Manor At Penn Village, The

Based on observation, clinical record review, and staff interview, it was determined that the facility failed to provide the highest practicable care regarding Transmission Based Precautions for three of 32 residents reviewed (Residents 19, 31, and 42) and failed to provide a safe and sanitary environment to help prevent development and transmission of disease and infection for one of 32 residents reviewed (Resident 10). Findings include: Observation of the room shared by Resident 31 and Resident 42 on December 3, 2025, at 2:20 PM revealed a sign on the door that directed visitors to Stop due to Contact Precautions (measures that are intended to prevent transmission of infectious agents which are spread by direct or indirect contact with the resident or the resident's environment). The sign instructed that everyone must clean their hands, put on gloves, put on a gown before room entry, and use dedicated or disposable equipment. Further observation of the room revealed a sign on the right doorframe that indicated Enhanced Barrier Precautions (EBP, utilized for residents with chronic…

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, review of facility documentation, and staff interview, it was determined that the facility failed to implement interventions to decrease the potential for resident elopements for one of four residents reviewed (Resident 1). Findings include: Clinical record review for Resident 1 revealed a progress note date August 1, 2025, at 6:19 PM that indicated she was exit seeking twice during the shift. Clinical record review for Resident 1 revealed a nursing progress note dated August 17, 2025, at 10:11 PM that indicated Resident 1 was anxious and exit seeking. The physician was notified and a one time dose of Seroquel (a medication used to treat psychosis) 25 milligrams was ordered. A nursing progress note dated August 21, 2025, at 12:08 AM revealed that Resident 1 was pacing in the hallway and set off the wander guard system at the elevators once. A nursing progress note dated August 21, 2025, at 6:22 PM revealed that Resident 1 was restless and wandering. She wanted to leave. She was on the elevator twice and activated the alarm. Clinical record review for…

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

Based on observation and staff interview, it was determined that the facility failed to provide adequate housekeeping and maintenance services to ensure a clean, comfortable, and homelike environment on two of four nursing units (Nursing Units C, and F; Residents 1, 2, 3, 4, 5, and 6). Findings include: Observation of Nursing Unit C (second floor) on March 26, 2025, at 10:33 AM revealed the following findings: A wheelchair in the hallway with no resident identifier had a significant accumulation of crumbs and debris under the seat cushion on the chair. There was also an unidentified piece of metal on the seat of the chair. A concurrent interview with Employee 1, nurse aide, revealed the wheelchair belonged to Resident 1. Resident 2's wheelchair had an accumulation of crumbs and debris under the seat cushion on the wheelchair. Resident 3's wheelchair had an accumulation of crumbs and debris under the seat cushion on the wheelchair. Another wheelchair with no resident identifier had an accumulation of crumbs and debris under the seat cushion on the wheelchair. A concurrent interview…

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

Based on clinical record review and resident and staff interview, it was determined that the facility failed to provide physician ordered services to maintain a resident's mobility for two of three residents reviewed (Residents 73 and 98) and maintain a resident's restorative nursing program for two of three residents reviewed (Residents 85 and 98). Findings include: Clinical record review for Resident 85 revealed a quarterly MDS (Minimum Data Set, an assessment tool completed at specific intervals to determine resident care needs) dated November 11, 2024, that indicated the resident had a BIMS (Brief Interview for Mental Status) score of 3 that indicated a severe cognitive impairment level. Review of the Tasks list for Resident 85 revealed the following restorative nursing program (a formal, planned, and organized care program designed to restore lost abilities or maintain potentially deteriorating functions): Ambulation/locomotion; patient will ambulate 100 to 150 feet with a rolling walker and supervision. A physical therapy discharge summary for Resident 85 dated September 25,…

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

Based on employee personnel record review and staff interview, it was determined that the facility failed to complete a performance evaluation of each nurse aide at least once every 12 months for two of three nurse aides reviewed (Employees 8 and 9). Findings include: The facility noted the following hire dates for two employees reviewed for performance evaluations: Employee 8's hire date: May 29, 2013. Employee 9's hire date: October 27, 1998 A request to review the annual performance evaluations revealed no documented evidence that the facility is completing the evaluations at least once every 12 months. Interview with Employee 10, human resources, on January 31, 2025, at 11:15 AM confirmed that performance evaluations were not completed on the two employees. 483.35(d)(7) Nurse Aide Perform Review-12 Hr/yr In-Service Previously cited 1/26/2024 28 Pa. Code 201.19 (2) Personnel policies and procedures

Based on clinical record review, review of select facility policies and procedures, and staff interview, it was determined that the facility failed to ensure that the resident's attending physician addressed pharmacy recommendations for three of five residents reviewed (Residents 77, 20, and 63). Findings include: The policy entitled Monthly Drug Regimen Review, last reviewed on December 16, 2024, indicates that during a drug regimen review, the consultant pharmacist is to identify drug regimen irregularities. Reports are to be addressed by the attending physician within one to 21 days, unless urgent. If follow up to the consultant pharmacist recommendations are not completed within the specified time frame, this should be reported to the Medical Director. Review of Resident 77's clinical record revealed a pharmacy form entitled Consultation Report dated June 21, 2024, indicating that the consultant pharmacist identified that Resident 77 was taking Ativan (for anxiety) 0.5 mg (milligrams) as needed longer than 14 days without a stop date. There was no documented evidence that…

