia, and a pressure ulcer of the right ankle. Review of…

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

Based on a review of the facility's plan of correction, documents and staff interviews it was determined that the facility failed to make a good faith effort to correct and sustain improvement for one of two citations issued for failure to provide the required number of Nurse Aides (NA) per resident per shift as required (Citation P5520).Findings include:A review of the facility's plan of correction revealed the following: Administrator and Director of Nursing (DON) educated by Regional Director of Clinical Operations on 1.19.26 on required state Certified Nursing Assistant ratios. In an attempt to achieve appropriate staffing ratios the facility has implemented a daily assignment grid that designates the required Certified Nursing Assistant ratios to meet state requirements. Assignment grids will be reviewed during labor meetings no less than 3x a week for 3 weeks. When a call off is received the supervisor will make every effort to fully replace hours. In the event it cannot be covered, the Director of Nursing will be notified so Administrative staff can reach out to employees 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 policy, resident observations, resident and staff interviews, it was determined that the facility failed to have sufficient nursing staff to provide nursing and related services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of five of six residents (Residents R2, R3, R4, R5, and R6).Findings include:Review of facility policy Activities of Daily Living (ADLs) dated 1/15/26, indicated care and services will be provided for the following activities of daily living: bathing, dressing, grooming, and oral care; transfer and ambulation; toileting; eating to include meals and snacks, and using speech, language or other functional communication systems. A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. Review of facility policy Activities dated 1/15/26, indicated it is the policy of this facility to provide an ongoing program to support residents in their choice of activities based on their…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to ensure that a resident received neurological assessments after an incident involving a fall for one of five residents (Resident R1).Findings include: Review of facility policy Fall Prevention and Management dated 1/15/26, indicated in the event of a fall, the resident will be assessed by a Licensed Nurse, the Physician/Nurse Practitioner and Responsible Party will be notified and an intervention(s) aimed to prevent further falls will be implemented. Details of the fall will be gathered and documentation completed as indicated.Review of the clinical record revealed Resident R1 was admitted to the facility on [DATE]. Review of Resident R1's Minimum Data Set (MDS - a periodic assessment of care needs) dated 1/20/26, indicated diagnoses of high blood pressure, seizure disorder, and hyponatremia (low levels of sodium in the blood). Review of a nursing progress note dated 1/18/26, stated, At…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical record, and staff interview it was determined that the facility failed to have the responsible party sign financial papers for one of two residents ( Resident R2).Findings include: Review of facility policy Resident Rights dated 2/19/25, indicated: The facility will inform the resident both orally and in writing, in a language that the resident understands, of his or her rights and all rules and regulations governing resident conduct and responsibilities during the stay in the facility. Information about resident rights will be given to the resident understands to the extent possible, considering impediments which may be created by the resident's health and mental status. Review of Resident R2 was admitted [DATE]. Review of Resident R2 MDS (minimum data set - a periodic assessment of resident needs) dated 8/28/25, indicated diagnosis of Multiple Sclerosis (is a disease that causes breakdown of the protective covering of the nerves) muscle wasting and atrophy (is 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 provided documents, clinical records and staff interviews, it was determined that the facility failed to ensure that a resident's legal surrogate (power of attorney) was utilized for legal action of non-payment of bills for one of two residents (Resident R1).Findings include: Review of the Resident Assessment Instrument 3.0 User's Manual effective October 2025, indicated that a Brief Interview for Mental Status (BIMS), is a screening test that aids in detecting cognitive impairment). The BIMS total score suggests the following distributions: 13-15: cognitively intact 8-12: moderately impaired 0-7: severe impairment Review of the clinical record revealed that Resident R1 was admitted to the facility on [DATE]. Review of Resident 1's MDS (Minimum Data Set, periodic assessment of resident care needs) dated 4/22/25, indicated diagnoses of high blood pressure, dementia (a group of symptoms that affects memory, thinking and interferes with daily life), and anxiety (a feeling of worry,…

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, facility provided documents, clinical records, and staff interviews, it was determined that the facility failed to report an allegation of abuse for one of two residents (Resident R1).Findings include: Review of the facility's policy Abuse, Neglect, Exploitation and Misappropriation of Resident Property dated 2/19/25, indicated that the facility will not tolerate abuse, neglect, and exploitation of its residents. The willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain, pain or mental anguish. This includes verbal abuse. Facility staff should immediately report all such allegations to the Administrator. The Administrator or his/her designee will notify the Department of Health of the alleged violations involving Abuse, Neglect, exploitation, mistreatment of a resident, or…

