Gardens At Stevens, The

Based on observations, staff interviews, and review of facility records and policies, it was determined that the facility failed to implement contact precautions for a resident diagnosed with scabies (Resident R3).Findings include:Review of Resident R3's clinical record on October 29, 2025, revealed a diagnosis of scabies (a skin infestation caused by microscopic parasites that results in intense itching) with a start date of October 28, 2025.Review of the facility policy titled Scabies Identification, Treatment and Environmental Cleaning, revised August 2016, indicated: Affected residents should remain on Contact Precautions until twenty-four (24) hours after treatment.Further review of the clinical record failed to reveal any physician orders for contact precautions.Review of Resident R3's physician orders revealed an order for Permethrin 5% cream (a topical medication used to treat scabies) with a start date of October 28, 2025, and with a note to hold treatment until after a dermatology appointment scheduled for October 30, 2025.Observations conducted of Resident R3's room…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of clinical records, as well as family and staff interviews, it was determined that the facility failed to ensure that residents were provided with showers as scheduled for six of 8 residents reviewed (Resident 1,4,5,6,7,8). Findings include: An annual Minimum Data Set (MDS) assessment (a federally mandated assessment of the resident's abilities and care needs) for Resident 1, dated May 5, 2025, revealed that the resident was cognitively impaired and required moderate assistance from staff for personal care needs. Resident 1's shower schedule revealed that the resident preferred showering two times per week on Tuesday and Friday evening shift. Review of Resident 1's bathing records for May and June 2025 revealed that the resident received a bed bath on May 6, 16, 27, and June 3, 2025. There was no documented evidence Resident 1 was offered a shower on May 2,13,20,23, and 30, 2025. An admission diagnosis for Resident 4 revealed the resident was admitted to the facility on [DATE], with diabetes…

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 policies and clinical records, as well as staff interviews, it was determined that the facility failed to have sufficient nursing staff to provide showers as scheduled for six of 8 residents reviewed (Residents 1,4,5,6,7). Findings include: The facility's policy regarding bathing/showering, dated February 18, 2025, indicated that all residents will be provided a shower at least one time weekly. An annual Minimum Data Set (MDS) assessment (a federally mandated assessment of the resident's abilities and care needs) for Resident 1, dated May 5, 2025, revealed that the resident was cognitively impaired and required moderate assistance from staff for personal care needs. Resident 1's shower schedule revealed that the resident preferred showering two times per week on Tuesday and Friday evening shift. Review of Resident 1's bathing records for May and June 2025 revealed that the resident received one shower in the last 34 days. She had not refused any showers. An admission diagnosis for Resident 4…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record reviews and facility investigations, as well as staff interviews, it was determined that the facility failed to ensure that residents' clinical records were complete and accurately documented for six of 8 residents reviewed (Resident 1,4,5,6,7,8), and that documentation of incident was in the clinical records for one of 8 residents reviewed (Resident 1). Findings include: An annual Minimum Data Set (MDS) assessment (a federally mandated assessment of the resident's abilities and care needs) for Resident 1, dated May 5, 2025, revealed that the resident was cognitively impaired and required moderate assistance from staff for personal care needs. The shower record for Resident 1 for May and June 2025 revealed that on May 2,13,20,23, and 30, 2025 had no documentation. An admission diagnosis for Resident 4 revealed the resident was admitted to the facility on [DATE], with diabetes mellitus. The shower record for Resident 4 for May and June 2025 revealed that on May 21, 2025 NA was documented,…

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

Based on review of facility policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure a system of surveillance was in place to identify, prevent, monitor, and report potential infectious skin conditions. Findings include: Observations of Resident 5 on June 4, 2025, at 9:21 a.m. revealed the resident had a rash on her upper arms, chest and back. An interview with the resident on June 4, 2025, at 9:21 a.m. revealed the resident has had this rash for a while, and it feels like bugs crawling on her. Observations of Resident 3 on June 4, 2025, at 9:15 a.m. revealed resident had a rash all over his arms, chest, and back. A review of the resident's clinical records revealed that the resident receives permethrin cream (a medication for the treatment of scabies) on June 3, 2025, at 6:00 p.m. Interview with Resident 3 on June 4, 2025, at 9:45 a.m. revealed that he wasn't itchy for the first time in months after the treatment. Interview with the Nurse Practitioner on June 4, 2025, at 12:04 p.m. revealed that it is the…

