Springfield Rehabilitation And Healthcare Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record reviews, interviews with residents and staff and reviews of policies and procedures, it was determined that the facility failed to provide foot care and treatment for one of eight residents reviewed. (Resident R1)Findings include: A review of the policy and procedures titled medication and treatment orders dated July 2016 revealed that orders for medications and treatments will be consistent with the principles of safe and effective writing. The policy indicated that only authorized licensed practitioners, or individuals authorized to take verbal orders from practitioners shall be allowed to write orders in the clinical record. The policy also said that verbal orders must be recorded immediately in the resident's clinical record. The order must include prescriber's last name, credentials and date and time of the order. A review of the policy and procedure titled consultant physician services dated February 2023 revealed that the consultant physician services must be inwriting and signed…

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 family member and staff interviews, it was determined that the facility failed to provide confidentiality of residents' personal health information during medication administration for two of three residents reviewed. (Residents R2 and R3). Findings include: Review of facility policy on Confidentiality of information and personal privacy with most recent revision date of October 2017, revealed that under section Policy Statement; our facility will protect and safeguard resident confidentiality and personal privacy. Under section Policy interpretation and implementation #1, the facility will safeguard the personal privacy and confidentiality of all residents and medical records. #4. Access to resident's personal and medical records will be limited to authorized staff and business associates. Interview with complainant revealed that when her husband Resident R1 was discharged home, medical records belonging to 2 other residents were included in her husband's discharge…

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, interview with staff and residents and review of facility provided documentation, it was determined that facility did not ensure residents received the necessary services to maintain personal hygiene and mobility for five out of 18 residents reviewed (Resident R35, R40, R65, R233, R13) Findings include: Review of facility's policy 'Activities of Daily Living (ADL), Supporting,' revised March 2018, indicates that appropriate care and services will be provided for residents who are unable to carry out ADL's independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: a. Hygiene (bathing, dressing, grooming, and oral care); b. Mobility (transfer and ambulation, including walking) Review of East side 7-3 shower schedule and skin checks revealed that Resident R35, in room [ROOM NUMBER]-A, was scheduled for shower on Tuesday, March 18, 2025 and Friday, March 21, 2025. Interview with nurse aide, Employee E4, on Monday,…

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, review of clinical record, and staff interview, it was determined that the facility failed to ensure that appropriate pain management was provided to a resident consistent with standards of professional practice for four of 18 residents reviewed (Residents R79, R290, R292 and R293). Findings include: Review of the facility Policy on Pain management revealed that the purpose of this procedure are to help the staff identify pain in the resident and to develop interventions that are consistent with the resident's goals and needs and that address. The underlying causes of pain under section General Guidelines: #1 The Pain Management program is based on facility wide commitment to appropriate assessment and treatment of pain, based and professional standards of practice, the comprehensive care plan and the residents' choices related to pain. Management. #2 being management is defined as the process of alleviating the residents pain based on his or her clinical condition 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 provided documentation and interview with residents and staff, it was determined that facility did not ensure there is sufficient nursing staff available at all times to provide nursing and related services to meet the residents' needs based on 43 out of 50 grievances reviewed for months of March 2025, February 2025, January 2025, December 2024, October 2024. Findings include: Review of facility's policy 'Answering the Call Light,' indicates that procedure's purpose is to ensure timely response to residents' requests . staff are to answer the resident call system as soon as possible Interview with nurse aide, employee E4, on Monday, March 24, 2025 revealed that residents do not receive scheduled showers due to facility being short staffed. Interview with Resident R67, on Monday, March 24, 2025 revealed that he had an unwitnessed fall I his room due to waiting for assistance for a long time after pressing the call bell. Review of R67's progress notes, dated March 23, 2025 at 9:15 am, revealed that unwitnessed fall from bed to floor while transferring…

