Somerset Healthcare & Rehabilitation Center

Based on review of clinical records, as well as staff interviews, it was determined that the facility failed to ensure that physician's orders were followed for one of 33 residents reviewed (Resident 49), and failed to obtain urine culture results for effective antibiotic treatment of a urinary tract infection for one of 33 residents reviewed (Resident 85).Findings include: Physician's orders for Resident 49, dated September 20, 2024, included an order for the resident to receive Refresh Relieva Opthalmic Solution 0.5-0.9% *Carboxymethylcellulose-Glycerin (eye drops used to rehydrate and protect hydration for eyes), instill 1 drop in both eyes three times a day for dry eyes unsupervised self-administration and may keep at bedside. Observations of Resident 49's room on April 16, 2026, at 10:10 a.m. revealed no evidence of Refresh Relieva Opthalmic Solution in her room. Interview with Licensed Practical Nurse 7 on April 16, 2026, at 10:10 a.m. revealed that she was not aware that Resident 49 did not have the physician ordered eye drops, and that the resident will inform staff when 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.

Based on review of facility policies, as well observations and staff interviews , it was determined that the facility failed to maintain an environment free from potential safety hazards related to resident beds for three of 33 residents reviewed (Residents 10, 28, and 56) and by not having a formal system for choosing the correct mechanical lift sling for one of 33 residents reviewed (Resident 47).Findings include: A facility policy for safe and homelike environment dated, February 4, 2026, revealed the facility will provide a safe, clean, comfortable and homelike environment, and includes ensuring that the resident can receive care and services safely and that the physical layout of the facility both inside and outside, maximizes resident independence and does not pose a safety risk. Observations during care to Resident 28 on April 13, 2026, at 10:53 a.m. revealed that when the resident was being rolled in bed, the bed moved several feet the opposite direction from the resident and the resident was close to rolling out of bed. The wheels of Resident 28's bed could not be safely…

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 policies and clinical records, as well as resident and staff interviews, it was determined that the facility failed to provide appropriate care for one of 33 residents reviewed (Resident 85) who had an indwelling urinary catheter. Findings include: The facility's policy regarding catheter use, dated February 4, 2026, indicated that residents with indwelling catheters should receive appropriate care for the catheter in accordance with current professional standards of practice. An admission note for Resident 85, dated April 7, 2026, at 5:24 p.m. indicated that the resident had a chronic indwelling catheter (a thin, flexible tube inserted into the bladder to drain urine from the bladder) related to cancer. An admission note for the resident, dated April 7, 2026, at 11:10 p.m. indicated that the resident was admitted related to a fall and urinary tract infection and his indwelling catheter was draining dark, amber colored urine. Observations of Resident 85 on April 13, 2026, at 11:37 a.m. revealed that the resident was sitting in wheelchair in his room with his…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that residents who were receiving enteral feedings received appropriate treatment and services to prevent complications for one of 33 residents reviewed (Resident 5). Findings include: A facility policy regarding care and treatment of feeding tubes, dated February 4, 2026, indicated that in accordance to facility protocol, licensed nurses will monitor and check that the feeding tube is in the right location. Tube placement will be verified before beginning a feeding and before administering medications. A significant change Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 5, dated March 1, 2026, revealed that the resident was cognitively intact, required assistance with care needs, had a feeding tube and had a diagnosis of cancer. A care plan for the resident, dated February 24, 2026, indicated that 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.

Based on review of facility policy and clinical records, as well as staff interviews, it was determined that the facility failed to maintain accountability for controlled medications (drugs with the potential to be abused) for two of 33 residents reviewed (Residents 37 and 49). Findings include: The facility's policy for medication administration, dated February 4, 2026, indicated that staff are to sign the Medication Administration Record (MAR) after a medication is administered; and if the medication is a controlled substance, staff are to sign the narcotic book. A significant change Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 37, dated March 16, 2026, indicated that the resident was cognitively intact, required assistance with daily care needs, and was receiving routinely scheduled and as needed pain medication. Physician's orders for Resident 37, dated January 21, 2026, included orders for the resident to receive 5 milligrams (mg) of oxycodone (a narcotic pain medication) every six hours as needed for pain.…

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 interviews, it was determined that the facility failed to provide a separately-locked, permanently-affixed compartment in the refrigerator for the storage of controlled drugs in one of one medication rooms reviewed. Findings include: Observations in the facility's medication room on A-Wing on April 15, 2026, at 10:55 a.m. revealed two locked compartments in the medication refrigerator that were secured to a shelf, and the shelf was not secured to the refrigerator and was able to be removed. This unsecured shelf with two locked compartments contained two opened bottles of liquid lorazepam (a controlled medication used to treat anxiety) and one unopened bottle of liquid lorazepam. Interview with Registered Nurse 9 at the time of the observation confirmed that the shelf with the fixed locked narcotic box was not secured to the refrigerator and was able to be removed from the refrigerator. Interview with the Nursing Home Administrator on April 15, 2026, at 10:57 a.m. confirmed that the shelf with the fixed locked narcotic box in the refrigerator in the…

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

Based on a review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to maintain clinical records that were complete and accurately documented for two of 33 residents reviewed (Residents 37 and 49).Findings include:The facility's policy for medication administration, dated February 4, 2026, indicated that staff are to sign the Medication Administration Record (MAR) after a medication is administered, and if the medication is a controlled substance, staff are to sign the narcotic book.A significant change Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 37, dated March 16, 2026, indicated that the resident was cognitively intact, required assistance with daily care needs, and was receiving routinely scheduled and as needed pain medication.Physician's orders for Resident 37, dated January 21, 2026, included orders for the resident to receive 5 milligrams (mg) of oxycodone (a narcotic pain medication) every six hours as needed for pain.Physician's orders for…

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

Based on review of the facility's plans of correction for previous surveys, and the results of the current survey, it was determined that the facility's Quality Assurance Performance Improvement (QAPI) committee failed to correct quality deficiencies and ensure that plans to improve the delivery of care and services effectively addressed recurring deficiencies. Findings include:.The facility's deficiencies and plans of corrections for a State Survey and Certification (Department of Health) survey ending March 13, 2025, revealed that the facility developed plans of correction that included quality assurance systems to ensure that the facility-maintained compliance with cited nursing home regulations. The results of the current survey, ending April 16, 2026, identified repeated deficiencies related to care plan revision/implementation, quality of care, labeling/storage/disposal of medications, and proper infection control practices. The facility's plan of corrections for deficiencies regarding developing/implementing comprehensive care plans, cited during the survey ending March 13,…