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

Based on review of policies, clinical records and investigative reports, as well as staff interviews, it was determined that the facility failed to complete thorough investigations of incidents to rule out that neglect and/or abuse were involved for two of eight residents reviewed (Resident 1 and Resident 8). Findings include: Review of the facility Abuse Policy, dated February 18, 2025, section labeled investigation and Reporting allegation of Abuse guidelines. States All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source shall be promptly reported to local state and federal agencies and thoroughly investigated by the administrator and or designee. A Quarterly Minimum Data Set (MDS) assessment (a federally mandated assessment of a resident's abilities and care needs) for Resident 1, dated May 5, 2025, indicated that the resident was cognitively impaired, was sometimes able to understand and sometimes understood by others, required moderate assistance from staff for her care, and had diagnoses 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.

Based on review of Pennsylvania's Nursing Practice Act, facility policies, and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that an assessment was completed by a registered nurse (RN) after an incident occurred where a male resident was found in her bed for one of 8 residents reviewed (Resident 1). Findings include: The Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.11 (a)(1)(2)(4) indicated that the registered nurse was to collect complete and ongoing data to determine nursing care needs, analyze the health status of individuals and compare the data with the norm when determining nursing care needs, and carry out nursing care actions that promote, maintain, and restore the well-being of individuals. The facility's risk management guide for incident and accidents, dated February 18, 2025, indicated that there should be an RN assessment after the incident in the clinical record. A Quarterly Minimum Data Set (MDS) assessment (a federally mandated assessment of a resident's abilities…

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 upon review of employee records, it was determined the facility failed to ensure that nuse aides completed 12 hours of annual inservice training for five of five employee files reviewed. Findings include: Five nurse aide employee files were reviewed for completion of the 12 hour annual inservice training. Review of the five nurse aide employee files failed to reveal evidence that the five nurse aides completed the required 12 hour annual inservice training. Interview with the Nursing Home Administrator on March 14, 2025 at 12:00 p.m. confirmed the five nuse aides did not complete the 12 hour annual inservice training required.

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 ensure that resident assessments accurately reflect the residents' status for five of 24 residents reviewed (Residents 1, 39, 45, 58 and 74). Findings include: Review of Resident 1 quarterly MDS (Minimum Data Set - periodic assessment of resident needs) dated February 2, 2025, revealed under section N0415 - High Risk Drug Classes, that the resident was marked as receiving anticoagulant medication. Review of Resident 1's physician orders revealed that the resident was not ordered an anticoagulant. Review of the Medication Administration Record (MAR) revealed that the resident did not receive an anticoagulant. Review of Resident 39's quarterly MDS dated [DATE], revealed under section N0350 - Insulin, that the resident was marked as receiving insulin medication. Review of Resident 39's physician's orders revealed that the resident was not ordered insulin. Review of the MAR revealed that the resident did not receive…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, resident interviews, clinical record review, review of facility documentation, and staff interview, it was determined that the facility failed to provide the necessary services to maintain personal hygiene for residents unable to carry out activities of daily living for four of 24 residents reviewed (Residents 2, 6, 14, and 25). Findings include: Review of facility policy, Shower/Bathing Policy, revised August 2018 revealed that resident's preferences will be considered and shower/bath/bed bath shall be provided at least weekly. Interview during a group meeting on March 12, 2024, at 1:30 p.m. with alert and oriented Residents 2, 6, 14, revealed that they do not receive showers as scheduled because of staffing shortages. Additional interview with Resident 25 on March 13, 2025, at 9:45 a.m. indicated that the resident does not receive showers. Review of Resident 2's admission MDS (Minimum Data Set - periodic assessment of resident needs) dated February 10, 2025, indicated 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.

