Silver Stream Rehabilitation And Nursing Center

Based on interviews, and reviews of clinical records, facility documentation and employee records, the facility failed to ensure that staff assigned to supervise residents during dining and provided cardio-pulmonary resuscitation (CPR) to a resident who was choking were certified in cardio-pulmonary resuscitation (CPR). One of 22 residents reviewed. Findings Include:Review of facility policy Cardiopulmonary Resuscitation (CPR) dated 2025, revealed that Personnel have completed training on the initiation of cardiopulmonary resuscitation (CPR) and basic life support (BLS), including defibrillation, for victims of sudden cardiac arrest. Obtain and/or maintain American Red ' Cross or American Heart Association certification in Basic Life Support (BLS)/ Cardiopulmonary Resuscitation (CPR) for key clinical staff members who will direct resuscitative efforts.Review of facility policy Meal Supervision Policy dated January 2025, revealed that This policy applies to all nursing staff, healthcare assistants, dietary aids and any designated personnel involved in supervision of patient meals.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, clinical record review and interviews with staff, it was determined that the facility failed to follow the physician orders related to Medication Administration for one of 23 residents reviewed (Resident R53) Review facility policy on administering medications dated December 2012 reveal that under section policy statement medication shall be administered in a safe and timely manner and as prescribed. under section policy interpretation and implementation #2 the director of nursing services will supervise and direct all nursing personnel who administer medications and or have related functions #3 medications must be administered in accordance with the orders including any required time frame #4 medications must be administered within one hour of their prescribed time unless otherwise specified for example before and after meal orders #7 the individual administering the medication must check the label three times to verify the right resident the right medication the right 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 the review of clinical records, it interviews with staff, it was determined that the facility failed to prevent accident hazards for 1 out of 22 residents reviewed (Resident R8). Findings include:Review of the January 2026 physician orders for Resident R8 included the following diagnosis: congestive heart failures (CHF-a long-term condition that affects your heart's ability to pump blood well); epilepsy (a brain disorders that causes recurring seizures); schizophrenia (a serious mental health disorder characterized by symptoms that include false beliefs seeing things that are not present, hearing voices, and sounds that are not real, and disorganized thinking, affecting how individuals perceive reality and interact with the world); intellectual abilities (a neurodevelopmental condition characterized by significant limitations in intellectual functioning and adaptive behavior, affecting everyday life skills and learning abilities); cognitive communication deficit (a condition that affects an individual's ability to communicate effectively due to impairments in cognitive…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 interviews and the review of facility documentation, it was determined that the facility failed to ensure that a resident's significant weight loss was addressed in a timely manner for 1 out of 22 residents reviewed (Resident R6).Findings include:Review of the facility policy, Weight Assessment and Intervention, with a revision date of March 2022 indicated that any weight change of 5% or more since the last weight assessment is taken is retaken the next day for confirmation. Review of the resident's January 2026 physician orders included the following diagnosis: hypertension (high blood pressure); cerebral infarction (a stroke); chronic kidney disease (when the kidneys have become damaged over a specific period of time and have a hard time doing all their important jobs).Review of a monthly weight in the resident's clinical record dated May 3, 2025 documented the resident's weight at 138 pounds. Review of a monthly weight dated June 6, 2025 documented the resident's weight as 129 pounds, which is -9 pounds weight loss and a significant weight loss of -6.5%. Continued review…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy and clinical records, resident and staff interviews, it was determined that the facility failed to offer routine dental services for one of 22 residents reviewed (Resident R74).Findings include: Review of the clinical record for Resident R74 revealed that the resident was admitted to the facility on [DATE], and the resident was a long-term care resident. The payment source for resident's stay was listed as Medicaid/Medicaid plans. Review of Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 74, dated December 10, 2025, revealed that the resident was cognitively intact. Review of Pennsylvania Medical Assistance Dental Coverage for Adults revealed that an adult can receive exams, x-rays, and cleanings once every 6 months.An interview with Resident R74 on January 20, 2026, at 2:01 p.m. stated he did not see dentist since she was admitted to the facility in March of 2025. He said he was having tooth pain, and he needed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 an interview with staff it was determined that the facility did not ensure that garbage and refuse was disposed of properly. Findings include:An initial tour of the Food Service Department was conducted on January 20, 2026, at 10:15 a.m. with Employee E5, Food Service Director (FSD), which revealed the following:Observation in the receiving area revealed a green dumpster with equipment piled behind it including a hospital style bedframe on the ground partially covered in snow, a stainless-steel counter height ice machine and a wheelchair with six leg rests piled on top of the armrests.Interview with the FSD at 9:30 a.m. on January 20, 2026, confirmed the above findings, and that the ice machine was no longer working. Interview with the Administrator on January 21, 2026, at 11:30 a.m. confirmed that the equipment did not belong in the receiving area and that it had been moved. 28 PA Code: 201.14(a) Responsibility of licensee.28 Pa. Code 201.18(b)(3) Management

