Stroudsburg Post Acute Nursing & Rehabilitationllc

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of clinical records, air mattress manufacturer guidance, select facility policy, observations, and staff interviews, it was determined the facility failed to consistently implement pressure injury prevention interventions by failing to ensure specialty air mattresses were properly configured and operated according to manufacturer guidance and resident-specific weight parameters for two of nine residents reviewed (Residents 2 and 4).Findings include: A review of facility policy titled Pressure Injury Prevention, last reviewed by the facility on May 30, 2025, revealed it is the facility policy to provide evidence-based preventive skin care and wound treatment to prevent skin complications. The facility will provide pressure redistribution and relief devices (bed support surface) according to interdisciplinary assessment and recommendation. All standard mattresses are pressure-relieving and will be used for all residents unless the provider orders a higher level of pressure reduction or specialty…

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, resident financial account documentation, billing records, and staff interview, it was determined the facility failed to provide a final accounting of personal funds for one discharged resident (Resident CR1) within 30 days of discharge, in accordance with regulatory requirements, for one of seven residents reviewed for resident funds.Findings include: Clinical record review revealed that Resident CR1 was admitted to the facility on [DATE], and was discharged on September 12, 2025. Review of financial documentation provided by the facility revealed that the resident's responsible party had paid the facility for the month of September 2025 in advance. Documentation provided by the facility included an email dated November 12, 2025, from the Nursing Home Administrator to the resident's responsible party indicating the resident's account had not yet been reconciled because the facility was awaiting payments from other sources and remained pending. Additional documentation…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of clinical records, facility policy, resident interviews, and staff interviews, it was determined the facility failed to develop and implement an individualized discharge planning process that addressed residents' discharge goals and incorporated those goals into the resident's comprehensive care plan for two of seven residents reviewed (Residents 3 and 4). Findings include: A review of Resident 3's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses including schizophrenia (a severe mental disorder that affects how a person thinks, feels, and behaves and may involve hallucinations, delusions, and disorganized thinking). A review of a quarterly Minimum Data Set assessment (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) dated January 2 2026, revealed that Resident 3 was cognitively intact with a BIMS score of 15 (Brief Interview for Mental Status a tool within the cognitive section of the MDS 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 a review of clinical records, select facility policy, observations, and resident and staff interviews, it was determined the facility failed to provide person-centered care as prescribed to meet the resident's current clinical needs and failed to follow physician orders for the management of a Peripherally Inserted Central Catheter (PICC) line for one of 7 sampled residents (Resident 2).Findings include: A review of the facility policy entitled PICC Dressing Change Policy, (PICC, a long, thin tube inserted into a vein and advanced to larger veins near the heart to deliver medications such as antibiotics directly into the bloodstream) last reviewed May 30, 2025, indicated staff are to change the transparent semi-permeable barrier dressing (a covering that allows gases such as oxygen to pass through while preventing bacteria and fluids from entering) every seven days and immediately if the dressing becomes loose, wet, soiled, or non-occlusive (not sealed and allowing fluid or air to pass through), or if…

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 maintain acceptable practices for the storage and service of food to prevent the potential for contamination and microbial growth in food, which increased the risk of food-borne illness in the food and nutrition services department. Findings include:Food safety and inspection standards for safe food handling indicate that everything that comes in contact with food must be kept clean and food that is mishandled can lead to foodborne illness. Safe steps in food handling, cooking, and storage are essential in preventing foodborne illness. You cannot always see, smell, or taste harmful bacteria that may cause illness according to the USDA (The United States Department of Agriculture, also known as the Agriculture Department, is the U.S. federal executive department responsible for developing and executing federal laws related to food). Observation during the initial tour of the food and nutrition services department on July 22, 2025, at 10:45 AM revealed a tray of seven (7) thawed 4-ounce nutritional…

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 policy, observations and staff interview, it was determined the facility failed to provide meal service in a manner that maintained the resident's dignity by allowing extended delays in meal delivery at shared tables for seven residents out of 21 sampled (Residents 33, 15, 67, 35, 2, 23, and 37)Findings include:Review of the facility policy titled Resident Rights last reviewed by the facility on May 30, 2025, revealed the facility will make every effort to assist each resident in exercising his/her rights to assure that the resident is always treated with respect, kindness, and dignity. An observation conducted on July 22, 2025, at 12:10 PM, revealed Residents 33, 15, 67, and 35 were seated together at Dining Table #5 in the main dining room. At 12:20 PM, Resident 35 was served her lunch meal and began eating. The other residents seated at the same table remained without meals. Staff continued serving lunch to other residents in the dining room. At 12:35 PM 15 minutes after Resident 35 received her meal Resident 67 was served. At 12:40 PM 20…