Based upon review of Pharmacy Medication Management Reviews (MRR), clinical record reviews, and staff interviews it was determined the facility failed to ensure the pharmacy reviewed the medication regimen of each resident monthly and failed to ensure the physician addressed all recommendations with rationales for disagreeing with recommendations timely for four of five residents reviewed (Resident 5, Resident 28, Resident 34 and Resident 59). Findings include: Review of Resident 5's clinical record revealed the pharmacist reviewed Resident 5's medications and made recommendations on March 18, 2024, June 21, 2024, September 16, 2024, and February 8, 2025. Further review of Resident 5's clinical record failed to reveal evidence the physician responded to the March 18, 2024, and September 16, 2024, pharmacy recommendations. Review of Resident 5's clinical record revealed a pharmacy recommendation dated June 21, 2024, to evaluate multiple medications for pain. Further review of this recommendation revealed the physician failed to supply a rationale for disagreeing with the pharmacy…

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

Based upon clinical record review and interview, it was determined the facility failed to monitor resident's fluid restriction and complete treatments according to physician orders for two of 24 residents reviewed (Residents 4 and 45). Findings include: Review of Resident 4's diagnosis list revealed diagnoses including congestive heart failure (excessive body/lung fluid caused by a weakened heart muscle). Review of Resident 4's physician's orders dated January 28, 2025, revealed an order for Fluid Restriction: 1500 ml (milliliters) total per 24 hours as follows: Dietary Dept. 1080 ml on meal trays: (breakfast 360 ml; lunch 360 ml; dinner 360 ml); Nursing Dept. 420 ml: (days 180 ml; p.m.'s 150 ml, night 90 ml). Review of Resident 4's clinical record including January, February and March 2025 Medication Administration Record (MAR) failed to reveal evidence that nursing was monitoring Resident 4's total daily fluid intake in conjunction with the Dietary department. Interview with the Nursing Home Administrator and Director of Nursing on March 14, 2024, at 11:00 a.m. confirmed 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 upon review of facility policy and procedure and clinical record review, it was determined the facility failed to ensure routine nutrition was monitored by failing to obtain re-weights and follow recommendations made by registered dietitian for one of eight residents reviewed (Resident 66). Findings include: Review of policy and procedure titled Weight Assessment and Intervention, revealed Any weight change of 5 pounds or more since the last weight assessment will be retaken for confirmation. If the weight is verified, nursing will notify the physician and dietitian. Further review of this policy revealed The threshold for significant unplanned and undesired weight loss will be based on the following criteria - a) 1 month - 5% weight loss is significant; b) 3 months - 7.5% weight loss is significant and c) 6 months - 10% weight loss is significant. Review of Resident 66's Weight Summary revealed a weight of 122.8 pound on February 26, 2025, and a weight of 116.2 pounds on March 7, 2025. Clinical record review revealed a dietitian note dated March 7, 2025, stating Resident 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 clinical record review and staff interview, it was determined that the facility failed to timely provide dental services for one of three residents reviewed (Resident 19). Findings include: Review of Resident 19's progress note of January 6, 2025, revealed that the resident's lower dentures fell on the floor and back part of the denture broke. Dentures were placed at the nursing station. Review of Resident 19's progress note of March 13, 2025, revealed that the resident's POA (power of attorney) felt that dentures would be beneficial and requested that process be initiated. Resident was added to the dentist list to be seen. Further review of the clinical record revealed no evidence that the resident was referred for dental services for the broken dentures. Interview with Employee E4 on March 14, 2025, at 12:20 p.m. confirmed that the resident had not been referred for dental services. 28 Pa. Code: 211.5(f) Clinical records Previously cited 2/1/24 28 Pa. Code: 211.12(d)(1)(3)(5) Nursing services Previously cited 2/1/24 28 Pa. Code: 211.15(a) Dental services