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 clinical records, review of facility policy, interview with residents and staff, it was determined that facility did not ensure to implement enhanced barrier precautions for four residents (Residents R14, R5, R70, R77), ensure that infection control standards were maintained during wound care for one resident, (Residenr R22), and did not ensure that tuberculosis testing was administered on entry to the facility as required for one resident (Resident R190) out of 18 residents reviewed. Findings include: Review of facility provided policy 'Enhanced Barrier Precautions,' revised March 2024, states Enhanced barrier precautions (EBPs) are used as an infection prevention and control intervention to reduce the transmission of multi-drug resistant organisms to residents, and signs are posted in the door or wall outside the resident room indicating the type of precautions and PPE (personal protective equipment) require; PPE is available outside of the resident rooms. Review of Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, review of clinical record, observations, and staff interviews, it was determined that the facility failed to develop comprehensive care plan for one of eighteen residents reviewed related to weight changes, and one resident related to long-term antibiotic use (Residents R2 and R43). Findings Include: Review of clinical documentation for Resident R2 revealed that she was admitted to the facility on [DATE], and had diagnoses which included, infection and inflammatory reaction due to unspecified internal joint prosthesis. Further review revealed a physician order for an antibiotic which read Bactrim DS Oral Tablet 800-160 MG (Sulfamethoxazole-Trimethoprim) Give 1 tablet by mouth two times a day for joint infection chronic- no stop date. Review of progress notes for Resident R2 revealed a note from Registered Nurse Practitioner, Employee E8, dated March 26, 2025, which stated Left prosthetic joint infection- continue Bactrim DS (chronic). Review of the care plan for Resident R2…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and interview with staff, it was determined that the facility did not ensure that care plans were revised in a timely manner for one of 18 records reviewed (Resident R81). Findings include: Review of clinical documentation revealed that Resident R81 was admitted to the facility on [DATE], and had diagnoses including, of malignant neoplasm (cancer) of the prostate. Review of the resident's MDS (Minimum Data Set, a periodic assessment of resident care needs) dated February 27, 2025, he died in the facility on February 27, 2025. Review of his physician orders revealed an order for DNR (Do Not Resuscitate), and an order for DNH (Do Not Hospitalize), both dated [DATE]. Review of his POLST (Pennsylvania Order for Life Saving Treatment, a document in which an individual expresses their wishes for end-of-life situations, such as whether or not they wish for CPR to be performed in the event that their heart stops) revealed that they wished for CPR (Cardio Pulmonary Resuscitation) to be…

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

Based on clinical record review, and interviews with staff, it was determined that the facility did not ensure that standards of practice for pressure ulcer treatment were followed related to a physician not being informed of a missed wound treatment for one of 18 records reviewed (Resident R59). Findings include: Interview with the representative of the County Ombudsman Program, Employee E9, on March 26, 2025, at 2:10 p.m., revealed that Resident R59 had stated to her that his wound care had not been done on March 25, 2025, and that the nurse had told him it was due to not having access to the supplies. Review of the resident's March 2025 Treatment Administration Record (TAR) showed that March 25, 2025, the evening shift treatment to the resident's sacrum was documented as code 22, which the TAR indicated meant treatment not given. Review of the notes revealed that a note written by Employee E5, which indicated that the reason for not administering the treatment was not available. No explanation was provided in the note as to why the treatment was not available. No note was found…

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 provided documentation and interview with staff, it was determined that facility did not ensure annual performance evaluation was completed for one nurse aide out of five nurse aides trainings reviewed (Employee E7) Findings include: Review of facility policy 'Performance Evaluations,' revised on September 2020, indicates that ' a performance evaluation will be completed on each employee at the conclusion of his/her 90-day probation period , and at least annually thereafter. Review of facility provided performance evaluations on Thursday, March 27, 2025 revealed that nurse aide, Employee E7 was hired on May 10, 2023; her last performance evaluation was on November 7, 2023. Finding confirmed with facility's Director of Nursing. 28 Pa Code 201.19(2) Personnel policies and procedures