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 the facility failed to develop and implement a baseline care plan within 48 hours for two of 17 residents reviewed that were admitted during the prior 30 days (Residents 88 and 90). Findings include: A review of Resident 88’s clinical record revealed that the resident was admitted to the facility on [DATE], with diagnoses that included End-Stage Renal Disease (ESRD) the final stage of chronic kidney disease where the kidneys can no longer function adequately, requiring dialysis (a medical process that filters waste and excess fluid from the blood) or a kidney transplant for survival and diabetes mellitus, a chronic condition characterized by elevated blood glucose (sugar) levels over an extended period. A nursing progress note dated July 17, 2025, at 11:19 PM, documented that the resident was alert and oriented, was actively receiving dialysis, and had a fistula on her left arm (a surgically created connection between an artery and a vein 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of clinical records, select facility policy, and staff interviews, it was determined the facility failed to provide nursing services consistent with professional standards of quality to ensure that licensed nurses properly evaluated and provided nursing care according to physician orders for one resident out of 21 residents reviewed (Resident 20). Findings include:A review of a facility policy titled Medication Administration, last reviewed on May 30, 2025, revealed that it is the policy of the facility to provide a secure and safe method of administering medications to the residents.According to the Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.11 (a)(1)(2)(4) indicates that the Registered Nurse (RN) was to collect complete 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…

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, a review of clinical records, select facility policy, and resident and staff interviews, it was determined the facility failed to implement interventions to prevent the development of a pressure injury for one resident out of 21 sampled (Resident 1). Findings include: A review of the facility policy titled Pressure Ulcer Prevention, last reviewed by the facility on May 30, 2025, revealed it is the facility's policy to promote healthy intact skin, educate patients and/or significant others about pressure ulcer prevention, identify at-risk residents, and implement appropriate skin care treatments as determined by the Registered Nurse (RN) or designated skin care provider. A clinical record review revealed Resident 1 was admitted to the facility on [DATE], with diagnoses that included diabetes (a chronic disease that occurs either when the pancreas does not produce enough insulin or when the body cannot effectively use the insulin it produces) and peripheral vascular disease (a condition in…

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, clinical record review, facility policy review, and staff interviews, it was determined the facility failed to ensure that appropriate physician's orders, a documented medical justification, and an individualized plan of care were in place for the use and management of an indwelling urinary catheter for one of 21 residents reviewed. (Resident 87).Findings include:A review of a facility policy titled Urinary Foley Catheter Care, last reviewed by the facility on May 30, 2025, revealed it is the policy of the facility that all residents who are either admitted , readmitted , or having an indwelling urinary catheter inserted or changed will have the procedure documented in the medical record by the licensed nurse. The licensed nurse will also document in the Medication Administration Record (MAR) the size of the Foley catheter, the balloon size, and any special instructions, and that appropriate nursing personnel will provide catheter care within the scope or function of their practice. Further…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of the facility's plan of correction from the survey ending July 25, 2025, the documented outcomes of the facility's Quality Assurance and Performance Improvement (QAPI) committee, observations, clinical record reviews, and staff interviews, it was determined the facility failed to ensure its quality assurance program effectively identified and addressed recurring deficient practices related to the development and implementation of resident baseline care plans (Residents 1 and 10) and nursing services consistent with professional standards of quality to ensure that licensed nurses properly evaluated and provided nursing care according to physician orders (Residents 1, 9 and 16). Findings include: As a result of the deficiencies cited under the requirements related to the development and implementation of resident baseline care plans and nursing services consistent with professional standards of quality to ensure that licensed nurses properly evaluated and provided nursing care according 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, a review of clinical records and select facility policy, and resident and staff interviews, it was determined the facility failed to implement procedures for smoking safety and safety of smoking areas, as evidenced by one out of the two residents sampled who smoke (Resident 39).A review of the facility policy titled Smoking/Vaping Policy, last reviewed by the facility on May 30, 2025, revealed it is the policy of the facility to maintain an environment that promotes the safety and well-being of our residents, employees, and visitors through established processes that support this goal. The policy indicates for residents an initial resident smoking assessment will be completed upon admission for all residents who smoke or vape. Safety considerations for each resident include, but are not limited to, whether the resident requires assistance, the extent of assistance or supervision required, and any restrictions or special equipment that might be needed to ensure safety. The interdisciplinary…

