Embassy Of Scranton

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, review of facility policies, care plan documentation, and staff interviews, it was determined the facility failed to ensure comprehensive care plans were reviewed, revised, and discussed with residents and/or resident representatives following Minimum Data Set (MDS) assessments for three of 22 residents reviewed (Resident 4, Resident 9, and Resident 58). Findings include: The Resident Assessment Instrument (RAI) User's Manual, [DATE] edition, provides federal guidance for completion of the Minimum Data Set (MDS), a standardized assessment process used to identify resident needs and direct care planning. The manual requires facilities to develop a comprehensive care plan within seven days of completing the comprehensive MDS and to review and update the plan after each subsequent assessment. It also states that facilities must support resident participation in care planning by holding care plan conferences and giving residents and their representatives advance notice to ensure…

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, review of facility policy, weight records, nutritional documentation, and staff interviews, it was determined the facility failed to consistently monitor resident weights, ensure accurate and timely weight tracking, and timely implement nutritional interventions to address significant weight loss for two (2) of twenty-two (22) residents reviewed (Residents 30 and 5).Findings include: A review of a facility policy entitled Weight Policy last reviewed by the facility on March 26, 2026, indicated resident weights will be obtained in a timely and accurate manner, documented and responded to appropriately. The Registered Dietitian (RD) will be notified of significant changes in weights, insidious weight loss, and other concerns related to diet and intake. Acute or chronic weight changes will be documented, and recommendations will be provided by the dietitian as appropriate. The dietitian will track weights and will review the ongoing monthly weights to determine if there has been 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 observation, select facility policy review, and staff interviews, it was determined the facility failed to implement and adhere to procedures to ensure acceptable storage and use-by dates for multi-dose medications in two of two medication rooms (Second floor medication room and third floor medication room).Findings include: A review of the facility policy titled Medication Storage, last reviewed March 26, 2026, indicated the facility required medications and biologicals (treatments made from living cells) to be stored safely, securely, and according to manufacturer recommendations. The procedure also stated that outdated medications were to be removed from stock immediately, disposed of per medication destruction procedures, and reordered from the pharmacy. Review of the policy titled Medication Disposal and Returns, Dating and Discarding of Multidose Parenteral Vials last reviewed on March 26, 2026, indicated that nursing staff will date multidose vials (containers of medication intended for use more than one time) and discard opened vials to decrease the risk 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 select facility policy, and resident and staff interviews, it was determined the facility failed to consistently provide snacks as desired by residents, including experiences reported by four of six residents participating in a group interview (Residents 15, 11, 59, and 74).Findings include: A review of the facility policy titled Snacks, last reviewed by the facility on March 26, 2026, revealed it is the facility policy that bedtime (HS- hour of sleep) snacks will be provided for all residents. Additionally, diabetic residents are required to have a nourishing snack consisting of two food groups. During a resident group interview on May 6, 2026, at 10:00 AM, four of six residents in attendance (Residents 15, 11, 59, and 74) stated that snacks are not routinely offered to them in the evenings, and they would like to receive an evening or bedtime snack. These four residents stated they have brought these concerns up during multiple resident council meetings and this is an ongoing concern. Residents 59 and 74 stated that the dietary department bring up the snacks…

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 Statement of Deficiencies from the survey ending May 8, 2026, the facility's Plan of Correction, revisit survey findings, and staff interview, it was determined the facility's Quality Assurance and Performance Improvement (QAPI) committee failed to maintain an effective, ongoing program that monitored and sustained corrective actions to prevent the recurrence of previously cited deficient practices related to infection prevention and control, food procurement, sanitary food storage, preparation and service, and qualified dietary oversight.Findings include:During the survey ending May 8, 2026, the facility was cited for failing to implement measures to prevent the potential spread of infection. In response, the facility submitted a Plan of Correction indicating personal protective equipment (PPE), such as gloves, gowns, and other protective items used to reduce the spread of infection, would be provided to residents who required it. The facility further indicated that each resident would be evaluated to determine the need for PPE, nursing staff, 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the Centers for Disease Control and Prevention (CDC) guidance, facility policy, clinical records, observations, and staff interviews, it was determined the facility failed to implement Enhanced Barrier Precautions (EBP) to prevent the potential spread of infection for two of 22 residents reviewed (Residents 9 and 34).Findings include: A review of the facility policy titled 'Enhanced Barrier Precautions', last reviewed March 26, 2026, revealed the policy was established to implement enhanced barrier precautions (EBP) for preventing the transmission of multi-drug resistant organisms. According to the policy, EBP refers to the use of gowns and gloves during high-contact resident care activities for residents known to be colonized or infected with a Multi-Drug Resistant Organism (MDROs, germs that are resistant to multiple antibiotics and are more difficult to treat), as well as those at increased risk of MDRO acquisition (e.g., residents with wounds or indwelling medical devices). The procedure…

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 the facility failed to maintain the privacy and confidentiality of residents' medical information and treatment during dental examinations on one of three clinical environments reviewed (Resident 12, Resident 28, and Resident 47). Findings include: Review of facility policy HIPAA Security Measures, (Health Insurance Portability and Accountability Act, a federal law enacted to protect the privacy and security of individuals' health information) last reviewed March 26, 2026, indicated it is the policy of the facility to implement reasonable and appropriate measures to protect and maintain the confidentiality, integrity, and availability of resident's identifiable information and records. Review of the document titled Notice of Rights of Nursing Facility Residents revealed residents are entitled to privacy regarding their medical treatment, written and verbal communication, and visits or meetings with family and resident groups. This document was provided to all residents as part of the facility's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of facility clinical records, select facility policy, and staff interviews, it was determined the facility failed to develop and update a resident-specific baseline care plan to include interim, person-centered interventions necessary to address newly identified care needs for one of 15 sampled residents reviewed (Resident 2).Findings include: According to the Centers for Disease Control and Prevention (CDC) guidance titled Public Health Strategies for Scabies Outbreaks in Institutional Settings, updated December 18, 2025, residents with confirmed or suspected scabies (a contagious skin infestation caused by microscopic mites that burrow beneath the skin, causing intense itching and a rash) should be placed on contact precautions, including the use of gowns and gloves and avoidance of direct skin-to-skin contact. The guidance further states that close contacts should be identified, monitored, and offered prophylactic treatment, as appropriate.A review of the facility's Baseline Care Plan…

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 investigative documentation, clinical records, hospital records, and staff interviews, it was determined that the facility failed to provide nursing services consistent with professional standards of practice by failing to ensure licensed nursing staff timely assessed, monitored, evaluated, documented, and responded to a resident's condition following a witnessed fall event for one (1) of twenty-two (22) sampled residents reviewed (Resident 91). Findings include: According to the Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.11 (a)(1)(2)(4) indicates the registered nurse was to collect complete ongoing data to determine nursing care needs, analyze the health status of individuals and compare the data with the norm when determining nursing care needs, and carry out nursing care actions that promote, maintain, and restore the well-being of individuals. The Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board…