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 policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that appropriate signage was posted for a resident with special infection control isolation needs for two of 33 residents reviewed (Residents 5 and 79). Findings include: The facility's policy regarding Enhanced Barrier Precautions (EBP-infection control intervention designed to reduce transmission of multi-drug resistant organisms (a germ that is resistant to many antibiotic making treatment difficult) that employs targeted gown and glove use during high contact resident care activities), dated February 4, 2026, indicated that an order for enhanced barrier precautions will be obtained for residents with indwelling medical devices, such as urinary catheters (a thin, flexible tube inserted into the bladder to drain urine from the bladder),and feeding tubes (a mechanical device surgically implanted into the stomach to provide nutrition, fluids and medications to a person who is unable to eat or drink by mouth). A significant change…

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 interviews, it was determined that the facility failed to ensure resident beds were in safe operating condition for 3 of 33 residents reviewed (Residents 28, 37 and 53).Findings include: An Annual Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 28, dated April 8, 2026, revealed that the resident was cognitively intact, and was dependent on staff for daily care needs.Observations in Resident 28's room on April 13, 2026, at 9:29 a.m. revealed that her bed was locked, however, it moved freely while locked. Interview with Resident 28 at the time of the observation revealed that the bed not locking had been an issue.Interview with Nurse Aide 2 on April 13, 2026, at 9:29 a.m. revealed that she was aware that the bed has not been locking and that she informed the Licensed Practical Nurse when she first noticed it.Interview with Licensed Practical Nurse 10 on April 13, 2026, at 11:37 a.m. confirmed that she was told that Resident 28's bed moved, and she told the Nurse Aides to lock the bed but…

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

Based on review of clinical records, as well as staff interviews, it was determined that the facility failed to have sufficient nursing staff to provide and document care as scheduled for two of 4 residents reviewed (Residents 2, 3). Findings include:An annual Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 2, dated November 20, 2025, indicated that the resident was severely cognitively impaired, rarely understands, never understood, and was totally dependent on staff for personal care needs.Review of clinical documentation in the task section of Resident 2's record indicated that he was to receive two showers per week.Review of bathing documentation for Resident 2 from March 22, 2026, through March 28, 2026, indicated that the resident received one shower during that time period instead of two. There was no documented evidence that the resident was offered and refused a second shower that week. A significant change Minimum Data Set (MDS) assessment for Resident 3, dated January 19, 2026, revealed that the resident 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.

Based on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to inform the resident/resident representative in advance of the risks and benefits of psychotropic medications (medications that affect the persons mental state, emotions and behavior) and the treatment alternatives prior to initiating the administration of the medication for one of 6 residents reviewed (Resident 4). Findings include: A facility policy related to psychotropic medications, dated February 4, 2026, indicated that prior to initiating or increasing psychotropic medications, the resident, family, and/or resident representative must be informed of the benefits, risks, and alternatives for the medication, including any black box warnings for antipsychotic medications (psychotropic medications used to treat mental health disorders), in advance of such initiation or increase. The facility will document that the resident or resident representative was informed in advance of the risks and benefits of the proposed care, the treatment alternatives or…

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

Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that the resident representative was notified timely about a change in condition for one of six residents reviewed (Resident 2).Findings include:The facility's policy regarding notification of changes, dated February 4, 2026, indicated that the facility will notify the resident's representative when there is a change requiring notification.A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 2, dated July 26, 2025, indicated that the resident was cognitively impaired and required assistance from staff for daily care needs. The resident's care plan, updated July 26, 2025, revealed that the resident was at risk for falls.A nursing note for Resident 2, dated August 1, 2025, revealed that the resident fell in his room. A nursing note dated August 9, 2025, revealed that Resident 2 was found on his knees in his room and that he had a bruised elbow. A nursing note dated August 15, 2025…

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 reviews, as well as staff interviews, it was determined that the facility failed to follow physician's orders for one of six residents reviewed (Resident 2). Findings include:A quarterly Minimum Data Set (MDS) assessment (a mandatory assessment of a resident's abilities and care needs) for Resident 2, dated July 26, 2025, revealed that the resident was cognitively impaired, required assistance with care needs, and had diagnoses that included a gastrointestinal bleed (stomach).Physician's orders for Resident 2, dated August 7, 2025, included an order for staff to obtain the residents stool three times and check for hidden blood.A review of Resident 2's Treatment Administration Record, dated August 2025, revealed that staff did not obtain and test any stool samples from the resident as ordered.Interview with the Director of Nursing on February 19, 2026 at 1:34 p.m. revealed that staff did not obtain any stool samples and check the for blood for Resident 2 and that they should have.28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services.

Based on review of facility policies, clinical records, observations and staff interviews, it was determined that the facility failed to ensure that a resident's environment remained free of accident hazards by failing to ensure care-planned interventions were in place and that fall risk assessments were completed for one of six residents reviewed (Resident 1), and failed to implement interventions after a fall for one of six residents reviewed (Resident 4). Findings include: The facility's policy regarding fall prevention dated February 4, 2026, indicated that each resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls. A fall risk assessment is to be completed every 90 days and as indicated when a resident has a change in condition. The nurse will indicate the residents fall risk and initiate interventions on the care plan in accordance with residents' level of risk. An annual Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care…

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

Based on clinical record reviews, as well as staff and resident interviews, it was determined that the facility failed to ensure that residents were provided with showers/complete bed baths as scheduled for three of four residents reviewed (Residents 1, 2, 3).Findings include:An annual Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated October 2, 2025, indicated that the resident was cognitively impaired, was dependent on staff for bathing/showering, and had diagnoses that included hypertension (high blood pressure) and osteoporosis (weak, thinning bones). Review of Resident 1's active task list, dated December 2025 and January 2026, revealed that showers were scheduled to be provided every Wednesday and Sunday on dayshift. Review of Resident 1's Bath/Shower record, dated December 2025 through January 2026, revealed no documented evidence that a shower or a complete bed bath was provided to the resident on December 3, 10, 14, 21, 28, and 31, 2025 and January 11, 2026. A significant change MDS assessment for…