Based on interview with resident and staff, and review of clinical record and facility provided documentation, it was determined facility did not ensure residents were free from significant medication errors for two out of 18 residents reviewed (Resident R235, R288) Findings include: Interview with Resident R235 on Monday, March 24, 2025 at 1:35 pm, revealed that she did not receive her scheduled antibiotic on March 7, 2025 and March 8, 2025. Review of R235's clinical record revealed a physician order placed on February 26, 2025 for Daptomycin intravenous solution reconstituted 350 milligrams (mg), to use 1200 mg intravenously in the evening for bacterial skin infection for 26 days in 0.9% NSS ( Normal Saline Solution) parental solution 50 ml at rate 50ml/hr. Review of progress notes dated March 6, 2025 and March 7, 2025 indicate that antibiotic was not administered due to clogged port. Review of R235's electronic medication administration record revealed Daptomycin was not administered on March 6, 2025 and was not administered on March 7, 2025. Interview with Assistant Director of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and interview with staff, it was determined that the facility did not ensure that laboratory study results were communicated to the physician in a timely manner for one of 18 records reviewed (Resident R2). Findings include: Review of clinical documentation for Resident R2 revealed that she was admitted to the facility on [DATE], and had diagnoses which included, but were not limited to, altered mental status, chronic pain, cognitive communication deficit, and morbid obesity. Review of progress notes revealed a physician note, dated March 11, 2025, at 1:01 p.m., signed by Medical Doctor, Employee E11, which stated that the resident reports dysuria (painful urination), pressure, [and] feeling as though she is not completely emptying. Spoke with team- will straight cath (straight catheterization is a temporary tube placed in the bladder for the purpose of emptying it or collecting a urine specimen) for urine [testing]. Review of laboratory results for Resident R2 revealed a urine…

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, and clinical record reviews, it was determined that the facility failed to provide as needed dental services for one of eighteen residents reviewed. (Resident R43) Findings include: Review of Resident R43's clinical record revealed that Resident R43 was admitted to the facility on [DATE], with diagnoses of but not limited to Anoxic Brain Damage, Tracheostomy Status. Review of Resident R43's annual MDS (minimum data set- a federally required resident assessment completed at a specific interval) dated March 18, 2025, Section GG0130. Self-Care, B. Oral hygiene: The ability to use suitable items to clean teeth. Dentures (if applicable): The ability to insert and remove dentures into and from the mouth and manage denture soaking and rinsing with use of equipment, was coded 01 indicating that Resident R43 was Dependent (Helper does ALL of the effort. Resident does none of the effort to complete the activity or the assistance of 2 or more helpers is required for 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 provided documentation and interview with staff, it was determined that facility did not ensure one Performance Improvement Project was completed as required. Findings include: According to §483.75(e)(3) - the facility must conduct distinct performance improvement projects, based on the scope and complexity of facility services and available resources, identified as a result of the facility assessment. While the number and frequency of improvement projects may vary, facility must conduct at least one improvement project annually that focuses on high-risk or problem-prone areas, identified by the facility through data collection and analysis. Review of facility's 'Risk Identification and Quality Assurance Performance Improvement,' indicates that the facility reviews data gleaned from risk meetings during the Quality Assurance Performance Improvement (QAPI) meetings. The QAPI committee will review data along with any suggestions and input from residents, staff, family members, and other stakeholders. The QAPI committee will prioritize opportunities 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 review and staff interview, it was determined that the facility failed to ensure that laboratory studies were promptly obtained as ordered by the physician for one of three clinical records reviewed (Resident R1). Findings include: Review of Resident R1's physician progress note dated November 22, 2024, indicated that resident was noted with hypotension and dehydration. Intravenous fluids were given and ordered to repeat BMP (basic metabolic panel blood test) tomorrow (November 23, 2024). Review of Resident R1's clinical records revealed the staff did not place an order in the electronic system to draw the lab. Further review of clinical record for Resident R1 revealed no evidence that the facility obtained the lab, and the results were obtained on November 22, 2024. Review of nurse's note for Resident R1 dated November 24, 2024, revealed that the resident was observed with weakness, in and out of consciousness and use of abdominal muscle to breath. Resident was transferred to the hospital per the family request. Interview with the 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical records, and 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 1 of 4 residents reviewed (Residents R1). Findings include: Review of Resident R1's admission MDS (Minimum Data Set - a mandatory periodic resident assessment tool), revealed that the resident was admitted to the facility on [DATE], and had diagnoses including muscle wasting, cognitive communication deficit, bed confinement status, and need for assistance with personal care. Continued review revealed that the resident had a BIMS (Brief Interview of Mental Status) of 0, which indicates that the resident was not cognitively intact. Review of Resident R1's clinical record, GG- Shower/Bathe Self indicated that resident refused a shower/or bath on 19 out of 30 days. Further review of Resident R1's clinical record revealed that shower/bathe self (3-11/ 11-7) revealed that resident refused 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of clinical records, facility policy, and interviews with resident and staff , it was determined that the facility failed to provide a reasonable accommodation of needs for one of nine sampled residents. (Resident R7) Findings include: Review of the facility policy titled Answering the call light not dated states, Be sue that the call light is plugged in and functioning at all times.: Review of Resident R7 order summary report revealed the resident was admitted on [DATE] diagnosed with a fractured pelvis due to a fall at home and ordered that the resident be toe touch weight-bearing, (meaning the ability to touch the foot or toes to the floor without the affected limb providing support and weight bearing as tolerated in the lower left extremity). Interview with Resident R7 and his family member on August 28, 2024, at approximately 10:30 a.m. revealed on admission the resident was given a small bell to use in place of his call bell. The resident's room was down the hall, one of the last rooms,…