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 resident and staff interviews, it was determined the facility failed to ensure a resident received necessary assistive devices and assistance to maintain vision abilities for one of 22 residents reviewed (Resident 28).Findings include: Review of Resident 28's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses that included bipolar disorder, (a mental health disorder characterized by significant mood changes, including periods of depression and periods of elevated or irritable mood). During an interview on May 5, 2026, at 12:30 PM, Resident 28 asked the surveyor if she worked for the eye doctor and stated he had been waiting a long time for his glasses. Resident 28 stated he could not see well without glasses and did not have any. Observation of the resident and the resident's room at that time revealed no glasses were present. Review of the resident's clinical record revealed an eye consult dated January 19, 2026, which indicated the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, review of select facility policy, and staff interviews, it was determined the facility failed to consistently implement a planned restorative nursing program to maintain mobility and functional abilities to the extent possible for one of 22 residents reviewed (Resident 5). Findings include: A review of the facility policy titled Restorative Nursing Services, last reviewed by the facility on March 26, 2026, revealed residents are typically referred to restorative nursing services by therapy staff and nursing staff evaluate the resident's physical and medical capabilities within 72 hours of referral. A review of the clinical record revealed Resident 5 was admitted to the facility on [DATE], with diagnoses that included displaced intertrochanteric fracture of the right femur (a severe hip fracture occurring between the upper portions of the thigh bone near the hip joint in which the broken bone fragments are separated and commonly require surgical repair with hardware such as rods,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and staff interview, it was determined the facility failed to maintain an environment free from accident hazards related to unsafe electrical connections and improper use of extension cords and power strips for resident care equipment and electrical devices in three resident rooms reviewed (Rooms 321 Bed 2, 308 Bed 2, and 306 Bed B).Findings include: During an observation on May 5, 2026, at 10:00 AM in room [ROOM NUMBER] Bed 2, the room window was observed open without a screen in place. No air conditioning unit was present in the window. A standing fan was positioned in front of the open window blowing air into the room. Observation revealed the standing fan, resident bed, nebulizer machine (a machine used to administer breathing treatments), and television were plugged into a multi-outlet power strip. The power strip was connected to an extension cord, which was then plugged into the wall electrical outlet. In addition, a tube feeding pump (an electrical medical device used to deliver…

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, facility policy, nutritional documentation, observations, and staff interviews, it was determined that the facility failed to provide care and services for a resident receiving enteral nutrition (nutrition provided through a feeding tube) to prevent significant weight loss and ensure adequate nutritional support for 1 of 1 resident reviewed for feeding tube management (Resident 10). Findings include: A review of the facility policy titled Care and Treatment of Feeding Tubes, last reviewed by the facility on March 26, 2026, revealed it was the policy of the facility to utilize feeding tubes in accordance with current clinical standards of practice, with interventions to prevent complications to the extent possible. The policy indicated periodic evaluation of the amount of feeding administered for consistency with practitioner orders and stated that nutrition staff would determine whether tube feedings met residents' nutritional needs and adjust feedings accordingly. 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 clinical record review, review of psychiatric consultation documentation, resident and staff interviews, and review of facility interventions, it was determined the facility failed to provide the necessary behavioral health care and services to attain or maintain the highest practicable mental and psychosocial well-being for one of 22 residents reviewed (Resident 28).Findings include: Review of Resident 28's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses that included bipolar disorder (a mental health disorder characterized by episodes of depression and periods of elevated mood, irritability, agitation, or depression). During an interview with Resident 28 on May 6, 2026, at 12:30 PM, the resident asked the surveyor if she worked for the eye doctor because he had been waiting for his glasses for a long time. The resident stated he could not see well without glasses and currently had none. The resident appeared visibly upset while discussing the lack of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of clinical records, facility policy, manufacturer's prescribing information, and staff interviews, it was determined the facility failed to ensure medications were free from unnecessary use by administering permethrin cream without adequate clinical indication and for an excessive duration for one of 15 sampled residents (Resident 2).Findings include:Review of the facility policy titled Medication Administration last reviewed March 26, 2026, indicates medications are administered as ordered by the physician and in accordance with professional standards of practice. The policy indicated the facility will administer medications by utilizing best practice guidelines (strategies, methods, or techniques that have been proven through research and evaluation to be effective and efficient in achieving desired results). A clinical record review revealed Resident 2 was admitted to the facility on [DATE], with a diagnosis of systolic heart failure (a condition in which the left side of the heart cannot…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, resident and staff interviews, and facility documentation review, it was determined the facility failed to maintain a safe, comfortable, and functional environment by failing to ensure four Packaged Terminal Air Conditioner (PTAC) units were operational within resident care areas of the facility, including one resident out of 22 reviewed (Resident 39). Findings include During an interview with Resident 39, on May 5, 2026, at 12:00 PM, she stated that the PTAC unit (a self-contained heating and cooling unit used to regulate room temperature and resident comfort) in her room was not functioning. Resident 39 stated her roommate preferred the air conditioning because she became hot; however, the unit had not been working. When asked how long the unit had been nonfunctioning, Resident 39 stated it had been a long time, months at least. During an interview on May 5, 2026, at 2:00 PM, the Director of Maintenance stated the facility had four nonfunctioning PTAC units within the building. 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 clinical records, select facility policies, and staff interviews, it was determined the facility failed to complete a comprehensive admission and readmission evaluation and failed to ensure physician diet orders were accurate, verified, and consistent with the resident's assessed swallowing needs and interdisciplinary care planning process for one of three residents reviewed with swallowing deficits (Resident 8).Findings include: Review of the facility policy titled Resident admission Procedure last reviewed by the facility on January 22, 2026, indicated that upon a resident's admission to the facility nursing staff will complete the admission packet, assessments, education, consents and documentation per facility policies and procedures. The 24-Hour Admission/readmission chart review checklist directed nursing staff to transfer information from the hospital obtained upon admission to the facility, and to complete admission and readmission assessments. Clinical record review 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, clinical record review, review of resident council meeting minutes and grievances, and interviews with residents and staff, , the facility failed to reasonably accommodate a resident's need to obtain staff assistance by failing to ensure the resident had access to a call bell to request help by failing to ensure the call bell was available preventing the resident from independently notifying staff when assistance was needed for 1 of 10 residents observed (Resident 1).Findings include: A review of a facility policy labeled Call Lights: Accessibility and Timely Response last reviewed by the facility on January 22, 2026, revealed it is the expectation of the facility staff to ensure residents have access to the call light. The policy further revealed all staff members who see or hear an activated call light are responsible for responding. A clinical record review revealed Resident 1 was admitted to the facility on [DATE], with diagnoses that included acquired absence of the left leg above knee…

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 observation, clinical record review, review of resident council meeting minutes and grievances, and interviews with residents and staff, , the facility failed to reasonably accommodate a resident's need to obtain staff assistance by failing to ensure the resident had access to a call bell to request help by failing to ensure the call bell was available preventing the resident from independently notifying staff when assistance was needed for 1 of 10 residents observed (Resident 1).Findings include: A review of a facility policy titled Call Lights: Accessibility and Timely Response last reviewed by the facility on January 22, 2026, revealed it is the expectation of the facility staff to ensure residents have access to the call light. The policy further revealed all staff members who see or hear an activated call light are responsible for responding. A clinical record review revealed Resident 1 was admitted to the facility on [DATE], with diagnoses that included acquired absence of the left leg above knee…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of clinical records, select facility policy, and staff interviews, it was determined the facility failed to implement procedures to ensure the accurate administration of prescribed medications for one of eight sampled residents (Resident 1).Findings include: A review of the facility policy titled Admission/ readmission Chart Review Process last reviewed January 22, 2026, revealed the facility will ensure there exist follow through of physician orders upon admission and / or readmission to the facility and a complete chart review will be conducted within 24 hours of the admission/ readmission. Review of the facility policy titled Use of Psychotropic Medication last reviewed January 22, 2026, revealed residents are not given psychotropic medications unless necessary to treat a specific condition and the medication is beneficial to the resident. The compliance guidelines in the policy indicated the attending physician will assume a leadership role in medication management by developing,…

