Masonic Village At Sewickley

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of resident clinical records, facility policy, and staff interview, it was determined the facility failed to ensure the coordination of hospice services with facility services to meet the needs of each resident for end-of-life care for one of two residents (Resident R44). Findings include: During a review of the facility policy End of Life Care dated 8/28/26, indicated that end-of-life care is approached in a comprehensive way with respect and dignity for the residents and their loved ones. The interdisciplinary delivery of services provided by a hospice organization. Review of the clinical record revealed that Resident R44 was admitted to the facility on [DATE]. Review of Resident R44's quarterly MDS dated [DATE], indicated diagnoses of coronary artery disease (damage or disease in the heart's major blood vessels), Alzheimer's disease (a type of brain disorder that causes problems with memory, thinking and behavior), and arthritis. Review of physician order dated 3/13/26, indicated Resident…

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

Based on review of job description, facility documents and staff interviews, it was determined that the facility failed to provide Infection Control training to one of five direct care facility staff reviewed (Nurse Aide (NA) Employee E19). Findings include: Review of the facility Nursing Assistant - HC Position Description indicated the position will perform various resident care activities and related non-professional nursing services while ensuring the care of our residents is provided in a safe, caring, timely, and appropriate manner by maintaining the appropriate competencies and skills through continued education that encompasses all of these areas. Essential Functions/Professional competencies: maintain compliance with yearly education requirements according to facility policies and DOH (Department of Health) regulations. Maintains competencies and skills through continued education, including in-service education, programs, floor conferences and nursing staff meetings. During an interview on 6/18/26, at 10:10 a.m. the Nursing Home Administrator (NHA) stated that education is…

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

Based on review of job description, facility documents and staff interviews, it was determined that the facility failed to ensure that all nurse aide staff received a minimum of twelve hours of in-service education training each year for one out of two Nurse Aide (NA) Employees (Employee E19).Findings include: Review of the facility Nursing Assistant - HC Position Description indicated the position will perform various resident care activities and related non-professional nursing services while ensuring the care of our residents is provided in a safe, caring, timely, and appropriate manner by maintaining the appropriate competencies and skills through continued education that encompasses all of these areas. Essential Functions/Professional competencies: maintain compliance with yearly education requirements according to facility policies and DOH (Department of Health) regulations. Maintains competencies and skills through continued education, including in-service education , programs, floor conferences and nursing staff meetings. During an interview on 6/18/26, at 10:30 a.m. the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review facility polices, observations, clinical records, and staff interviews it was determined that the facility failed to make certain that appropriate treatments and services were provided for the use of an indwelling urinary catheter as required for three of four residents (Resident R11, R17, and R41). Findings include: Review of facility policy Continence Care Program and Indwelling Catheter Management dated 8/8/24/25, indicated drainage bags should be covered for dignity. Review of the clinical record indicated Resident R11 was admitted to the facility on [DATE]. Review of Resident R11's minimum data set (MDS - a periodic assessment of care needs) dated 6/30/25, indicated the diagnosis of hypertension (high blood pressure) obstructive uropathy (blockage of urinary flow) and Parkinson's disease (brain condition that causes slowed movements, rigidity and tremors). Review of the clinical record revealed Resident R11 had a physician's order dated 4/25/25, for an indwelling urinary catheter (closed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, observations and staff interviews, it was determined that the facility failed to properly store medical supplies in two of three medication rooms (Maple Place and [NAME] Court), and on two of three medication carts (Birch Place and [NAME] Court).Findings: Review of facility “Storage of Medications” policy dated [DATE], indicated medications and biologicals are stored safely, securely, and properly following manufactures recommendations or those of pharmacy. Insulin pens should be dated when fires opened. A pharmacy consultant or facility designee will monitor medication storage, medication records, and expiration dates. During a medication storage room review on [DATE], at 11:15 a.m. the following were observed: - A vial of tuberculin (medication used to detect a respiratory disease) was dated [DATE] and was expired in Maple Place medication storage room. During a medication cart review on [DATE], at 11:25 a.m. the following were observed: - Novolog Insulin Pen (used to treat…