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, facility documentation, clinical record reviews and interviews with staff, it was determined that the facility failed to ensure that residents remained free from significant medication errors for one of nine residents reviewed (Resident R9). Findings include: Review of the facility policy titled, Administering Medications not dated states, The individual administering the medication checks the label three times to verify the right resident, right medication, right dosage, right time, and right method of administration before giving the medication. Review of Resident R9's physician admission note dated August 1, 2024 indicated the resident presented to the emergency room on July 30, 2024 with left-sided weakness and balance issues. The resident reported lower extremity weakness to be progressive over the last month and associated with intermittent slurred speech and trouble swallowing. The resident reported earlier hospitalization at another hospital for the same symptoms. Continuing with the same note states to see therapy for left sided…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record reviews and interviews with residents and staff, it was determined that the facility failed to ensure that residents received assistance with bathing for three of seven residents reviewed (Residents R1, R2 and R4). Findings include: Interview on August 19, 2024, at 9:12 a.m. Resident R1 stated that she did not receive a shower for a week after her admission to the facility. Resident R1 stated that she prefers to have a shower and not a bed bath or bedside basin. Review of Resident R1's care plan, dated initiated August 5, 2024, revealed that the resident was admitted to the facility on [DATE], and had an activities of daily living deficit related to deconditioning. Continued review revealed that there was no indication of level of assistance needed or preferences related to bathing. Review of Resident R1's nurse aide [NAME] (instructions for nurse aide staff for performing resident care) revealed that the resident was scheduled to receive showers on Mondays and Thursdays during the…

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

Based on observation, a review of facility documentation and interviews with staff, it was determined that the Nursing Home Administrator failed to effectively manage the facility related to hot water temperatures in one of two nursing units which resulted in an immediate jeopardy situation. (North Side Nursing Unit) Findings Include: Review of the job description for the Nursing Home Administrator (NHA) revealed the Nursing Home Administrator (NHA) primary purpose of the job position is to direct the day-to-day functions of the Center in accordance with current federal, state and local standards, guidelines, and regulations that govern nursing Centers to assure that the highest degree of quality care can be provided to our residents at all times. Observation and water temperature checks on the North Side nursing unit were conducted with the [NAME] President for Plant Operations, Employee E3 on July 1, 2024, from 9:03 a.m. to 10:09 a.m. in Resident rooms 19, 20, 21, 22, 23, 24, 25, 26, 27, 28,129, 30. The hot water temperature at the hand sink in the room mentioned above range from…