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 clinical records, employee job descriptions, and staff interviews, the facility's administration, including the Nursing Home Administrator (NHA) and Director of Nursing (DON), failed to effectively manage facility operations to ensure resident safety and to maintain the highest practicable physical and mental well-being of residents. This failure occurred because the facility did not ensure the environment was maintained as free of accident hazards as possible, did not ensure adequate supervision and environmental safety, and did not ensure appropriate management of a resident's psychiatric care and medication regimen for one of eight residents sampled (Resident 1), who was able to exit the facility through a second-floor window and landed on a porch into the snow. This failure resulted in Immediate Jeopardy to resident health and safety.Findings included: A review of the job description for the Nursing Home Administrator (NHA) signed and dated September 16, 2024, revealed the administrator will direct day-to-day functions of the facility in accordance with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of select facility policy and resident and staff interviews, it was determined the facility failed to ensure that fresh drinking water was consistently readily accessible to residents to promote adequate hydration, meet resident preferences, and maintain their comfort for six of 22 residents reviewed (Residents 78, 21, 30, 5, 65, and 9).Findings include: A review of the facility policy titled Hydration/Fresh Water and Fluids last reviewed by the facility on May 1, 2025, indicated the facility will provide a fresh supply of drinking water. Residents will be provided fresh water to residents each shift and repeat [NAME] delivery as needed throughout the shift and upon request for fresh water. During an environmental tour of the Third-Floor Pantry conducted on July 23, 2025, at approximately 10:00 AM, observations of the unit's ice chest contained approximately 5 inches of stagnant water with visible strands of hair and dead insects inside and the resident's freezer had a tray with six 6 oz…

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

Based on observation and staff interview, it was determined the facility failed to maintain acceptable practices for the storage and service of food to prevent the potential for contamination and microbial growth in food, which increased the risk of food-borne illness in the dietary department and in two out of two resident pantry areas located on second and third floor.Findings include: Food safety and inspection standards for safe food handling indicate that everything that comes in contact with food must be kept clean and food that is mishandled can lead to foodborne illness. Safe steps in food handling, cooking, and storage are essential in preventing foodborne illness. You cannot always see, smell, or taste harmful bacteria that may cause illness according to the USDA (The United States Department of Agriculture, also known as the Agriculture Department, is the U.S. federal executive department responsible for developing and executing federal laws related to food). A review a facility policy entitled Use and Storage of Food Brought in by Family or Visitors last reviewed 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 a review of select facility policy, facility grievance forms, resident interviews, staff interviews, and observations it was determined the facility failed to make ongoing efforts to resolve grievances and provide timely follow up with residents regarding the status update on the resolution process of call bell response times for 8 of 22 residents interviewed (Resident 5, 9,13 ,21 , 30, 45 ,65,78).Findings include: A review facility policy entitled Resident and Family Concerns last reviewed by the facility on October 21, 2024, indicated that it is the grievance official's responsibility to receive and track all grievances through to their conclusion. The policy further indicated the grievance official is responsible to provide a copy of the grievance policy to the resident. The policy further revealed it is the grievance officer's responsibility to issue written grievance decisions to the residents. A Resident Council meeting was conducted on July 23, 2025, at 10:00AM with six alert and oriented…

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 reviews and staff interviews, it was determined that the facility failed to ensure that a discharge summary, including a recapitulation of the resident's stay, were completed for two of three discharged residents reviewed (Residents 96, and 98). A review of Resident 96's clinical record revealed that he was admitted to the facility on [DATE], with diagnoses that included metabolic encephalopathy (ME) are brain dysfunctions due to problems with metabolism, or the body's chemical processes that turn food into energy and filter out harmful toxins), transient cerebral ischemic attacks (TIA - is a short period of symptoms similar to those of a stroke and caused by a brief blockage of blood flow to the brain), and weakness. A nursing note for Resident 96, dated June 10, 2025, at 5:45 PM, revealed that the resident was slumped over in his wheelchair drooling, responded to painful stimuli but when speaking words were garbled and not making sense. Nurse Practitioner (NP) updated and order to send…

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, a review of clinical records, review of facility policies, and facility provided investigative documentation, and staff interviews, it was determined the facility failed to provide adequate staff supervision to a resident identified at risk of elopement to prevent unsupervised exits from the facility for one resident (Resident 74) and failed to provide supervision to prevent a fall for one resident ( Resident 35) out of 22 residents sampled.Findings included: A review of a facility policy entitled Elopement and Wandering Residents last reviewed by the facility on October 21, 2025, indicated the facility ensures that residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering and elopement risk. The facility is equipped with door locks/alarms to help avoid elopements but are not a replacement 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 a review of clinical records and staff interview, it was determined the physician failed to act upon pharmacist identified irregularities in the medication regimen for one of twenty-two residents sampled (Resident 30).Findings include: A review of a facility policy Consulting Pharmacist Monthly Drug Review last reviewed by the facility on October1, 2024, revealed the resident's attending physician must document in the medical record that the identified pharmacist recommendation has been reviewed, and what, if any action has been taken to address it. The policy further stated if there is to be no change in the medication, the attending physician must document his or her rationale in the resident's medical record. A review of the clinical record revealed that Resident 30 was admitted to the facility on [DATE], and had diagnoses that included depressive disorder (condition characterized by persistent low mood, loss of interest, and other symptoms that significantly interfere with daily life), and weakness.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of clinical records, and staff interviews, it was determined the facility failed to ensure that a resident's drug regimen was free of unnecessary antibiotics for one out of 22 residents sampled (Resident 8).Findings include:A review of a facility policy Antibiotic Stewardship Program last reviewed by the facility on October 1, 2024, revealed it is the facility's responsibility to utilize McGeer criteria (a standardized set of definitions for identifying infections in long term care facilities) to define infections. The policy further revealed the Loeb Minimum criteria (a set of minimum clinical criteria designed to help clinicians in long-term care facilities determine when to initiate antibiotic therapy for suspected infections, particularly urinary tract infections, even before diagnostic test results are available) may be used to determine where to treat an infection with antibiotics. A review of Resident 8's clinical record revealed the resident was admitted to the facility on [DATE], 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 observations, and staff and resident interviews, it was determined the facility failed to ensure that essential equipment, it was determined that essential equipment for the mechanical preparation of ice was not being maintained in a safe operating condition.Findings include: During a resident group interview on July 23, 2025, at 10:30 AM, six of six alert and oriented residents in attendance (Residents 78, 21, 30, 5, 65, and 9) voiced concerns that fresh ice water was only consistently provided during all shift due to the facility's ice machine being broken. The residents in attendance reported that they were purchasing their own bags of ice through an online website and had them delivered to the facility. An interview with Employee 8, a Nurse Aide (NA), stated the facility's ice machine had been broken for the past two weeks and confirmed the residents did not consistently receive fresh water that shift due to the lack of ice. Interview with the Nursing Home Administrator (NHA) on July 22, 2025, at 1:00 PM, reported the only ice machine in the facility had been 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 observations and staff interview, it was determined the facility failed to provide housekeeping services necessary to maintain a clean and sanitary environment and resident care equipment for one of two residents receiving enteral tube feeding. (Resident101)Findings include: Observations conducted in Resident 101's room on July 22, 2025, at 11:00 A.M. and 1:30 P.M., and again on July 23, 2025, at 8:30 A.M. and 1:00 P.M., revealed dried tube feeding residue in multiple locations within the resident's room. Specifically, dried nutritional formula was observed on the base of the resident's tube feeding pole, on the fall mat placed on the floor to the right side of the bed, and on the surface of the resident's bedside table. During an interview July 24, 2025, at 10 A.M., the Nursing Home Administrator confirmed the resident's tube feeding pole and surrounding areas in his room should be free from liquid tube feed.28 Pa code 201.18 (b)(1) Management

