Embassy Of Hearthside

Based on a review of select facility policies and procedures, clinical record review, observation, and resident and staff interview, it was determined that the facility failed to obtain informed consent prior to the installation of bedrails for two of eight residents reviewed (Residents 8 and 11), and failed to assess all potential risks for entrapment for five of eight residents reviewed for bedrail use (Residents 4, 8, 9, 11, and 93). Findings include: The facility policy entitled, Bed Rail Procedure, last reviewed without changes on January 21, 2026, revealed that if a resident is appropriate for a bed rail, nursing and/or designee will complete a Bed Rail Education/Consent with the resident and/or responsible party. Note, consent must be completed prior to bed rail(s) being placed on the resident's bed. Nursing will place a request for bed rails in TELS (maintenance communication system). Maintenance will confirm that consent/education was completed before placing bed rails to the bed, will install bed rails as requested, will ensure that manufacturer's recommendations and…

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

Based on clinical record review, observation, and resident and staff interview, it was determined that the facility failed to ensure a medication error rate less than five percent (Residents 17 and 100).Findings include: The facility's medication error rate was eight percent based on 25 medication opportunities with two medication errors. Observation of a medication administration pass on February 18, 2026, at 12:36 PM revealed Employee 4 (licensed practical nurse) administer Carafate (anti-ulcer medication, adheres to the stomach lining to protect it from acids and enzymes) 1 gm (gram) to Resident 17. The packaging of the Carafate medication included instructions to administer the medication on an empty stomach. Resident 17 had her lunch tray in front of her on her overbed table and was beginning to eat her lunch at the time of the medication administration. Employee 4 stated, normally trays are not this early, as she administered the medication to Resident 17, to which Resident 17 responded, I didn't eat a lot. Interview with Employee 4 on February 18, 2026, at 12:54 PM verified…

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 documents, and resident and staff interview, it was determined that the facility failed to provide menu items as indicated for the dining room and two of four nursing units (Heirloom and Nittany, Residents 51 and 89).Findings include: In an interview with Resident 51 on February 17, 2026, at 1:05 PM they stated that they often do not receive what they are supposed to on their meal tray. Review of the menu for lunch on February 19, 2026, included maple glazed ham, macaroni and cheese, Prince [NAME] vegetable blend, wheat dinner roll, and rainbow sherbet. During an observation of the tray line service on February 19, 2026, at 11:40 AM the plating of the meals for the dining room and Heirloom unit were observed. No wheat dinner rolls or bread was plated with the meal. Observation on February 19, 2026, at 12:18 PM on the Nittany unit of Resident 89's tray revealed that no bread was present. Observation of lunch meal service on the Heirloom unit on February 19, 2026, 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.

Based on observation, and resident and staff interview, it was determined that the facility failed to serve food at palatable temperatures on three of four nursing units (Heirloom, University, and Nittany; Residents 3, 13, 17, 89, and 93). Findings: Review of the mealtime documentation provided by the facility revealed the Heirloom food carts are scheduled to arrive on the nursing unit at 12:00 PM. Observation of the Heirloom nursing unit meal cart revealed it was observed outside the kitchen on February 19, 2026, at 11:55 AM. Observation of the lunch meal service on February 19, 2026, on the Heirloom nursing unit revealed that food trays arrived on the meal cart at 12:29 PM. Staff immediately began passing the food trays until the last tray was passed at 12:42 PM. The surveyor began testing the food temperatures of Resident 3's tray at this time with the following results: Puree ham was cold at 90.4 degrees FahrenheitPuree mixed vegetables were cold at 92.2 degrees FahrenheitPuree mac and cheese was cold at 91.4 degrees FahrenheitContainer of sherbert was melted Interview with…

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

Based on review of the facility's arbitration agreements and resident and staff interview, it was determined that the facility's arbitration agreements failed to ensure the selection of a neutral arbitrator for two of three residents reviewed with a signed arbitration agreement (Residents 93 and 118); and failed to include required regulatory language for one of three residents reviewed with a signed arbitration agreement (Resident 49).Findings include: Review of an Arbitration Agreement (an agreement that the resident/resident's responsible party and the facility will resolve legal disputes through binding arbitration, waiving their right to a trial) signed by Resident 93 on December 13, 2023, revealed that the document stipulated that, The arbitration shall be conducted by the National Arbitration Forum (NAF). If the NAF process is no longer in existence at the time of dispute, or NAF is unwilling or unable to conduct the arbitration, a mutually acceptable neutral third-party alternative will be agreed to by the parties. The agreement afforded the facility the initial selection of…

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

Based on clinical record review and resident and staff interviews, it was determined that the facility failed to ensure that written notice, including the reason for a room change, was provided to a resident prior to a facility-initiated room change for one of one resident reviewed for concerns related to resident choice (Resident 11).Findings include: Interview with Resident 11 on February 18, 2026, at 11:15 AM revealed that she, .got room moved and do not know why, staff just came in and started taking stuff out of closets and drawers and was moved that day. Resident 11 further stated, I'm not cattle, they could have talked to me about it. I speak English and understand what they say. Clinical record review for Resident 11 revealed census information that she did reside in the same room from November 18, 2024, to February 8, 2026, when she moved to her current room. Nursing documentation by the registered nurse dated February 8, 2026, at 12:17 PM noted, We spoke with resident about moving rooms and she agreed she is okay with moving rooms, I also called and left a message for her…

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, facility documentation review, and resident and staff interview, it was determined that the facility failed to obtain written authorization to manage personal funds for one of two residents reviewed for personal funds concerns (Resident 12).Findings include: Interview with Resident 12 on February 18, 2026, at 9:23 AM revealed that the business office in the facility held money for him, that a cousin deposited a check in that account for him, but that he did not receive a statement or had knowledge of how much money was in the account. Clinical record review for Resident 12 revealed a Resident Personal Funds agreement dated November 7, 2022, that Resident 12 signed to elect to manage his own funds (declined to have the facility manage his funds). A Resident Fund Management Service (RFMS) Authorization and Agreement to Handle Resident Funds form signed by Resident 12 on November 8, 2022, declined an RFMS account. A Resident Personal Funds agreement dated November 5, 2024, signed by Resident 12, again documented his election to manage his own funds…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff interview, it was determined that the facility failed to establish clear end of life directives for one of six residents reviewed (Resident 13).Findings include: A review of Resident 13's clinical record revealed an active physician's order dated [DATE], that indicated the resident was a DNR (do not resuscitate, do not attempt CPR (cardiopulmonary resuscitation) when the person has no pulse and is not breathing) and stated, DNR (Do Not Resuscitate)-LIMITED: NO INTUBATION, use medical treatment, IVF, ABX Discussed with daughter, new POLST completed. Resident 13's POLST (Pennsylvania Orders for Life-Sustaining Treatment, a form directing medical staff to complete life-sustaining treatment or allow a natural death) dated on [DATE], was noted to be signed by the resident's daughter due to confusion at that time. Clinical record review for Resident 13 revealed a quarterly MDS (Minimum Data Set, an assessment completed at periodic intervals of time to assess resident care…