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 on the review of clinical records and facility documentation, observations, interview with residents and staff, it was determined that the facility did not ensure an environment was free of potential hazards related to medications left at bedside, a fall incident, and no railing around the loading dock for three of 30 residents' records reviewed (Rooms R326, R328, R329). Findings include: Review of facility policy named, Safety and Supervision of Residents, initially adapted in 2001, stated; Resident safety and supervision and assistance to prevent accidents are facility-wide priorities .Resident supervision is a core component of the systems approach to safety. On [DATE] at 10:24 a.m. observation was made of Resident R326's room. Observation of the room revealed two medications bedside on the night stand. The medications at bed side included lactase enzyme 375 milligrams (mg) capsules and a bottle of Artificial Tears. Further observation of the lactase enzyme pill bottle revealed an expiration date 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 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 Policy: Food Receiving and Storage, which was revised in November 2022, states, All foods stored in the refrigerator of freezer are covered, dated and labeled. An initial tour of the Food Service Department was conducted on May 14, 2024, at 9:30 a.m. with Employee E3, Food Service Director (FSD), which revealed the following: Observation in the mop room revealed the floor and walls were very dirty, the white mop sink was black with a heavy buildup of dirt and grime, and the floor was littered with debris and equipment. Observation in the kitchen near the pot sink revealed the walls were spattered with food particles and the sanitizer mount on the wall had a thick buildup of dirt and dust. Observation in the walk-in freezer revealed a box of breaded veal patties that was open and the inner…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of facility documents and resident clinical records and interviews with staff and residents, it was determined that the facility failed to ensure that residents had the capacity to understand the terms of a binding arbitration agreement for three of nine residents reviewed (Resident R226, R227 and Resident R228). Findings include: Review of the Resident Assessment Instrument 3.0 User's Manual effective October 2019, indicated that a Brief Interview for Mental Status (BIMS) is a screening test that aides in detecting cognitive impairment. The BIMS total score suggests the following distributions: 13-15: cognitively intact 8-12: moderately impaired 0-7: severe impairment Review of admission record indicated Resident R226 was admitted to the facility on [DATE]. Review of Resident R226's Minimum Data Set (MDS - a periodic assessment of care needs) dated March 17, 2024, indicated the diagnoses of fracture and orthopedic aftercare and a BIMS score of 3 - severe impairment of cognition. Review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, review of facility policy and procedure, and interviews with staff, it was determined that the facility failed to maintain an effective infection control program, related with linen transportation, and personal protective equipment disposal for one of one resident observed during trancheotomy care. (Resident R56). Findings include: Observation on May 15, 2024, at 11:33 a.m., revealed that a Nurse Aide, Employee E15, was taking clean linen from the Linen Storeroom, located adjacent to Resident room [ROOM NUMBER], was holding the clean linen letting it to touch the Nurse Aide's uniform of her upper body area, and was carrying the linen the same manner, up to Resident room [ROOM NUMBER], located in the other nursing unit, for the use of residents. At the time of the finding, interviewed with nurse aide, Employee E15, and confirmed that the linen should have been transported without letting it touch the employee's clothing, to prevent contamination and to maintain infection control. Observation…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, review of facility policy, and interviews with staff and residents, it was determined that the facility did not ensure that residents were treated with dignity and respect for two of two residents reviewed. (Residents R13 and R47) Findings Include: Review of the Resident Rights policy with a revision date of October 2010 states, Purpose-To provide general guidelines for resident rights while caring for the resident. Preparation 1. Prior to having direct-care responsibilities for residents, staff must have appropriate in-service training on resident rights, including: a. Preventing, recognizing and reporting resident abuse; b. Resident dignity and respect; c. Resident notification of rights, services, and health/medical condition; d. Protection of resident funds and personal property; e. Confidentiality of protected health information; f. Resident right of refusal (medications and treatments); g. Use of restraints; h. Resident freedom of choice; i. Resident/Family participation in care…