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, clinical record review, facility policy review, and staff interview, it was determined the facility failed to protect one of 23 sampled residents (Resident 9) from neglect. Findings include: A review of the facility policy titled Abuse Policy last reviewed by the facility on October 21, 2024, revealed it is the facility's policy that a resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. The policy defines neglect as the failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress.A clinical record review revealed that Resident 9 was admitted to the facility on [DATE]. 2025, with diagnoses that included below-the-knee right and left leg amputations, generalized weakness, and need for personal assistance. A review of a quarterly Minimum Data Set assessment (MDS - a federally mandated standardized…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of clinical records, the facility's abuse neglect and exploitation policy, information provided by the facility, and staff interviews, it was determined that the facility failed to promptly conduct a thorough investigation to rule out abuse and implement corrective action for one of 22 residents reviewed (Resident 9).Findings include: A facility policy entitled Abuse, Neglect and Exploitation, last reviewed by the facility on October 21, 2024, indicated an immediate investigation is warranted when suspicion of abuse, neglect or exploitation occurs. The policy further indicated the investigation is to include identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations. The policy further indicated the result of the investigation should include analyzing the occurrence to determine why neglect occurred and what changes are needed to prevent further occurrences. The facility is to define how…

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 select facility policy, staff interview, and review of facility documentation, it was determined the facility failed to ensure that a resident who is unable to maintain adequate nutrition and hydration status received appropriate nutritional support, physician notification, and timely interdisciplinary assessment to prevent further nutritional decline for one of 21 residents reviewed (Resident 76). Findings include: A review of the clinical record revealed that Resident 76 was admitted on [DATE], with diagnoses that included multiple sclerosis (MS), a chronic, progressive disease of the central nervous system, and dysphagia (difficulty swallowing), related to MS. A physician's order dated January 31, 2025, directed that the resident receive a regular diet with pureed texture and honey/moderately thick consistency liquids, fortified foods with all meals, and a frozen nutritional treat (120 ml) twice daily with lunch and dinner, with intake percentages to be recorded. These…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of clinical records and staff interview, it was determined the facility failed to develop and implement an individualized person-centered care plan to render trauma informed care to a resident with a diagnosis of Post-Traumatic Stress Disorder (PTSD) for one out of 22 residents reviewed. (Resident 90)A review of Resident 90's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses that included metabolic encephalopathy (ME brain dysfunctions due to problems with metabolism, or the body's chemical processes that turn food into energy and filter out harmful toxins), major depressive disorder (mood disorder that causes a persistent feeling of sadness and loss of interest, and it affects how one feels, thinks and behaves and can lead to a variety of emotional and physical problems), and post-traumatic stress disorder (PTSD a mental health condition that's caused by an extremely stressful or terrifying event, either being part of it or witnessing it. Symptoms may…

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

Based on observation, review of facility policy, test tray results, and interviews with staff and residents, the facility failed to serve meals that were palatable and maintained at a safe and appetizing temperature for 6 of 10 residents sampled (Residents 2, 3, 5, 6, 7, and 8). Findings include: According to the federal regulatory guidance at 483.60(i)-(2) Food safety requirements - the definition of Danger Zone, found under the Definitions section, is food temperatures above 41 degrees Fahrenheit and below 135 degrees Fahrenheit that allow rapid growth of pathogenic microorganisms that can cause foodborne illness. On April 1, 2025, at 8:20 a.m., an observation was made of a breakfast cart on the second floor, positioned directly across from the elevator with no staff present to distribute trays. Upon re-observation at 8:45 a.m., the cart remained in the same location, and staff were just beginning to pass trays at that time. A test tray evaluation was conducted on the last tray from the same cart at 8:48 a.m. The regular diet meal included waffles, ham, hot cereal, and coffee.…

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

Based on observation and staff interview, it was determined the facility failed to maintain a safe, clean, and homelike environment in two areas of the facility (the kitchen entrance door and the laundry room entrance door), affecting the safety and security of the environment for both staff and residents. Findings include: On April 1, 2025, at 10:00 A.M. in the presence of the of the Dietary Manager, an observation of the kitchen's dishwasher entrance revealed the double entrance doors were broken. The doors could not be properly closed or locked. When attempting to open the doors, they swung off the hinges, making it difficult to completely open them for tray carts to pass through. This entryway was used for transporting both clean and soiled food carts. The door locks were inoperable, and instead, two sliding locks located at the top inside of the doors were used at night to secure the area. Staff would exit the kitchen through alternate doors. During an interview at the time of the observation, the Dietary Manager stated she was hired in December 2024 and that the doors were…

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, the minutes from facility Resident Council meetings, and grievances lodged with the facility, and resident and staff interviews, it was determined the facility failed to put forth sufficient efforts to promptly resolve continued resident complaints and grievances expressed during Resident Council meetings and verbal grievances, including those voiced by four residents attending a resident group meeting (Residents 46, 57, 16, and 35) and failed to keep the residents apprised of the status of the facility's decisions and efforts toward grievance resolution. Findings include: A review of the facility's Grievance Policy, last revised on June 1, 2024, indicated the facility has a system in place to ensure the resident's right to prompt efforts to resolve grievances that they may have. A review of the minutes from the Residents' Council meeting dated June 2024 indicated the residents in attendance at that meeting reported call bells were not being answered timely. A review of the minutes from the Residents' Council meeting dated July 2024 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 observations, review of select facility policy, and staff interviews, it was determined the facility failed to develop a comprehensive grievance policy and ensure the necessary information for filing a grievance was posted and/or provided/available to residents or their representatives. Findings include: A review of the facility's policy entitled Resident and Family Grievances (last revised June 1, 2024) indicated it is the facility's policy that all grievances and complaints filed will be investigated and corrective actions will be taken to resolve the grievance. The policy failed to include procedures designed to support the resident's right to file a grievance anonymously, and failed to identify the current grievance official. Observations of the nursing units conducted on September 5, 2024, revealed a posting regarding the facility's grievance policy, which failed to include procedural information to include: where the grievance forms are located, how to file anonymously with the contact information of the grievance official with whom a grievance can be filed; to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, facility policy review and staff interview, it was determined the facility failed to ensure that nursing services met professional standards of quality according to the Pennsylvania Code Title 49, Professional and Vocational Standards, by failing to implement nursing practices for the administration of an intravenous medication via central venous catheter for one of 6 residents reviewed. (Resident A1). Findings include: According to the Pennsylvania Code Title 49, Professional and Vocational Standards Department of State, Chapter 21 State Board of Nursing, Chapter 21.145 Functions of the LPN (Licensed Practical Nurse) requires the following: The LPN is prepared to function as a member of the health care team by exercising sound nursing judgement based on preparations, knowledge, skills, understandings and past experiences in nursing situations. The LPN participates in the planning, implementation and evaluation of nursing care in settings where nursing takes place. (b) The LPN…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of clinical records and select facility policy and staff interview, it was determined the facility failed to timely respond to a resident's increased level of pain and provide an effective pain management to alleviate pain for four residents of 18 residents sampled (Residents 17, 3, 41, and 18). Findings include: Review of facility policy entitled Pain Management (no date indicated as when it was last reviewed) provided by the facility on September 5, 2024, revealed based upon the evaluation, the facility, in collaboration with the attending physician/prescriber, other health care professionals, and the resident and /or resident's representative will develop, implement, monitor, and revise as necessary interventions to prevent or manage each individual resident's pain beginning on admission. For residents with an addiction history or opioid use disorder, the facility should use strategies to relieve pain while also considering opioid use addiction history. These strategies may include…