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

Based on review of facility policies, observations, and staff interviews, it was determined that the facility failed to serve food that was palatable and at safe and appetizing temperatures.Findings include: The facility's policy regarding food preparation, dated November 19, 2025, indicated that all foods will be held at appropriate temperatures, greater than 135 degrees Fahrenheit (or as state regulations requires) for hot holding, and less than 41 degrees Fahrenheit for cold food holding. Review of the residents' food committee meetings dated October 2, 2025, and November 6, 2025, revealed that residents that attended the meeting answered the question Are foods served at the proper temperature? as sometimes.Interview with Resident 2 on December 10, 2025, at 10:50 a.m. revealed that food served during all meals that should be served hot is often served cold. Observations in the kitchen for the lunch meal service on December 10, 2025, at 11:01 a.m. revealed that a test tray left the kitchen and arrived on the C wing at 11:39 a.m. The lunch meal on December 10, 2025, consisted of 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 review of facility policies and observations, as well as resident and staff interviews, it was determined that the facility failed to serve food items at appetizing temperatures. Findings include: The facility's policy regarding food quality and palatability, dated February 24, 2025, indicated that food would be palatable, attractive, and served at a safe and appetizing temperature. Food was to be at the appropriate temperature as determined by the type of food to ensure resident's satisfaction and minimize the risk for scalding and burning. Food Committee meeting minutes, dated February 5 and March 7, 2025, revealed that residents complained that food was not served at the proper temperature and the food was cold. Interview with Resident 6, during the initial tour on March 10, 2025, at 11:49 a.m. revealed that meals were usually served cold. Resident 6 was alert and oriented, able to make her needs known, and usually eats in her room. Interview with Resident 14 on March 10, 2025, at 10:31 a.m. revealed that he will eat his meals in his room and in the main dining room and…

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

Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included specific and individualized interventions for three of 37 residents reviewed (Residents 38, 57, 60). Findings include: A facility policy for comprehensive care plans, dated February 24, 2025, included that the facility will develop and implement a person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing and mental and psychological needs and all services that are identified in the resident's comprehensive assessment and meet professional standards of quality. The comprehensive care plan will be developed within seven days after the completion of the comprehensive MDA assessment. CDC guidance on isolation precautions and Implementation of Personal Protective Equipment (PPE) use in Nursing Homes to Prevent Spread of Multidrug-Resistant Organisms (MDRO's -…

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

Based on clinical record reviews and staff interviews, it was determined that the facility failed to ensure that interventions to prevent weight loss were provided as recommended by the dietician for one of 37 residents reviewed (Resident 46). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 46, dated August 8, 2024, revealed that the resident had moderate cognitive impairment, required set up and clean up assistance with eating, had diagnoses that included left hemiplegia (loss of strength in the arm, leg, and sometimes the face on one side of the body) following a stroke, and had unplanned weight loss. A care plan for Resident 46, dated August 8, 2024, indicated that the resident had the potential for a nutritional problem and that a registered dietician was to evaluate and make diet change recommendations as needed, and Med Pass supplement (a fortified nutritional shake that provides additional calories and protein) was to be provided as ordered. A Nutritional Review assessment 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 clinical record reviews and staff interviews, it was determined that the facility failed to complete treatments as ordered by the physician for one of 37 residents reviewed (Resident 48) who received dialysis services. Findings include: An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 48, dated February 9, 2025, revealed that the resident understood and understands, was cognitively intact, received dialysis, and had diagnoses that included end-stage renal disease. A care plan, dated February 4, 2025, revealed that the resident received peritoneal dialysis (a treatment for kidney failure that uses the lining of your abdomen, or belly, to filter your blood inside your body), and staff were to check and change the dressing at the access site daily. Physician's orders for Resident 48, dated February 3, 2025, and February 13, 2025, respectively, included orders for the resident to have 0.1 percent Gentamicin ointment applied to the peritoneal dialysis site topically every day shift and to receive…

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 policies and clinical records, as well as observations and resident and staff interviews, it was determined that the facility failed to ensure that call bells were within reach for one of 37 residents reviewed (Resident 8). Findings include: The facility's policy for call lights: accessibility and response, dated February 24, 2025, indicated that the purpose was to ensure the facility is adequately equipped with a call light at each residents' bedside, toilet, and bathing facility, to allow residents to call for assistance. Staff will ensure the call light is within reach of residents and secured, as needed. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's care needs and abilities) for Resident 8, dated February 18, 2025, revealed that the resident had moderate cognitive impairment, required assistance from staff for care needs, and had diagnoses that included right-sided hemiplegia (loss of strength in the arm, leg, and sometimes face on one side of the body) following a stroke. A care plan for Resident 8, dated March 7, 2025,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policies and observations, as well as interviews with staff, it was determined that the facility failed to maintain the confidentiality of medical information for one of 37 residents reviewed (Resident 54). Findings include: The facility's policy regarding confidentiality and medical records, dated February 24, 2024, indicated that employees are to ensure computer screens with health information are minimized or closed to ensure resident confidentiality. Observations on March 12, 2025, at 8:00 a.m. revealed a laptop on top of a medication cart in the hallway outside of room [ROOM NUMBER] that was open and the Medication Administration Record (MAR) for Resident 54 was visible to staff, residents, and visitors in the hallway. No nurse was observed near the medication cart. Interview with Registered Nurse 2 on March 12, 2025, at 8:06 a.m. revealed that she had walked away from the medication cart for a few minutes to get something she needed and did not minimize the laptop screen,…

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 reviews and staff interviews, it was determined that the facility failed to notify the resident and legal guardian in writing regarding the reason for hospitalization for three of 37 residents reviewed (Residents 27, 49, 71). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 27, dated January 17, 2025, indicated that the resident was understood, could understand others, and was cognitively intact. A nursing note, dated October 20, 2024, at 3:28 p.m., revealed that the Certified Registered Nurse Practitioner (CRNP) was notified of the resident's laboratory test results showing an elevated white blood cell count and the resident's continued complaint of abdominal pain, nausea, and chills. Orders were received to transfer the resident to the hospital for evaluation and treatment. Interview with the Assistant Director of Nursing on March 11, 2025, at 12:41 p.m. confirmed that there was no documented evidence that a written notice of Resident 27's transfer to the hospital…