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

Based on review of select facility policies and procedures, clinical record review, and staff interview, it was determined that the facility failed to thoroughly investigate and report to the appropriate agencies a potential allegation of misappropriation of resident property for one of 24 records reviewed (Resident 30). Findings include: The facility policy entitled Abuse, Neglect, and Exploitation, last reviewed without changes on January 21, 2026, revealed an immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect, or exploitation occur. The facility will report all alleged violations to the Administrator, state agency, adult protective services, and all other required agencies (i.e. law enforcement, when applicable) within specified timeframes, not later than 24 hours if the events that cause the allegation do not involve abuse, and do not result in serious bodily injury. Nursing documentation dated January 23, 2026, at 2:25 PM revealed Resident 30 put her husband on the phone with Employee 5 (licensed practical nurse).…

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 implement a comprehensive, person-centered care plan for suicidal ideations one of 24 residents reviewed (Resident 101).Findings include: Clinical record review revealed the facility admitted Resident 101 on September 22, 2025. Nursing documentation dated January 30, 2026, at 2:55 PM noted Resident 101 was very tearful, stating she was scared and wanted to go home. Documentation revealed Resident 101 stated she wanted a straight razor because if she does not do it to herself, this place will, stating she would be better off dead. Documentation revealed the facility contacted Resident 101's daughter and she was unable to calm Resident 101. The facility placed Resident 101 on every 15-minute checks. Review of Resident 101's care plan on February 20, 2026, revealed no comprehensive, person-centered care plan that addressed Resident 101's suicidal ideation. Interview with Employee 3 (social worker) on February 20, 2026, at 1:11 PM confirmed the above findings for Resident 101 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 clinical record review and resident and staff interview, it was determined that the facility failed to assist dependent residents with activities of daily living for two of two residents reviewed for activities of daily living concerns (Residents 11 and 8). Findings include: Clinical record review for Resident 11 revealed a quarterly MDS (Minimum Data Set, an assessment tool completed at specific intervals to determine resident care needs) assessment dated [DATE], that staff determined Resident 11 needed partial/moderate staff assistance for showering/bathing. Review of a plan of care initiated by the facility on November 20, 2024, to address Resident 11's care preferences, revealed interventions that included that staff honor that Resident 11 stated that she preferred a shower in the morning. Resident 11 is scheduled for a shower on day shift. Review of a plan of care initiated by the facility on November 19, 2024, to address assistance Resident 11 needed for activities of daily living (ADLs), revealed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and resident and staff interview, it was determined that the facility failed to provide services to maintain a resident's range of motion (ROM) for two of six residents reviewed for ROM concerns (Residents 59 and 118). Findings include: Clinical record review revealed the facility admitted Resident 59 on August 8, 2025. Review of Resident 59's most recent quarterly MDS (Minimum Data Set, an assessment completed at specific intervals to determine care needs) dated January 20, 2026, noted staff assessed Resident 59 as having impairment to his range of motion (ROM, movement of the body to maintain a resident's ability) of one side of his upper extremities. Review of Resident 59's discharge progress note from occupational therapy dated September 30, 2025, indicated discharge recommendations for a restorative nursing program. There was no evidence in Resident 59's clinical record that Resident 59 received a passive range of motion program. Review of Resident 59's therapy 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.

Based on clinical record review, observation, and resident and staff interviews, it was determined that the facility failed to implement a CPAP (continuous positive airway pressure) machine as recommended by a physician for one of one resident reviewed for oxygen concerns (Resident 93). Findings include: Interview with Resident 93 on February 17, 2026, at 3:13 PM revealed that her cardiologist was upset that she still does not have a CPAP machine (a device used to treat sleep apnea by delivering a steady gentle stream of pressurized air through a mask to keep the airway open during sleep). She indicated that her cardiologist had asked for her to have a CPAP machine three times now. She also indicated that the staff have never discussed the CPAP machine with her. Review of a cardiology consult visit form dated September 26, 2024, indicated that the cardiologist wanted the facility to get Resident 93's CPAP as she was on it at home. Further clinical record review for Resident 93 revealed cardiologist visit note dated March 18, 2025, that indicated he strongly recommends Resident 93…

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

Based on observation, clinical record review, and resident and staff interview, it was determined that the facility failed to secure medications on one of four nursing units (Nittany, Residents 13 and 51).Findings include: Observation of Resident 51's room on February 17, 2026, at 1:05 PM revealed an eye dropper container of Refresh Tears (artificial tears designed to provide temporary relief from dry eyes, irritation, and discomfort caused by insufficient tear production) on their bedside table. During a concurrent interview with Resident 51, they stated that the facility was aware they had the eye drops in their room. Observation of Resident 13's room February 17, 2026, at 1:15 PM revealed an eye dropper container of Genteal Tears (eye drops used to relieve dry, irritated eyes) on their bedside table. There was no evidence Resident 51 or Resident 13 was evaluated or ordered to self-administer the eye drops as indicated above and the eye drops were stored in the resident's room. The Nursing Home Administrator and the Director of Nursing were made aware of the above findings on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff interview, it was determined that the facility failed to provide routine dental services for two of four residents reviewed for dental concerns (Residents 2 and 30). Findings include: Clinical record review revealed the facility admitted Resident 30 on March 18, 2025. Observation of Resident 30 on February 17, 2026, at 11:08 AM revealed Resident 30 was in the dining room. Observation of Resident 30's mouth revealed several broken teeth. Review of Resident 30's admission MDS (Minimum Data Set, an assessment completed by the facility, at intervals to determine the care needs of the resident) dated March 24, 2025, revealed that she had some of her own natural teeth and that she had obvious or was likely to have cavities or broken teeth Review of Resident 30's care plan-initiated April 6, 2025, revealed Resident 30 is at risk for dental or chewing problems related to missing and broken teeth. Further review of Resident 30's clinical record revealed Resident 30 was not seen…

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 documents, and resident and staff interview, it was determined that the facility failed to provide food and drink to accommodate individualized preferences for one of 24 sampled residents. (Resident 89).Findings include: Interview with Resident 89 on February 17, 2026, at 2:05 PM revealed that despite explaining to the facility that she is vegetarian, eating only occasionally some chicken or turkey, she is continually served meat. Resident 89 stated she was served ham for breakfast this morning and received the meat at lunch (menu reveals that the meat was Salisbury steak). Resident 89 also stated that she only receives water to drink and she does not receive ice. Evidence the facility obtained food preferences/choices for Resident 89 was requested from facility staff on February 18, 2026, at 2:30 PM but was not provided during the survey. Interview with Resident 89 on February 19, 2026, at 9:36 AM revealed that she received bacon for breakfast that morning and only received water as her beverage without ice. Review of Resident 89's dietary…