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

Based on clinical record review and staff interview, it was determined that the facility failed to ensure a resident's medication regime was free from potentially unnecessary medications for three of six residents reviewed (Residents 69, 77, and 85). Findings include: Review of Resident 69's clinical record revealed a physician's order dated January 5, 2025, that indicated nursing staff may administer Ativan (for anxiety) 0.5 mg (milligrams) every six hours as needed for agitation or anxiety. There was no documented evidence that Resident 69's physician documented a rational for the continued use of the Ativan beyond a 14-day period. The facility obtained a physician's order on January 30, 2025, to discontinue the use of the Ativan after the surveyors questioning. Review of Resident 77's clinical record revealed a physician's order dated May 21, 2024, that indicated nursing staff may administer Ativan 0.5 mg every six hours as needed for agitation or anxiety. There was no documented evidence that Resident 77's physician documented a rationale for the continued use of the Ativan…

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 that the facility failed to ensure a medication error rate below five percent (C Nursing Unit and F Nursing Unit; Residents 40 and 66). Findings include: The facility's medication error rate was 10 percent based on 30 medication opportunities with three medication errors. Observation of Resident 40's medication administration pass on January 30, 2025, at 9:00 AM revealed that Employee 7, licensed practical nurse (LPN), prepared the medications prior to administration. Employee 7 proceeded to place the resident's medications in a disposable medication pouch and crush them with a tablet crusher and then mix them in pudding. Clinical record review for Resident 40 revealed a physician/'s order dated May 20, 2024, that noted crushable medications may be crushed, mixed, and administered together unless contraindicated. Physician orders for Resident 40 dated April 25, 2022, revealed Isosorbide Mononitrate (a medication used to help widen the blood vessels and prevent chest pain) ER (extended release) 30 milligrams (mg), give one…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, clinical record review, and resident and staff interview, it was determined that the facility failed to provide necessary dental services for one of one resident reviewed for dental concerns (Resident 20). Findings include: In an interview and observation of Resident 20 on January 28, 2025, at 12:46 PM the resident was observed to have visible black/decayed appearance of her lower teeth with multiple teeth missing. Resident 20 stated she did not recall seeing a dentist since she had been at the facility. Clinical record review for Resident 20 revealed the resident was admitted to the facility on [DATE]. Review of an annual MDS (Minimum Data Set, an assessment tool completed at specific intervals to determine resident care needs) dated June 20, 2024, revealed the resident was assessed as having natural teeth with no likely cavities or broken natural teeth. A review of Resident 20's active plan of care revealed the resident has a care plan initiated on February 5, 2019, indicated 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 review of select facility policies and procedures, clinical record review, and staff interview, it was determined that the facility failed to ensure that residents were educated, offered, and received the COVID-19 vaccine if they consented for five of five residents reviewed for immunizations (Residents 4, 16, 21, 53, and 85) and failed to screen, educate, and offer the COVID-19 vaccine for one of one employee reviewed (Employee 12). Findings include: The policy entitled, COVID-19 Vaccine, Resident, last reviewed on December 16, 2024, indicates that residents or their representatives will be educated about and offered the COVID-19 vaccine. The vaccines will be offered to residents per CDC (Centers for Disease Control and Prevention) and/or FDA (Food and Drug Administration) guidelines unless such an immunization is medically contraindicated, the individual has already been immunized during this time or the individual refuses to receive the vaccine. The policy entitled COVID-19 Vaccine, Staff, last…

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 establish clear advance directives for one of four residents reviewed (Resident 108). Findings include: A review of the census for Resident 108 revealed the resident was admitted to the facility on [DATE]. Current physician orders for Resident 108 revealed an order dated [DATE], that indicated the resident was a Full Code (attempt resuscitation and CPR when the person has no pulse and is not breathing). Review of the current care plan for Resident 108 revealed the resident has advanced directives related to full code. An intervention included a physician order for full code. Facility documentation titled, Advanced Directives Discussion Document for Resident 108 and dated [DATE], indicated Withhold was marked with an X for cardiopulmonary resuscitation (CPR) indicating the resident and/or resident representative did not want CPR administered. The document was signed and dated by the Power of Attorney and 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 clinical record review, review of select facility policies and procedures, observation, and staff interview, it was determined that the facility failed to thoroughly investigate incidents and implement interventions to prevent future falls or accidents for two of six residents reviewed for falls (Residents 83 and 164). Findings include: Clinical record review for Resident 83 revealed a physician's order dated November 1, 2023, for staff to position fall mats beside Resident 83's bed bilaterally. A plan of care developed by the facility identified Resident 83's risk for falls related to gait and balance problems, incontinence, sits himself up on the side of the bed, and is impulsive (will attempt to pick things off floor independently). The plan of care listed interventions that included Resident 83 was not to sit on the side of his bed for meals. He was to be out of bed in his wheelchair for meals or sit up 90 degrees in bed with a tray table in front of him. The plan of care did not include an active intervention to use bilateral fall mats beside his bed although there was…

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

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 interventions to promote acceptable parameters of nutrition resulting in a significant weight loss for two of six residents reviewed (Residents 100 and 101). Findings include: Clinical record review for Resident 100 revealed the resident was admitted to the facility on [DATE], from the hospital, with a history of multiple stokes (when blood flow to the brain is interrupted leading to brain cell damage). Further review revealed Resident 100 had required the insertion of a PEG tube (percutaneous endoscopic gastrostomy tube, a tube inserted into the stomach to administer food and fluids when a person is unable to eat or drink normally) on September 3, 2024, and had since transitioned to eating again by mouth. Review of Resident 100's hospital records for October 18 - November 6, 2024, prior to her admission revealed the resident was noted to be receiving a regular diet in the hospital with nutritional…

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 interview, it was determined that the facility failed to provide respiratory care consistent with professional standards of practice for two of four residents reviewed for respiratory concerns (Residents 49 and 96). Findings include: Clinical record review for Resident 96 revealed a diagnosis list that included the following: respiratory failure with hypoxia (low levels of oxygen in the body), chronic obstructive pulmonary disease (COPD, a lung disease that causes restricted airflow and breathing problems), and dependence on supplemental oxygen. Review of current physician orders for Resident 96 revealed an order dated January 15, 2025, that instructed staff to administer supplemental oxygen at four liters per minute (LPM) by nasal cannula (medical tubing that delivers supplemental oxygen directly to the nose) with humidification. Resident 96's care plan revealed the resident has COPD and an intervention noted is to administer humidified oxygen via nasal prongs as ordered. Observation of Resident 96 on January 29, 2025, at…