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

Based on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to issue a bed-hold notice at the time of an anticipated leave of absence from the facility for one of 37 residents reviewed (Resident 71). Findings include: The facility's policy regarding bed hold notices and transfer, dated February 24, 2025, indicated that in the event of an emergency transfer of a resident, the facility will provide written notice of the facility's bed-hold policies to the resident and/or the resident's representative within 24 hours. The facility will document multiple attempts to reach the resident's representative in cases where the facility was unable to notify the representative. The facility will keep a signed and dated copy of the bed-hold notice information given to the resident and/or resident's representative in the resident's file and/or medical record. The facility will provide this written information to all facility residents, regardless of their payment source. An annual Minimum Data Set (MDS) assessment (a mandated…

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 the Resident Assessment Instrument User's Manual and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that comprehensive significant change Minimum Data Set assessments were completed in the required time frame for one of 37 residents reviewed (Resident 65). Findings include: The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which provides instructions and guidelines for completing required Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2024, indicated that the Assessment Reference Date (ARD) was to be no later than the 14th calendar day after determination that a significant change in the resident's status occurred (determination date + 14 calendar days) and the significant change comprehensive MDS assessment was to be completed no later than the 14th calendar day after determination that significant a change in the resident's status occurred (determination date + 14 calendar days). A care plan for Resident 65, dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of the Resident Assessment Instrument User's Manual and clinical records, as well as staff interviews, it was determined that the facility failed to complete accurate Minimum Data Set assessments for seven of 37 residents reviewed (Residents 9, 23, 36, 39, 49, 55, 57). Findings include: The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which provides guidance and instructions for the completion of Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2024, indicated that Section N0415I1 (Antiplatelet Medications - medications used to reduce the risk of blood clots) was to be checked if the resident received an anti-platelet medication during the seven-day assessment period. Physician's orders for Resident 9, dated January 7, 2021, included an order for the resident to receive 81 milligrams (mg) of aspirin daily. The resident's Medication Administration Record (MAR) for February 2025 revealed that the…

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

Based on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that a resident's care plan was updated/revised to reflect the resident's specific care needs for two of 37 residents reviewed (Residents 8, 55). Findings include: A facility policy for care plan revision upon status change, dated February 24, 2025, indicated that the comprehensive care plan will be reviewed and revised as necessary when the resident experiences a status change. The care plan will be updated with new or modified interventions. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's care needs and abilities) for Resident 8, dated February 18, 2025, revealed that the resident had moderate cognitive impairment, required assistance from staff for care needs, and had diagnoses that included right-sided hemiplegia (loss of strength in the arm, leg, and sometimes face on one side of the body) following a stroke. Care plan for Resident 8, dated March 7, 2025, included that the resident was dependent 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 clinical record reviews and staff interviews, it was determined that the facility failed to ensure that a discharge summary, including a recapitulation of the resident's stay, was completed for one of one discharged residents reviewed (Resident 70). Findings include: Physician's orders for Resident 70, dated January 4, 2025, included an order for the resident to be discharged home with the services of Home Health including physical therapy, occupational therapy, and nursing. A nursing note for Resident 70, dated January 4, 2025, revealed that the resident was discharged from the facility at 11:15 a.m. to home with all of his possessions. As of March 13, 2025, there was no documented evidence that a discharge summary that included a recapitulation of the resident's stay was completed for Resident 70. Interview with the Assistant Director of Nursing on March 13, 2025, at 3:18 p.m. confirmed that there was no documented evidence that a discharge summary was completed for Resident 70. 28 Pa. Code 211.5(d) Clinical Records.

Based on review of facility policy and clinical records, as well as staff interviews, it was determined that the facility failed to follow physician's orders for medication administration for one of 37 resident (Resident 27) and failed to follow physician's orders related to bowel protocols for two of 37 residents reviewed (Residents 9, 60). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 27, dated January 17, 2025, revealed that the resident was cognitively intact and had diagnoses that included septicemia (a life-threatening condition where bacteria or other microorganisms enter the bloodstream and cause a systemic infection). Physician's orders for Resident 27, dated January 10, 2025, included orders for the resident to receive 100 milligrams (mg) of Doxycycline every 12 hours for cellulitis (a common bacterial infection of the skin and underlying tissues) for 10 days. The resident's Medication Administration Record (MAR) for January 2025 revealed that the 9:00 p.m. dose of Doxycycline…

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 policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that recommended pressure ulcer interventions were provided to prevent skin breakdown for one of 37 residents reviewed (Resident 56). Findings include: A facility policy regarding pressure injury prevention and management, dated February 24, 2025, revealed that the facility was to provide treatment and services to heal the pressure ulcer, prevent infection, and the development of additional pressure ulcers. A quarterly Minimum Data assessment Set (MDS) (a mandated assessment of a resident's abilities and care needs) for Resident 56, dated February 26, 2024, revealed that the resident had no speech, was rarely or never understood, was dependent on staff for all care areas, had diagnoses that included Alzheimer's disease and non traumatic brain dysfunction, and had one non-stageable pressure ulcer (unable to determine the depth of the wound) that was not present on admission. A pressure ulcer investigation for Resident 56, dated December 9, 2024, revealed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policies, observations, and staff interviews, it was determined that the facility failed to properly label a multi-use vial of Aplisol in one of one medication rooms reviewed, and failed to secure medication in a medication cart. Findings include: The facility's policy regarding medication labeling and storage, dated February 24, 2025, indicated that multi-dose vials that have been opened or accessed are dated and discarded within 28 days unless the manufacturer specifies a shorter or longer dated for the open vial. The facility stores all medications and biologicals in locked compartments under proper temperature, humidity, and light controls. Compartments (including but not limited to drawers, cabinets, rooms, refrigerators, carts, and boxes) containing medications and biologicals are locked when not in use. Current manufacturer's directions for Aplisol (tuberculin purified protein derivative) indicated that vials in use for more than 30 days should be discarded due to possible…

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 hospice contracts and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that the designated interdisciplinary team member obtained the required information from the contracted hospice provider for one of two residents reviewed (Resident 65) who received hospice care. Findings include: An agreement between the facility and a hospice provider (provider of end-of-life services), dated April 8, 2024, indicated that the hospice provider would provide the following information to the facility to facilitate coordination of care: a hospice election form (a form signed to indicate that the individual waives all rights to traditional Medicare Part A payments for treatment related to the terminal illness). The skilled nursing facility shall identify a skilled nursing facility designee within the skilled nursing facility and shall be responsible for obtaining the follow information from the hospice: the hospice election form. A care plan for Resident 65, dated July 24, 2024, revealed that the resident required hospice care…