Based on the review of facility documentation, clinical records and staff and resident interviews, it was determined that the facility failed to provide necessary pharmaceutical services for one of five residents reviewed. (Resident R1).Findings include: Review of physician order for Resident R1 dated May 28, 2025, revealed that the resident was ordered for Lidocaine external patch 4% to skin topically one time a day for pain; Bacitracin (Antibiotic ointment) zinc external ointment to left ear topically two times daily; Balsam Peru Castor Oil (used to promote healing and treat certain types of skin ulcers and wounds.) external ointment to bilateral elbows and heels topically two times a day; Naproxen (a nonsteroidal anti-inflammatory drug ) oral Tablet 500 MG tablet by mouth two times a day for pain for 14 days. Review of Medication Administration Record for Resident R1 for the month of May 2025 revealed that the resident did not receive the above medications as ordered by the physicians on May 28, 2025. The reason documented was that the medications were not available. Interview…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record reviews, interviews with staff and hospital record and policy and procedure review, it was determined that the facility failed to ensure that breathing treatments were prescribed upon admission and that medications were administered as order by the physician for one of fourteen residents reviewed. (Resident R1) Findings include: A review of the facility policy titled administering medications dated December, 2012 revealed that the all medications were to be administered by a licensed person(s) in a safe and timely manner as prescribed by the attending physician. The policy indicated that medications must be administered in accordance with orders, including any required time frames. A review of the policy titled reconciliation of medications on admission dated July 2027 revealed that it was the responsibility of the nurse to ensure the accurate accounting of residents' medications, routes and dosages upon admission to the facility. The nurse was to use the discharge summary from the…

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

Based on observations of the Food and Nutrition Services Department, interviews with residents and staff, reviews of clinical records and policies and procedures, it was determined that essential pieces of food service equipment used for the transportation, holding and delivery of hot foods from the dietary services department to the nursing units, resident rooms and dinning areas were not in use, to ensure consistently safe and satisfactory food temperatures of foods for the residents. (Residents R11, R57, R56, R5, R55, R28, R64, R46, R37, R34, R41, R27, R14 and R19). Findings include: A review of the undated facility policy titled resident tray assessment indicated that all hot foods were to be served hot at a temperature greater than or equal to 130 degrees Fahrenheit and served satisfactory for the residents' preferences and dietary care planning. A review of the undated policy titled service of hot liquids to prevent spills revealed that hot beverages were to be served hot and at a temperature less than 140 degrees Fahrenheit to meet the food preferences of the residents.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 financial and accounting documentation and interview with administrative staff, it was determined that the facility failed to demonstrate the maintenance of a complete, separate, and accurate accounting of each residents personal funds entrusted to the facility on the residence behalf for one of 24 residents reviewed (resident R28). Findings include: Review of facility policy Titled Personal Funds revealed If the facility has been designated to handle the personal funds of the resident, the business office will maintain a full complete and separate accounting according to generally accepted accounting principles of each resident's personal fund entrusted to the facility. A copy of the quarterly statement will be submitted to the resident, or the residents designated representative on a quarterly basis and or at the request of the designated representative or resident. Review of information submitted to the Department revealed that On October 21, 2024, nursing home administrator employee E1 became aware that resident R28 alleged that there were…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews with resident and staff, review of clinical records, and facility policy, it was determined that the facility failed to ensure one of 24 residents records reviewed were free from abuse/neglect (Residents 25). Findings include Review of the facility's employee abuse education received from the Nursing [NAME] Administrator defines abuse as the willful infliction of injury, unreasonable confinement intimidation or punishment with resulting physical harm, pain or mental anguish. The documentation defines types of abuse and explains Mental/Emotion abuse, verbal or nonverbal acts which causes humiliation, shame, degradation, intimidation, fear and agitation. Review of the same documentation states verbal abuse is a