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

Based on observation, review of nursing staffing schedules, and resident and staff interview, it was determined that the facility failed to have sufficient nursing staff to meet residents' schedules for activities of daily living for two of three residents reviewed for concerns regarding resident choices (Residents 66 and 25). Findings include: Observation of Resident 66 on January 29, 2025, at 9:13 AM revealed he was in his bed. Resident 66 stated that he must wait for staff to transfer him out of bed to his wheelchair. Resident 66 stated that the time he gets out of bed is dependent upon how many nurse aides are working. Resident 66 stated that he is usually out of bed at 6:30 AM, which is his choice and preference. Resident 66 stated that he considered it to be exceptionally late for him to still be in bed at 9:13 AM. Interview with Resident 25 on January 29, 2025, at 9:33 AM revealed that staff assisted her out of bed at 8:00 AM that morning. Resident 25 stated that she prefers to be out of bed early, by 6:30 AM, because she does not like to eat her breakfast in her bed due to…

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

Based on clinical record review and staff interview, it was determined that the facility failed to ensure accurate clinical documentation for one of 23 residents reviewed (Resident 108). Findings include: Physician orders for Resident 108 revealed an order for a Prenatal Oral Tablet (6.75-0.2 milligrams), prenatal vitamin with ferrous fumarate-folic acid (a multivitamin that contains different concentrations of vitamins and minerals), give one table by mouth in the afternoon. Review of the Medication Administration Record (MAR) for Resident 108 for January 2025, revealed the Prenatal Oral Tablet was documented by staff as being administered on January 4-9, 13, 17, 19, 21-29, 2025. Clinical documentation for Resident 108 revealed the following MAR notes regarding the Prenatal Oral Tablet: January 11, 2025, at 11:13 AM: This medication is not available to give; we do not carry this as house stock. FYI (for your information) to doctor was written to switch this medication to multi-vitamin with minerals instead. RN (registered nurse) aware. January 12, 2025, at 1:31 PM: Medication not…

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

Based on clinical record review, review of select facility policies and procedures, and staff interview, it was determined that the facility failed to provide recommended pneumococcal immunizations for three of five residents reviewed for immunizations (Resident 21, 53, and 85). Findings include: The policy entitled Pneumococcal Vaccine, last reviewed December 16, 2024, indicates that prior to or upon admission, residents will be assessed for eligibility to receive the pneumococcal vaccine, and when indicated, will be offered the vaccine within 30 days of admission. Administration of the pneumococcal vaccines or revaccinations will be made in accordance with the current CDC (Center for Disease Control and Prevention) recommendations at the time of the vaccinations. Review of Resident 21's clinical record revealed that the facility admitted her on June 20, 2021. Documentation in Resident 21's clinical record revealed that she received a pneumococcal vaccine (Prevnar 13) prior to her admission in 2016. According to the CDC guidance entitled Pneumococcal Vaccination Timing dated April…

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 policies and procedures, clinical record review, and staff interview, it was determined that the facility failed to provide comprehensive skin assessments, and implement recommended interventions, that are consistent with professional standards of practice, to promptly identify and promote healing of a pressure ulcer for one of two residents reviewed for pressure ulcers (Resident CR1). Findings include: A review of the policy titled, Skin Evaluation, noted that, a licensed nurse will complete a total body evaluation on each resident weekly, and prior to a hospital or other facility transfer/discharge, paying particular attention to any skin tears, bruises, stasis ulcers, rashes, pressure injury, lesions, abrasions, reddened areas, and skin problems. The policy further noted the licensed nurse will complete a total body evaluation on each resident weekly and document the observation on the skin evaluation form. If a resident is assessed as having a skin problem, the evaluating…

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 closed clinical record review, facility documentation, and staff interview, it was determined that the facility failed to develop and implement an effective discharge planning process for one of two residents reviewed (Resident CR1). Findings include: Closed clinical record review for Resident CR1 revealed the resident was [AGE] years old and admitted to the facility on [DATE], from the hospital for rehabilitation following compression fractures of the spine and difficulty walking. Review of a five-day MDS (Minimum Date Set, an assessment completed at periodic intervals of time by facility staff to determined resident care needs) completed on July 7, 2024, by facility staff revealed staff assessed the resident of having a BIMS score (brief interview of mental status) of 12, indicating some cognitive impairment. Resident CR1 had a power of attorney listed as a responsible party with several other emergency contacts listed in the clinical record. Review of a social services assessment completed for…

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

Based on observation, clinical record review, review of facility documents, and resident and staff interview, it was determined the facility failed to investigate an incident of elopement and reassess and implement measures to ensure resident safety for one of five residents reviewed for resident safety (Resident 1). Findings include: Upon entrance to the facility on September 12, 2024, at 9:00 AM a resident was observed sitting outside the facility's main entrance door on the patio smoking a cigarette. A bench seating area was also observed to the right of the main entrance of the facility. A parking lot was observed in front of the patio situated along a busy main road. In an interview with Employee 4, marketing, on September 12, 2024, at 11:45 AM who was working in an office located directly inside the main entrance of the building with windows facing the areas mentioned above indicated she observes many residents sitting outside the main entrance of the building. Employee 4 indicated there was a recent incident where the receptionist alerted Employee 4 along with another…