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

Based on observation, it was determined that the facility failed to maintain a safe, clean, comfortable and homelike environment for 16 out of 21 residents reviewed. (Residents R42, R44, R28, R4, R63, R43, R329, R52, R35, R51, R19, R7, R44, R58, R30 and R34). Findings Include: An initial tour was taken on May 14, 2024 at 10:00 a.m. of n the East and North units revealed the following: Observation of Resident R35's room revealed an air conditioning unit that had liquid spilled on top of it. Observation of Resident R51's room at 10:04 a.m. revealed her call bell hanging on the wall and not within reach of her, this was confirmed by licensed nurse, Employee E6 at 10:08 a.m. A tour of Resident R42's room revealed trash on the floor and linens that were dirty. An interview with the resident revealed the facility phone in his room doesn't work. The resident stated the phone has not been working for about two weeks. A tour of Resident R51's room revealed the call bell on the floor out of reach of the resident, this was confirmed at 10:21 a.m. by licensed nurse Employee E6. Further…

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, interviews with staff and review of facility policy, it was determined that the facility failed to develop a comprehensive person-centered care plan for three of 21 resident reviewed (Residents R32, R46 and Resident 48). Findings include: Review of facility policy titled Care Plans, Comprehensive Person-Centered revised on March 2022, states that it includes measurable objective and timetables to meet the resident's physical, psychosocial and functional needs and is developed and implemented for each resident. Review of Resident R32's clinical record revealed that the resident was admitted to the facility on [DATE], with the diagnosis of Type Two Diabetes Mellitus (a chronic condition that causes high blood glucose levels (hyperglycemia). Review of Resident R32's progress notes revealed on February 9, 2024 the resident was transferred to the hospital when he was hypoglycemic (low blood glucose levels) and found with fecal impaction (chronic constipation, hard dry stool stuck…

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 interviews with residents and staff it was determined the facility did not ensure physicians order were followed related to medication administration and care to a pleurax catheter for two of 21 residents reviewed. (Residents R326 and R329) Findings Include: During Resident Council held on May 15, 2024 at 2:00 p.m. Resident R326 stated during medication administration this morning, she dropped a pill, told the nurse, the nurse did not come back with a replacement pill, and she still hadn't gotten it for the day. The resident was asked by the surveyor if she knew what pill it was and she stated, No, but I have it still I saved it in my room At the end of Resident Council, the surveyor approached licensed nurse, Employee E5 and stated what Resident R326 had said during Resident Council. The surveyor went into Resident R326's accompany by licensed nurse, Employee E5. Observation of resident's room on May 15, 2024 at 2:40 p.m. with Licensed nurse, Employee E5 revealed a purple and orange pill sitting on the resident bed-side tray table. Licensed nurse, Employee…