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 documents, and resident and staff interview, it was determined that the facility failed to provide sufficient staff to carry out the functions of food and nutrition services in the main kitchen for one of four units (University, Residents 1, 2 and 3).Findings include: Interview with Resident 3 on February 2, 2026, at 11:05 AM, revealed that the resident sometimes receives food served on Styrofoam for all three meals in a day. The resident stated they did not like Styrofoam because the food gets cold quickly. Interview with Resident 2 on February 2, 2026, at 11:15 AM, revealed that meals are served on Styrofoam often and it has happened recently, even in the last week. The resident stated, when it is a hot meal, it can be less hot, and this continues to happen about once a week. In an interview with Resident 1 on February 2, 2026, at 11:25 AM, the resident stated eating off Styrofoam makes her feel sick, and she does not like Styrofoam. Interview with Employee 1, dietary manager, on February 2, 2026, at 10:15 AM revealed that there was a…

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

Based on review of facility documents, and resident and staff interviews, it was determined that the facility failed to provide an ongoing program of activities designed to meet the individual needs and interests for four of four residents reviewed (Residents 1, 2, 3 and 4).Findings include: In an interview with Resident 3 on February 2, 2026, at 11:05 AM, the resident stated activities are often cancelled because there are only two activity staff and there are often days with no activities at all. In an interview with Resident 2 on February 2, 2026, at 11:15 AM, the resident stated the activities used to be better than they are now, and there are not always activities to attend. Resident 2 also stated there are no alternative activities if they do not like an activity scheduled, and they are very concerned that the facility is cutting the activities. In an interview with Resident 1 on February 2, 2026, at 11:25 AM, the resident stated activities have been cancelled and now there are days without any activities at all, which bothers them. In an interview with Resident 4 on February…

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

Based on observation and staff interview, it was determined the facility failed to store food in accordance with professional standards for food service in the facility's main kitchen. Findings include: An observation in the facility's main kitchen on August 25, 2025, at 11:30 AM with Employee 1 (dietary manager) revealed the following: In the dry storage area, there was a bag of elbow macaroni, and a bag of opened egg noodles, with no open or use by dates. On the bread racks, there were six packs of English muffins, three loaves of bread, two packs of sandwich rolls, and one pack of hotdog rolls with no received or use by dates. In the walk-in Freezer, there was a box of mixed vegetables with no open or use by dates. The vegetables were not covered or sealed. In the walk-in refrigerator, there were boxes of mushrooms, lemons, and oranges with no open or use by dates. The items were not covered or sealed. In the reach-in cooler, there was an opened container of grape jelly and strawberry juice with no open or use by dates. In the production area, there was an opened box of thick and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of select facility policies and procedures, clinical record review, observation, and staff interview, it was determined that the facility failed to provide the highest practicable care regarding elopements for one of five residents reviewed (Resident 4) and medication errors for one of five residents reviewed (Resident CR1). Findings include: The current facility policy entitled Elopements and Wandering Residents, revealed the facility ensures that residents who exhibit wandering behavior and/or are at risk of elopement receive adequate supervision to prevent accidents and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement risk. The facility will establish and utilize a systematic approach to monitoring and managing residents at risk for elopement or unsafe wandering, including identification and assessment of risk, evaluation and analysis of hazards and risks, implementing interventions to reduce hazards and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of select facility policies and procedures, clinical record review, and staff interview, it was determined that the facility failed to thoroughly investigate and report to the appropriate agencies an allegation of resident-to-resident physical abuse for one of five records reviewed (Resident 1). Findings include: The current facility policy entitled Abuse, Neglect, and Exploitation, revealed an immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur. Investigation of alleged abuse includes identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, or others who might have knowledge of the allegations. The facility will have written procedures that include reporting of all alleged violations to the Administrator, state agency, adult protective services, and to all other required agencies (law enforcement when applicable) within specified timeframes. Report…

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

Based on staff interview, it was determined that the facility failed to employ a full-time qualified director of food and nutrition services in the absence of a full-time qualified dietitian. Findings include: During an interview on March 12, 2025, at 1:45 PM the Administrator stated the facility was utilizing a registered dietitian on a part time basis who was primarily working remotely with some onsite visits, and the facility did employee a full-time dietary manager (Employee 1). The Administrator was not sure of Employee 1's qualifications. In a follow up interview on March 13, 2025, at 10:00 AM, the Administrator confirmed Employee 1 was not a certified dietary manager, certified food service manager, did not have a national certification for food service management and safety, and did not hold a degree in food service management. The Administrator also indicated the registered dietitian onsite visits to the facility occurred over the night shift hours when no food service operations were taking place, and residents were likely sleeping. The facility did not employe a full-time…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and staff interview, it was determined that the facility failed to store food and maintain food service equipment in accordance with professional standards for food service safety in the facility's main kitchen, and one of four nursing units ([NAME]). Findings include: An observation in the facility's main kitchen on March 11, 2025, at 10:26 AM with Employee 1, dietary manager revealed the following: A large hole in the left lower wall inside the entrance doors to the kitchen. Dried food splatter and staining were observed on the ceiling tiles and light covers in the dish room area. The top of the dishwasher was covered in debris and dust. The tile flooring in the dish room contained multiple cracks and broken tiles. Water and food particles were observed pooling in the areas where the tiles were broken off. Two stacks of dish washing racks were observed on carts in the center of the dish machine room. The gray colored plastic wash racks were worn, with multiple broken plastic pieces at 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 observation and staff interview, it was determined that the facility failed to provide adequate housekeeping and maintenance services to ensure a clean, safe, and orderly environment on three of four nursing units ([NAME], Nittany, University and Residents 8, 15, 43, 54, 64, 81, 82, 91, 100). Findings include: Observation of Resident 64's room on March 11, 2025, at 12:59 PM revealed an electrical outlet box lying on the floor connected to wires, which extended into a long piece of conduit that was hanging off the wall behind the resident's bed. An unpainted area with empty screw holes was observed on the wall above where the outlet box was laying. Some dry wall debris and wire clippings were observed along the wall. An oxygen concentrator was plugged into the outlet box on the floor. A follow up observation of Resident 64's room on March 12, 2025, at 10:07 AM also revealed significant brown/black buildup along the baseboard heater under the window of the room where the floor meets the wall. An…

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

Based on review of facility documentation and staff interview, it was determined that the facility failed to ensure that nursing staff possessed the appropriate competencies and skill sets related to the care and assessment of residents with enteral tube feeding, catheter care, medication administration, and dressing changes for four of four employees reviewed for competencies (Employees 11, 12, 13, and 14). Findings include: A review of the facility documentation revealed that the facility had a total of 118 residents receiving medications, eight residents with indwelling catheters (insertion of a tube into the bladder to remove urine), seven residents with pressure ulcers, and three residents with enteral tube feedings (device that allows liquid food to enter your stomach or intestine through a tube). A request for nursing staff competencies for enteral tube feeding, catheter care, medication administration, and dressing changes revealed the facility was unable to provide any competencies for Employees 11 and 12 (registered nurse), and Employees 13 and 14 (licensed practical…