type of mental abuse that can be oral, written, gestured language or sounds. It can be directed at or within hearing distance of the resident. Examples included: Harassment, mocking, yelling, intimation, talking disrespectfully and scolding. Review of clinical records…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 interviews with residents and staff, clinical record and and policy and procedure reviews, it was determined that the facility failed to evaluate each resident for their discharge needs upon admission and throughout the resident's stay to ensure a successful individualized discharge plan was implemented for three of seven residents reviewed. (Residents R11, R34 and R46) Findings include: A review of the facility's policy and procedure titled Discharge Summary and Plan dated December, 2016 revealed that all residents would have a discharge plan developed to assist the resident to adjust to his/her living environment. The policy also indicated that every resident was to receive evaluation by the interdisciplinary care team to develop a plan for discharge to the community or to another facility with the resident and their family member. The policy indicated that each resident and representative would be asked about their interest in returning to the community or other plans for transferring to another…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record reviews, interviews with residents and staff, observations of care and services and policy and procedure reviews, it was determined that for one of three residents reviewed the facility failed to provide safe and comfortable adaptive equipment to ensure activities of daily living were maintained for mobility. (Resident R34) Findings include: A review of the policy titled Activities of Daily Living, Supporting dated March of 2018 revealed that the facility was responsible for providing care, services and treatment to maintain or improve a residents' ability to carry out activities of daily living (hygiene, mobility, elimination, dining or communication). This policy indicated that the care and services was to be provided for residents who were unable to carry out ADL's independently. Clinical record review for Resident R34 revealed a quarterly comprehensive assessment dated [DATE] that indicated this resident was cognitively intact. The assessment also indicated that this 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews with residents and staff, review of clinical records and facility documentation and policies it was determined that the facility failed to provide the necessary treatment for opioid addiction for two residents (Resident R56 and R61) in a timely manner which resulted in and/or a potential to cause the residents experiencing unwanted discomfort and withdrawal symptoms and failed to adequately assess a resident (Resident R61) in accordance with professional standards of practice and failed to inform the medical director when services were not rendered for two residents reviewed (Resident R56 and R61) and failed to properly assess and provide bowel care for one resident (Resident R81) of the 24 resident records reviewed. Findings include: Review of facility policy for Medication Shortage/Unavailable Medication revised April 2018 states when medications are not received for the resident the licensed nurse will urgently initiate action in cooperation with the attending physician and the pharmacy…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on the review of facility documentation, clinical records, staff and resident interviews, it was determined that the facility failed to provide necessary pharmaceutical services for two of 24 residents reviewed. (Resident R56 andR61). Findings include: Review of facility policy for Medication Shortage/Unavailable Medication revised April 2018 states when medications are not received for the resident the licensed nurse will urgently initiate action in cooperation with the attending physician and the pharmacy provider. If unable to obtain a response from the attending physician in a timely manner notify the nursing supervisor and contact the Medical Director for orders/directions. During a group session on December 10, 2024, at approximately 10:30 a.m., Resident R56 and R61 both agreed there are times the facility fails to have their medication Suboxone. Suboxone is a prescription drug used to treat opioid dependence. Withdrawal symptoms from Suboxone occur when the medication is missed in approximately…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, interviews with staff and policy and procedure reviews, it was determined that the facility failed to use, monitor and assess one of six residents for continued psychotropic drug use. (Resident R88) Findings include: A review of the policy titled psychotropic drug use dated January 1, 2021 revealed that it was the responsibility of the physician, facility staff, psychiatrist and pharmacist to choose the most effective medication for the resident that had the fewest possible side effects, adverse drug reactions and in the smallest effective dose. The policy indicated that each resident using psychotropic drugs would be monitored for adverse side effects, appropriate drug selection and appropriate drug dose. Clinical record review revealed a physician's ordered for divalproex sodium (depakote) oral capsule delayed release 125 mg give three capsules by mouth two times a day for agitation, since October 30, 2024. Pharmaceutical diagnoses for use of depakote was for epilepsy, mood…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of clinical records, and staff and resident interviews, it was determined that the facility failed to ensure two residents were free from significant medication errors for 2 of 8 residents reviewed. (Residents R69 and R64) Findings: Review of the National Institute of Health article titled Nursing rights of medication administration dated September 2023 revealed that it is standard during nursing education to receive instruction to clinical medication administration and upholding patient safety known as the five rights of medication administration, the five rights are : the right patient, right drug, right route, right time, and right dose. Patient safety and quality of care are essential components of nursing practices and priorities that demand consideration to enable the delivery of high-quality patient centered care and overall, well-being. Review of the Centers for Medicare and Medicaid Services Drugs and biologicals must be prepared and administered in accordance with the federal and state…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on the review of facility policies, resident interviews, and interview with staff, it was determined that the facility failed to maintain proper infection control practices related to wound care for one of three residents reviewed for wound care. (Resident R47) Findings include: Review of facility policy titled Wound Care revised October 2010 revealed the purpose of this policy is to provide guidelines for the care of wounds to promote healing. One key element is cleanliness. Items to be used during procedure must be clean and arranged on a clean environment. Review of facility policy titled Enhanced Barrier Precautions Policy, revealed enhanced barrier precautions EBP will be initiated for residents as an applicable in accordance with CMS and or state regulations in accordance with the CDC guidance to reduce the risks of transmission of multiple drug resistant organisms MDROS. Enhanced barrier precautions are applicable for residents with any of the following infection where colonization with an MDRO,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 documentation, facility policies, Centers for Disease Control and Prevention (CDC) guidelines and staff interview, it was determined that the facility failed to maintain an effective antibiotic stewardship program that includes a system to effectively monitor antibiotic usage for four or four months of antibiotic stewardship program data reviewed. (August 2024, September 2024, October 2024, and November 2024) Findings include: A review of CDC (Centers for Disease Control and Prevention) guidelines, The core Element of Antibiotic Stewardship for Nursing Homes, revealed that Improving the use of antibiotics in healthcare to protect patients and reduce the threat of antibiotic resistance is a national priority. 1. Antibiotic stewardship refers to a set of commitments and actions designed to optimize the treatment of infections while reducing the adverse events associated with the antibiotic use. 2. The Center for Disease Control and Prevention (CDC)recommends that all acute care hospitals implement an antibiotic stewardship program (ASP) and outline the…

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

Based on observations of the physical environment of the food and nutrition department, reviews of the pest control operators reports and interviews with staff, it was determined that the facility failed to maintain an effective pest control program so that the facility was free of common household pests and rodents. Findings include: Observations of the main kitchen of the Food and Nutrition Department in the presence of the director of dietary services, Employee E10, at 9:30 a.m., on December 9, 2024 revealed the following: The industrial sized dish machine and the flooring surrounding this food service equipment was covered with a white/grayish tinted film, resembling hard water deposits of calcium and lime. The boundary of the flooring next to the wall area underneath the dish machine and three compartment sink contained a heavy accumulation of dirt and brown saturated slim. The grouting was missing between the ceramic tiles in the dish room and the food preparation area near the steam table, of the main kitchen. The flooring was porous, not easily cleanable and contained…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, interviews with staff, and a review of facility policies and documentation, it was determined that the facility did not ensure that food was stored, prepared, distributed, and served in accordance with professional standards for food service safety. Findings include: The undated Policy: Food Storage Policy, states, he Food Service Director and/or Cook(s) will insure that all food items are stored properly, covered containers must be airtight, labeled and dated using a two date system (prepared date and use by date). An initial tour of the Food Service Department was conducted on February 21, 2024, at 9:15 a.m. with Employee E5, AM Cook, which revealed the following: Observation in the food preparation area revealed a 5-pound tub of peanut butter with no date of when it was opened or a use by date and it had peanut butter smeared on the outside of the container. Observation in the walk-in freezer revealed a brown cardboard box of fish cakes with the inner plastic liner open to the circulating air. Interview with the AM [NAME] at 9:30 a.m. on February 21, 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 observations and an interview with staff it was determined that the facility did not ensure that garbage and refuse was disposed of properly. Findings include: An initial tour of the Food Service Department was conducted on February 21, 2024, at 9:15 a.m. with Employee E5, AM Cook, which revealed the following: Observation in the receiving area revealed three green dumpsters, the middle dumpster had the one of the lids on the top open. Around the dumpster on the right was a lot of debris including used latex gloves, paper, straws, cups, lids, empty pudding cup, empty yogurt cup and a plastic bag sticking out from underneath the dumpster. Interview with the AM [NAME] at 9:30 a.m. on February 21, 2024, confirmed the above findings. 28 PA Code: 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(3) Management