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based upon review of facility policy and procedure, observation and clinical record review, it was determined the facility failed to ensure appropriate personal protective equipment was available and appropriate door notification was in place for residents on Enhanced Barrier Precautions for two of five residents reviewed (Resident 4 and Resident 63). Findings include: Review of facility policy and procedure titled Enhanced Barrier Precautions revealed Enhanced Barrier Precautions (EBP) are utilized as an infection prevention and control intervention to reduce the spread of multi-drug-resistant organisms (MDROs) to residents. EBPs are indicated (when contact precautions do not otherwise apply) for residents with wounds and/or indwelling medical devices regardless of MDRO colonization. Further review of this policy revealed Examples of high-contact resident care activities requiring the use of gown and gloves for EBPs include dressing; bathing/showering; transferring; providing hygiene; changing linens; changing…

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 records review, and staff interviews, it was determined that the facility failed to provide nail care for one of the three residents reviewed (Resident 1). Findings include: A review of Resident 1's admission Minimum Data Set (MDS-a standardized assessment tool that measures health status in long-term care residents), dated January 6, 2025, revealed that the resident had a moderate cognitive impairment. The same MDS indicated that the resident required partial/moderate assistance with personal hygiene. An observation conducted on January 21, 2025, at 10:40 a.m. revealed that Resident 1 was lying in bed and was calm and cooperative. The resident's fingernails were observed: left-hand pinky, middle, thumb, and right hand. All five fingernails were approximately 0.5-1 cm (centimeter) long and had dried brown stain/substance underneath. An interview conducted with non-licensed Employee E3 on January 21, 2025, at 12: 15 p.m. revealed that morning care was provided to the resident around 11:00 a.m. The resident's long and dirty fingernails were observed but…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based upon observation, it was determined the facility failed to properly label insulin pens and vials with open and expiration dates for four of four medication carts observed (First floor medication carts and Second Floor medication carts). Findings include: Observation on [DATE], at 11:30 a.m. of the first Second Floor medication cart revealed one open Basaglar Insulin pen with no open or expiration date on the label. Further observation of the first Second Floor medication cart revealed one open Humalog Insulin Pen with an open date of [DATE]. This insulin pen expired [DATE]. Observation on [DATE], at 11:45 a.m. of the First Floor Back Hall medication cart revealed two open Lispro Insulin Pens with an open date of [DATE], and no expiration date. This insulin expired [DATE]. Further observation of the First Floor Back Hall medication cart revealed a Lantus Insulin pen with no open date. Observation on [DATE], at 11:50 a.m. of the First Floor Front Hall medication cart revealed one open Lispro Insulin vial…

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 upon clinical record review and observation, it was determined the facility failed to accurately complete an assessment prior to the placement of a wanderguard for one of 18 residents reviewed (Resident 55). Findings include: Review of Resident 55's Quarterly Minimum Data Set (MDS - periodic assessment of resident needs) dated May 25, 2023, revealed Resident 55 had a Brief Interview for Mental Status Score of 15 indicating Resident 55 was cognitively intact. Review of Resident 55's progress notes dated June 28, 2023, revealed Resident triggered alarm on exit doors, attempting to go outside to smoke per his statement to staff. Wanderguard bracelet to right ankle for elopement risk. Educated resident to what it was and why it was being placed. Resident allowed this writer to place bracelet. Review of Resident 55's clinical record failed to reveal evidence of an Elopement Risk Assessment completed prior to June 28, 2023, or prior to the June 28, 2023, incident. Review of Resident 55's clinical record failed to reveal if Resident 55 was trying to elope or just attempting to go…