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

Based on observation and staff interview, it was determined the facility failed to ensure adherence to medication expiration/use by dates on two of four medication carts (Second Floor - Long hall and Short hall). Findings include: Observation of the medication cart on Second Floor identified as the Long Hall cart, on September 5, 2024, at 11:27 a.m., in the presence of Employee 1, Licensed Practical Nurse (LPN) revealed one multidose vial of Humalog insulin opened and not dated to when it was opened, and one multidose vial of Humalog insulin not opened or dated and labeled refrigerate. Interview with Employee 1, LPN revealed that multidose vials of Humalog insulin should be discarded 28 days after being opened and dated when opened. Employee 1, LPN further confirmed that unopened multidose insulin should remain refrigerated until needed. Observation of an additional medication cart on the Second floor (short hall) on September 5, 2024, at approximately 11:45 a.m. revealed a Novolog insulin pen that was opened and not dated. Further review of the cart revealed an opened and undated…

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, resident and staff interview, and test tray results, it was determined the facility failed to serve meals that are palatable, attractive, and at safe and appetizing temperature for two of the 18 residents sampled (Resident 44 and 6) and including experiences reported by 4 out of four residents during a group interview (Residents 46, 57, 16, and 35). Findings include: According to the federal regulation 483.60(i)-(2) Food safety requirements - the definition of Danger Zone, found under the Definitions section, is food temperatures above 41 degrees Fahrenheit and below 135 degrees Fahrenheit that allow rapid growth of pathogenic microorganisms that can cause foodborne illness. During a group resident council meeting conducted with four cognitively intact residents revealed at times the meals were not consistently served at palatable temperatures. An interview with Resident 44, a cognitively intact resident, on September 4, 2024, at 10:30 a.m., revealed the facility's food was served cold most times and that the food was not palatable. A review of the facility's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of clinical records and the facility's planned cycle menu, observation and staff and resident interviews it was determined that the facility failed to provide therapeutic diets prescribed by resident's attending physician for two residents out of 18 sampled (Resident 3 and 44). Findings include: A review of a facility policy entitled Therapeutic Diets provided by the facility on September 5, 2024, indicated that the facility provides therapeutic diets per need and resident preference. Therapeutic diets are prescribed by the Physician or Dietitian and used to balance medical needs of the resident with their preferences. A review of the facility's approved diet manual (serves as a guide in prescribing diets, and an aid in planning regular and therapeutic diet menus, and as a reference for developing recipes and preparing diets) dated June 2015, indicated that the facility's carbohydrate consistent diet/consistent carbohydrate diet was used to help diabetic resident manage blood glucose levels.…

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 QAPI meeting attendance records and staff interviews, it was determined the facility failed to ensure that the required committee members met at least quarterly for one quarter out of three reviewed. Findings include: An interview was conducted with the Nursing Home Administrator (NHA) on September 6, 2024, at approximately 11:30 AM, revealed that facility's QA/QAPI committee members included the NHA, Director of Nursing (DON), Medical Director, and department heads. The NHA reported that the committee meets at least quarterly. Review of the facility's QA/QAPI committee attendance sheets revealed the committee met in April 2024 and July 2024. Further review of the QA/QAPI committee attendance sheets revealed there was no documented evidence the Medical Director attended the meeting held July 2024. Interview with the NHA on September 6, 2024, at approximately 11:35 AM, confirmed the facility's QA/QAPI committee failed to provide documented evidence that the facility's Medical Director consistently attended/participated in the meetings at least quarterly.…

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 select facility policy, review of Center for Medicare and Medicaid services memo, a review of ASHRAE guidelines for Legionella, review of facility documentation, and staff interviews it was determined that the facility failed to maintain a comprehensive program for water management to monitor the potential development and spread of Legionella and failed to implement control measures for Legionella within the facility for twelve of twelve months (August 2023 through August 2024). Findings Include: Review of Department of Health and Human services, Centers for Medicare and Medicaid services (CMS) memo Requirement to Reduce Legionella Risk in Healthcare Facility Water Systems to Prevent Cases and Outbreaks of Legionnaires' Disease (LD) dated July 6, 2018, revealed facilities must develop and adhere to policies and procedures that inhibit microbial growth in building water systems that reduce the risk of growth and spread of Legionella and other opportunistic pathogens in water. This policy memorandum applies to Hospitals, Critical Access Hospitals, and Long-Term…

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 regulations, facility policy review, and staff interviews, it was determined that the facility failed to have an Infection Preventionist (IP) that worked at least part time at the facility. Findings Include: The Centers for Medicare and Medicaid Services regulation §483.80(b)(3) states the facility must designate one or more individuals as the infection preventionist who are responsible for the facility's Infection Prevention and Control Program. The IP must work at least part-time at the facility, physically work onsite in the facility, cannot be an off-site consultant, or perform the IP work at a separate location. During an interview with the Nursing Home Administrator (NHA) and Director of Nursing (DON) on September 5, 2024, at 11:40 AM, they stated that the prior IP left the role in the beginning of August 2024, and there was currently no designated IP. Further they stated the facility has hired two new Registered Nurses, but neither had completed the required IP training. In an interview on September 6, 2024, at 9:47 a.m., the Director of Nursing confirmed…

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

Based on review of select facility policy, and resident and staff interviews, it was determined the facility failed to provide an environment, which promotes each resident's quality of life by failing to accommodate cognitively intact resident's snack cart for four residents out of four sampled residents (Residents 46, 57, 16, and 35). Findings include: A group meeting conducted with four residents (Residents 46, 57, 16, and 35) on September 5, 2024, at 10:30 a.m. revealed the residents reported being very upset that a resident run snack cart had been abruptly taken away from them. The residents reported Activities staff would buy items and residents would go around facility and resell these snacks to other residents. Any profit from this snack cart was to be used for activity purposes i.e. pizza parties, bingo prizes etc. The residents stated they were not given any reason for the snack cart being taken from them, they were only informed they had to use the facility vending machines. The residents were very unhappy and stated the snack cart was not only a way to make money 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 clinical record review and staff interview it was determined the facility failed to include, in the resident's baseline plan of care, minimum standards of care to fully address the resident's immediate needs upon admission for one resident out 6 sampled (Resident B1). Findings include: A review of a facility policy entitled Resident admission Procedure (no date of policy development) that was provided by the facility on November 1, 2024, indicated the upon a resident's admission to the facility the nurse was to measure and record the resident's temperature, pulse, respiration, blood pressure, weight, and height. The nurse was to observe the general condition of the resident's skin (i.e., wounds, rashes, burns, bruises, scars, or surgical incisions), as well as his or her reaction to the admission. Additionally, the nurse was to notify the administrator, Director of Nursing (DON), attending/other involved physicians of the admission and acute issues such as respiratory or other distress, wounds, etc.…

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 select facility policy and interviews with residents and staff, it was determined the facility failed to review and revise the resident's plan of care in response to a significant weight loss for one resident out 18 residents (Resident 66). Findings include: Review of the clinical record of Resident 66 revealed admission to the facility on September 20, 2023, with diagnoses to include anoxic brain damage (brain damage from a lack of oxygen to the brain). On August 20, 2024, the resident weighed 81 pounds which was a 14.7% weight loss in 180 days. A nutritional note dated August 22, 2024, revealed that the dietitian has continued to implement interventions to address the residents weight loss, however a review of residents care plan, dated as last revised on May 30, 2024, revealed he resident was nutritionally at risk related to cardiovascular disease, diabetes, renal disease, respiratory disease, swallowing problems, NPO (nothing by mouth) requiring tube feeding, hypernatremia (high sodium levels in the blood), and hyperglycemia (high sugar levels in the blood).…