Based on the review of clinical records and interview with staff, it was determined that the facility failed to ensure that there was sufficient nursing staff to complete residents' comprehensive and quarterly assessments in a timely manner. for eight of eight residents reviewed. (Resident R79, R59, R15, R3, R38, 6, R1 and R50) Findings Include: Refer to citation: 636, 638. Based on the review of clinical records and interview with staff, it was determined that the facility failed to ensure that a comprehensive assessment was completed every 12 months as required. Based on the review of clinical records and interview with staff, it was determined that the facility failed to ensure that a quarterly assessment was completed not less frequency than once every 3 months as required. Interview with MDS coordinator, Employee E7 on February 23, 2024, at 10:44 a.m., confirmed that the MDS's were completed late. She stated she was busy with case management responsibilities and there were over 17 short term residents that required case management services. She did not have enough time 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 facility documentation and staff interview, it was determined that the facility failed to ensure that licensed nursing staff had the proper competencies including intravenous (IV) catheter care, trach care and total parenteral nutrition (TPN) administration care for six of six licensed nurse training records reviewed (E11, E13, E14, E15, E21 & E22). Findings include: Review of the provided facility policies did not reveal any policy related to nursing competencies. Review of training records provided did not reveal any competencies requested including IV (Intravenous) catheter care, trach care and TPN (Total Parental Nutrition) administration care for Employees E13, E14 and E21. A review of training records for Employees E11, E15 and E22 revealed incomplete competencies as follows: -Employees E11 & E22 had TPN partially completed (no skill assessment) and no competencies for IV or Trach care. -Employee E15 had no competency for TPN. Interview with the Director of Nursing on February 26, 2024, at 1:45 p.m. confirmed the above findings. 28 Pa. Code: 211.12(d)(1)…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 the review of facility policy, review of facility documentation and interview with staff, it was determined that the facility failed to establish an antibiotic stewardship program that included antibiotic use protocols and a system to monitor and track the antibiotic use for seven of nine months of antibiotic data requested for review (June, July, August, September, October, November and December, 2023). Finding Include: Review of facility policy Antibiotic Stewardship- Review and Surveillance of Antibiotic use and outcome dated December 2016, revealed that Antibiotic usage and outcome data will b collected and documented using a facility-approved antibiotic surveillance racking form. The data will be used to guide decisions for improvement of individual resident antibiotic prescribing practices and facility-wide antibiotic stewardship. Policy Interpretation and Implementation 1. As part of the facility Antibiotic Stewardship Program, all clinical infections treated with antibiotics will undergo review by the Infection Preventionist, or designee. 2. The IP, or designee,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 interviews with residents and staff, and review of clinical records, it was determined that the facility failed to ensure a resident had the right to be informed of their care plan meeting for one out of 21 residents reviewed (Resident R59). Findings include: Review of the facility policy, Care Planning-Interdisciplinary Team, with a revision date of September 2013, indicated that the resident, the resident's family and/or the resident's legal representative/guardians or surrogate are encouraged to participate in the development of and revisions to the resident's care plan. Review of the February 2024 physician orders for Resident R59 included the diagnoses of morbid obesity, post-traumatic stress disorder (a mental health condition that's triggered by a terrifying event - either experiencing it or witnessing it); atrial fibrillation (an irregular heart rhythm that can cause fatigue, palpitations, stroke, and other complications); depression (a mental health condition that causes a persistent feeling of sadness and loss of interest) ; muscle weakness, and hypertension (high…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 resident interviews, it was determined that the facility failed to ensure that personal belongings were accounted for three of 21 residents reviewed (Resident R83, R58 and R60). Findings include: Review of the facility policy, Admissions, Transfers and Discharge, with a revision date of September 2013 indicated that when taking inventory of a resident's personal effects, staff should inventory all clothing, equipment, valuables, etc. and record the quantity of each item, a discreption of each item and other identifying factors as necessary or appropriate. The policy also indicated that when all items have been inventoried and recorded on the Inventory of Personal Effects form, staff is to sign their name, and instruct the resident and/or his/her family member who witnessed the inventory to also sign the form. Continued review of the policy also indicated that staff is to provide the reident and/or family member with a copy of the completed and signed inventory form. Review of