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

Based on review of facility policy, observations and staff interview, it was determined that the facility failed to determine it was safe to self-administer medications for one of three residents (Resident R6). Findings include: Review of the facility policy Resident Self -Administration of Medications last reviewed 8/8/24, indicated residents will be permitted to self-administer medication after evaluation by their interdisciplinary team and approval from their medical provider. If the interdisciplinary team indicates that a resident is able to safely self-administer medications the provider will write an order authorizing the resident to self-administer the medication. Review of Resident R6's Minimum Data Set (MDS - a periodic assessment of care needs) dated 5/14/25, indicated reentry to facility on 10/30/24, with diagnoses of hypertension (high blood pressure), diabetes (high sugar in the blood) and chronic obstructive pulmonary disease (COPD- causes breathing problems). During a medication pass observation completed on 7/29/25, at 9:24 a.m. Licensed Practical Nurse (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 facility documents, clinical record, and staff interviews, it was determined that the facility failed to ensure a Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNF ABN) form were provided in a timely manner for two of three residents (Resident R32 and CR Resident R333). Findings include: Review of facility policy Informing the Resident of Medicare A/Skilled Managed Care Denial dated 8/8/24, indicated the policy is to protect the rights of each resident, it is required by a facility to provide beneficiaries advanced notice that care and services will not be or will no longer by covered by their Medicare Part A or Managed Skilled Care benefit. The facility has established this policy and the associated procedure to ensure that notices of Medicare non-coverage are issued timely and in adherence with the guidelines. Review of Resident R32's admission record indicated the resident was admitted to the facility on [DATE]. Review of Resident R32's Minimum Data Set (MDS -…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to make certain that the necessary resident information was communicated to the receiving health care provider for two of five resident hospital transfers (Residents R4, and R8).Findings include: Review of the facility policy Bed Hold, Transfer, Discharge and readmission Policy for Nursing Care dated 8/8/24, indicated appropriate information will be communicated to the receiving health care provider/facility that will be caring for the resident. The information should include but is not limited to: 1. Contact information of the provider responsible for the care of the resident 2. Resident representative/POA (power of attorney) Contact information 3. Copy of Advanced Directive 4. All special instructions/precautions for ongoing care 5. Comprehensive care plan goals/discharge care instructions 6. Any other information that will ensure a safe and effective transition of care including 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 and staff interview, it was determined that the facility failed to obtain a physician order for two of five residents (Resident R18 and R19), and failed to follow the bowel protocol in a timely fashion for one of five residents (Resident R17).Findings include: Review of the facility policy Bowel Protocol dated 8/8/24, indicated treatment after 72 hours with no documented bowel movement:- the evening shift nurse should examine abdomen. If there are abnormal findings, give Senna (laxative) and notify the provider for further orders.-the day shift nurse the following day will determine and evaluate effectiveness of the Senna by reviewing documentation in the clinical record. For residents with no bowel movement (BM) the day nurse will perform an additional exam, notify the provider for further orders and give a Dulcolax suppository and document on the Medication Administration Record (MAR).-If the protocol is ineffective, this should be noted in the resident's medical record and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of clinical record review, observations, and staff interviews, it was determined that the facility failed to ensure a resident with limited mobility receives appropriate services, equipment, and assistance to maintain or improve mobility for two of three residents (Resident R17 and R77).Findings include: Interview with the Director of Nursing on 7/31/25, at 11:00 a.m. indicated the facility did not have a policy for assistive devices/splints. Review of the clinical record indicated Resident R17 was admitted to the facility on [DATE]. Review of Resident R17's Minimum Data Set (MDS - a periodic assessment of care needs) dated 5/14/25, indicated diagnoses of high blood pressure, hyperlipidemia (high levels of fat in the blood), and Alzheimer’s Disease (a progressive disease that destroys memory and other important mental functions). Review of Resident R17's progress note dated 7/15/2025, 8:59 p.m. indicated resident returned from the Orthopedic appointment with a back brace that is to be removed at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, observations, and staff interviews, it was determined that the facility failed to provide adequate treatment and care for a peripheral inserted central catheter (PICC - a thin tube that's inserted through a vein in your arm and passed through to the larger veins near your heart) in accordance with professional standards of practice for one of two residents (Resident R77).Findings include: Review of the facility policy PICC and Midline Management and Protocol last reviewed 8/8/24, indicated with intermittent infusions (antibiotics) are flushed with 10 millimeter (ml) normal saline solution (NSS) then infuse medication. After medication is infused, flush with 10 ml NSS. Review of the clinical record indicated Resident R77 was admitted to the facility on [DATE], with the diagnosis of osteomyelitis (infection of the bone) of vertebra, thoracic region (back), depression and atrial fibrillation (irregular heart rhythm). Review of physician orders dated 7/26/25, indicated Cefepime…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, observations, staff interviews, and clinical record review, it was determined that the facility failed to provide appropriate respiratory care for two of six residents (Resident R17 and R35).Findings include:Review of facility policy Oxygen Concentrator/Oxygen Tank dated 8/8/24, indicated to change the bottle and tubing weekly when oxygen concentrators are in use.Review of the clinical record indicated Resident R17 was admitted to the facility on [DATE]. Review of Resident R17's Minimum Data Set (MDS - a periodic assessment of care needs) dated 5/14/25, indicated diagnoses of high blood pressure, hyperlipidemia (high levels of fat in the blood), and Alzheimer's Disease (a progressive disease that destroys memory and other important mental functions).Review of the clinical record revealed Resident R17 had a physician's order dated 7/14/25, for oxygen via nasal cannula (a thin flexible tube that goes around your head and into your nostrils to provide supplemental oxygen) at 2…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility documents, resident clinical records and staff interviews it was determined that the facility failed to ensure a resident had the capacity to understand the terms of a binding arbitration agreement (a binding agreement by the parties to submit to arbitration all or certain disputes which have arisen or may arise between them in respect of a defined legal relationship, whether contractual or not. The decision is final, can be enforced by a court, and can only be appealed on very narrow grounds) for one of three residents (Resident R14). Findings include: Review of the Resident Assessment Instrument 3.0 User's Manual effective October 2019, indicated that a Brief Interview for Mental Status (BIMS) is a screening test that aides in detecting cognitive impairment. The BIMS total score suggests the following distributions: 13-15: cognitively intact8-12: moderately impaired0-7: severe impairment Review of the admission record indicated Resident R14 was admitted to the facility on [DATE].…