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, review of select facility policies, and staff interviews, it was determined that the facility failed to investigate the potential cause of new pressure injuries and failed to consistently implement preventive interventions to avoid the development of pressure injuries for one of five sampled residents (Resident 2). Findings include: A review of a facility policy for Pressure Ulcer/Wound Treatment Protocol and Policy, adopted April 2, 2025 revealed, the purpose of the procedure is to provide guidelines for the care of existing pressure ulcers and the prevention of additional pressure ulcers. General guidelines to include the pressure ulcer treatment program should focus on the following strategies: assessing the resident and the pressure ulcer managing tissue loads pressure ulcer care education and quality improvement. When eschar is present, a pressure ulcer cannot be accurately staged until the eschar is removed. Determine, based on physician order if the resident will be 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, facility policy review, and staff interview, it was determined the facility failed to implement non-pharmacological interventions prior to the administration of a narcotic pain medication and failed to ensure that physician orders for the administration of the narcotic pain medication contained clear parameters for use, for one of five sampled residents (Resident 2). Findings include: A review of the facility's policy titled Pain Management, adopted April 2, 2025, indicated the goal of pain management is a pain level of zero or a pain level considered tolerable by the resident and that does not interfere with activities of daily living (ADLs). The policy instructed nursing staff to evaluate and document pain findings every shift on the electronic medication administration record (eMAR) and required that PRN (as needed) pain medications include a documented pain level at the time of administration. Pain was to be assessed using a numerical scale from 1 to 10 (1 representing no…

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

Based on observation and staff interview, it was determined the facility failed to ensure adherence to medication expiration/use by dates on one of six medication carts (A2/Cart E even) and failed to ensure biologicals were properly dated when opened and available for use for one of 21 residents reviewed. (Resident 14). Findings include: A review of manufacturer instructions for storage of Lantus Solostar Insulin Pen revealed that the pen should be stored in the refrigerator until ready to use. Once the insulin pen is taken out of refrigerator for use, it may be used for up to 28 days. Observation of the medication cart on A2 identified as Cart E even, on September 12, 2024, at 9:08 a.m., in the presence of Employee 4, a Licensed Practical Nurse (LPN) revealed two opened Lantus insulin pen(medication to treat diabetes) in individual pharmacy labeled bags. Further review of the insulin pens revealed that neither pen was dated when opened or had an expiration/use by date indicated on the packaging. Additional observation of the undated insulin pens revealed that each individual…

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

Based on a review of the facility's plan of correction from the survey ending September 13, 2024, the results of the current revisit survey on November 27, 2024, observation, and staff interviews it was determined the facility's Quality Assurance Performance Improvement (QAPI) committee failed to correct quality deficiencies and identify ongoing deficient practices related to storage and use by dates of multi-use medications and controlled substance accountability. Findings include: As a result of the deficiencies cited under the requirements related to the acceptable storage and use by dates of multi-use medications, and pharmacy procedures to promote accurate controlled medication records during the survey of September 13, 2024, the facility developed a plan of correction to serve as their allegation of compliance, which included a quality assurance monitoring component to ensure solutions were sustained. The corrective plan was to be completed and functional by October 31, 2024. However, during the survey ending November 27, 2024, continuing deficient facility practice was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of clinical records and the Resident Assessment Instrument (RAI) and staff interview, it was determined the facility failed to ensure the Minimum Data Set Assessments (MDS - a federally mandated standardized assessment conducted at specific intervals to plan resident care) accurately reflected the status of three residents out of 21 sampled (Residents 59, 66, and 24). Findings included: A review of Resident 59's clinical record revealed the resident was admitted to the facility on [DATE] with diagnoses which included dementia (a condition characterized by progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change, resulting from disease of the brain). A review of Resident 59's Quarterly MDS assessment dated [DATE], revealed in Section P0100, Physical Restraints, Resident 59 required a trunk restraint while in a chair documented as Code 1 indicating the device was used less than daily. A review of…