the resident's February 2024 physician orders indicated 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 staff interviews and review of the clinical record, it was determined that the facility failed to ensure that the physician was notified of a fall incident sustained by a resident for one out of 21 residents reviewed (Resident R89). Findings include: Review the February 2024 physician orders for Resident R89 indicated that the resident was admitted into the facility from the hospital on January 5, 2024 with the diagnoses of seizures (a sudden, uncontrolled burst of electrical activity in the brain that can cause changes in behavior, movements, feelings and levels of consciousness); cerebral infarction (a stroke); chronic obstructive pulmonary disorder (COPD- a condition involving constriction of the airways and difficulty or discomfort in breathing); alcohol abuse; substance abuse; anxiety (a feeling of worry, nervousness, or unease, typically about an imminent event or something with an uncertain outcome); depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), in addition to a right below the knee amputation. Review of a nursing…

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

Based on the review of clinical records and interview with staff, it was determined that the facility failed to ensure that a comprehensive assessment was completed every 12 months as required for two of eight residents reviewed. (Resident R1 and R50) Findings Include: Review of clinical record for Resident R50 revealed that the resident had an admission MDS (Assessment of Resident Care Needs) assessment completed on January 27, 2023. Further review of the clinical record the revealed that the annual assessment was scheduled with an assessment reference date (ARD) of January 10, 2024. Continued review of the clinical record revealed that the assessment was not completed until February 19, 2024. Review of clinical record for Resident R1 revealed that the resident had a modification admission MDS assessment completed on January 18, 2023. Further review of the clinical record the revealed that the annual assessment was scheduled with an assessment reference date (ARD) of January 10, 2024. Continued review of the clinical record revealed that the assessment was not completed until oon…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 the review of clinical records and interview with staff, it was determined that the facility failed to ensure that a quarterly assessment was completed not less frequency than once every 3 months as required for six of eight residents reviewed. (Resident R79, R59, R15, R3, R38, R6) Findings Include: Review of clinical record for Resident R79 revealed that the resident had an admission MDS (Assessment of Resident Care Needs) assessment completed on October 13, 2023. Further review of the clinical record the revealed that the quarterly assessment was scheduled with an assessment reference date (ARD) of January 10, 2024. Continued review of the clinical record revealed that the assessment was not completed until February 19, 2024. Review of clinical record for Resident R59 revealed that the resident had a quarterly MDS assessment completed on October 18, 2023. Further review of the clinical record the revealed that the quarterly assessment was scheduled with an assessment reference date (ARD) of January 17, 2024. Continued review of the clinical record 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interviews and the review of clinical records, it was determined that the facility failed to ensure that the State mental health authority and/or the State intellectual disability authority was notified of a significant change in resident's mental health status which required admission into a psychiatric facility for one out of 21 residents reviewed (Resident R48). Findings include: Review of the February 2024 physician orders for Resident R48 included the diagnoses of anxiety (a feeling of worry, nervousness, or unease, typically about an imminent event or something with an uncertain outcome); cognitive communication deficit (a group of disorders that affect a person's ability to communicate); depression (a mood disorder that causes a persistent feeling of sadness and loss of interest); schizophrenia (a mental disorder characterized by fixed false convictions in something that is not real of shared by other people, seeing, hearing, feeling or smelling something that does not exist, disorganized…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, interviews, and the review of clinical records, it was determined that the facility failed to ensure that resident received activities of daily living care related to shaving and haircuts for 2 out of 21 residents reviewed (Resident R58 and R60). Findings include: Review of the facility policy, Activities of Daily Living (ADLs), Supporting, with a revised date of October 2021, indicated that resident will be provided with care, treatment, and services as appropriate to maintain or improve their ability to carry out activities of daily living. The policy also stated that appropriate care and services will be provided for resident who are unable to carry out activities of daily living independently with the consent of the resident in accordance with the plan of care, including appropriate support and assistance with hygiene (bathing, dressing, grooming, and oral care); toileting mobility and eating. Review of the February, 2024 physician orders for Resident R58 included the following diagnoses: cerebral infarction (a stroke); lymphedema (a condition that results…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, observations and resident and staff interviews, it was determined that the facility failed to ensure that foot care needs were provided timely for one of 