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

Based on review of the facility's plans of correction for previous surveys, and the results of the current survey, it was determined that the facility's Quality Assurance Performance Improvement (QAPI) committee failed to correct quality deficiencies and ensure that plans to improve the delivery of care and services effectively addressed recurring deficiencies. Findings include: The facility's deficiencies and plans of corrections for a State Survey and Certification (Department of Health) survey ending April 25, 2024; July 10, 2024; October 23, 2024; November 20, 2024; December 13, 2024; December 30, 2024; and January 22, 2025, revealed that the facility developed plans of correction that included quality assurance systems to ensure that the facility maintained compliance with cited nursing home regulations. The results of the current survey, ending March 13, 2025, identified repeated deficiencies related to personal privacy and confidentiality of records, abuse and neglect policy, accuracy of assessments, comprehensive care plans, care plan revision, quality of care, treatment and…

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

Based on review of established infection control guidelines, facility policies, and clinical records, as well as observations and staff interviews, it was determined that the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one of 37 residents reviewed (Residents 56). Findings include: CDC guidance on Implementation of Personal Protective Equipment (PPE) use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs), dated July 12, 2022, indicated that multidrug-resistant organism (MDRO) transmission was common in skilled nursing facilities, contributing to substantial resident morbidity and mortality and increased healthcare costs. Enhanced Barrier Precautions (EBP) are an infection control intervention designed to reduce transmission of resistant organisms that employs targeted gown and glove use during high contact resident care activities. CMS updated its infection prevention and…

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

Based on review of policies and personnel files, as well as staff interviews, it was determined that the facility failed to complete a Nurse Aide Registry verification upon hire for two of two newly hired nurse aides reviewed (Nurse Aides 1 and 2), failed to ensure that nursing licenses were checked with the Pennsylvania State Board of Nursing for three of three newly hired nurses (Licensed Practical Nurse 1, Registered Nurse 1 and 2) and failed to complete a criminal background check for four of five newly hired nursing staff reviewed (Nurse Aide 1, Licensed Practical Nurse 1, Registered Nurse 1 and 2). Findings include: The facility's abuse policy, dated March 19, 2024, indicated that the facility will provide protections for health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. Background, reference and credential checks shall be conducted on all potential employees. The personnel file for Nurse Aide 1 revealed that she was hired…

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 policies, as well as observations and staff interviews, it was determined that the facility failed to provide confidentiality of residents' personal health information during medication administration for one of nine residents reviewed (Resident 2). Findings include: The facility policy regarding electronic health records, dated March 19, 2024, indicated that the resident's health information needs to remain private. Observations on December 30, 2024, at 9:05 a.m. revealed that Licensed Practical Nurse 1 was not near her medication cart. Resident 2's personal health information was visible on the computer screen, which was facing the hallway. Interview with Licensed Practical Nurse 1 on December 30, 2024, at 9:11 a.m. confirmed that she should have covered the resident's personal information when leaving the medication cart by securing the computer screen. Interview with the Director of Nursing on December 30, 2024, at 12:31 p.m. confirmed that the computer screen with Resident 2's personal health information should have been covered when the nurse was 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 review of facility policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that medications were stored in a secure manner for two of three medication carts reviewed (A unit long hall cart and C unit cart). Findings include: The facility's policy on administering medications, dated March 19, 2024, indicated that during administration of medications, the medication cart is kept closed and locked when out of sight of the medication nurse. No medications are kept on top of the cart. The cart must be clearly visible to the personnel administering medications, and all outward sides must be inaccessible to residents or others passing by. Observations on December 30, 2024, at 8:54 a.m. revealed that the medication cart for A unit long hall was in the hallway, against the wall, unlocked and unattended. A medication cup containing various medications was stored on top of the medication cart. Interview with Licensed Practical Nurse 2 on December 30, 2024, at 8:57 a.m. indicated that she was called away by a…

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

Based on review of clinical records, as well as observations and resident and staff interviews, it was determined that the facility failed to honor food preferences for one of nine residents reviewed (Resident 5). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 5, dated December 7, 2024, indicated that the resident was cognitively intact, was clearly understood and able to clearly understand others, and was independent with care needs. An interview with Resident 5 on December 30, 2024, at 9:19 a.m. revealed that she was no longer able to get yogurt and a banana for breakfast. She indicated that she gets too many eggs and does not like eggs, and that prior to the new owners taking over, she was able to get yogurt and a banana for breakfast daily. Interview with the Dietary Manager on December 30, 2024, at 12:01 p.m. revealed that she was not permitted to purchase yogurt and bananas when the new owners took over. She indicated that if Resident 5 wanted these items, the family would have 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 a review of facility policies and clinical records, as well as resident and staff interviews, it was determined that the facility failed to ensure that the residents were provided with nightly snacks in accordance with their preferences for seven of nine residents reviewed (Residents 1, 2, 3, 4, 5, 7, 8). Findings include: A facility policy on snack serving dated, March 19, 2024, revealed that snacks will be provided to residents between meals, per resident's request, and at nighttime. A review of resident council meeting minutes for November and December 2024 revealed that residents stated they were not being provided with evening snacks and would like to be. A Quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated November 25, 2024, indicated that the resident was cognitively intact, understood, was understood by others, was independent for eating, and had diagnoses that included hemiparesis (a medical condition where there is weakness or paralysis on one side of the body). Review of Resident 1's…

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

Based on clinical record reviews and staff interviews, it was determined that the facility failed to monitor intake and output for one of 11 residents reviewed (Resident 3) who had an indwelling urinary catheter and failed to follow physician's orders related to bowel protocols for one of 11 residents reviewed (Resident 6). Findings include: An admission nursing note for Resident 3, dated December 4, 2024, at 5:30 p.m. indicated that the resident arrived at the facility via ambulance and had a suprapubic catheter (a flexible tube that drains urine from the bladder through the abdomen). A physician's order for Resident 3, dated December 10, 2024, revealed that the resident had a suprapubic catheter for neurogenic bladder (bladder lacks control due to nerve or muscle problems). A care plan for Resident 3, dated December 6, 2024, revealed that the resident had a suprapubic catheter in place for neurogenic bladder and the facility was to monitor and document intake and output as per facility policy. Review of Resident 3's Medication Administration Record, Treatment Administration…