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

Based on review of clinical records, select facility policy, and resident and staff interviews it was determined the facility failed to maintain an environment free of potential accident hazards during medication administration for one resident of 21 sampled (Resident 39). Findings include: A review of facility policy titled Medication Administration, last reviewed by the facility on November 17, 2023, indicated that for each medication, the medication administration record and the label on the medication container will be checked for the correct name of the resident and medication, time to be administered, strength, and route of administration. If any discrepancies, check with the physician's order and the pharmacy before giving the medication. The policy also indicated that residents may self-administer their own medications unless their attending physician deemed them not capable of doing so. Review of clinical records for Resident 39 revealed admission to the facility on December 17, 2023, with diagnosis to include Alzheimer's disease (a progressive brain disease that destroys…

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 policy and clinical records, and staff interview it was determined the facility failed to monitor the nutritional parameters of a resident with an identified significant weight loss and weight gain for 2 of 21 residents sampled (Resident 25 and Resident 64). Findings include: Review of a facility policy titled Weight Monitoring last reviewed by the facility on November 7, 2023, revealed the unit manager or designee will notify the clinical dietary department of any 5 pound fluctuation in weight within 24 hours. Further the physician and responsible party will be notified. If a fluctuation of 5 pounds or greater is noted, the resident must again be weighed immediately to verify accuracy. A review of Resident 25's clinical record revealed admission to the facility on November 12, 2015, with diagnoses to include dementia (the loss of thinking, remembering, and reasoning to such an extent that it interferes with a person's daily life and activities) and severe protein calorie malnutrition (lack of sufficient nutrients in the body). A review of 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 a review of clinical records and select facility policy and staff interview, it was determined the facility failed to attempt non-pharmacological interventions to alleviate pain prior to the administration of pain medication prescribed on an as needed basis for one out of 21 residents reviewed (Residents 24 ) Findings include: Review of a facility policy entitled Pain Management Nursing last revised July 2023, indicated that non drug interventions should be tried prior to medication administration and as appropriate in conjunction with medication usage to provide pain relief. Interventions can include positioning, PT/OT (physical therapy/occupational therapy) modalities, relaxation techniques, and diversional activities. A review of Resident 24's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses that included rheumatoid arthritis (chronic inflammatory disease that affects the joints. This results in painful joints, swelling and stiffness in the joints), chronic…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of clinical records and staff interview, it was determined that the facility failed to develop and implement an individualized person-centered plan to render trauma informed care to a resident with a diagnosis of Post-Traumatic Stress Disorder for one out of 18 residents reviewed (Resident 71). Findings include: A review of the clinical record revealed that Resident 71 was admitted to the facility on [DATE], with diagnoses that included Post Traumatic Stress Disorder (PTSD). The resident's current care plan, in effect at the time of review on September 13, 2024, did not identify the resident's PTSD symptoms or triggers related to this diagnosis and resident specific interventions to meet the resident's needs for minimizing triggers and/or re-traumatization. The facility failed to develop and implement an individualized person-centered plan to address, this resident's diagnosis of PTSD according to standards of practice to promote the resident's emotional well-being and safety. 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 select facility policy and controlled drug shift count records, observations, and staff interview, it was determined that the facility failed to implement pharmacy procedures for the reconciliation of controlled drugs on one of four medication carts (A2 Cart E even). Finding include: A review of the Shift Change Checks sheet for September 2024, for the medication cart on A2 Cart E even September 12, 2024, at approximately 9:00 a.m., revealed that the on-coming nurse and/or off-going nurse failed to sign the sheets during shift change on the following dates to verify completion of the task to count the controlled drugs in the respective medication cart on: September 1, 2024, off-going 11p.m. to 7a.m. shift September 2, 2024, off-going 7a.m. to 3p.m. shift September 9, 2024, on-coming 7a.m. to 3p.m. shift September 10, 2024, on-coming and off-going for the 3p.m. to 11p.m. shift September 12, 2024, on-coming 7a.m. to 3p.m. shift. Interview with Employee 4 (LPN), on September 12, 2024, at approximately 9:00 a.m., confirmed the observation and acknowledged the licensed…