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 maintain pharmacy recommendations or evidence pharmacy recommendations were addressed by the physician for five of five residents reviewed (Residents 8, 16, 101, 108). Findings include: Clinical record review for Resident 8 revealed pharmacy notes dated July 22, August 22, September 11, December 15, 2024, and January 16, 2025, which indicated a pharmacy review was completed for the resident and pharmacy recommendations were made to the physician. There was no evidence of the pharmacist report of recommendations or a physician's response to the pharmacy recommendations for the dates indicated. Clinical record review for Resident 101 revealed pharmacy notes dated August 20, 2024, and January 17, 2025, which indicated a pharmacy review was completed and pharmacy recommendations were made. There was no evidence of the pharmacist report of recommendations or a physician's response to the pharmacy recommendations for the dates indicated. Clinical record review for Resident 108 revealed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and staff interview, it was determined that the facility failed to implement appropriate enhanced barrier precautions for three of 24 residents reviewed (Residents 40, 72, and 325) and ensure an environment free from the potential spread of infection with the storage of resident equipment and supplies for one of four nursing units ([NAME]; Residents 8, 54, 64, and 81), and the facility laundry area. Findings include: An observation of Resident 81's bathroom, which is shared with an adjoining room with Resident 64 on March 11, 2025, at 1:20 PM revealed a raised toilet seat sitting beside the toilet directly on the floor. An observation of Resident 8's bathroom on March 12, 2025, at 10:19 AM revealed a raised toilet seat sitting directly on the floor beside the toilet in the bathroom. An observation of the [NAME] unit nourishment room, located behind the nursing station on March 13, 2025, at 1:09 PM revealed a rusted white metal cabinet in the room labeled personal hygiene. The cabinet…

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

Based on clinical record review, observation, and resident and staff interview, it was determined that the facility failed to ensure that the facility determined a resident's ability to self-administer medications for one of one resident reviewed (Resident 72). Findings include: Observation of Resident 72 on March 11, 2025, at 12:25 PM revealed the resident was in bed. An adjacent bedside table had Fluticasone nasal spray (a steroid medication used to treat various signs and symptoms that could be caused by allergies). A concurrent interview revealed the resident utilized the medication to treat allergies. A current physician's order dated February 22, 2025, for Resident 72 revealed an order for Fluticasone Propionate Nasal Suspension 50 micrograms per actuation (mcg/act)c, use two sprays in both nostrils one time daily related to allergic rhinitis (an allergic reaction to allergens in the air that may cause nasal congestion, sneezing, and watery eyes). Further clinical record review for Resident 72 revealed no physician's order that the resident may self-administer the medication,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff interview, it was determined that the facility failed to establish clear advance directives for one of four residents reviewed (Resident 323). Findings include: A review of the census for Resident 323 revealed that the resident was admitted to the facility on [DATE]. Current physician orders for Resident 323 revealed no orders related to the code status (instructions for health care personnel if the resident's heart stopped beating or the resident stopped breathing; does the resident want cardiopulmonary resuscitation) for the resident. Review of the current care plan for Resident 323 revealed no care plan related to code status. Review of the POLST (Pennsylvania Orders for Life-Sustaining Treatment, a form directing medical staff to complete life-sustaining treatment or allow a natural death) documentation for Resident 323 on March 12, 2025, at 2:18 PM revealed a form located in the POLST binder on the Nittany Nursing Unit for Resident 323 that was signed by the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff interview, it was determined that the facility failed to provide care and services to maintain or improve the ability to perform activities of daily living for one of three residents reviewed for eating concerns (Resident 105). Findings include: Clinical record review for Resident 105 revealed an MDS (Minimum Data Set, assessment completed at specific intervals to determine care needs) assessment dated [DATE], that staff assessed Resident 105 as requiring the supervision with set up help only for eating. Resident 105's next MDS assessment dated [DATE], revealed staff assessed Resident 105 as now requiring extensive assistance of one staff for eating. There was no documented evidence in Resident 105's clinical record to indicate that the facility identified or assessed Resident 105's decline in her ability to perform this activity of daily living. Speech Therapy did not assess Resident 105 until January 19, 2025. Further review of Resident 105's clinical record revealed…

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

Based on clinical record review and resident and staff interview, it was determined that the facility failed to implement physician orders for two of 24 residents reviewed (Residents 104 and 115). Findings include: In an interview with Resident 115 on March 12, 2025, at 9:44 AM the resident indicated she was recently admitted to the facility about a month prior and had a feeding tube in place when she arrived but was no longer receiving feedings through the tube because she was eating. Resident 115 then indicated the tube had not been flushed since the feedings through the tube had stopped. Resident 115 stated she asked a nurse about the tube not being flushed and was told everything had been discontinued. Resident 15 stated she was concerned because the tube had an odor. No odor was observed near Resident 115, although the resident lifted her shirt to expose a feeding tube coming from her abdomen area and the tubing had particles and a red substance observed inside the exposed area of the tubing. Clinical record review for Resident 115 revealed the resident did have a G-tube…

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

Based on observation, clinical record review, and resident and staff interview, it was determined that the facility failed to offer a resident to receive proper treatment and care to maintain good foot health in accordance with professional standards of practice for one of 24 residents reviewed (Resident 81). Findings include: An observation of Resident 81's left foot during a pressure ulcer dressing change to the same foot, on March 14, 2025, at 10:26 AM revealed the resident's toenails on the left foot were yellow and extremely thick, one-half inch in depth raised up on top of the center surface of the toenails. A closer look revealed the toenails had extended from each toe and curled upward and had attached to the top flat surface portion of the nail with a fungal looking appearance. The skin on the toes was scaled and peeling. Upon concurrent interview with the resident regarding his toenails, the resident stated he has asked three times to see a podiatrist since he has been there and hasn't seen one yet. In an interview with the Director of Nursing on March 14, 2025, at 10:35…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff interview, it was determined that the facility failed to provide services to maintain a resident's range of motion for two of three residents reviewed for ROM concerns (Residents 101 and 25). Findings include: Clinical record review revealed the facility admitted Resident 101 on November 9, 2023. Review of Resident 101's most recent quarterly MDS (Minimum Data Set, an assessment completed at specific intervals to determine care needs) dated February 7, 2025, noted staff assessed Resident 101 as having impairment to his range of motion (ROM, movement of the body to maintain a resident's ability) of his bilateral lower extremities. Nursing documentation dated January 24, 2025, at 3:07 PM revealed Resident 101's daughter was made aware of his fall and that therapy was being discontinued. Review of Resident 101's physical therapy Discharge summary dated [DATE], noted he exhausted his benefits. Therapy documentation revealed Resident 101 was provided education for proper…