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

Based on facility policy review, review of Quality Assurance attendance records, and staff interview, it was determined that the facility failed to conduct Quality Assessment and Assurance (QAA) meetings at least quarterly with all the required committee members for one of four quarterly meetings (Quarter One of 2025). Findings Include: The facility Quality Assurance and Performance Improvement (QAPI) policy dated 8/8/24, indicated it is the policy of the facility to develop a QAPI plan in accordance with Federal Guidelines to describe how the facility will address clinical care, resident quality of life and residents' choice and is based on the scope and complexity of services defined by the Facility Assessment. Review of Quality assurance and Performance Improvement sign in sheets and attendance records for Quarter One of 2025, failed to reveal the Director of Nursing was in attendance. During an interview on 7/28/25, at 2:35 p.m. the Director of Nursing confirmed that the facility failed to conduct Quality Assessment and Assurance (QAA) meetings at least quarterly with all 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 facility policy, clinical record review, observation, and staff interviews, it was determined that the facility failed to prevent cross contamination during a medication pass for one of three residents (Resident R6), failed to prevent cross contamination and follow enhanced barrier precaution during a dressing change for one of three residents (Resident R7) and failed to properly monitor residents in room personal refrigerator temperatures for four of five residents (Resident R1, R34, R35, and R67) which created the potential for food borne illness.Findings include: Review of the facility policy Infection Transmission Prevention and Interventions last reviewed 8/8/24, indicated enhanced barrier precautions are uses for residents that have a wound or wounds which require a dressing for treatment. Review of facility policy Refrigerator and Freezer Temperatures last reviewed 8/8/24, indicated all resident and medication refrigerators are monitored using an electronic monitoring system. Staff will notify…