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, facility provided documents, clinical records, and staff interviews , it was determined that the facility failed to identify and investigate an incident of possible abuse for one of two incidents (Resident R1).Findings include: Review of the facility's policy Abuse, Neglect, Exploitation and Misappropriation of Resident Property dated 2/19/25, indicated that the facility will not tolerate abuse, neglect, and exploitation of its residents. The willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain, pain or mental anguish. This includes verbal abuse. Facility staff should immediately report all such allegations to the Administrator. The Administrator or his/her designee will notify the Department of Health of the alleged violations involving Abuse, Neglect, exploitation, mistreatment of…

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

Based on review of facility documentation and staff interview it was determined that the facility failed to employ a qualified actives director from October 6, 2025. Findings include: Review of facility documentation: job description Activity Director: The primary purpose of your job position is to plan, organize, develop, direct and implement the overall operation of the Activity Department in accordance with current, federal, state, and local standards, guidelines and regulations, our established policies and procedures, and as may be directed by the Administrator, to assure that an on-going program of activities is designed to meet, in accordance with the comprehensive assessment, the interests and the physical, mental, and psychosocial well-being of each resident. During an interview on 11/13/25, at 10:30 a.m. Activity Director Employee E8 indicated her previous employment was as a Nurse Aide, and they did not have prior experience in an activity program. Review of Activity Director Employee E8 file failed to include documentation meeting federal standards. During an interview…

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

Based on a review of the facility's plan of correction, documents and staff interviews it was determined that the facility failed to make a good faith effort to correct and sustain improvement for two of two citations issued for failure to provide the required number of Nurse Assistants (NA) and Licensed Practical Nurse (LPN) per resident per shift as required ( Citations P 5520, and P5530). Findings include: A review of the facility's audit completed to measure improvement and compliance with the facility's plan of correction for citations P5520 and P5530 revealed that the facility was not meeting staffing ratios for the NA position. Each audit entry was documented as reviewed by the Nursing Home Administrator (NHA). The audit failed to contain corrective action and measurable data for the continued deficient practice. Further review of the facility's audit revealed two forms that contained no audit information (blank) but were documented with the NHA's initials indicating review of the information by the NHA. During an interview on 1/7/26, at 2:30 pm the NHA indicated that she was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, observations and staff interviews it was determined that the facility failed to provide a clean, safe, comfortable, and homelike environment for two of five rooms (C Hall and Shower Room). Findings include: Review of the facility policy Resident Environmental Quality dated 2/19/25, indicated the policy of this facility is to be designed, constructed, equipped, and maintained to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public. On 8/12/25, at 10:01 a.m. observation of D hall floor included: - room [ROOM NUMBER] had two ceiling tiles that had brown stains on them.- During an interview on 8/12/25, at 10:22a.m. Anonymous Resident R1 stated, When I get a shower and move the towel under my feet, it is black. On 8/12/25, at 10:45 a.m. observation of Shower Room included: - Walls throughout the shower room had paint off in sections- Plaster repairs not painted- Shower 1 and Shower 2, on the left-hand side walking into shower room,…