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, observation, and staff interviews, it was determined the facility failed to ensure care and services are provided in accordance with professional standards of practice that will meet each resident's physical, mental, and psychosocial needs for one of 16 residents reviewed (Residents 51). Findings include: According to the Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.11 (a)(1)(2)(4) indicates that the registered nurse was to collect complete ongoing data to determine nursing care needs, analyze the health status of individuals and compare the data with the norm when determining nursing care needs, and carry out nursing care actions that promote, maintain, and restore the well-being of individuals. Review of Resident 51's clinical record revealed admission to the facility on October 3, 2020, with diagnoses that included chronic obstructive pulmonary disease (COPD-type of obstructive lung disease characterized by long-term poor airflow. The main symptoms include shortness of breath and cough with sputum…

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 observation, select facility policy review and staff interview it was determined the facility failed to maintain an environment free of potential accident hazards during medication administration on one of two resident care units. (second floor) for one of two residents observed. Findings include: A review of facility policy entitled Medication Administration, provided by the facility on September 6, 2024, indicated the nurse preparing the medication for administration is to observe resident consumption of medication. An observation on the second floor on September 6, 2024, at 9:26 a.m. during observation of medication administration revealed there were medications located on overbed table in room [ROOM NUMBER]. Two white tablets were observed in a clear plastic medication cup on Resident 32's overbed table. During an interview with Resident 32, who resides in room [ROOM NUMBER] on September 6, 2024, at 9:27 a.m. the resident stated the nurse left the medications on his table for him to take during…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of select facility policy, and clinical records, and staff interview, it was determined the facility failed to thoroughly assess and evaluate bowel function and implement individualized approaches to restore normal bowel function to the extent possible for one out of 6 sampled residents (Resident A2). Findings include: A review of the facility policy for incontinence management reviewed September 30, 2024 revealed, the facility will assess residents for their continence status, potential contributing factors and if incontinent, provide interventions to attempt to maintain or attain their highest level of continence. The procedure includes: A resident's continence status will be assessed within 2 weeks of admission, routinely and upon significant change in continence status, If a resident is incontinent, the type of continence will be determined if able, Interventions and treatment will be provided to help residents restore or improve bowel and or bladder function and prevent urinary tract…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of clinical records, observations and staff interviews it was determined that the facility failed to provide pharmacy services, routine drugs and pharmaceuticals, to ensure timely medication administration as prescribed for one resident out of 18 sampled (Resident 180) and maintain accurate narcotic administration records for one resident out of 18 sampled (Resident 18). Findings include: A review of the clinical record revealed that Resident 180 was admitted to the facility on [DATE], with diagnoses, which included human immunodeficiency virus (HIV), Type 2 diabetes, and Alzheimer's disease. Resident 180 had admission physician orders for Miralax oral powder 17 GM/scoop one scoop daily for constipation, Mirtazapine 15mg daily for depression, Symtuza (Darunavir-Cobicistat-Emtricitabine-Tenofovir Alafenamide) daily for HIV, Tamsulosin HCL 0.4mg daily for BPH (benign prostatic hyperplasia), Zyprexa 2.5mg daily for psychosis, and Namenda 10mg twice a day for Alzheimer's disease. During observation…

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 clinical record, facility provided documents, the facility's plan of correction from the surveys ending on August 9, 2024, and on September 6, 2024, and the outcome of the activities of the facility's quality assurance committee it was determined the facility failed to develop and implement a quality assurance plan, which was able to identify, and correct ongoing quality deficiencies related to the assessment and implementation of bowel and bladder programs for one of 6 residents sampled (Resident A2). Findings included: During survey ending August 9, 2024 deficient facility practice was identified related to the facility's failure to assess and implement a program to maintain or restore this same resident's bowel function. The facility developed a plan of correction that included, The bowel and bladder documentation will be assumed by the nursing staff. The documentation will be audited daily by the nursing supervisor to ensure completion. The nursing staff will be educated on the new process…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of clinical records, select facility policy facility documentation, and staff interview, it was determined the facility failed to ensure that three residents out of 6 sampled were free from physical abuse (Residents 2, 3 and 4). Findings include: A review of facility policy entitled Abuse Reporting and Investigation (no revision date available) revealed, the facility will thoroughly investigate all reports of suspected or alleged abuse. Clinical record review revealed Resident 2 was admitted to the facility on [DATE] with diagnosis to include but not limited to, psychosis, mood disorder, intermittant explosive disorder and seizure disorder. An annual minimum data set assessment (Minimum Data Set - a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated May 3, 2024 indicated he was moderately, cognitively impaired with a BIMS score of 9 (Brief Interview for Mental Status. The BIMS test is used to get a quick snapshot of how well you are…

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, facility policy provided to residents upon transfer from the facility, and interview with facility staff revealed the facility failed to demonstrate the implementation of specifically delineated procedures for Medicaid payor source bed holds and the provision of notices of the facility's bed hold policy in an understandable language that allow a resident to return to the facility after a transfer to the emergency room for one resident out of six reviewed. (Resident 5). Findings include: A review of a facility policy, Discharge/Transfer Letter Policy and Bed Hold Notices for bed-holds and returns, (policy review date unavailable at the time of the survey), revealed, prior to transfers and therapeutic leaves, residents or resident representatives will be informed in writing of the bed-hold and return policy. The policy revealed the residents may return to and resume residence in the facility after hospitalization or therapeutic leave as outlined in this policy. Prior to a transfer, written information will be given to the residents and the resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of select facility policy, and clinical records, and staff interview, it was determined the facility failed to thoroughly assess and evaluate bowel function and implement individualized approaches to restore normal bowel function to the extent possible for one out of 6 sampled residents (Resident 1). Findings include: A review of the facility policy entitled Continence Status Guidelines (no date as reviewed provided at the time of the survey), revealed residents admitted to the facility will be assessed to determine their level of bowel and bladder continence and appropriate interventions put into place when indicated. Guidelines to include: Residents will be assessed within two weeks of admission, upon significant change in status on incontinence and routinely, to determine their continence status; After an assessment residents will be placed in one of the following categories for bowel and bladder: Continent-resident is continent of bowel and bladder. Residents will be provided products 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 staff interviews and a review of employee personnel records it was determined that the facility failed to provide abuse prevention training to four employee out of four reviewed. (Employees 1,2,3, and 4). Findings include: During an interview with Employee 1 (agency Licensed Practical Nurse) on August 9, 2024 at 9:45 AM she stated that she worked at the facility on and off for the past four months. Employee 1 stated that she was never trained on the facility's abuse prohibition policy prior to assuming her duties today. During an interview with Employee 2 (agency registered nurse) on August 9, 2024 at 9:55 AM she stated this is the fourth shift she had worked at the facility and stated she was never trained on the facility's abuse prohibition policy prior to assuming her duties today. During an interview with Employee 3 (agency nurse aide) on August 9, 2024 at 10:00 AM she stated that she worked at the facility on and off for the past 6 months. Employee 3 stated she was never trained on the facility's abuse prohibition policy prior to assuming her duties today. 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 clinical records and staff interview, it was determined the facility failed to timely notify the resident's responsible representative of a change in condition for one resident out of 6 sampled (Resident 5). Findings include: A review of the clinical record revealed that Resident 5 was admitted to the facility on [DATE], with diagnoses which included diabetes mellitus (commonly referred to as diabetes, is a group of metabolic diseases in which there are high blood sugar levels over a prolonged period) and dementia (a condition in which a person loses the ability to think, remember, learn, make decisions, and solve problems). A review of a nurses note dated June 24, 2024 at 1:08 P.M. revealed, Resident 5 was complaining of right upper extremity pain and edema (swelling) and the CRNP(certified registered nurse practioner) was made aware. A new order noted for Doppler study (Doppler ultrasound is a noninvasive test that can be used to measure the blood flow through the blood vessels. It works by…