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

Based on review of facility policies, in-service documentation, personnel records, and staff interviews it was determined that the facility failed to implement and maintain an effective annual in-service training program for four of of eight personnel records (Nurse Aide Employee E3, Nurse Aide Employee E4, Nurse Aide Employee E5, and Nurse Aide Employee E6). Findings include: The facility Employee Compliance Education procedure policy dated 8/21/23, indicated that it is the policy of the facility to provide employees with compliance education and training. Education and issues on specific issues will be provided to staff members. The facility Employee policy handbook dated 12/2023, indicated in order to remain at the highest level of skill and training, employees are requested and may be required to attend or complete the periodic in-service training programs. Review of the facility Annual In-Service course listing dated 2024, included the following courses: Abuse Prevention, Reporting, and Resident Rights Active Shooter: Emergency Preparedness Communicating with Older Adults…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical records, facility provided documents, resident, and staff interviews, it was determined that the facility failed to report an alleged allegation of abuse for one of two residents (Resident R31). Findings include: Review of the policy Abuse Prevention dated 8/21/23, indicated it is the facility's policy to assure residents the right to freedom from abuse. This is assured by implementing a system of prevention, screening, identification, and training. When an allegation is made, the facility will investigate, report, and respond appropriately to the allegation. Review of admission record indicated that Resident R31 was admitted to the facility on [DATE]. Review of R31's Minimum Data Set (MDS - a periodic assessment of care needs) dated 7/11/24, indicated the diagnoses of renal insufficiency (condition where the kidneys lose the ability to remove waste and balance fluids), high blood pressure, and heart failure (the heart doesn't pump blood as well as it should). 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical records, facility documents, and staff interview, it was determined that the facility failed to fully investigate alleged allegation of abuse for one of two residents (Resident R31). Findings include: Review of the policy Abuse Prevention dated 8/21/23, indicated it is the facility's policy to assure residents the right to freedom from abuse. This is assured by implementing a system of prevention, screening, identification, and training. When an allegation is made, the facility will investigate, report, and respond appropriately to the allegation. Review of admission record indicated that Resident R31 was admitted to the facility on [DATE]. Review of R31's Minimum Data Set (MDS - a periodic assessment of care needs) dated 7/11/24, indicated the diagnoses of renal insufficiency (condition where the kidneys lose the ability to remove waste and balance fluids), high blood pressure, and heart failure (the heart doesn't pump blood as well as it should). Review of 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 clinical and facility record review, facility provided documents and staff interviews, it was determined that the facility failed to provide adequate supervision for one resident resulting in elopement (resident exited to an unsupervised and unauthorized location without staff's knowledge) for one of two resident (Residents R17). Findings include: Review of the admission Record indicated Resident R17 was admitted to the facility on [DATE]. Review of Resident R17's Minimum Data Set (MDS - a periodic assessment of care needs) dated 6/6/24, indicated the diagnoses of Dementia (a group of symptoms that affects memory, thinking and interferes with daily life), chronic kidney disease and venous insufficiency (leg veins don't allow blood to flow back up to your heart). Section C: Cognitive Patterns, Question C0100 indicated a BIMS score of 1- severe cognitive impairment. Review of the Resident Assessment Instrument 3.0 User's Manual effective October 2019, indicated that a Brief Interview for Mental Status…

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, observations, and staff interviews, it was determined that the facility failed to provide appropriate respiratory care for one of three residents (Resident R25). Findings include: Review of federal guidance §483.25(i) Respiratory care, including tracheostomy care and tracheal suctioning. The facility must ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences. Review of facility policies failed to reveal a policy for oxygen therapy. Review of the clinical record indicated that Resident R25 was admitted to the facility on [DATE]. Review of Resident R25's Minimum Data Set (MDS - a periodic assessment of care needs) dated 5/17/24, indicated diagnoses of Alzheimer's disease (a type of brain disorder that causes problems with memory, thinking, and behavior. This is a gradual…

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.