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

Based on facility policy, observations and staff interview, it was determined that the facility failed to properly label and date food products, in the Main Kitchen. (Main Kitchen). Findings include: Review of facility policy Dating for Dry Food Storage, dated 2/19/5, indicated that when receiving foods from delivery, assure the foods are packaged with a shipping label. If the food item is a shelf stable item, and left in the original container/box it was shipped in with a dated label, it does not require additional label or dating. If a food item that is shelf stable is removed from the original packaging/box from shipment, the item must have a date marked that it was received. During an observation in the Main Kitchen on 6/2/25, at 9:15 a.m. the following was noted: · An opened bag of lettuce was in the tray line refrigerator with no label or date. · Two cans of tuna with no receive date in the dry storage area. · An open bag of garlic, and a bag of celery with no label or date in the walk-in refrigerator. · Two apple pies with no receive date in the walk-in freezer. During an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to make certain that the necessary resident information was communicated to the receiving health care provider for two of three residents sampled with facility-initiated transfers (Residents R28 and R61), failed to notify the resident or resident's representative of the facility bed-hold policy (an agreement for the facility to hold a bed for an agreed upon rate during a hospitalization) for three of three resident hospital transfers (Residents R28, R41, and R61), and failed to notify the Office of the State Long-Term Care Ombudsman upon transfer to the hospital for three of three resident hospital transfers (Resident R28, R41, and R61). Findings include: Review of facility policy Transfer and Discharge reviewed 2/19/25, indicated the facility's transfer/discharge notice will be provided to the resident and the resident's representative in a language and manner in which they can understand.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of facility policy, Resident Assessment Instrument (RAI) User's Manual, clinical records, and staff interviews, it was determined that the facility failed to ensure that Minimum Data Set (MDS - a periodic assessment of care needs) assessments accurately reflected the resident's status for three of three residents (Resident R66). Findings include: The 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 2024, indicated the following instructions: Section A2105: Discharge Status: This item documents the location to which the resident is being discharged at the time of discharge. Select the two-digit code that corresponds to the resident's discharge status. Code 01, Home/Community: if the resident was discharged to a private home, apartment, board and care, assisted living facility, group home, transitional living, or adult foster care. A…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff interview it was determined that the facility failed to make certain that residents were provided appropriate treatment and care for two of eight sampled residents (Resident R39, and R61). Findings include: Review of Resident R39's admission record indicated resident was admitted on [DATE], with diagnoses of high blood pressure, Post Traumatic Stress Disorder (PTSD - a disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event and may have triggers that can bring back memories of trauma accompanied by intense emotional and physical reactions), and encounter for other orthopedic aftercare. Review of Resident R39's quarterly MDS assessment (MDS-Minimum Data Set assessment: periodic assessment of resident care needs) dated 4/29/25, indicated that the diagnoses were current upon review. During an observation on 6/2/25, at 12:40 p.m. Resident R39 was observed with knee immobilizer braces on both legs. Review of Resident R39's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, resident record review, and staff interviews, it was determined that the facility failed to provide trauma survivors with trauma informed care to eliminate or mitigate triggers that may cause re-traumatization of the resident for one of three residents (Resident R39). Findings include: Review of facility policy Trauma Informed Care, dated 2/19/25, indicated that the facility will identify triggers which may re-traumatize residents with a history of trauma. Trigger specific interventions will identify ways to decrease the resident's exposure to triggers which re-traumatize the resident, as well as identify ways to mitigate or decrease the effect of the trigger on the resident, and will be added to the resident's care plan. Review of the clinical record indicated Resident R39 was admitted to the facility on [DATE]. Review of Resident R39's Minimum Data Set (MDS - a periodic assessment of care needs) dated 4/29/25, indicated diagnoses of high blood pressure, Post Traumatic Stress…

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, staff, and resident interviews, it was determined that the facility failed to provide Activity of Daily Living (ADL) assistance for three out of nine residents (Resident R2, R3, and R4). Findings include: Review of the facility Activities of Daily Living last reviewed 2/19/25, indicated that residents who are unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. Review of the facility policy Personal Care Procedure last reviewed 2/19/25, indicates the facility will provide/assist resident care and hygiene to each resident based on their individual status and needs. Bath/showers may be given at any time the resident chooses. They may be done in the morning, before bed or any other time of the resident's preference. Review of Resident R2's admission record indicated resident was admitted to facility on 1/15/24, with the diagnosis of multiple sclerosis (MS- an autoimmune disease…

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

Based on facility policy, clinical record review and staff interviews, it was determined the facility failed to notify a family representative of a change in condition for one of three residents. (Resident R1). Findings include: A review of the facility Change in Condition Notification Protocol reviewed 3/27/24, indicates the facility will inform the resident; consult with the residents physician; and if known notify the residents legal representative/and or resident representative when there is a significant change in the resident's physical, mental or psychosocial status (i.e., a deterioration in health, mental or psychosocial status in either life threatening conditions or clinical complications). A need to alter treatment significantly (i.e., a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment). A review of Resident R1's clinical record indicates an admission date of 11/21/2023, with the diagnosis of peripheral vascular disease (PVD-narrowing of blood vessels), hypertension (high blood pressure), and atrial…

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

Based on clinical record review and staff interview it was determined the facility failed to obtain laboratory services as ordered for one of two residents (Resident R1). Findings Include: A review of the facility Medication and Treatment Orders reviewed 3/27/24, indicated physician orders for medications and treatments will be consistent of safe and effective order writing. Treatment orders and follow up appointments will be documented in Point Click Care (PCC) and on the treatment administered record (TAR). A review of Resident R1's clinical record indicates an admission date of 11/21/2023, with the diagnosis of peripheral vascular disease (PVD-narrowing of blood vessels), hypertension (high blood pressure), and atrial fibrillation (abnormal heart rhythm). Review of Resident R1's physician orders revealed an order dated 4/9/24, indicated cbc-diff, cmp (bun, creatinine, lytes, ast, alt, t. billi, d. billi,Ibilli, alk phos) weekly for screening every Tuesday. Review of the Resident R55's clinical record failed to reveal the resident's labs were obtained on 8/6/24, as ordered.…