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, review of the facility grievance log, and staff interview, it was determined that the facility failed to provide written notice, including the reason for the change, prior to moving a resident to another room, for seven of seven residents reviewed for room moves (Residents 4, 6, 11, 12, 13, 14, and 15). Findings include: Review of the facility grievance log (a log of received concerns/complaints) revealed a concern form submitted by Resident 4's family related to a room move. The grievance form was dated June 4, 2024. The concern was presented in an attached letter. The letter was from Resident 4's daughter and indicated that her brother was in to visit her father on June 4, 2024, and was told by her father that he was moving to another room. The letter indicated that they were upset because of the lack of communication as they were not notified ahead of time of the room move. Interview with the Nursing Home Administrator (NHA) on June 13, 2024, at 12:15 PM revealed that Resident 4's room was moved from B unit to C unit, along with several 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 and resident interview, it was determined that the facility failed to ensure dependent residents received assistance with bathing for three of five residents reviewed for bathing concerns (Residents 1, 2, and 3) and appropriate positioning for meals for one of five residents reviewed for nutritional concerns (Resident CR1). Findings include: Closed clinical record review for Resident CR1 revealed a written physician telephone order that noted a diet of dysphagia advanced (difficulty swallowing food and liquids), thin liquids with aspiration precautions, and out of bed for meals as tolerated. A physician's order reviewed in the electronic health record for a diet dated May 4, 2024, that included a controlled carbohydrate diet, no added salt, dysphagia advanced texture, and regular/thin liquids consistency. The diet order did not note anything about the resident being out of bed for meals as tolerated. Further review of the physician orders for Resident CR1 revealed 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.

Based on clinical record review and staff interview, it was determined that the facility failed to ensure staff with appropriate competencies and skills provided care for resident needs for nine of nine residents reviewed for activities of daily living concerns (Residents 7, 8, 9, 10, 11, 12, 13, 14, and 15). Findings include: Clinical record review of POC (Point of Care, electronic documentation completed by nurse aide staff upon completion of activities of daily living) documentation completed during the evening shift on May 4, 2024, revealed that Employee 4, administration, initialed completion of Resident 7's care for bed mobility, dressing, personal hygiene, toilet use, transferring, ambulation in the room and corridor, bowel and bladder functioning, eating, and restorative nursing programs for walking and range of motion. Clinical record review of POC documentation completed during the evening shift on May 4, 2024, revealed that Employee 4 initialed completion of Resident 8's care for bed bath, bed mobility, dressing, personal hygiene, toilet use, transferring, ambulation 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 observation and resident and staff interview, it was determined that the facility failed to provide a clean, comfortable, and homelike environment on three of four nursing units reviewed (Nursing Units A, B, and F; Residents 3, 4, 6, 8, and 7). Findings include: Observation of room [ROOM NUMBER] on May 30, 2024, at 10:22 AM revealed the room was currently empty and the previous resident had been discharged . The heating/air conditioning unit located on the wall had a significant accumulation of dust and debris located between the vents of the unit. Observation of room [ROOM NUMBER] on May 30, 2024, at 10:24 AM revealed the room was currently empty and the previous resident had been discharged . The heating/air conditioning unit located on the wall had a significant accumulation of dust and debris located between the vents of the unit. Observation of Resident 7 and Resident 8's room on May 30, 2024, at 10:30 AM revealed the heating/air conditioning unit located on the wall had a significant accumulation…

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 closed clinical record review and staff interview, it was determined that the facility failed to develop and implement a resident baseline care plan within 48 hours of the resident's admission for one of one resident reviewed (Resident CR1) Findings Include: Closed clinical record review for Resident CR1 revealed the resident was admitted to the facility on [DATE]. Further review of Resident CR1's closed clinical record revealed documentation titled, Baseline Care Plan and Summary, and dated May 2, 2024. The copy of the care plan was signed by the registered nurse and Resident CR1 on May 2, 2024. Review of the Baseline Care Plan and Summary revealed the following care plans marked by facility staff; however, there were no associated person-centered interventions marked on the document or identified. Discharge care plan was marked with a resident goal of will discharge to community. Resident's routine/activity preference with the following goals: Resident will self-direct activities of choice and will…

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

Based on clinical record review and staff interview, it was determined that the facility failed to ensure the accurate acquiring and administration of medications to meet the needs for one of seven residents reviewed (Resident CR1). Findings include: Closed clinical record review revealed nursing documentation for Resident CR1 dated May 2, 2024, at 6:22 PM revealed the resident was admitted to the facility. Review of the physician documentation for Resident CR1 dated May 7, 2024, at 11:29 AM revealed the resident had a history of Crohn's disease (an inflammatory disease that impacts the digestive system). Physician orders for Resident CR1 revealed an order dated May 3, 2024, at 8:00 AM that instructed staff to administer Budesonide Extended-Release oral tablet (a medication used to treat inflammation of the digestive tract), give 3 mg (milligrams) by mouth one time a day. Review of the Medication Administration Record (MAR, tool to document the administration of medication) for Resident CR1 revealed that staff had not documented the resident as having received the medication as…

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 investigations, and staff interview, it was determined that the facility failed to prevent and thoroughly investigate an elopement for one of one resident reviewed (Resident 1). Findings include: Review of Resident 1's clinical record revealed nursing documentation dated April 27, 2024, at 10:29 AM that indicated that the resident was admitted to the facility on [DATE], at 1:00 PM. The documentation further noted the resident was alert and oriented, and forgetful/confused at times. A Brief Interview for Mental Status (BIMS, an assessment tool to help determine the cognitive status of a person) evaluation for Resident 1 dated April 27, 2024, at 7:47 PM was completed by facility staff who assessed the resident as having a score of 14, which indicated the resident was cognitively intact. Nursing documentation for Resident 1 dated April 27, 2024, at 6:56 PM revealed that the resident was noticed to be missing when the food trays were being passed for dinner. 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 facility failed to provide the highest practicable care regarding physician ordered medications and treatments for four of four residents reviewed (Residents 1, 2, 3, and 4). Findings include: Clinical record review for Resident 1 revealed active physician orders for staff to administer the following: Levothyroxine Sodium (medication used to treat an underactive thyroid, hypothyroidism) 125 mcg (micrograms) via G-tube (tube inserted through the abdominal skin into the stomach for the purpose of instilling nutrition, fluids, and/or medications) in the morning Omeprazole (medication used to treat certain stomach problems such as acid reflux or ulcers) 20 mg (milligrams) via G-tube daily Famotidine (medication used to treat ulcers of the stomach and intestines) 20 mg via G-tube twice daily Petroleum jelly (topical ointment for moisturization) external ointment to lips twice a day Check enteral (involving or passing through the…