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 the Resident Assessment Instrument User's Manual and clinical records, as well as staff interviews, it was determined that the facility failed to complete accurate comprehensive Minimum Data Set assessments for two of 11 residents reviewed (Residents 2, 10). Findings include: The Resident Assessment Instrument (RAI) User's Manual, which gives instructions for completing Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2024, revealed that Sections H0100 through H0300 were to gather information on the use of bowel and bladder appliances and urinary and bowel continence. Section H0300 was to be coded nine (9), not rated if during the seven-day look-back period the resident had an indwelling bladder catheter (a tube held in the bladder to drain urine), or other types of catheters or no urine output for the entire seven days. Section H0400 (Bowel Continence) was to be coded zero (0) if the resident was always continent, coded one (1) if the resident was occasionally incontinent, coded two (2) if 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 clinical records, as well as staff interviews, it was determined that the facility failed to ensure that the resident's clinical record contained signed and dated reports of radiologic and other diagnostic services for one of 11 residents reviewed (Resident 2). Findings include: Physician's orders for Resident 2, dated June 20, 2024, included an order for the resident to have an ultrasound (an imaging test that uses sound waves to make pictures of organs, tissues, and other structures inside your body) of her bilateral breasts as a screening for any abnormal lumps/masses. However, review of Resident 2's clinical record revealed no documented evidence of a signed and dated ultrasound report for the resident that was ordered on June 20, 2024. Interview with the Assistant Director of Nursing on December 12, 2024, at 4:08 p.m. indicated that Resident 2 had the ultrasound completed and confirmed that there was no documented evidence of a signed and dated ultrasound report in the resident's clinical record. 28 Pa. Code 211.5(f) Clinical Records. 28 Pa. Code…

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 facility policies, established infection control guidelines, and residents' clinical records, as well as observations and staff and resident interviews, it was determined that the facility failed to follow infection control guidelines from the Centers for Medicare/Medicaid Services (CMS) and the Centers for Disease Control (CDC) to reduce the spread of infections and prevent cross-contamination for two of 11 residents reviewed (Residents 3, 7). Findings include: CDC guidance on Implementation of Personal Protective Equipment (PPE) use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs), dated July 12, 2022, indicated that multidrug-resistant organism (MDRO) transmission was common in skilled nursing facilities, contributing to substantial resident morbidity and mortality and increased healthcare costs. Enhanced Barrier Precautions (EBP) are an infection control intervention designed to reduce transmission of resistant organisms that employs targeted gown and glove use during high contact resident care activities. CMS updated its infection…

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 policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that pressure ulcers were monitored for one of seven residents reviewed (Resident 2). Findings include: The facility's policy regarding prevention of pressure injuries, dated March 19, 2024, revealed that the resident was to be assessed on admission for existing pressure injury risk factors, and repeat the assessment weekly and upon any changes. An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 2, dated October 20, 2024, revealed that the resident was understood, could understand others, and had one Stage 1 pressure injury (a mild pressure-related skin change that appears as a reddened area that does not turn white when pressed), as well as one unstageable pressure injury (a full-thickness tissue loss that is covered by a layer of dead tissue) that was present upon admission. The resident's care plan, dated October 15, 2024, indicated that the resident has a right lateral…

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

Based on review of clinical records and facility investigations, as well as staff interviews, it was determined that the facility failed to revise residents' care plans with individualized interventions to address their care needs for one of seven residents reviewed (Resident 1). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated November 3, 2024, revealed that the resident sometimes could make himself understood, sometimes could understand others, was cognitively impaired, and had diagnoses that included dementia and a stroke. The resident's care plan, dated April 21, 2021, revealed that he required a mechanical lift with the assistance of two staff for transfers. A facility investigation, dated November 11, 2024, at 6:20 p.m., revealed that staff was attempting to transfer Resident 1 to his wheelchair during active fire evacuation. They were unable to safely transfer him to his chair without more assistance, so he was lowered to the floor with two staff members present. A draw sheet…

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 policies and clinical records, as well as staff interviews, it was determined that the facility failed to develop comprehensive care plans that included specific and individualized interventions to address resident care needs for one of four residents reviewed (Resident 2). Findings include: The facility's policy regarding care plans, dated March 19, 2024, revealed that the interdisciplinary team, in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. The comprehensive, person-centered care plan includes measurable objectives and timeframes; describes services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being; and reflects currently recognized standards of practice for problem areas and conditions. An admission Minimum Data Set (MDS) assessment (a…

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

Based on clinical record reviews, as well as staff interviews, it was determined that the facility failed to follow recommendations from the hospital for a follow-up appointment and failed to follow physician's orders for one of four residents reviewed (Resident 2). Findings include: An admission Minimum Data Set (MDS) assessment (a mandatory assessment of a resident's abilities and care needs) for Resident 2, dated July 18, 2024, revealed that the resident was understood, could usually understand others, and had a diagnosis which included Raynaud's syndrome (a condition that causes blood vessels to suddenly constrict, resulting in the fingers or toes turning white, blue, and then red) with gangrene (the death and decay of body tissues due to a lack of oxygen). Hospital Discharge Instructions for Resident 2, dated July 11, 2024, revealed that the resident had a follow-up appointment scheduled on August 21, 2024, at 2:00 p.m. with the endocrinologist (a doctor who specializes in diagnosing and treating disorders of the endocrine system) for adrenal adenoma (a type of benign…

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 policies, personnel files, and education records, as well as staff interviews, it was determined that the facility failed to implement its written abuse prevention policies by failing to ensure that the status of nursing licenses were checked with the State Board of Nursing for three of three newly hired nurses reviewed (Registered Nurse 2, Registered Nurse 3, Licensed Practical Nurse 4), failed to complete a nurse aide registry verification for one of one nurse aides reviewed upon hire (Nurse Aide 5), failed to ensure that criminal background checks were completed prior to hire for one of five employee files reviewed (Nurse Aide 5), failed to ensure that reference checks were obtained prior to hire for four of five employee files reviewed (Registered Nurse 2, Registered Nurse 3, Licensed Practical Nurse 4, Nurse Aide 5), and failed to ensure that staff received annual abuse training for three of six staff reviewed (Registered Nurse 6, Licensed Practical Nurse 7, Licensed Practical Nurse 8). Findings include: The facility's policy regarding abuse, neglect,…