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 interview, it was determined that the facility failed to properly label and date food products in the reach-in cooler and walk- in freezer and failed to maintain sanitary conditions which created the potential for cross contamination (Main Kitchen). Findings include: During an observation of the main designated kitchen on 6/30/24, at 9:05 a.m. the following was observed: - 6 sandwiches no label or date (reach in cooler) - 1 salad, not covered no label or date - 4 foam containers, no label or date - 2 bags (reach in freezer), not secured, no label or date - 6 bags hoagie buns (walk in freezer), no label or date - 2 boxes, magic cup, ice cream (walk in freezer) on the floor During an observation of the dish room on 6/30/24, at 10:00 a.m. the following was observed: -Dietary employee drying dishes with a towel During an interview on 7/1/24 at 1:30 p.m. Dietary Manager E1 confirmed that the facility failed to properly label and date food products and practice proper infection control in the dish room which created the potential for food borne illness. 28…

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

Based on facility policy, observation and staff interview, it was determined that the facility failed to maintain the personal dignity for a resident during the dressing change observation (Resident R42). Findings include: Review of the facility policy Resident Rights dated 3/27/24, indicated the resident has a right to be treated with respect and dignity. During an observation of a dressing change on 6/30/24, at 10:15 a.m. Licensed Practical Nurse (LPN) Employee E5 performed the treatment and then took a marker from her pocket and dated the dressing after placing the outer dressing to Resident R42's abdomen. During an interview on 6/30/24, at 10:25 a.m. LPN Employee E5 confirmed that the facility failed to provide a dignified experience during the dressing change. 28 Pa. Code: 201.29 (a)(b)(c) Resident Rights 28 Pa. Code 211.12(d)(1)(2)(3)(5) Nursing services

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical records, incident reports, State reportable incidents, and staff interview it was determined that the facility failed to report an incident of resident-to-resident abuse altercation for one out of five sampled residents (Residents R24). Findings include: The facility Abuse, neglect and exploitation policy last reviewed 3/27/24, indicated that the facility will provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect and exploitation. The facility will have written procedures to assist staff in identifying different types of abuse. This includes certain resident to resident altercations. Reporting of all alleged violations to the Administrator, State agency, adult protective services and all other required agencies within specified time frames, which includes not later than 24-hours if the event that caused the allegation do not result in serious…

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, observations, and staff interviews it was determined that the facility failed to ensure that a resident's care plan was updated and revised to reflect the resident's specific care needs for one of four residents (Resident R56). Findings include: Review of facility policy Comprehensive Care Plans dated 3/27/24, indicated the care plan will describe, at a minimum, the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being and resident specific interventions that reflect the resident's needs. Review of the admission record indicated Resident R56 was admitted to the facility on [DATE]. Review of Resident R56's Minimum Data Set (MDS - a periodic assessment of care needs) dated 5/10/24, indicated the diagnoses of unspecified dementia with unspecified severity and other behavioral disturbances (a general term for loss of memory, language, problem solving and other thinking abilities…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy, observation, clinical record review, and staff interview, it was determined that the facility failed to provide treatment and services to prevent further decrease in range of motion for one of three residents (Resident R41). Findings include: Review of the facility policy Prevention of Decline in Range of Motion dated 3/27/24, indicated the facility will provide treatment and care in accordance with professional standards of practice. This includes appropriate equipment (braces or splints). Review of the admission record indicated R41 was admitted to the facility on [DATE]. Review of Resident R41's Minimum Data Set (MDS - a periodic assessment of care needs) dated 5/31/24, indicated the diagnoses of dementia (a general term for loss of memory, language, problem solving and other thinking abilities that are severe enough to interfere with daily life), anxiety, and high blood pressure. Review of Resident R41's current physician orders on 7/2/24, indicated washcloth to be put between…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy, clinical and facility record review, facility provided documents and staff interviews, it was determined that the facility failed to provide adequate supervision for two of six residents, resulting in a fall for one of six residents (Resident R24), and resulting in potential interaction with an unsecured disinfectant for one of six residents (Resident R56). Findings include: Review of facility policy Accidents and Supervision dated 3/27/24, indicated the resident environment will remain as free of accident hazards as is possible. Each resident will receive adequate supervision and assistive devices to prevent accidents. This includes identifying hazards and implementing interventions to reduce hazards and risks. Review of the Resident Assessment Instrument 3.0 User's Manual effective October 2019, indicated that a Brief Interview for Mental Status (BIMS) is a screening test that aides in detecting cognitive impairment. The BIMS total score suggests the following distributions: 13-15:…