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

Based on review of select facility policies and procedures, clinical record review, and resident and staff interview, it was determined that the facility failed to implement necessary treatment and services to promote pressure ulcer healing, prevent pressure ulcer worsening, and prevent new ulcers from developing for two of two residents reviewed for pressure ulcer concerns (Residents 1 and 2). Findings include: The facility policy entitled, Skin and Wound, last reviewed without changes on January 4, 2023, indicated that the facility's policy is to provide a system for identifying risk and implementing resident-centered interventions to promote skin health, prevention, and healing of pressure injuries. The process includes that resident's skin is evaluated upon admission/re-admission and documented in the medical record. The nurse is to complete skin evaluations weekly and document in the medical record. Pressure Injury Mitigation Strategies include developing resident-centered interventions based on resident risk factors. Skin Impairment Identification includes: Document presence…

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 policies and procedures, clinical record review, and staff interview, it was determined that the facility failed to implement interventions to maintain acceptable parameters of nutritional status for two of two residents reviewed for weight loss concerns (Residents 1 and 4). Findings include: The facility policy entitled, Best Practice Weight Change, last reviewed without changes on January 4, 2023, revealed that an identified weight change (gain or loss) is 2.5 percent in one week, five percent in one month, or 10 percent in three months. The document listed interventions that included a referral to the registered dietitian for a nutritional review and to update food preferences. Clinical record review for Resident 1 revealed diagnoses that included cerebral palsy (group of disorders of the brain that affects movement and posture) and dysphagia (difficulty swallowing food or liquid). Resident 1's physician orders indicated that Resident 1 was to have nothing by mouth since August 22, 2022. A physician's order dated January 25, 2024, instructed…

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 that the facility failed to ensure security of medications and biologicals on one of four nursing units (Unit C, second floor, Resident 6). Findings include: Observation of the second-floor nursing unit on April 8, 2024, at 4:55 PM revealed the door to the medication prep room was open. The cabinet doors were visibly open from the doorway and noted to contain numerous over-the-counter medications such as: Acetaminophen (Tylenol), analgesic Multivitamin nutritional supplement Hydrogen peroxide (liquid antiseptic) Low dose aspirin, 81 milligrams (analgesic used to reduce risk of heart attacks) Milk of Magnesia (liquid laxative) FeSO4 (iron nutritional supplement) The room also contained two unlocked treatment carts that contained numerous creams, lotions, and medicated treatments such as: Diclofenac Sodium (medication used to treat swelling/inflammation) Premarin vaginal cream (estrogen hormone medication) Nystatin topical powder (antifungal medication) Fluocinolone acetonide topical solution (steroid topical skin treatment…

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 policies and procedures, staff and resident interview, and observation, it was determined that the facility failed to provide residents with palatable food on two of four nursing units (Unit C, second floor, Residents 2 and 3; Unit F, third floor, Resident 5). Findings include: The facility policy entitled, Food: Quality and Palatability, last reviewed without changes on January 4, 2023, revealed that food will be prepared by methods that conserve nutritive value, flavor, and appearance. Food will be palatable, attractive, and served at a safe and appetizing temperature. The policy did not indicate any temperatures used as a guide to ensure the food delivered to the residents met an expected palatable temperature. Interview with Resident 2 who resided on the second-floor nursing unit on April 8, 2024, at 11:36 AM revealed that he thought that the food was, .not that great, most of the time cold. Interview with Resident 3 who resided on the second-floor nursing unit on April 8, 2024, at 5:41 PM revealed that he requested the nurse aide call 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 observation and staff interview, it was determined the facility failed to store food and maintain food service/storage equipment in a sanitary manner in the facility's main kitchen and one of four nursing units (unit F). Findings include: An observation in the facility's main kitchen on January 23, 2024, at 9:15 AM revealed the following: Upon entering the kitchen from the main entrance from inside the facility, a metal shelving unit was observed to the right of the door frame just inside the kitchen doors. Several bottle and boxes of cleaning chemicals were observed on the shelves. Yellow dried spills were observed on the exterior of several large bottles labeled Grease Strip Plus. Boxes labeled as degreaser were observed on the shelf below the bottles also containing a dried yellow substance and yellow powdery substance on the exterior top of the boxes. The shelving unit was observed directly inside the kitchen entrance and dietary staff were observed wheeling food carts in and out of the doorway. Employee 15, dietary manager, indicated she did not know what the yellow…

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

Based on clinical record review and staff interview, it was determined that the facility failed to provide the correct required notification to a resident whose payment coverage changed for two of three residents reviewed (Residents 66 and 184). Findings include: A review of the form Instructions for the Notice of Medicare Non-Coverage (NOMNC) CMS-10123, (a notice that informs the recipient when care received from the skilled nursing facility is ending; and how to contact a Quality Improvement Organization (QIO) to appeal) revealed instructions that a Medicare provider must ensure that the notice is delivered at least two calendar days before Medicare covered services end. The provider must ensure that the beneficiary or their representative signs and dates the NOMNC to demonstrate that the beneficiary or their representative received the notice and understands the termination of services can be disputed. If the provider is personally unable to deliver a NOMNC to a person acting on behalf of an enrollee, then the provider should telephone the representative to advise him or her when…