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

Based on a review of clinical records and select facility reports and staff interviews it was determined that the facility failed to develop and implement a person-centered care plan that fully addressed a resident's behavior management, included repeated non-compliance with the facility's leave of absence policy, to consistently meet the resident's safety needs for one resident out of 10 sampled (Resident A1). Findings included: A review of Resident A1's clinical record revealed admission to the facility on April 14, 2023, with diagnoses including diabetes, depression and a history of falling. Resident A1's quarterly Minimum Data Set (MDS - a federally mandated assessment of a resident's abilities and care needs) dated December 13, 2023, revealed that the resident was cognitively intact with a BIMS score of 15 (Brief Interview for Mental Status Score - a tool to assess cognitive function). A review of Resident A1's care plan, initially dated April 21, 2023, indicated that Resident A1 has potential to exhibit increased behaviors as evidenced by ineffective coping and increased…

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

Based on observation and a review of clinical records and staff and resident interviews it was determined that the facility failed to efficiently deploy sufficient nursing staff to consistently provide timely quality of care and services to maintain the physical and mental well-being of the residents in the facility, including experiences reported by four out of 10 residents sampled (Residents B1, B2, B3, and B4). Findings include: During interview with Resident B1, a cognitively intact resident, on February 14, 2024, at 12:40 PM the resident stated that nursing staff do not answer call bells timely and residents must wait times more than 15 minutes. Resident B1 stated that staff are busy and today and as result morning hygiene care was not provided as of 12:40 PM. Resident B1 stated that the facility has also reduced showers from twice per week to just once per week because of insufficient nurse staffing to provide showers twice a week. During interview with Resident B2, a cognitively intact resident, on February 14, 2024, at 12:50 PM the resident stated when she rings for 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 staff interviews and observations it was determined that the facility failed to employ sufficient staff qualified staff to provide oversight of the food and nutrition services department. Findings include: An interview with the Employee 2, AM cook, on January 4, 2024, at 11 AM, revealed that there was no qualified dietary manager in the facility and that the facility had employed a full-time Registered Dietitian (RD) for the past 2 weeks. However, she stated that the RD was not providing oversight of the food service and dietary department, but only performing clinical nutrition duties. Employee 2 (cook) stated that the current full-time RD only provided clinical nutrition services until the facility hired someone qualified to oversee the food service and dietary department. Observation January 4, 2023 at 12 P.M. on the third floor hallway, on the wall on the outside the resident dining room, revealed that the posted weekly resident menu (regular diet) was dated for Thursday January 11, 2024, indicating the menu for lunch was as follows; chicken vegetable stew over noodles,…

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

Based on observation and staff interview, it was determined the facility failed to maintain necessary electrical equipment in safe operating condition in the kitchen. Findings include: A tour of the facility's kitchen on January 4, 2024, at approximately 10:00 AM revealed the steam table (a table having openings to hold containers of cooked food over steam or hot water circulating beneath them) was not fully functional. An interview at the time of the observation, Employee 1 (cook) stated that the steam table had been broken for months. She stated that it was operable, but if the temperature dial was placed to 8 ( the temperature was noted on the dial as 1, least hot to 10, most hot for holding food) whenever the steam table was in use the steam table would short out. She stated that the dial should be placed on 10 to provide the optimal heating capacity to keep hot foods at a safe temperature while in serving pans in the table and plating resident meals. Employee 1 (cook) stated that if the temperature was placed over 8 it would short out the table (electricity cut off). She…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of nursing staffing hours and ratios, observations and resident, family and staff interviews it was determined that the facility failed to provide sufficient nursing staff to consistently provide timely quality of care and services to maintain the physical and mental well-being of the residents, in accordance with the resident's plan of care, including Resident 2. Findings include: Clinical record review revealed that Resident 2 was admitted to the facility on [DATE] with diagnosis to include diabetes, contractures of the right and left ankles, depression and anxiety and was cognitively intact. The resident's care plan revealed a problem/need of ADL deficit initiated May 30, 2022 and revised November 12, 2023, with an intervention dated August 16, 2023, for a bowel and bladder toileting program, 5 times a day at 6 AM 10 AM, 2 PM, 6 PM and 10 PM During an interview conducted on January 4, 2024 at 1:20 P.M. Resident 2 stated that nursing staff on the 11 PM to 7 AM shift provided her care,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of clinical records and the facility's planned cycle menu, observation and staff and resident interviews it was determined that the facility failed to prepare, in advance, a nutritionally adequate menu, reflecting cultural and ethnic needs of one resident (Resident C1) and failed to follow planned menus, including the lunch meals observed served to two residents (Residents C2 and C3) out of 15 residents sampled (Resident C1). Findings include: A review of the clinical record revealed that Resident C1, was severely cognitively impaired, admitted to the facility on [DATE], with diagnoses that included dementia, muscle weakness, and vitamin deficiency. The resident dietary preferences indicated that he was a vegetarian. A review of the resident' meal tray card dated January 4, 2024, revealed that Resident C1 was to receive a regular diet and vegetarian preferences. Observation of Resident C1's lunch meal on January 4, 2024, revealed he was served mashed potatoes, mixed vegetables, pasta, peas 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 observation, resident and staff interview, test tray results, and a review of select facility policy, it was determined that the facility failed to provide meals that are served at safe and palatable temperatures. The findings include: Review of the current facility policy entitled Temperatures indicated that all hot food items must be held and served at a temperature of at least 135 degrees Fahrenheit and cold food items must be maintained at served at a temperature of 41 degrees Fahrenheit or below. A test tray was performed on the third floor on January 4, 2024, at 1:15 PM. Observation revealed that the lunch tray delivery cart arrived on the unit at 12:27 PM and nursing staff began passing lunch trays at 12:38 PM. The final tray was passed at 12:43 PM, a test tray was tested. Acceptable temperature for hot foods should be >/= 135 degrees Fahrenheit and cold food should be </= 41 degrees Fahrenheit. The test tray food temperatures results were as follows: linguini was at 120 degrees Fahrenheit, meatballs were at 100 degrees Fahrenheit, mixed vegetables were at 110…

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 the statement of deficiencies from the survey ending October 20, 2023, and the activities of facility's quality assurance committee and staff interviews it was determined that the facility failed to implement effective plans to correct quality deficiencies in food and nutrition services, including planned nutritionally adequate menus, sufficient qualified staff, food temperature and taste, and hydration to ensure that corrective action plans designed to improve the delivery of care and services were consistently implemented to correct and deter future quality deficiencies. Findings included: During the survey ending October 20, 2023, quality deficiencies were cited under the requirements for nutrition/hydration, qualified dietary staff, planned menus, taste, and temperature and appearance of food. In response to these deficiencies, the facility developed plans of correction to correct the deficient practices that included quality assurance monitoring plans to assure solutions were sustained. These corrective plans were to be completed and functioning…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of clinical records, the facility's abuse prohibition policy, select facility incident reports, and information submitted by the facility, and staff interview, it was determined that the facility failed to ensure that one resident out of 12 residents sampled were free from physical abuse (Resident A9). Findings include: A review the facility's Abuse Protection policy dated as reviewed by the facility September 2022 revealed that The resident has the right to be free from verbal, physical and mental abuse, corporal punishment, involuntary seclusion, neglect and misappropriation of property. The facility shall have processes in place to include screening, training, prevention, identification, protection, investigation, reporting and response to allegations of potential or actual abuse. Clinical record review revealed that Resident A8 had diagnoses, which included depression. According to the resident's clinical record the resident had a history of verbal and physical aggression with other…