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, observation, and staff and resident interview, it was determined that the facility failed to ensure the availability of necessary emergency supplies for one of one resident reviewed receiving hemodialysis (Resident 15). Findings include: In an interview and observation of Resident 15 on March 11, 2025, at 1:39 PM revealed she was lying in bed eating lunch. The resident indicated she attended dialysis outside the facility three days a week. Resident 15 pointed to her dialysis access site on her left chest area and indicated she used to have it on the right side, but they had to change it. Concurrent observation of Resident 15's room did not reveal any emergency supplies in the resident 's room for the central line to include sterile gauze, hemostat (a tool used to control bleeding), needleless connector, or tape. With the resident's permission to look in her bed side drawers, closet, and wheelchair bag, there was also no evidence of any emergency supplies in those areas belonging…

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 develop and implement an individualized person-centered care plan to address dementia and cognitive loss displayed by one of two residents reviewed (Resident 25). Findings include: Clinical record review for Resident 25 revealed the facility admitted her on March 8, 2019, with diagnosis including Dementia (loss of memory, language, problem-solving, and other thinking abilities that interfere with daily life). A review of Resident 25's significant change Minimum Data Set Assessment (MDS, a form completed at specific intervals to determine care needs) dated May 28, 2024, indicated that the facility assessed Resident 25 as having a diagnosis of dementia. The facility determined that a care plan for dementia and cognitive loss would be developed. A review of Resident 25's care plan entitled Cognitive Status: has an impaired cognitive function r/t (related to) dx (diagnosis) vascular Dementia revealed that there was no indication that the facility had implemented an individualized…

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 resident and staff interview, it was determined that the facility failed to ensure that medically related social services were provided to one of one resident reviewed (Resident 100). Findings include: Clinical record review revealed a nursing progress note date [DATE], at 4:19 PM that indicated Resident 100's family was in and notified her that her husband had passed away. The progress note indicated that Resident 100 cried for a while with family present and was doing well while they were visiting. Further clinical record review for Resident 100 revealed a progress note dated [DATE], at 1:58 PM that indicated she was mildly depressed today due to the passing of her spouse and family was in to visit. A social service progress note dated [DATE], at 11:16 AM revealed that the social service worker met with Resident 100 regarding her depression after her husband passed away. The note indicated that Resident 100 stated that she is doing okay and is still feeling sad. She also…

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 employee education records and staff interview, it was determined that the facility failed to ensure that nurse aides received 12 hours of in-service training annually for two of two nurse aides reviewed (Employees 16 and 17). Findings include: During a meeting with the Nursing Home Administrator and Director of Nursing on March 13, 2025, at 1:45 PM the surveyor asked for training records to indicate that nurse aides had received at least 12 hours of in-service training in the last year for Employees 16 and 17 (nurse aides). Interview with the Director of Nursing on March 14, 2025, at 10:41 AM confirmed there was no documented evidence that Employee 16 received the required 12 hours of annual in-service training in the last year. Review of Employee 17's Employee Annual Education Tracking Sheet, revealed that the Director of Nursing documented Employee 17 completed 27.5 hours of training on February 11, 2025. Interview with the Director of Nursing on March 14, 2025, at 10:40 AM revealed the facility gave Employee 17 a packet of information to review and the…

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

Based on clinical record review, and staff interview, it was determined that the facility failed to ensure complete and accurate clinical documentation for one of one resident reviewed (Resident 1). Findings include: Clinical record review revealed the facility admitted Resident 1 on June 12, 2024. Nursing documentation dated on November 12, 2024, at 12:27 PM revealed the licensed practical nurse noted after Resident 1 began eating his meal tray, he began to have a mild coughing episode and indicated he was not feeling well. The licensed practical nurse documented the registered nurse was aware. Nursing documentation dated November 12, 2024, at 1:13 PM indicated that the licensed practical nurse documented Resident 1's oxygen saturation was at 75% on room air and the registered nurse was aware. Nursing documentation dated November 12, 2024, at 4:35 PM indicated the licensed practical nurse noted while Resident 1 was eating dinner he began coughing and spitting up large amounts of mucus with particles of food. The licensed practical nurse noted the registered nurse was aware. 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 review of clinical records and staff interview, it was determined that the facility failed to obtain laboratory work as ordered by the physician for five of seven residents reviewed (Residents 1, 3, 4, 6, and 7). Findings include: Review of the facility's contracted laboratory order sheet revealed that a Dermatology panel included skin testing for Sarcoptes scabiei (the mite that causes scabies). Clinical record review for Resident 1 revealed that on October 27, 2024, at 9:53 PM staff indicated that they had a continuing itchy rash with raised areas. On October 29, 2024, there was a physician's order for staff to obtain a Dermatology panel. Review of Resident 1's Dermatology panel results dated October 30, 2024, revealed that the facility's contracted laboratory did not test for Sarcoptes scabiei or report the results of the Sarcoptes scabiei test to the facility. Clinical record review for Resident 3, 4, 6, and 7 revealed that on October 29, 2024, there was a physician's order for staff to obtain a Dermatology panel. Review of Resident 3, 4, 6, and 7's Dermatology panel…