48 residents reviewed (Resident 73). Findings include: Review of a quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 73, dated November 22, 2023, revealed that the resident had a BIMS (Brief Interview for Mental Status) score of 3 which indicated that resident's cognitive status was severely impaired. Review of care plan for Resident R73 dated June 8, 2023, revealed that the resident required assistance for mobility and Activities of Daily Living functions. Observation of Resident R73 on February 23, 2024, at 12:41 p.m. with Director of Nursing, Employee E2, revealed that the resident had long and thick toenails on both feet. The nail was discolored with yellowish and whitish discoloration which appeared like infected nails. Employee E2 confirmed the finding and stated she would be contacting the physician 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 observations, interviews with staff and residents, review of clinical records and facility documentation, it was determined that the facility failed to ensure adequate supervision during medication administration for one out of 21 residents reviewed (Resident R59). Findings include: Review of the facility policy, Administering Medications, with a revised date of December 2012 indicated that medications shall be administered in a safe and timely manner, and as prescribed.The policy also indicated that residents may self-administer their own medications only if the attending physician, in conjunction with the interdisciplinary care planning team, has determined that they have the decision-making capacity to do so safely. Review of the February 2024 physician orders for Resident R59 included the following diagnoses: morbid obesity, post-traumatic stress disorder (a mental health condition that's triggered by a terrifying event - either experiencing it or witnessing it); atrial fibrillation (an irregular heart rhythm that can cause fatigue, palpitations, stroke, and other…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, review of facility policies, clinical record review and interviews with residents and staff, it was determined that the facility failed to administer intravenous (IV) nutrition in accordance with physician orders and professional standards of practice for one of one resident reviewed on IV therapy (Resident R245). Findings include: Review of facility policy Parenteral Nutrition (TPN - a method of providing nutrition where a liquid formula is given into a vein through an intravenous catheter), revised July 2017, revealed a physician order is necessary for this treatment. The TPN order should include the formula or a list of all ingredients/nutrients in the base solution, volume, and rate of administration as well as an order for monitoring lab results on a routine basis. The facility must verify with the State Nurse Practice Act the role of the Nurse. Continued review of section Safety Precautions revealed the event that the TPN is stopped or discontinued suddenly, parenteral nutrition will…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on the review of clinical records, and interviews with staff, it was determined that the facility failed to ensure that pain management was provided consistent with physician orders for two of 21 residents reviewed. (Resident R89 and Resident R81) Findings include: Interview with Resident R89 on February 21, 2024, at 11:46 a.m. stated he did not receive her pain medications and some other medications ordered by the physician consistently. He stated she was admitted to the facility on [DATE], and staff stated, some of his medications were not available as they were waiting for the pharmacy to deliver the medications. He did not receive the medication for three days after the admission and he was in pain, with pain level ranging from 8 to 10 of a scale of 10. Resident also stated two weeks ago that happened again, his pain medication was not available, and staff told him they were waiting for the pharmacy to deliver. Review of physician orders for Resident R89 revealed an order dated January 5, 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on the review of facility documentation, clinical records, staff and resident interviews, it was determined that the facility failed to provide necessary pharmaceutical services for one of 21 residents reviewed. (Resident R89) Findings include: Review of the facility policy, Providing Pharmacy Services with a revision date of January 1, 2021, indicated that the pharmacy will ensure that facility staff has access to medications, emergency services for medications, and drug information on a 24 hour basis. Interview with Resident R89 on February 21, 2024, at 11:46 a.m. stated he did not receive her pain medications and some other medications ordered by the physician consistently. He stated she was admitted to the facility on [DATE], and staff stated, some of his medications were not available as they were waiting for the pharmacy to deliver the medications. He did not receive the medication for three days after the admission and he was in pain, with pain level ranging from 8 to 10 of a scale of 10. 