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

Based on observations, review of facility policy, review of clinical records, and interviews with staff it was determined that the facility failed to monitor a resident's needs to maintain acceptable parameters of nutritional status for one of 21 residents reviewed for nutritional status. (Resident R13). Findings Include: Review of the facilities policy titled, Weight Assessment and Intervention with a revision dated on March 2022 state, Resident weights are monitored for undesirable and unintended weight loss or gain. Review of Resident R13's clinical record revealed the diagnoses of muscle wasting and atrophy, hyperlipidemia, hypothyroidism, diverticulitis of large intestine without perforation or abscess without bleeding, unspecified hearing loss, abnormalities of gait and mobility, dysphagia, and cognitive communication deficit. Review of Resident R13's clinical record revealed that the resident was to receive feeding assistance of 1:1 at all meals. Review of Resident R13's hospital discharge records from April 3, 2024 revealed the resident has a weight recorded on April 4, 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 resident council interviews, review of the established meal time schedule, and clinical record review, it was determined that the facility failed to ensure a nourishing snack was provided when in between meals for five of 21 residents reviewed. (Residents R275, R22, R326, R14, and R13). Findings Include: Resident Council was held on May 15, 2024 at 2:00 p.m. When asked if the resident's receive snacks in the evening four out of five residents stated that they have never received a snack in the evening. Review of Resident R275's evening snack record revealed, no snack was given on May 14, 2024. Review of Resident R22's evening snack record revealed, no snack was given on April 20, April 26. May 1, May 2, May 4, May 5, May 14, 2024. Review of Resident R326's evening snack record revealed, no snack was given on May 11, May 14, and May 16, 2024. Review of Resident R14's evening snack record revealed, no snack was given on May 6, May 9, and May 14, 2024. Review was made of Resident R13's clinical record due to the resident having a significant weight loss over the period of 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 observations and an interview with staff, it was determined that the facility did not ensure that garbage and refuse was disposed of properly. Finding include: An initial tour of the Food Service Department was conducted on May 14, 2024, at 9:30 a.m. with Employee E3, Food Service Director (FSD), which revealed the following: Observation in the receiving area revealed one of three dumpsters with the lid open revealing the contents including cardboard boxes. Further observations revealed that the employee smoking area was adjacent to the loading dock and that the ground all around the loading dock was littered with hundreds of cigarette butts. Interview with the FSD on May 14, 2024, at 9:35 a.m. confirmed the above findings. 28 Pa. Code 201.18(b)(3) Management 28 Pa. Code 201.14(a) Responsibility of Licensee

Based on observation and staff interview, it was determined that the facility failed to ensure that the loading dock was in safe conditions. Findings include: Observations during the tour of the kitchen on May 14, at 9:30 a.m. revealed a loading dock door that was open leading to the receiving area where there was a wooden loading dock structure that was five feet off the ground with no railing or chain to restrict access and provide safety for staff, delivery drivers and anyone who may exit the rear door including wandering residents. Interview with Food Service Director, Employee E3, on May 14, at 9:30 a.m. confirmed that the loading dock door was open due to receiving a delivery that morning, and that the loading dock structure does not have any safety railing and that Dietary staff receive deliveries there daily. The FSD indicated that while this is an employee only area, residents have entered the hallway leading to the receiving area to come to the kitchen and that if no one was in the area and the receiving door was open, they could wander out to the loading dock and fall.…

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

Based on observation, review of facility policy and procedure, and interviews with staff, it was determined that the facility failed to handle and transport linens to prevent the spread of infection on one of two nursing units. (East wing) Findings include: Observation at the East Wing of the facility, on March 201, 2024, at 10:07 a.m., revealed that a Nurse Aide, Employee E6, was transporting clean linen for the use of residents by holding the linens letting it to touch the Nurse aide's uniform. Interviewed conducted with Nurse aide, Employee E6, at the timed of the interview, it was confirmed that the linens should have been transported without letting it touch the employee's clothing to prevent contamination and to maintain infection control practices. 28 Pa Code 201.14(a) Responsibility of licensee 28 Pa Code 211.12 (d)(1)(5) Nursing services