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 that the facility failed to provide a clean, homelike environment on two of four nursing units (units B and F; Residents 76, 6, 120, and 50). Findings include: An observation of Resident 76's room on January 23, 2024, at 10:49 AM revealed a buildup of dirt, dust, and debris along the cove base where it meets the flooring and corners of the alcove upon entering the room. The cove base was observed with multiple black streaks and visible dust hanging off it. An observation of Resident 120's room on January 23, 2024, at 11:15 AM revealed visible dirt buildup along the cove base where it meets the floor of the alcove upon entering the resident room and significant buildup in the corners. An observation of Resident 6's room on January 23, 2024, at 10:59 AM revealed deep gauges in the wall behind the resident's recliner. A yellow hardened foam was visible and exposed all around the resident's heater. The cove base along the wall of the heater contained dried brown splatter. The cove base under the closets along the front of the…

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

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 provide a written notice of the facility's bed-hold policy to residents or the residents' responsible parties for four of seven residents reviewed for hospitalization concerns (Residents 82, 10, 35, and 120). Findings include: Clinical record review for Resident 82 revealed nursing documentation dated November 3, 2023, at 6:38 PM that emergency services were contacted to transfer Resident 82 to a local hospital at 9:00 AM the following morning. Nursing documentation dated November 4, 2023, at 11:30 AM noted that Resident 82 left the facility for admission to a local hospital for a psychiatric (behavioral health) stay. Nursing documentation dated November 13, 2023, at 3:00 PM indicated that Resident 82 returned to the facility. Resident 82's clinical record did not include evidence to indicate that Resident 82's responsible party received written notice of the facility's bed-hold policies upon his transfer 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 clinical record review and resident and staff interview, it was determined that the facility failed to provide the highest practicable care regarding pain and bowel protocol medication administration for two of 25 residents reviewed (Residents 121 and 44). Findings include: Interview with Resident 121 on January 24, 2024, at 12:29 PM revealed that she did not have a bowel movement daily. She stated that it was not, every day, not every other day, we're working on that right now. Resident 121 stated that staff told her that they could not give her the type of medication that she took while she was at home without a doctor's order; however, Resident 121 was not aware if staff contacted the physician for the order. Resident 121 stated, the majority of any of those other things (bowel stimulating medications) acts too fast and (she) can't get there (to the bathroom) in time, I rely on the things only that work. Resident 121 indicated that she may not have had a bowel movement in one week. Clinical record review for Resident 121 revealed the following physician orders to promote…

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, clinical record review, and staff interview, it was determined that the facility failed to implement treatment to prevent a decline in range of motion for one of one resident reviewed (Resident 1). Findings include: Review of a therapy communication to RNP (restorative nursing program) dated October 24, 2023, for Resident 1 revealed that the resident had a left hand and thumb contracture (occurs when muscles, tendons, joints, or other tissue shortens causing a deformity). The occupational therapist recommended a ROM (range of motion) program for the bilateral upper extremities (both upper arms, forearms, and hands). A gentle slow stretch was recommended to the left hand. The left thumb is contracted in towards the palm and is painful. It cannot be moved very much. Staff are to move the thumb enough just to get the washcloth roll in. Review of a physician's order for Resident 1 dated October 24, 2023, instructed staff to place a rolled clean washcloth in the left hand and remove it for hygiene and skin checks. Observation of Resident 1 on January 24, 2024, at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of select facility policies, clinical record review, review of facility documentation, observation, and staff and resident interview, it was determined that the facility failed to investigate falls and implement interventions to prevent accidents for two of seven residents reviewed for falls (Resident 14 and 35), and one of three residents reviewed for smoking (Resident 183). Findings include: Clinical record review for Resident 35 revealed the resident had a history of falls, with a recent series of falls beginning November 27, 2023. Review of a progress note dated November 27, 2023, at 2:28 PM for Resident 35 revealed the resident was found on the floor in her room and stated she became dizzy and fell. Resident 35 sustained a skin tear to her right forearm, left wrist, and a left finger. Facility documentation noted staff review of the fall on November 27, 2023, to note orthostatic blood pressures and visual cues in the bathroom to alert the resident to ring for assistance as interventions. It…

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

Based on observations and staff interview, it was determined that the facility failed to properly store and secure resident medications and biologicals on three of four nursing units (Unit B, Unit C, and Unit F, and Resident 12) and dispose of expired supplies and medications on one of four nursing units reviewed (Unit F, Resident 56) Findings include: Observations of the Unit F North Hall medication cart on January 25, 2024, at 8:55 AM revealed a tray on top of the cart that held various supplies that included plastic disposable cups and plastic medication dispensing cups. The tray had a significant build-up of dried stains and debris in the bottom. There was an open pack of thick and easy thickener with no date on the package. The cart had several (too numerous to count) unsecured and unidentified medication tablets, pills, and capsules on the bottom of two of the drawers. The internal metal bottom of the cart that was visible when pulling out the bottom drawer also held debris, a white tablet stuck to the bottom of it, and an unidentified capsule. Employee 17, LPN (licensed…

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 policies and procedures, clinical record review, observation, and staff and resident interview, it was determined that the facility failed to implement an infection control program to prevent the potential spread of infection for two of five residents reviewed for infection control practices (Residents 12 and 183) and in the main laundry room. Findings include: The facility policy entitled, Isolation-Initiating Transmission-Based Precautions last reviewed on January 4, 2023, revealed that (TBP) Transmission Based Precautions are utilized when a resident develops signs and symptoms of a transmissible infection; arrives for admission with symptoms of an infection; or has a laboratory confirmed infection; and is at risk of transmitting the infection to other residents. TBP are utilized when a resident meets the criteria for a transmissible infection and the resident has risk factors that increase the likelihood of transmission. These may include bar are not limited to uncontained excretions/secretions. There was no mention of Enhanced Barrier…