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 documents, clinical records and staff interviews it was determined that the facility failed to identify and meet residents' highest practicable psych-social needs for one of six residents (Resident R33). Findings include: Review of the facility policy Behavioral Health Services dated 3/27/24, indicated it is the facility's policy to ensure all residents receive necessary behavioral health services to assist them in reaching and maintaining their highest level of mental and psychosocial functioning. The facility will monitor the resident closely for expressions or indications of distress and ensure appropriate follow-up assessments. Review of the admission record indicated Resident R33 was admitted to the facility on [DATE]. Review of Resident R33's Minimum Data Set (MDS - a periodic assessment of care needs) dated 5/6/24, indicated the diagnoses of diabetes (a long-term condition in which the body has trouble controlling blood sugar and using it for energy), high blood pressure, and…

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

Based on review of facility policy, observations and staff interview it was determined that the facility failed to date opened medications and properly store medications in one of three medication carts observed (Middle medication cart). Findings include: Review of facility policy Storage of Medications dated 3/27/24, indicated the facility shall store all drugs and biologicals in a safe, secure, and orderly manner. Observation on 6/30/24, 8:40 a.m. the Middle medication cart indicated the following medications stored in the drawer without a date and time on the insulin pens, indicating date opened as required for Resident R33's Lispro insulin pen (a short acting, manmade version of human insulin), and Tresiba (an ultralong-acting insulin). Interview on 6/30/24, 8:40 a.m. Licensed Practical Nurse (LPN) Employee E5 verified the two medications were not dated when opened as required. Interview on 6/30/24, at 2:00 p.m. the Director of Nursing confirmed that the facility failed to date opened medications and properly store medications in one of three medication carts observed (Middle…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy, clinical record review, observation, and staff interview, it was determined that the facility failed to prevent cross contamination during a dressing change for one of four residents (Resident 42) and failed to provide a safe and sanitary environment to help prevent the potential for cross contamination in the sole shower room. Findings include: Review of facility policy Dressing Change, Dry/Clean dated 3/27/24, indicated facility nurses will position the resident and adjust clothing to provide access to affected area. Pull glove over soiled dressing and discard into plastic bag. Wash and dry hands thoroughly. Put on clean gloves. Use clean technique (a set of practices used in healthcare to reduce the number of microorganisms and prevent contamination). Review of facility policy Infection Prevention & Control Program dated 3/27/24, indicated the facility will provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases…

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

Based on clinical record review and staff interview, it was determined the facility failed to notify the physician of a change in condition for twelve of nineteen residents testing positive for Covid-19 (Resident R1, R2, R5, R7, R8, R10, R11, R12, R16, R17, R18, R19). Findings include: Review of the facility policy Notification of Changes last reviewed 2/15/23, indicate the facility must inform the resident, consult with the resident's physician and/or notify the resident's family member or legal representative when there is a change requiring such notification. Circumstances requiring notification include but not exclusive to circumstances that require a need to alter treatment, significant change in the resident's physical, mental or psychosocial condition. Review of Resident R1's clinical record indicated admission to facility on 9/11/20, with the diagnosis of Lymphoma (form of cancer), diabetes (high blood sugar levels) edema (swelling). Review of facility covid line listing indicated Resident R1 tested positive for COVID-19 on 2/21/24. Review of Resident R1's progress notes did…

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

Based on clinical record review and staff interview, it was determined the facility failed to obtain physician orders for transmission-based precautions for three of nineteen residents (Resident R1, R5, R8). Findings include: Review of the facility policy Infection Prevention and Control Program revised 8/1/23, indicates the facility has established and maintains an infection control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infections as per accepted national standards and guidelines. Isolation protocol includes but not exclusive to: - resident with an infection or communicable disease shall be placed on transmission-based precaution as recommended by current CDC guidelines. Review of Resident R1's clinical record indicated admission to facility on 9/11/20, with the diagnosis of Lymphoma (form of cancer), diabetes (high blood sugar levels) edema (swelling). Review of facility covid line listing indicated Resident R1 tested positive for COVID-19 on 2/21/24. Review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical records, and staff interview, it was determined the facility failed to update a care plan for one of three residents (Resident R23) to accurately reflect the current status of the resident after an elopement event. Findings include: Review of facility policy Comprehensive Care Plan dated 2/15/23, indicated the facility will develop and implement a comprehensive care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. The objectives will be utilized to monitor the residents progress. The comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS (a periodic assessment of care needs). Alternative interventions will be documented, as needed. Review of the facility policy Elopements and Wandering Residents 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.