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 the facility failed to ensure residents had physician orders corresponding with their end of life care wishes for two of 24 residents reviewed. (Residents 15 and 21) Findings include: Review of Resident 15's clinical record revealed an admission date of November 21, 2023. A POLST (Pennsylvania Orders for Life Sustaining Treatment) located on paper chart indicated the resident wishes but was unsigned. Further review of the clinical record failed to reveal further documentation of who completed the POLST or why it continued to be unsigned. Review of the physician orders from admission indicated the resident was a DNR (Do Not Rescusitate). Interview conducted with the Nursing Home Administrator (NHA) and Director of Nursing (DON) on February 1, 2024, revealed neither individual knew who completed the POLST documentat and why document was not signed. Administration confirmed the physician's order should not be completed until a family signature or verbal agreement was obtained. Review of Resident 21's clinical record…

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 interviews it was determined that a change in condition for one out of 24 residents (Resident 46) was not reported to the physician and a delay in diagnostic testing for one out of 24 residents (Resident 62) was not reported to the physician. Findings include: Review of Resident 46's clinical record revealed a COVID positive test on December 8, 2023 and the family was notified. There was no further documentation stating that the physician was told of this change in condition. Review of Resident 62's clinical record revealed a nursing note dated December 15, 2023, indicating the resident presented with a productive cough and wheezing presented in b/l lobes (both lungs) on expiration. Resident 02 (oxygen) is 95 on RA (room air). This nurse notified PCP (primary care physician). New orders include Ipratropium-Albuterol Solution QID X3 days (type of inhaler) and Chest X-ray 2 view. This nurse called {xray company] and ordered the xray. Noting the confirmation number. Further investigation revealed that the X-Ray company called the facility 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 observation and staff interview it was determined that the facility failed to maintain clean resident care equipment for one of 24 residents (Resident 2). Findings include: Observations conducted during an environmental tour of the facility on January 29, 2024, at approximately 9:05 a.m. on the second floor revealed Resident 2 sitting in a wheelchair with dried brown substance on his/her right armrest and a dried white substance on his/her right armrest. Follow up observations conducted January 30, 2024, at 9:06 a.m. and January 31, 2024, at 8:52 a.m. revealed Resident 2's wheelchair was observed with the same dried brown and white substances on his/her armrests. Interview conducted with the Nursing Home Administrator (NHA) on January 31, 2024, at 1:15 p.m. produced copies of daily wheelchair cleaning logs for the months of December 2023, and January 2024. Review of daily wheelchair logs, revealed Resident 2's wheelchair was last cleaned on December 19, 2023. The Nursing Home Administrator confirmed Resident 2's wheelchair was last cleaned on December 19, 2023. Pa. Code…

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

Based on facility policy, clinical record review, and interviews with staff it was determined that the facility failed to investigate an injury of unknown origin for one of 24 residents reviewed (Resident 66). Findings include: Review of the facility Abuse Policy, dated January 2020, section labeled investigation and Reporting allegation of Abuse guidelines. States All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source shall be promptly reported to local state and federal agencies and thoroughly investigated by the administrator and or designee. Investigation -Timely and thorough investigations of all reports and allegations of abuse to include injuries of unknown origin. Review of Resident 66's clinical record revealed a nursing note dated January 6, 2024, stated during the shift, this nurse was notified that the resident is experiencing pain, swelling and hematomas (bruise) on the left foot. Site is warm to the touch, no erythema (unusual redness) present . Resident stated she is having difficulty…

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 upon clinical record review and interview, it was determined the facility failed to complete an accurate Minimum Data Set assessment for one of 18 residents reviewed (Resident 26). Findings include: Review of Resident 26's clinical record revealed an Annual Minimum Data Set (MDS -periodic assessment of resident needs) completed on November 2, 2023. Further review of Resident 26's Annual MDS revealed Resident 26 had a urinary catheter. Review of Resident 26's clinical record failed to reveal evidence of a urinary catheter. Interview on January 31, 2024, at 10:15 a.m. with Employee E3 revealed that the Annual MDS submitted and completed on November 2, 2023, did indicate Resident 26 had a urinary catheter. Additional interview with Employee E3 revealed, Resident 26 did not have a urinary catheter. The above information was conveyed to the Nursing Home Administrator at 10:00 a.m. on February 1, 2024. 28 Pa. Code 211.5(f) Clinical Records Previously cited 3/15/2023