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

Based on a review of the Resident Assessment Instrument User's Manual and clinical records, as well as staff interviews, it was determined that the facility failed to complete accurate Minimum Data Set assessments for five of 36 residents reviewed (Residents 3, 14, 29, 35, 70). Findings include: The Long Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which gives instructions for completing Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2023, revealed that Section N0415F (Antibiotic - medications) was to be checked if the resident was taking any medications by pharmalogical classification, not how it was used, during the last seven days, or since admission/entry or reentry if less than seven days. Current physician's orders for Resident 3 included orders for the resident to receive 1 Gram of Methenamine Hippurate (antibiotic medication) two times a day. Medication Administration Record's (MAR's) for Resident 3, dated February, 2024, revealed that the resident received antibiotic medications…

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

Based on review of facility policy and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that a resident's care plan was updated/revised to reflect the resident's specific care needs for six of 36 residents reviewed (Residents 5, 10, 28, 41, 43, 55). Findings include: The facility's policy regarding care plans, dated March 19, 2024, indicated that the interdisciplinary team would review and update the care plan when there was a significant change in the resident's condition; when the desired outcome was not met; when the resident had been readmitted to the facility from a hospital stay; and at least quarterly in conjunction with the required quarterly MDS assessment. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 5, dated February 22, 2024, revealed that the resident was usually understood and could usually understand others. A care plan for the resident, dated November 19, 2023, revealed that the resident has impaired visual function related to the need 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 review of the Pennsylvania Nurse Practice Act and residents' clinical records, as well as staff interviews, it was determined that the facility failed to ensure that physician's orders were clarified for two of 36 residents reviewed (Residents 14, 28). Findings include: The Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.11 (a)(1)(2)(4) indicated that the registered nurse was to collect complete and ongoing data to determine nursing care needs, analyze the health status of individuals and compare the data with the norm when determining nursing care needs, and carry out nursing care actions that promote, maintain and restore the well-being of individuals. Physician's orders for Resident 14, dated July 21, 2023, included orders for the resident to have blood sugar checks one time a day on Monday, Wednesday and Friday, and to receive 24 units of 100 unit/milliters of Lantus Solostar Solution one time a day for diabetes. The medication was to be held if the resident's blood sugar was less than 100 milligrams/deciliter (mg/dL). A…

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

Based on review of facility policy and clinical record reviews, as well as staff interviews, it was determined that the facility failed to follow recommendations from a neurologist (a medical doctor with specialized training in diagnosing, treating, and managing disorders of the brain and nervous system) for a follow-up appointment for one of 36 residents reviewed (Resident 5), and failed to follow physician's orders for three of 36 residents reviewed (Residents 29, 34, 43). Findings include: The facility's medication administration policy, dated March 19, 2024, indicated that procedures were in place to provide guidelines for the safe administration of medications, and staff were to verify that there was a physician's order for the medication. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 5, dated February 22, 2024, revealed that the resident was usually understood, could usually understand others, and had a diagnosis of Parkinson's disease. A neurology consult for Resident 5, dated January 25, 2024,…

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 reviews, as well as observations and staff interviews, it was determined that the facility failed to ensure that physician's orders were obtained for dialysis per facility policy for one of 36 residents reviewed (Resident 42). Findings include: The facility's policy regarding dialysis care, dated March 19, 2024, indicated that the facility would require an order from the resident's primary care physician for dialysis treatments. An annual Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 42, dated February 1, 2024, indicated that the resident was cognitively intact and required hemodialysis (a process of cleaning the blood of toxins and returning it into the body). A care plan for the resident, dated June 29, 2023, revealed that the resident required hemodialysis related to end-stage renal disease. A nursing note for Resident 42, dated April 10, 2024, indicated that the dialysis center reported that the resident had cough and congestion, and that he coughed once or twice at dialysis. A review of…

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

Based on clinical records and staff interviews, it was determined that the facility failed to ensure the accountability of controlled medications (drugs with the potential to be abused) for three of 36 residents reviewed (Residents 15, 33, 43). Findings include: An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 15, dated February 13, 2024, revealed that the resident was cognitively intact, was understood and understands, required assistance with care needs, had an unstageable deep tissue injury (pressure injury that affects the underlying soft tissues and may not be visible until advanced), and had diagnoses that included diabetes with diabetic neuropathy (nerve damage that affects people with diabetes). Physician's orders for Resident 15, dated February 20, 2024, included and order for the resident to receive hydrocodone-acetaminophen 7.5-325 milligrams (mg) one tablet every six hours as needed for moderate to severe pain. Review of the controlled drug record (a form that accounts for each tablet/pill/dose…

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 resident interviews, observations, and staff interviews, it was determined that the facility failed to serve food that was palatable to residents. Findings include: During interviews with Residents 3, 14, 33, and 36 on April 22, 2024, at 10:30 a.m., 11:51 a.m., and 2:22 p.m., the residents stated that the food served to them was disgusting and lousy. Interview with Resident 28 on April 22, 2024, at 11:58 a.m. revealed that the potatoes were not peeled when served. Observations in the kitchen on April 23, 2024, at 11:24 a.m. revealed that the lunch meal consisted of chicken breast covered with gravy, oven-browned potatoes, corn, and sliced pears. These items were placed on a test tray, and the meal cart containing the test tray left the kitchen at 11:42 a.m. and arrived on the nursing unit at 11:43 a.m. The last resident was served and eating at 11:52 a.m At 12:00 p.m. the test tray was tasted, and the oven-browned potatoes were dry, bland and had the skin intact. The recipe for oven-browned potatoes, undated, indicated that the potatoes were to be peeled and diced, and…