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 complete and accurate clinical documentation for five of five residents reviewed (Residents 1, 2, 3, 4, and 5). Findings include: Clinical record review for Residents 1, 2, 3, 4, and 5 revealed that staff failed to consistently document (leaving several blank areas or areas that indicated not applicable) on their ADL Task Documentation form (Activities of Daily Living, a document staff use to indicate the Resident's self-performance and staff support needed while completing a task and/or receiving care) that indicated staff provided ADL care, such as bed mobility, transfers, skin care, eating assistance, continence status and care, and resident behaviors, on the following dates: Resident 1 August 1, 3, 6, 8, 11, 13, 15, 17, 18, 20, 25, 26, 27, 28, and 31, 2024 September 2, 4, 5, 6, 12, 13 and 17, 2024 Resident 2 August 6 and 9, 2024 September 2, 4, 5, 6, 9, 12 and 17, 2024 Resident 3 August 17, 20, 21, 22, 24, 25, 26, 29, and 31, 2024 September 2, 4, 5, 6, 12, 13 and 17, 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 a review of select facility policies and procedures, employee personnel record review, and staff interview, it was determined that the facility failed to obtain attestation of Pennsylvania residency or criminal background checks as required for four of five personnel records reviewed (Employees 3, 4, 5, and 6); and failed to ensure the completion of abuse training for one of five newly hired employees reviewed (Employee 5). Findings include: In accordance with Act 13 Elder Abuse Mandatory Reporting and Act 169 Criminal Background Checks, nursing facilities are required to obtain a criminal background check on all newly hired employees. Facilities are required to obtain the Pennsylvania State Police (PSP) background check within 30 days of hire on all prospective employees. If the applicant has not been a Pennsylvania resident for the two years before application, they will need to have a PSP criminal history background check completed and an FBI Background Check. The applicant will obtain an FBI fingerprint card either from their prospective employer or by contacting…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff interview, it was determined that the facility failed to provide the appropriate recommended services for a resident's range of motion for four of nine residents reviewed (Residents 6, 11, 14, and 51). Findings included: Clinical record review for Resident 11 revealed a quarterly MDS (Minimum Data Set, an assessment tool completed at specific intervals to determine resident care needs) dated March 6, 2024, that indicated the resident had a BIMS (Brief Interview for Mental Status) score of 3 that indicated a severe cognitive impairment level. The current care plan for Resident 1 revealed the resident requires assistance with activities of daily living (ADL) care related to dementia, weakness, and impaired balance. The care plan indicated the resident was dependent on staff for transfers and required extensive assistance of two from staff for bed mobility. A review of the most current physical therapy discharge summary for Resident 11 dated March 6, 2024, at 11:42 AM…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff interview, it was determined that the facility failed to identify triggers related to a resident's diagnosis of Post-Traumatic Stress Disorder, to provide culturally, competent, trauma-informed care, and to eliminate or mitigate re-traumatization for two of four residents reviewed for mood/behavior (Residents 14 and 28). Findings include: Clinical record review for Resident 14 revealed a diagnosis of Post Traumatic Stress Disorder (PTSD, a mental and behavioral disorder that develops related to a terrifying event) since admission on [DATE]. Resident 14 was unable to be interviewed related to his diagnosis of PTSD due to his current cognitive status. A review of Resident 14's admission minimum data set (MDS, an assessment completed by the facility at intervals to determine care needs) assessment dated [DATE], indicated a diagnosis of PTSD for Resident 14. A review of Resident 14's most recent quarterly MDS assessment dated [DATE], indicated PTSD continued to be an active…

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

Based on review of select facility policies, observation, and staff interview, it was determined that the facility failed to store food items in a safe and sanitary manner, maintain equipment in a sanitary condition, and prepare food items in accordance with professional standards in the main kitchen. Findings include: Initial tour of the facility's main kitchen with Employee 19, Dietary Manager, on April 23, 2024, between 9:18 AM and 10:30 AM revealed the following: A white dry erase board was falling off the wall. There was a six pack of hoagie rolls located in a walk-in cooler with no date or label on them. There was a roll of thawed beef with a prepared date of 4/17 and an expired use by date of 4/20 on it. There was a significant amount of dust and debris on a window air conditioning unit in the dry goods storage area. There was a build-up of a black substance on the corners of the air vents and a significant build-up of the same substance on the interior vents. There was a significant number of cobwebs located on the ceiling border with the wall located in the dry goods…

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

Based on observation, clinical record review, and resident and staff interview, it was determined that the facility failed to implement appropriate enhanced barrier transmission-based precautions for five of 18 residents reviewed (Residents 6, 33, 40, 68, and 69). Findings include: Review of the memo entitled Enhanced Barrier Precautions (EBP, gown and glove use) in Nursing Homes to Prevent the Spread of Multi-drug Resistant Organisms released by the Center for Medicaid and Medicare Services (CMS) on March 20, 2024, with an implementation date of April 1, 2024, revealed that nursing care facilities are to use EBP for residents with chronic wounds or indwelling medical devices (i.e., indwelling urinary catheters) during high-contact resident care activities regardless of their multidrug-resistant organism status. High-contact activity would include things like dressing, transferring, changing linens, providing hygiene, changing briefs, wound care, or device care. Clinical record review for Resident 33 revealed current physician orders that included the following: change the 16 French…

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

Based on clinical record review and resident and staff interview, it was determined that the facility failed to ensure resident and/or responsible party participation in comprehensive care plans for two of two residents reviewed for care planning concerns (Residents 8 and 69). Findings include: Interview with Resident 8 on April 23, 2024, at 3:32 PM revealed that she denied any invitation to participate in her care plan meetings. Resident 8 stated, I haven't had no meetings like that at all. Clinical record review for Resident 8 revealed an undated printed invitation, addressed to Resident 8, that indicated there would be a meeting to discuss a care plan. The letter instructed that she should RSVP to the social service office as soon as possible or the facility would continue with the care conference, .as scheduled above; however, there was no date or time included on this page of the invitation. There was no email, phone number, or facility staff member name provided on the invitation to inform Resident 8 who or how to contact someone regarding the letter. A Care Plan Meeting Note…

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 select policy review, clinical record review, and resident and staff interview, it was determined that the facility failed to provide the highest practicable care regarding a fluid restriction for one of one resident reviewed (Resident 62), and physician ordered treatments for one of one resident reviewed (Resident 2). Findings include: The facility policy entitled, Fluid restriction or Encouragement last reviewed without changes on March 29, 2024, revealed that residents are encouraged and assisted as needed to consume the amount of fluids appropriate for their diagnoses and medical status. Fluid restrictions will have a dietician or physician's order specifying the total amount of fluid per day. The total amount may be broken down into recommendations for the fluids at meals, between meals, and with medication passes. Fluids consumed should be recorded as accurately as possible. Appropriate documentation should be completed regarding the resident's compliance or refusal regarding fluid…

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 resident and staff interview, it was determined that the facility failed to obtain necessary audiology services for one of one resident reviewed for hearing concerns (Resident 8). Findings include: Interview with Resident 8 on April 23, 2024, at 3:12 PM revealed she was extremely hard of hearing and that she required the use of a dry erase board to communicate every question to her during the interview. Resident 8 stated that, .they've been promising me that a hearing doctor would come in and clean my ears and give me hearing aids, but no one has come, haven't seen anyone. Clinical record review for Resident 8 revealed an admission MDS (Minimum Data Set, an assessment tool completed at specific intervals to determine resident care needs) assessment dated [DATE], that assessed Resident 8 as having highly impaired hearing (with the use of a hearing aid if used); but that no hearing aid was used. The care assessment area (CAA, section of the assessment that documents the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and family and staff interview, it was determined that the facility failed to implement treatment and services to promote the healing of a pressure ulcer for one of four residents reviewed for pressure ulcer concerns (Resident 40). Findings include: Clinical record review revealed the facility admitted Resident 40 on [DATE]. Review of Resident 40's admission assessment noted nursing staff assessed Resident 40 with an unstageable pressure sore on his coccyx measuring 1.5 centimeters (cm) by 0.5 cm with an unknown depth. Review of Resident 40's care plan initiated on [DATE], revealed the facility implemented a wound treatment, and instructed nursing to observe the wound dressing daily to ensure that the dressing remains intact and there are no signs and symptoms of infection or increased drainage. Review of Resident 40's Treatment Administration Record (TAR, a form the facility utilizes to document treatments) dated [DATE] revealed the facility did not initiate a treatment to…