Based on clinical record review and interviews with the staff it was revealed that the facility failed to create a suicidal ideation baseline care plan for one of 24 residents reviewed (Resident 66). Findings include: Review of Resident 66's clinical record revealed an admission date of November 20, 2023. Review of the hospital discharge records revealed that the resident was admitted to the emergency room because her son was concerned about a suicidal statement (with a plan) when they were at home. The resident was admitted to the hospital for suicidal ideation. Review of Resident 66's care plan revealed that suicidal ideation was not on the baseline care plan. An interview with the Nursing Home Administrator and Director of Nursing on February 1, 2024, revealed that the facility did not have a baseline careplan for suicidal ideation. 28 Pa Code 201.18(b)(3) Management 28 Pa. Code 211.12 (d)(1)(3)(5) Nursing services

Based upon review of clinical records, it was determined the facility failed to establish a care plan for the development of a wound for one of 18 residents reviewed (Resident 14). Findings include: Review of Resident 14's progress notes dated December 11, 2023, revealed 2.5cm x 2cm open area noted on residnets left testicle during HS care. Zicn oxide ointment applied. Will continue to monitor. Review of Resident 14's care plan failed to reveal evidence that a care plan was established regarding the above-mentioned wound. Interview with the Nursing Home Administrator and Director of Nursing on February 1, 2024, at 10:15 a.m. confirmed the facility did not have a care plan for Resident 14's wound. 28 Pa. Code 211.11(a)(b)(c)(d)(e) Resident care plan Previously cited 5/13/2023

Based on review of the clinical record and interviews with staff it was determined that the facility failed to follow physician orders for one of 24 residents reviewed ( Resident 59). Findings include: Review of Resident 59's clinical record revealed physician orders on June 15, 2023, for HumaLOG KwikPen Solution Peninjector 100 UNIT/ML (Insulin Lispro (1 Unit Dial)) Inject 8 unit subcutaneously three times a day for diabetes Hold if BS (blood sugar) < (less than) 110, for diabetes. Review of the Medication Administration Records (MAR) revealed the resident was given insulin when the blood sugars were below 110: October 11 (89), October 16 (108), November 17 (104), December 12 (84), January 11 (94), and January 28 (108). An interview with the Nursing Home Administrator and Director of Nursing was conducted on February 1, 2024, at 9:35 a.m., revealed that the insulin should not have been administered on the dates mentioned above for Resident 59. 28 Pa. Code 201.18(b)(1) Management 28 Pa. 211.12(d)(1)(3)(5) Nursing services 28 Pa. Code 211.5(f) Clinical records

Based on clinical record review and interviews with staff, it was determined that the facility failed to ensure that diagnostic services were provided in a timely manner to meet the needs one of 24 residents reviewed. (Resident 62). Findings include: Review of Resident 62 clinical record revealed a progress note dated December 15, 2023, which revealed, the resident presented with a productive cough and wheezing presented in (both) lobes on expiration. Resident 02 (oxygen) is 95 on RA (room air). This nurse notified the physician. New orders include Ipratropium-Albuterol Solution QID X3 days (an inhaler) and Chest X-ray 2 views. The diagnostic company was called, and confirmation number obtained. On December 15, 2023, the diagnostic company called and stated that they will not be able to get her today for the ordered x-ray but will be in the following day. On December 16, 2023, the facility phoned the diagnostic company and asked when they planned to do x-ray on this resident, the receptionist apologized and stated that she could not provide the exact time because they are very busy…

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 that the facility failed to maintain infection control practices to prevent spread of infection for one of 24 sampled residents. (Resident 52). Findings include: Interview conducted with the Nursing Home Administrator (NHA) on January 29, 2024, at 9:03 a.m. revealed Resident 52 tested positive for COVID-19 on January 19, 2024, and was subsequently placed on contact precautions (precautionary measures used while caring for residents with infections, diseases, or germs that are spread by touching the resident or items in the resident's room) on January 19, 2024. Observations conducted on January 29, 2024, at 9:20 a.m. revealed Resident 52 did not have any PPE (personal protective equipment) stationed outside the room door. Further observation noted absence of signs on the resident's door indicating PPE required to enter Resident 52's room. Interview conducted with the infection preventionist coordinator (IPC) on January 31, 2024, at 1:50 p.m. confirmed PPE should be present outside Resident 52's room along with signs…