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of clinical records and staff interview, it was determined that the facility failed to developed a baseline care plan for one of six residents reviewed related to a community-acquired infectious disease (Resident R1). Findings: Review of the clinical record for Resident R1 revealed that the resident was admitted to the facility on [DATE], for skilled nursing care post discharge from an acute care hospital. At the time of admission the resident had been diagnosed with an infection (clostridium difficile - an inflammation of the colon caused by a bacterial infection) and was on an antibiotic therapy regimen. Review of hospital documentation dated September 15, 2024 at the time of discharged noted You had a c-difficile infection for which we are treating you with oral Vancomycin and holding off other antibiotics. Review of Resident R1's care plan revealed that a care plan for c-difficile infection was not developed until September 18, 2024. 28 Pa. Code 211.12 (d)(1)(5) Nursing services 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of clinical records and staff interview, it was determined that the facility failed to follow acceptable infection control practices related to the admission to the facility of a resident with a community-acquired infectious disease for one of six residents reviewed (Resident R1). Findings: Review of the clinical record for resident R1 revealed that the resident was admitted to the facility on [DATE], for skilled nursing care post discharge from an acute care hospital. At the time of admission the resident had been diagnosed with an infection (clostridium difficile - an inflammation of the colon caused by a bacterial infection) and was on an antibiotic therapy regimen. An entry in the progress notes dated September 18, 2023, documented that the resident was transferred to a private room and that transmission-based precautions were implemented. An interview was conducted with the facility's infection Preventionist Employee E3 on February 1, 2024, at 11:00 a.m. confirmed that there was no…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of clinical records, facility policies and procedures, and interviews with residents and staff, it was determined that the facility failed to ensure an alleged allegation involving suspected abuse was reported, as required, to the Department of Health for one of eight residents reviewed (Residents R8). Findings include: Review of the facility policy, Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating revised September 2022, stated that, If resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law. The policy further states that the administrator or the individual making the allegation immediately reports his or her suspicion to the following persons or agencies: the state licensing agency; ombudsman; resident representative; adult protective services; law enforcement; physician and medical director.…

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 interviews with staff, it was determined that the facility failed to ensure that essential equipment related to vital signs was readily available for use by nursing staff on two of two nursing units (North and East nursing units). Findings include: Observation on August 3, 2023, from 8:35 a.m. through 9:00 a.m. of morning medication pass on the North nursing unit, revealed Employee E11, licensed nurse, prepare and administer medications to Residents R35 and R60. During medication administration, Employee E11, licensed nurse, was observed obtaining both Resident R35 and R60's blood pressure and heart rate using a wrist blood pressure monitor and their oxygen levels using a fingertip pulse oximeter. Interview, on August 3, 2023, at 8:45 a.m. Employee E11, licensed nurse, stated that she brings her own equipment, including the wrist blood pressure monitor and fingertip pulse oximeter, from home because there was no equipment available at the facility to use to obtain resident vital signs. Continued observation, on August 3, 2023, at 8:47 a.m. Employee E11,…

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 and documentation, clinical record reviews and interviews with staff, it was determined that the facility failed to ensure that medications were administered per physician's orders for three of 27 residents reviewed (Residents R59, R112 and R60). Findings include: Review of facility policy, Unavailable Medication dated June 2021, revealed, the facility will make every effort to ensure that a medication ordered for the resident is available to meet their needs. Continued review revealed that if a medication is unavailable, nursing staff shall notify the physician, notify the pharmacy, attempt to obtain the medication from the facility's automated medication dispensing system and provide alternative medications as recommended. Observation on August 3, 2023, at 8:53 a.m. of morning medication pass on the North nursing unit, revealed Employee E11, licensed nurse, prepare and administer medications for Resident R60. Employee E11, licensed nurse, stated that Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record reviews and interviews with staff, it was determined that the facility failed to ensure that respiratory therapy treatments and equipment were provided in a timely manner for one of three residents reviewed related to respiratory care (Resident R59). Findings include: Review of Resident R59's MDS (Minimum Data Set - a mandatory periodic resident assessment tool)assessment, dated July 5, 2023, revealed that the resident was admitted to the facility on [DATE], and had diagnoses including coronary artery disease (damage in the heart's major blood vessels), aphasia (loss of ability to understand or express speech, caused by brain damage), chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe) and chronic respiratory failure (a condition in which a person's lungs cannot release oxygen into and/or remove carbon dioxide from the blood). Review of Resident R59's hospital discharge records, dated July 1, 2023, revealed respiratory…

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.