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

Based on clinical record review and responsible party and staff interview, it was determined that the facility failed to notify the responsible party of a resident's change in condition requiring interventions for one of three residents reviewed (Resident 23). Findings include: Interview on January 24, 2024, at 9:45 AM with Resident 23's responsible party revealed they were not notified about the resident's testing positive for COVID-19 (a highly contagious respiratory disease) until months later and indicated not knowing how much the resident weighed as she is only told this during the care plan conferences every three months. Review of a nursing progress note for Resident 23 dated October 5, 2023, at 5:35 AM revealed the resident tested positive for COVID and isolation precautions (specific methods to reduce the spreading of the disease) were initiated. Clinical record review for Resident 23 revealed no documented evidence that the resident's responsible party was notified of the resident testing positive for COVID-19. Review of a dietary note dated November 1, 2023, at 12:54 PM…

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, staff interview, and observation, it was determined that the facility failed to timely identify and treat a pressure ulcer for one of five residents reviewed (Resident 23). Findings include: Observation on January 23, 2024, at 10:00 AM revealed Resident 23 sitting in a wheelchair with a seatbelt attached and, on a pressure relieving cushion. The resident was observed moving the wheelchair using body motion. Review of a care plan for Resident 23 dated December 11, 2020, revealed that the resident is dependent for transfers by two staff members. Review of a Braden Scale for Predicting Pressure Sore risk for Resident 23 dated November 16, 2023, revealed the resident scored a 14, which placed her a moderate risk for developing a pressure sore. Review of a physician's order dated August 22, 2022, instructed staff to apply barrier cream (a product applied to the skin to maintain the skin's barrier and providing protection from irritants) every shift and as needed after incontinence for preventative skin care. Review of a nursing progress note dated January…

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

Based on clinical record review and staff interview, it was determined that the facility failed to provide the highest practicable care regarding coordination of dialysis services and administration of physician ordered medications for one of one resident reviewed (Resident 54). Findings include: Clinical record review for Resident 54 revealed that he received kidney dialysis (a procedure to remove waste products and excess fluid from the blood when the kidneys stop working properly) on Mondays, Wednesdays, and Fridays at an outside provider at 11:30 AM. He is picked up at 11:00 AM. Review of a physician's order for Resident 54 dated April 8, 2019, instructed the nurse to not give medications on dialysis days. The order did not specify which medications. Resident 54 received the following medications in the morning prior to dialysis: Depakote Delayed Release (to prevent seizures) 125 mg (milligrams) tablet orally at 8:00 AM Fluoxetine (to treat depression) 10 mg oral tablet orally at 8:00 AM Levetiracetam (to prevent seizures) 500 mg tablet orally at 5:00 AM Tizanidine (a muscle…

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 interview and review of facility documentation, it was determined that the facility failed to ensure that nurse aides received an annual performance review for three of three nurse aides reviewed (Employees 5, 6, and 7). Findings Include: Review of the facility's list of active nurse aide staff revealed Employee 5 had a hire date of July 18, 2019. Employee 5 should have had an annual performance review by July 18, 2023. Employee 6 had a hire date of November 22, 2005. Employee 6 should have had an annual performance review by November 22, 2023. Employee 7 had a hire date of May 13, 1993. Employee 7 should have had an annual performance review by May 13, 2023. Requests to review Employees 5, 6, and 7's performance reviews revealed no documented evidence that the facility completed the reviews at least once every 12 months. Interview with the Employee 1, Regional Director of Clinical Services, on January 26, 2024, at 12:30 PM confirmed the above findings. 28 Pa. Code 201.19(2) Personnel policies and procedures

Based on clinical record review and staff interview it was determined that the facility failed to ensure an appropriate response to consultant pharmacist recommendations for two of five residents reviewed for potentially unnecessary medications (Residents 82 and 101). Findings include: Clinical record review for Resident 82 revealed a consultant pharmacist report dated October 2, 2023, that requested a monitor for involuntary movements to prevent potentially irreversible tardive dyskinesia (neurological side effects of medications that can include permanent or temporary involuntary repetitive movements). The only response on the report was a handwritten note that read, currently at hospital 11/6/23. A consultant pharmacist's report dated January 2, 2024, requested consideration of the following changes to Resident 82's medication regimen: Discontinue Acidophilus (supplement used to promote beneficial bacteria in the digestive system) Reduce Aripiprazole (antipsychotic medication) dose to 10 mg (milligrams) daily Evaluate dose of Sertraline (antidepressant) Check serum lipids (fat…

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

Based on clinical record review and staff interview, it was determined that the facility failed to ensure a resident's medication regime was free from potentially unnecessary medications for one of five residents reviewed (Resident 103). Findings include: Review of Resident 103's clinical record revealed a physician's order dated September 20, 2023, for staff to administer Lorazepam (generic name of Ativan, medication used to treat anxiety) 0.25 milligrams oral every six hours PRN (as needed) for increased anxiety/agitation. Review of Resident 10's Medication Administration Record (MAR, form used to document the administration of medications) revealed the resident received Lorazepam PRN numerous times a month: September 20 - 30, 2023, 2 doses October 2023, 16 doses November 2023, 18 doses December 2023, 15 doses January 1 - 23, 2024, 10 doses Clinical record review for Resident 103 revealed that the Lorazepam PRN did not have a 14 day stop date nor was there a documented rational to indicate the continued use and the duration of the PRN medication. The above information for 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, and resident and staff interview, it was determined that the facility failed to provide necessary dental services for one of two residents reviewed for dental concerns (Resident 82). Findings include: Clinical record review for Resident 82 revealed a quarterly MDS (Minimum Data Set, an assessment tool completed at specific intervals to determine resident care needs) dated December 8, 2023, that indicated that Resident 82 had a BIMS (Brief Interview for Mental Status) score of three. The RAI (Resident Assessment Instrument, instructions regarding completion of the MDS assessment) version 3.0 manual noted that a score of three out of a possible 15 indicated severe cognitive impairment. An admission MDS assessment dated [DATE], indicated that Resident 82 was dependent on the extensive physical assistance of two staff for personal hygiene (which included brushing his teeth). Clinical record review for Resident 82 revealed that the facility initiated a plan of care on…