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

Based on clinical record review, observation, and family and staff interview, it was determined that the facility failed to implement interventions to deter resident falls and prevent potential injury for two of 12 residents reviewed for fall concerns (Residents 20 and 48). Findings include: Clinical record review for Resident 20 revealed a plan of care developed by the facility to address her risk for falls. Interventions listed in the plan of care included bilateral fall mats at all times when she is in bed since October 17, 2023. Observation of Resident 20 on April 23, 2024, at 3:00 PM revealed she was in bed. There was a fall mat on the left side of her bed. There was no fall mat on the right side of her bed. Observation of Resident 20 on April 26, 2024, at 10:51 AM revealed she was in bed with a fall mat on only the left side of her bed. Interview with Employee 2 (licensed practical nurse) on April 26, 2024, at 10:56 AM at Resident 20's bedside, confirmed that there was only one fall mat in her room. The right side of her bed was not equipped with a fall mat. The surveyor…

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

Based on clinical record review, observation, and staff interview, it was determined that the facility failed to administer supplemental oxygen as prescribed by the physician for two of five residents reviewed for oxygen concerns (Residents 8 and 62). Findings include: Clinical record review for Resident 8 revealed an active physician's order dated December 14, 2023, that instructed staff to administer supplemental oxygen via a nasal cannula (NC, flexible tubing with small prongs at one end inserted into the nostrils for the application of supplemental oxygen) at 3 liters per minute (l/m) continuously. Observation of Resident 8 on April 23, 2024, at 3:52 PM revealed the application of supplemental oxygen via a NC and a room concentrator (medical device used to concentrate the oxygen available in room air to administer oxygen-enriched supply back to the resident). The administration setting on the room concentrator was 2.5 l/m. Observation of Resident 8 on April 26, 2024, at 11:13 AM again revealed the application of supplemental oxygen via a NC and room concentrator at a rate of 2.5…

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

Based on review of select facility policies and procedures, clinical record review, observation, and staff interview, it was determined that the facility failed to assess the entrapment risk of assist bar use for two of six residents reviewed for accident concerns (Residents 8 and 20) Findings include: The facility policy entitled, Proper Use of Bed Rails, last reviewed without changes on March 29, 2024, revealed that it is the policy of the facility to utilize a person-centered approach when determining the use of bed rails. Entrapment, is an event in which a resident is caught, trapped, or entangled in the space in or about the bed rail. Resident assessment must also assess the resident's risk from using bed rails. Examples of the potential risks with the use of bed rails include accident hazards (e.g., falls, entrapment, and other injuries sustained from attempts to climb over, around, between, or through the rails, or over the footboard). The resident assessment should assess the resident's risk of entrapment between the mattress and bed rail or in the bed rail itself. The…

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

Based on clinical record review, observation, and family, resident, and staff interview, it was determined that the facility failed to arrange for behavioral health care and services to maintain the highest practicable well-being for one of four residents reviewed for behavioral concerns (Resident 78; University nursing unit, Resident 69). Findings include: Review of the Facility Assessment (document developed by the facility to determine what resources are necessary to care for its residents competently) revealed that the facility identified the number of specialty unit beds specifically for those with dementia and the diseases/conditions and physical/cognitive disabilities cared for included psychiatric/mood disorders. Resident acuity affecting licensed nurses included behavioral health, dementia, mood disorders (like bipolar disorder) and schizophrenia. Specific Care or Practices for the Mental Health and Behavior category included a current contract with a new service. Clinical record review for Resident 78 revealed a diagnoses list that included Wernicke's encephalopathy…

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 develop and implement individualized person-centered care plans to address dementia and cognitive loss displayed by one of two residents reviewed (Residents 56). Findings include: Clinical record review for Resident 56 revealed that the facility admitted him on June 20, 2023, with diagnoses including dementia (loss of memory, language, problem-solving, and other thinking abilities that interfere with daily life) with other behavioral disturbances. A review of Resident 56's admission Minimum Data Set Assessment (MDS, a form completed at specific intervals to determine care needs) dated June 28, 2023, indicated that the facility assessed Resident 56 as having a diagnosis of dementia. The facility determined that a care plan for dementia and cognitive loss would be developed. A review of Resident 56's care plan revealed that there was no indication that the facility had developed and implemented a person-centered care plan to address the resident's dementia and cognitive loss. The…

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

Based on clinical record review and staff interview it was determined that the facility failed to ensure that the consultant pharmacist reported irregularities to the attending physician and that the physician appropriately responded to reported irregularities for two of five residents reviewed for potentially unnecessary medications (Residents 20 and 52). Findings include: Clinical record review for Resident 20 revealed a consultant pharmacist recommendation to the physician on July 28, 2023, to evaluate Resident 20's use of the Oxcarbazepine medication (anti-seizure medication used to treat Resident 20's dementia with psychotic disturbance, condition where individuals with cognitive decline experience symptoms such as hallucinations and delusional thinking) from 150 mg twice daily. The certified registered nurse practitioner (CRNP) responded to the recommendation on August 25, 2023, that the recommendation was declined because the reduction would likely exacerbate Resident 20's underlying psychiatric disorder. Resident 20's active physician order for the Oxcarbazepine medication…

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

Based on clinical record review and staff interview, it was determined that the facility failed to ensure a resident's medication regime was free from potentially unnecessary medications for two of six residents reviewed for medication regime review (Residents 56 and 20). Findings include: Clinical record review revealed the facility admitted Resident 56 on June 20, 2023. Resident 56's clinical record revealed a physician's order dated June 26, 2023, noting the facility added Trazodone (an antidepressant-sedative medication) 100 milligrams (mg), one tablet on June 26, 2023, for insomnia. There was no diagnosis of insomnia at this time. Review of the consultant pharmacist recommendation dated September 25, 2023, revealed hypnotic/sedative medications should be reviewed for gradual dose reductions (GDR) to determine if symptoms can be controlled at a lower dose, or without the medication. The consultant pharmacist recommended a gradual dose reduction. Resident 56's physician indicated he is stable on his current regimen and his mood instability is too great. Review of the consultant…