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 observations and interview with staff, it was determined that the facility failed to store, label, and dispense drugs according to professional standards of practice for one of 28 resident medication observations. (Resident R15) Findings Include: During a medication administration observation on February 22, 2024, at 8:54 a.m. with Employee E24, Licensed Practical Nurse, for Resident R15. It was observed that staff took an unlabeled clear 30 ml medication cup from the cart. Inside the cup there were white colored tablets. Staff administered the medication to the resident. During interview with Licensed staff, Employee E24 at the time of the observation Employee E24 stated that the medication Colace 100mg tablet was not available in the medication cart, and she took few pills from the other cart in a cup and placed it inside the cart to administer to the resident for morning medication administration. Interview with Director of Nursing, Employee E2, on February 23, 2024, at 12:30 p.m. stated that the staff should not keep the medication in unlabeled containers. Employee E2…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 interviews, review of facility's policy and the review of clinical records, it was determined that the facility failed to ensure that complete and accurate documentation for one out of 21 residents reviewed (Resident R89). Findings include: Review of the facility policy, Charting and Documentation, with a revision date of July 2017 indicated that all services provided to the resident progress toward care plan goals, or any change in the resident's medical, physical, function or psychosocial conditions, shall be documented in the resident's medical record. The policy also indicated that the medical record should facilitation communication between the interdisciplinary team regarding the resident's condition and response to care. Review the February 2024 physician orders for Resident R89 indicated that the resident was admitted into the facility from the hospital on January 5, 2024 with the following diagnosis seizures (a sudden, uncontrolled burst of electrical activity in the brain that can cause changes in behavior, movements, feelings and levels of consciousness);…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 documentation and staff interview, it was determined that the facility failed to ensure its nurse aide staff was receiving in-service training to be proficient and competent and that the training be no less that 12 hours annually for two of six nurse aides reviewed (Employees E19 and E16). Findings Include: Review of the nurse aide annual training information provided for nurse aide Employee E19 during the survey revealed that there were only six hours of annual training documentation to review and did not meet the twelve hours of annual training requirement. Review of the nurse aide annual training information provided during the survey revealed that nurse aide Employee E16 had only eight hours of training documentation to review and did not meet the twelve hours of annual training requirement. An interview with the Director of Nursing on February 26, 2024, at 1:45 p.m. confirmed that these nurse aides did not meet the minimum required hours of training. 28 Pa. Code 201.14(a) Responsibility of licensee.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, observations, and interviews with residents and staff, it was determined that the facility failed to ensure resident dignity for one out of seven residents reviewed (Resident R1). Findings include: Review of the clinical record revealed that Resident R1 was admitted to the facility on [DATE], with diagnoses of Obstructive Sleep Apnea (OSA) (OSA occurs when the upper airway becomes blocked, leading to brief pauses in breathing during sleep), and Asthma (Asthma is a chronic lung disease caused by inflammation and muscle tightening around the airways, which makes it harder to breathe). Observation of Resident R4 on January 26, 2024, at 10:40 a.m., revealed the Resident R1 had untrimmed facial hair, and long fingernails with dark substance under the fingernails. During interviewed with Resident R1 on January 25, 2024 the resident stated that no staff offered him to trim the facial hair and nails. 28 Pa. Code: 211.11(d)(1)(5) Nursing services

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, clinical record review, review of facility policy and staff interview, it was determined that the facility failed to provide appropriate respiratory care and services for one of seven residents reviewed (Resident R1). Findings include: Review of the clinical record revealed that Resident R1 was admitted to the facility on [DATE], with diagnoses of Sleep Apnea (OSA) (OSA occurs when the upper airway becomes blocked, leading to brief pauses in breathing during sleep), and Asthma (Asthma is a chronic lung disease caused by inflammation and muscle tightening around the airways, which makes it harder to breathe). A review of Resident R1's clinical records revealed a physician order, dated March 21, 2023, to administer Oxygen 4 liters/minute, via nasal canula (nasal cannula is a thin tube, often affixed behind the ears and used to deliver oxygen directly to the nostrils from a source connected with tubing), every shift; and a physician order, dated, December 1, 2023, to change oxygen tubing…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, review of facility policy, clinical record review, review of facility records and documents and staff interview, it was determined that the facility failed to implement a system of records of receipt and disposition of all controlled drugs between shifts to enable an accurate reconciliation and accountability for four of four medication carts observed. (1st Floor front cart and back cart, Second Floor front cart and back cart) Findings include: Observation conducted on October 31, 2023, from 9:38 am to 11:05 during the tour of the first and second floor units revealed that there were two medication carts (front cart and back cart) for the First-floor unit and two medication carts (front cart and back cart) on the Second-floor unit. Interview with Second floor unit manager, Employee E3 conducted on October 31, 2023, at 9:50 am confirmed that the Second floor had two medication carts and one med room. Further Employee E3 revealed that only the medication nurses, the DON (Director of Nursing),…

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