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

Based on review of select facility policies and procedures, clinical record review, and staff interview, it was determined that the facility failed to ensure that each resident received education regarding the pneumococcal vaccine; and that each resident received the pneumococcal immunization unless contraindicated or refused for one of five residents reviewed for immunizations (Resident 50). Findings include: The facility policy entitled, Pneumococcal Vaccine, last reviewed January 4, 2023, revealed that all residents will be offered pneumococcal vaccines to aid in preventing pneumonia/pneumococcal infections. Before receiving a pneumococcal vaccine, the resident or legal representative shall receive information and education regarding the benefits and potential side effects of the pneumococcal vaccine. Provision of such education shall be documented in the resident's medical record. Pneumococcal vaccines will be administered to residents (unless medically contraindicated, already given, or refused) per the facility's physician-approved pneumococcal vaccination protocol. If…

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 select facility policies and procedures, clinical record review, and staff interview, it was determined that the facility failed to ensure that each resident or resident representative received education regarding the COVID-19 vaccine; and that each resident received the COVID-19 vaccine unless contraindicated or refused for one of five residents reviewed for immunizations (Resident 82). Findings include: The facility policy entitled, COVID-19 Vaccine - Resident, last reviewed January 4, 2023, revealed that residents or their representatives will be educated about and offered the COVID-19 vaccine. COVID-19 vaccinations will be offered to residents (or their representative if they cannot make health care decisions) per CDC and/or FDA guidelines unless such immunization is medically contraindicated, the individual has already been immunized during this time period, or if the individual refuses to receive the vaccine. Residents/representatives will be educated on the COVID-19 vaccine they 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 observation, clinical record review, and staff interview, it was determined that the facility failed to implement physician ordered interventions to maintain nutritional status for three of six residents reviewed for weight loss (Residents 2, 3, and 4). Findings include: Review of the CMS 802 (Center for Medicare and Medicaid Services form for identifying residents and their pertinent care categories) that was provided to the surveyor on entrance on January 2, 2024, revealed residents with unplanned excessive weight loss. The surveyor selected a percentage of the residents with unplanned weight loss and identified them as Residents 2, 3, and 4. Observation on January 2, 2024, at 12:10 PM on B Wing revealed staff were passing lunch trays and residents were eating in the two dining areas off the nursing station. On the counter at the nursing station was a tray of supplements and snacks labeled for 10 residents, not counting coffee. These items included three Ready Care shakes (health shakes with extra protein and calories), two puddings, one yogurt, and three Magic Cups…

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 provide a timely assessment and implement interventions to promote acceptable parameters of nutritional status for one of six residents reviewed for nutritional concerns (Resident 1). Findings include: Clinical record review for Resident 1 revealed the resident was admitted to the facility on [DATE], and had a gastrostomy tube (tube surgically inserted in the stomach to deliver nutritional formula, water, and medicines). The resident was unable to eat or drink. Review of physician orders for Resident 1 dated August 2, 2023, through November 2, 2023, indicated the resident was to receive a bolus tube feeding (a syringe is connected to gastrostomy tube to instill formula) of Jevity 1.2 (type of formula), 237 ml (milliliters) four times a day on Tuesdays, Thursdays, Saturdays, and Sundays and Jevity 1.2, 237 ml five times a day on Mondays, Wednesdays, and Fridays. Review of Resident 1's weight record revealed the…

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

Based on observations and staff interview, it was determined that the facility failed to ensure that medications were appropriately labeled and stored in three of seven medication carts reviewed (A and F Wing). Findings include: Observation on January 2, 2024, at 12:18 PM revealed two medication carts were on A Wing in front of the nursing station. The distance between the two carts was three and a half feet and they were placed at an angle aligned with the nursing station. The first cart the surveyor approached was unlocked and had a white tablet in a clear medication cup unlabeled on top of the cart. The surveyor used the hand sanitizer that was on top of the medication cart and pulled open the drawer to observe medications in the cart. Next to this medication cart was Employee 2, licensed practical nurse, who was administering medications to a resident from the second medication cart. After Employee 2 completed administering medications to the resident, the surveyor asked Employee 2 what the medication was in the unlabeled cup and who it was for. Employee 2 indicated that 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 observations and staff interview, it was determined that the facility failed to provide a clean, comfortable, homelike environment on three of three nursing units (first floor nursing unit, second floor nursing unit, and third floor nursing unit; Residents 2, 3, 4, 5, 6, 10, 11, 13, and 15). Findings include: Observation of the first-floor nursing unit on December 7, 2023, between 10:35 AM and 11:20 AM revealed the following: Resident 2's bathroom had multiple dried drip stains on the walls adjacent to the commode. There were also dried dark colored splash stains on the wall behind the commode and the base of the commode where it screwed into the floor had dried stains. A wall pocket in the hallway had an N95 mask and balled up gloves discarded in it. Resident 3's bathroom had an accumulation of multiple cobwebs hanging from the ceiling where it met the wall. There was a golf-ball sized hole surrounding a screw in the wall behind the commode. A resident lounge on A Hall had two adjacent tiles that 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.