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 policy review, and staff interview it was determined the facility failed to report an allegation of abuse for one of 5 residents reviewed. (Resident 5) Findings Include: Review of facility policy titled Abuse Policy, last revised September 2022 revealed all reports of resident abuse .shall be promptly reported to local, state and federal agencies (as defined by regulations). Review of Resident 5's clinical record revealed a behavior note dated October 1, 2023 at 12:30 p.m. stating This writer observed resident playing with Resident 4's breast Resdient 5 removed hands leaving Resident 4's breast exposed. Review of facility incident report revealed there was no evidence the state agency was notified of this incident of abuse. Review of Event Report system revealed no event report for this incident of abuse. Interview with the Director of Nursing on October 4, 2023 at 1:30 p.m. confirmed this incident of abuse was not reported to the state agency. 28 Pa. Code: 201.18(b)(1)(e)(1) Management 28 Pa. Code: 201.29(d) Resident rights 28 Pa. Code:…

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

Based on clinical record review, staff and resident interviews it was determined that the facility failed to ensure sufficient staffing to promote physical and wellbeing of four of six residents reviewed were honored for showering for four of five residents reviewed (Residents R1, R2, R5, and CL1). Findings include: Interview conducted with Resident R1 approximately 5:25 p.m. revealed that Resident R1 has not received showers per his preference of minimum of twice weekly. Further interview with resident revealed, I was told that they don't have enough staff to give us residents showers more than once per week. Resident stated that he only got one shower since he/she was admitted in June 2023. Additional interview conducted with Resident R1 revealed that he/she has not refused bathing/shower at any time during stay at facility. Review of Resident R1's clinical record including Resident R1's shower/bathing tasks revealed on July 25, 2023 Resident R1 was given a shower. Further review revealed that Resident R1 was given a bed bath on July 11, 2023. Additional review of Resident R1's…

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

Based on facility policy, resident interview, and observation it was determined the facility failed to ensure residents are treated with respect and dignity for one of five residents reviewed (Resident R1). Findings include: Review of facility policy titled, Quality of life -Dignity with revision date of August 2009, indicated; Residents shall be treated with dignity and respect at all times. Further review of facility policy titled Quality of life -Dignity revealed under number six, Residents' private space and property shall be respected at all times. Additional review of same policy revealed 6a indicated, staff will knock and request permission before entering residents' rooms. Interview conducted on August 7, 2023 at approximately 5:00 p.m. with Resident R1 revealed concerns for interactions with staff caring for Resident R1. Resident R1 reported, There are a few that are mean and talk to you like a child. Resident R1 stated, the staff are not very friendly, it's like they don't want to help you. Observation conducted on August 7, 2023 at approximately 5:15 p.m. revealed non…

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, staff and resident interviews it was determined that the facility failed to ensure that resident preferences were honored for showering for four of five residents reviewed (Residents R1, R2, R3 and R5). Findings include: Interview conducted with Resident R1 approximately 5:25 p.m. revealed that Resident R1 has not received showers per his preference of minimum of twice weekly. Further interview with resident revealed, I was told that they don't have enough staff to give us residents showers more than once per week. Resident stated that he only got one shower since he/she was admitted in June 2023. Additional interview conducted with Resident R1 revealed that he/she has not refused bathing/shower at any time during stay at facility. Review of Resident R1's clinical record including Resident R1's shower/bathing tasks revealed on July 25, 2023 Resident R1 was given a shower. Further review revealed that Resident R1 was given a bed bath on July 11, 2023. Additional review of Resident R1's clinical record indicated Resident R1 refused bath/showers on July…

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.