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

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 accurately monitor a fluid restriction prescribed to address a resident's clinical condition and maintain fluid balance and adequate hydration status for one resident (Resident B3) out of 12 sampled. Findings include: Review of education provided to the facility licensed nursing staff dated November 15, 2023, indicated that all resident fluid} intakes and outputs need to have a task entered in POC (Point of Care) for accurate totaling. A review of the clinical record revealed that Resident B3 was admitted to the facility on [DATE], with diagnoses which included hypertension, chronic obstructive pulmonary disease, and malignant neoplasm (cancer) of the throat. A physician's order dated December 21, 2023, was noted for the resident to be maintained on a 1500 cc fluid restriction with the following breakdown of the fluid distribution: 7:00 AM - 3:00 PM shift nursing 240 mL and dietary 600 mL. 3:00 PM - 11:00 PM shift…

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 select facility policy and minutes from Resident Council meetings and resident and staff interviews it was determined that the facility failed to put forth sufficient efforts to promptly resolve continued resident complaints/grievances expressed during Resident Council Meetings including those voiced by four of four residents attending a resident group meeting (Residents 55, 63, 61, and 40) Findings include: Review of the facility's current Grievance policy indicated that it is the facility's policy to provide an opportunity for residents to express concerns at any time. The facility's goal is to resolve resident and family concerns in a timely basis. Review of the minutes from the Resident Council meetings held between June 2023 through September 2023, revealed that residents in attendance at these resident group meetings voiced their concerns regarding facility services during the meetings. During the August 2023 Resident Council meeting the residents in attendance relayed concerns with staff responding their requests for assistance via the nurse call bell…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and staff interview, it was determined that the facility failed to provide housekeeping services to maintain a clean and orderly environment in resident areas on two of three resident units (Second and Third Floor Nursing Units) Findings include: Observations on at 11:47 AM on October 17, 2023, of the Second Floor Nursing Unit revealed in dirt, debris, and food particles on the floor and under the bed in resident room [ROOM NUMBER]. Dirt, debris and food particles were observed on the floor in resident room [ROOM NUMBER]. The drawer of the dresser in the room was broken. The door frame was cracked and peeling. There was a dried brown substance on the wall by the light switch. There was toilet paper and a wash basin on the bathroom floor. [NAME] and red spots and stains were observed on the privacy curtains. Brown spots and dried liquid drips on the wall of resident room [ROOM NUMBER]. There was a dried sticky area on the floor, with paper debris, dust and dirt, stuck to the spot. A dried…

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 select facility policy, and staff and resident interviews it was determined that the facility failed to provide nursing services consistent with professional standards by failing to timely and fully assess wounds for two residents (Resident 237 and 52) and to timely administer prescribed medications for one resident (Resident 237) out of 19 residents sampled. The findings include: According to the Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.11 (a)(1)(2)(4) indicates that the registered nurse was to carry out nursing care actions that promote, maintain, and restore the well-being of individuals. The Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.145 Functions of the Licensed Practical Nurse (LPN) (a) The LPN is prepared to function as a member of the health-care team by exercising sound judgement based on preparation, knowledge, skills, understandings, and past experiences in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of nursing staffing hours and ratios, observations and resident, family and staff interviews it was determined that the facility failed to provide sufficient nursing staff to consistently provide timely quality of care and services to maintain the physical and mental well-being of the residents, in accordance with the resident's plan of care, including Resident 2. Findings include: Clinical record review revealed that Resident 2 was admitted to the facility on [DATE] with diagnosis to include diabetes, contractures of the right and left ankles, depression and anxiety and was cognitively intact. The resident's care plan revealed a problem/need of ADL deficit initiated May 30, 2022 and revised November 12, 2023, with an intervention dated August 16, 2023, for a bowel and bladder toileting program, 5 times a day at 6 AM 10 AM, 2 PM, 6 PM and 10 PM During an interview conducted on January 4, 2024 at 1:20 P.M. Resident 2 stated that nursing staff on the 11 PM to 7 AM shift provided her care,…

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

Based on observation, resident and staff interviews and a review of meal service delivery schedule and the minutes from resident food committee meetings it was determined that the facility failed to consistently maintain sufficient staffing in the dietary department to effectively and efficiently carry out the functions of the food and nutrition service department. Findings include: A review of the minutes from the resident food committee meeting dated June 26, 2023, at 2:00 PM, revealed that residents in attendance at this meeting voiced concerns that their meals were arriving late and were cold by the time they received them. The identified resolution noted by the facility was for staff to conduct food delivery audits to ensure that meals arrive to the units on time and that the nursing staff passes the meals in a timely fashion. A review of resident food committee meeting minutes dated July 25, 2023, at 2:00 PM, revealed that residents in attendance continued to voice concerns with their food arriving cold. The noted facility resolution was for staff to conduct food delivery…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of clinical records, the facility's abuse prohibition policy, select facility incident reports, and information submitted by the facility, and staff interview, it was determined that the facility failed to ensure that one resident out of 12 residents sampled were free from physical abuse (Resident A9). Findings include: A review the facility's Abuse Protection policy dated as reviewed by the facility September 2022 revealed that The resident has the right to be free from verbal, physical and mental abuse, corporal punishment, involuntary seclusion, neglect and misappropriation of property. The facility shall have processes in place to include screening, training, prevention, identification, protection, investigation, reporting and response to allegations of potential or actual abuse. Clinical record review revealed that Resident A8 had diagnoses, which included depression. According to the resident's clinical record the resident had a history of verbal and physical aggression with other…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of clinical records and select facility policies and resident and staff interviews, it was determined that the facility failed to timely and thoroughly investigate injuries of unknown source to rule out abuse, neglect or mistreatment for one of the 19 residents sampled (Resident 31). The findings include: A review of the facility's policy Abuse Policy that was last reviewed by the facility on October 1, 2023, indicated that a timely and thorough investigations of all reports and allegations of abuse to include injuries of unknown origin. An alleged violation of abuse, neglect, exploitation or mistreatment (including injuries of unknown sources, misappropriation of resident property) and reasonable suspicion of a crime resulting in bodily injury will be reported immediately, but not later than two (2) hours if the alleged violation involves abuse OR has resulted in serious bodily injury; or twenty-four (24) if the alleged does not involve abuse AND has not resulted in serious bodily injury. 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 clinical record review and staff interview it was determined that the baseline care plan of one of 19 residents sampled (Resident 237) failed to fully address the resident's immediate needs upon admission. Findings: A review of Resident 's 237 clinical record revealed that the resident was admitted to the facility on [DATE], with diagnoses that included hemiplegia (paralysis of one side of the body) and hemiparesis (weakness on one side of the body) following a cerebral infarction (occurs because of disrupted blood flow to the brain due to problems with the blood vessels that supply it. A lack of adequate blood supply to brain cells deprives them of oxygen and vital nutrients which can cause parts of the brain to die off.) and cutaneous abscess (a localized collection of pus in the skin and may occur on any skin surface) of the abdominal wall. Review of the Resident 237's baseline care plan revealed that the it failed to identify the wounds the resident had at the time of admission due the cutaneous…

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 implement pharmacy procedures to promote accurate controlled medication records for one resident (Resident 86) out of 19 residents sampled. Finding include: A review of the clinical record revealed that Resident 86 was admitted to the facility on [DATE], and discharged on July 20, 2023, with diagnoses of depression and anxiety. The resident had a physician order dated from July 4, 2023 to July 20, 2023 for Klonopin (used to prevent and treat anxiety disorders) 1 milligram (mg) orally every 8 hours as needed for for anxiety. Review of the Controlled Drug Record for the resident's supply of Klonopin indicated that it was administered to the resident on July 13, 2023 at 8:00 a.m. July 18, 2023 at 8:00 a.m. July 18, 2023 at 5:00 p.m. and July 20, 2023 at 8:30 a.m. However, a review of the resident's Medication Administration Record (MAR) for July 2023 revealed no documented evidence that nursing staff had administered…

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.