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

Based on observation, clinical record review, review of select facility policies and procedures, and staff interview, it was determined that the facility failed to ensure a medication error rate below five percent (Residents 56 and 61). Findings include: The facility's medication error rate was 7.89 percent based on 38 medication opportunities with three medication errors. The policy entitled Medication Administration, last reviewed on March 29, 2024, indicates that medications will be administered by legally authorized and trained persons in accordance with applicable State, Local, and Federal laws and consistent with accepted standards of practice. The nurse is responsible to read the label comparing it to the medication administration record before preparing the medication. Observation of a medication administration pass on April 23, 2024, at 9:35 AM revealed Employee 15 (licensed practical nurse, LPN), prepared and administered Resident 56's medications. Employee 15 administered Resident 56's medications with water. Review of Resident 56's pharmacy medication label revealed that…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and resident and staff interview, it was determined that the facility failed to properly secure medications on one of three nursing units ([NAME] unit, Resident 23). Findings include: Observation of Resident 23's room on the [NAME] Hall on April 24, 2024, at 11:55 AM revealed her in her bed with her overbed table beside the bed on her left-hand side. Noted on the overbed table was a small medicine cup with four pills in it. Resident 23 reached over to her bedside stand to get the remote to turn down her television and she knocked over the medication cup spilling the four pills to the floor. She indicated to the surveyor that they were her morning pills that she did not finish taking because she forgot. The surveyor immediately alerted Resident 23's medication nurse about the event. Concurrent interview with Employee 16, Licensed Practical Nurse, revealed that he thought Resident 23 took the medications and was unaware they were still in a cup on her bedside table. The medications that were…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, observation, and staff and resident interview, it was determined that the facility failed to provide dental care services for two of five residents reviewed for dental concerns (Residents 8 and 20). Findings include: Interview with Resident 8 on April 23, 2024, at 3:12 PM revealed that she had not received dental services since being admitted to the facility on [DATE]. Resident 8 stated, My teeth are breaking and falling out. Observation of Resident 8 on the date and time of the interview revealed that she had missing, likely broken, and discolored natural teeth. Clinical record review for Resident 8 revealed an admission MDS (Minimum Data Set, an assessment tool completed at specific intervals to determine resident care needs) assessment dated [DATE], that assessed Resident 8 as having obvious or likely cavity or broken natural teeth with mouth or facial pain, discomfort, or difficulty with chewing. The dental care area triggered for staff to develop a plan of care to address…

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

Based on review of the facility's arbitration agreement and staff interview, it was determined that the facility's arbitration agreement failed to ensure a neutral and fair arbitration process by ensuring both the resident or his or her representative, have the opportunity for the selection of a venue convenient to both parties, and the selection of a neutral arbitrator, for one of one resident reviewed with a signed arbitration agreement (Resident 8). Findings include: Review of an Arbitration Agreement (an agreement that the resident and the facility will resolve legal disputes through binding arbitration, waiving their right to a trial) signed by Resident 8 on December 13, 2023, revealed that the arbitration agreement failed to allow for a choice of venue convenient to both parties. Further review of the facility's arbitration agreement revealed that the facility failed to provide for the selection of a neutral arbitrator (an impartial, or unbiased third-party decision maker, contracted with, and agreed to by both parties to resolve their dispute) as one is designated in the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on select facility policy and procedures, clinical record review and staff interview, it was determined that the facility failed to ensure that the resident and resident representative received written notice of the facility's bed hold policy at the time of transfer for two of four residents reviewed for hospitalizations (Residents 3 and CR1 ). Findings include: The current facility policy entitled, Transfer/Bed Hold/Return Policy, revealed that the facility provides the resident and responsible representative with notice of its bed hold policy upon admission and at the time of transfer or therapeutic leave from the facility to ensure continuity of care. Clinical record review for Resident 3 revealed that he was transferred to the hospital on January 18, 2024, for behavioral issues. A progress note dated January 18, 2024, at 3:08 PM revealed that the facility bed-hold agreement was printed and sent with the resident to the hospital per policy. Review of Resident 3's quarterly Minimum Data Set (MDS, an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy, review of clinical records, and staff interview, it was determined that the facility failed to ensure that a resident who was transferred from the facility with the expectation of returning was permitted to return, had met the specific requirements for a facility-initiated discharge, and/or provided evidence that the facility was not able to meet the resident's needs for one of four residents reviewed (Resident CR1). Findings included: The current facility policy entitled Transfer/Bed-Hold/Return Policy, revealed that the resident may resume residence in the facility following therapeutic leave or hospitalization if the resident required services provided by the facility and the resident was eligible for Medicaid nursing facility services or agrees to pay privately for these services. Closed clinical record review revealed that Resident CR1 was admitted on [DATE], with diagnoses of a tracheostomy (surgically placed throat breathing tube), enteral tube feed (surgically placed stomach…

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 thoroughly investigate and report allegations of potential staff to resident abuse for four of nine residents reviewed for abuse (Residents 3, 4, 12, and 13). Findings include: Interview with Employee 4, Director of Memory Care unit and Activities, on November 21, 2023, at 11:11 AM revealed that she did not witness any abuse related to Resident 3, but that her staff told her about it, and she directed them to write statements and give them to the Director of Nursing (DON). She also indicated that she knows the statements were reviewed but the event was not investigated because it was determined it was not verbal abuse and that the alleged perpetrator is always loud. She did not know who made that determination. Interview with the DON on November 21, 2023, at 12:25 PM revealed that she did receive staff statements alleging verbal abuse by Employee 8, nurse aide, but that after review determined that it was not abuse or a reportable event. Review of the staff statements provided to the…

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

Based on observation and staff interviews, it was determined that the facility failed to provide a clean, comfortable environment on one of four nursing units (Heirloom unit; Residents 1 and 6). Findings included: Observation of Resident 1's bathroom on September 19, 2023, at 11:20 AM revealed that there was paint chipping on the inside door frame. The cover on the light over the sink was falling off. The mirror in the medicine cabinet was not fitted right and appears to be off track. There appeared to be rust on the shelves inside the medicine cabinet and on the frame outside of the cabinet. The inside of the toilet bowl was dirty with a black ring. There was loose dirt behind the toilet and around the toilet base. There was paint peeling on the left wall (when looking at the toilet) beside the toilet. Observation of Resident 6's room at 11:30 AM on September 19, 2023, revealed his overbed table had a white colored spillage on the wheelbase. Behind the head of Resident 6's bed there was a broken floor tile that appeared to be wet. Further observation revealed that there was water…

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 personnel files, Pennsylvania State nurse aide registry information, and staff interview, it was determined that the facility failed to ensure current registry verification for one out of 20 registries reviewed (Employee 1). Findings include: Review of Employee 1's personnel file revealed that the facility hired her on June 5, 2023, and she began working in the facility on July 10, 2023. Further review revealed that Employee 1 completed the Personal Care Home and Assisted Living Direct Care Staff Training and Competency Test on November 15, 2023. Employee 1 did not complete a Pennsylvania State Nurse Aide Training Program, nor has she passed the Pennsylvania State Nurse Aide Written Examination or Skills Evaluation. A review of facility staffing records revealed that Employee 1 worked and provided resident care and services at the facility without appropriate Nurse Aide training and certification a total of 25 days since July 10, 2023. Interview with the Nursing Home Administrator and Director of Nursing on August 15, 2023, at 3:50 PM confirmed the above findings.…

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.