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

Based on review of facility policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that food was served under sanitary conditions. Findings include: The facility's policy regarding meal distribution, dated March 19, 2024, revealed that staff were to use proper food handling techniques to prevent contamination and that temperature maintenance controls will be used for point-of-service dining. Observations in the main kitchen on April 22, 2024, at 8:42 a.m. and 11:06 a.m. revealed that four air vents on the right side of kitchen, on the upper wall, had a thick accumulation of dust and debris and six air vents on the left side of the kitchen, on the upper wall, had an accumulation of dust and debris. A review of the maintenance kitchen vent cleaning log, undated, revealed that the kitchen vents were last cleaned on January 10, 2024. Interview with the Dietary Manager on April 23, 2024, at 9:52 a.m. confirmed that there was an accumulation of dust and debris on the air vents and the maintenance department was 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 review of the facility's plans of correction and the results of the current survey, it was determined that the facility's Quality Assurance Performance Improvement (QAPI) committee failed to correct quality deficiencies and ensure that plans to improve the delivery of care and services effectively addressed recurring deficiencies. Findings include: The facility's deficiencies and plans of correction for a State Survey and Certification (Department of Health) survey ending May 18 and November 17, 2023, and February 22, 2024, revealed that the facility developed plans of correction that included quality assurance systems to ensure that the facility maintained compliance with cited nursing home regulations. The results of the current survey, ending April 25, 2024, identified repeated deficiencies related to a failure to complete accurate Minimum Data Set (MDS) assessments (mandated assessments of residents' abilities and care needs), revising residents' care plans to include current care needs and interventions, to follow physician's orders, issues with oxygen therapy,…

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 established infection control guidelines, facility policies, documents, residents' clinical records, and employee files, as well as observations and staff interviews, it was determined that the facility failed to follow infection control guidelines from the Centers for Medicare/Medicaid Services (CMS) and the Centers for Disease Control (CDC) to reduce the spread of infections and prevent cross-contamination for seven of 36 residents reviewed (Residents 14, 18, 28, 34, 41, 42, 68), and failed to ensure that proper infection control practices and techniques were followed after the hiring of two of five employees reviewed (Registered Nurse 2, Nurse Aide 5). Findings include: CDC guidance on isolation precautions for MRSA residents contained in Implementation of Personal Protective Equipment (PPE) use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs), dated July 12, 2022, indicated that multidrug-resistant organism (MDRO) transmission is common in skilled nursing facilities, contributing to substantial resident morbidity and mortality 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 a review of a list of nurse aides currently employed by the facility, including their hire dates and training hours, as well as staff interviews, it was determined that the facility failed to ensure that nurse aides had 12 hours of in-service training annually for three of three nurse aides reviewed (Nurse Aide 10, Nurse Aide 11, Nurse Aide 12), failed to ensure that nurse aides received annual in-service training regarding abuse for three of three nurse aides reviewed (Nurse Aide 10, Nurse Aide 11, Nurse Aide 12), and failed to ensure that nurse aides received annual in-service training regarding dementia for one of three nurse aides reviewed (Nurse Aide 12). Findings include: A list of nurse aides provided by the facility revealed that based on their months and days of hire: Nurse Aide 10 should have received at least 12 hours of in-service training between March 25, 2023, and March 25, 2024. However, there was no documented evidence that she received at least 12 hours of in-service training as required. Nurse Aide 11 should have received at least 12 hours of in-service…

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

Based on review of facility policy, clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that a resident's respiratory status was properly monitored for one of 36 residents reviewed (Resident 43). Findings include: The facility's policy regarding oxygen administration, dated March 19, 2024, indicated that the facility would verify the physician's order and review facility protocol for oxygen administration. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 43, dated February 25, 2024, revealed that the resident was understood and could understand, was independent with care needs, and was on oxygen therapy. Physician's orders for Resident 43, dated August 25, 2023, included an order for the resident to receive oxygen at a flow rate of 4 liters per minute via nasal cannula (tubes placed in the nostrils to deliver oxygen) to keep the resident's oxygen saturation (the percentage of oxygen in the blood) greater than 88 percent every shift. A care plan…

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

Based on review of policies, clinical records, and information submitted by the facility, as well as staff interviews, it was determined that the facility failed to review and revise care plans for one of three residents reviewed (Resident 2). Findings include: The facility's policy regarding care plans, dated February 1, 2024, revealed that a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. The care plan interventions are derived from a thorough analysis of information gathered as part of the comprehensive assessment. The comprehensive, person-centered care plan describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. Assessments of the residents are ongoing and care plans are revised as information about the residents and the resident's condition change. The interdisciplinary team reviews and updates the care plan when there has…

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

Based on clinical records reviews and staff interviews, it was determined that the facility failed to ensure that intravenous fluids were administered according to physician's orders for one of 18 residents reviewed (Resident 10) and failed to ensure that Certified Registered Nurse Practioner's (CRNP - an advanced practice registered nurse who can work independently from a physician) orders were followed for one of 18 residents reviewed (Resident 11). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 10, dated September 15, 2023, indicated that the resident was cognitively intact and required extensive assistance for daily care needs. A nursing note, dated November 3, 2023, at 9:19 p.m. revealed that Resident 10 was seen and examined by the physician during the evening after being seen earlier in the day at the emergency room. Physician's orders were received for 1/2 normal saline (half strength salt water) IV at 100 milliliters per hour (ml/hr) for three days for dehydration and to increase…

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

Based on review of facility policy and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that the Certified Registered Nurse Practioner (CRNP - an advanced practice registered nurse who can work independently from a physician) wrote, signed, and dated progress notes with each visit for one of 18 residents reviewed (Resident 11). Findings include: The facility's policy regarding coordination of medical care, dated October 6, 2023, indicated that the physician would be responsible for creating and managing systems to ensure that practitioners who may perform physician-delegated tasks act within the regulatory requirements and the scope of practices as defined by state law. A CRNP note for Resident 11, dated October 30, 2023, revealed that the CRNP ordered for the resident to get a chest x-ray and to test for COVID. There was no documented evidence that the resident was tested for COVID per the CRNP's orders. A CRNP note for Resident 11, dated November 6, 2023, revealed that the CRNP ordered for the resident to get intravenous (IV)…

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 guidance from the Pennsylvania Department of Health (DOH) and review of the facility's policies, as well as observations and staff interviews, it was determined that the facility failed to follow infection control standards and DOH guidelines to reduce the spread of infections and prevent cross-contamination for one of 18 residents reviewed (Resident 1). Findings include: The COVID-19 Infection Control and Outbreak Response Toolkit for Long-Term Care, dated July 2023, revealed that symptomatic residents should be tested with even mild symptoms of COVID-19 as soon as possible. The facility's policy regarding transmission-based precautions for COVID-19, dated October 6, 2023, indicated that the facility would follow federal and state guidelines regarding testing residents for COVID-19. A nursing note for Resident 11, dated October 27, 2023, revealed that the resident had a change in condition, her cheeks were reddened and warm to touch, and her oxygen level was lower. There was no documented evidence that the resident was tested for COVID after developing those…

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