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, select facility policy, and staff interview, it was determined the facility failed to adequately indicate the need for an opioid pain medication for one resident out of 13 residents reviewed (Resident 9). Findings include: A review of facility policy titled, Pain Management, last revised July 2023, revealed it is facility policy to evaluate and manage pain for all residents. The policy indicates pain management orders should always have parameters using the numerical scale to be given for a pain of Mild 1-3, Moderate 4-6, or Severe 7-10. A clinical record review revealed Resident 9 was admitted to the facility on [DATE], with diagnoses that include unspecified psychosis (a condition that indicates the presence of psychosis but with inadequate information to make the diagnosis of a specific psychotic disorder) and major depressive disorder (a mental health disorder characterized by a persistently low or depressed mood, decreased interest in pleasurable activities, feelings of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of the facility's abuse prohibition policy, select investigative reports, and clinical records, and resident and staff interviews, it was determined that the facility neglected to provide the care and services necessary to avoid physical harm and maintain physical health planned for two residents (Resident 1 and Resident 2) out of six sampled residents. Findings include: A review of the facility policy titled Resident Abuse & Neglect Prevention Program, revealed that management and staff are jointly and individually responsible to ensure each resident shall be free from abuse, neglect, and misappropriation of property. Further policy review revealed that the facilities define neglect as the deprivation by a caretaker of goods or services (failure to provide goods and services) necessary to maintain physical or mental health and avoid physical harm, mental anguish, or mental illness. Clinical record review revealed that Resident 1 was admitted to the facility on [DATE], with diagnoses to include…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of clinical records and staff interviews it was determined that the facility failed to implement pharmacy procedures to assure timely acquiring and administration of medications to one of six sampled residents (Resident 1). Findings include: Clinical record review revealed that Resident 1 was admitted to the facility on [DATE], with diagnoses to include incomplete quadriplegia (severe or complete loss of motor function in all four limbs) and neurogenic bowel (loss of bowel control due to brain or spinal cord damage). Further review of the resident's clinical record revealed the resident was transferred to the hospital on April 15, 2024, and returned April 22, 2024. The resident had physician orders for: Bactrim DS oral tablet 800-160MG one by mouth every 12 hours at 9:00 AM and 9:00 PM starting April 22, 2024 Prednisone 20MG tablet give three by mouth for one day on April 23, 2024, at 9:00 AM Plavix 75mg tablet give one by mouth daily at 9:00 AM starting April 23, 2024 Vancomycin 125MG capsule…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of clinical records and staff interview, it was determined that the facility failed to maintain accurate and complete clinical records, according to professional standards of practice for one of six sampled residents (Resident 1). Findings include: According to the American Nurses Association Principles for Nursing Documentation, nurses document their work and outcomes and provide an integrated, real-time method of informing the health care team about the patient status. Timely documentation of the following types of information should be made and maintained in a patient record to support the ability of the health care team to ensure informed decisions and high quality care in the continuity of patient care: Assessments, Clinical problems, Communications with other health care professionals regarding the patient, Communication with and education of the patient, family, and the patient's designated support person and other third parties. According to the Title 49, Professional and Vocational…

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

Based on the minutes from Resident Council meetings and the facility's call bell audits and resident and staff interviews, it was determined that the facility failed to put forth sufficient efforts to promptly resolve continued resident complaints and grievances expressed during Resident Council meetings, including those voiced by nine (9) of nine (10) residents attending a group meeting (Residents 2, 3, 9, 15, 18, 36, 42, 59, and 74). Findings Include: During a group meeting conducted on September 13, 2023, at 10:00 a.m. with 10 alert and oriented residents, nine residents (Residents 2, 3, 9, 15, 18, 36, 42, 59, and 74) voiced concerns over long waits for staff to respond to their call bells when care and assistance is needed. The resident stated that there have been recent incidents when they have waited over an hour for nursing staff to respond to their call bells. The residents in attendance at this meeting reported voicing their concerns over the past few months during Resident Council meetings and through individual grievances. The residents stated that the issue with the long…

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 grievances lodged with the facility and facility call bell audits and staff and resident interviews it was determined that the facility failed to demonstrate prompt efforts to resolve repeated resident complaints regarding untimely staff response to residents' requests for assistance, and to sustain corrective actions identified in the grievance resolutions to prevent similar complaints including those voiced by four residents (Resident 53, 1, 13, and 63). Findings included: A review of grievances filed with the facility revealed a grievance filed by Resident 53 on June 5, 2023, indicating that the resident waited an hour and fifteen minutes for assistance after activating the call bell. The grievance form indicated that the issue was resolved. However, Resident 53 filed another grievance on September 6, 2023, indicating that the resident is having on-going issues with long waiting periods for staff assistance when utilizing the call bell, including waiting over an hour for assistance to use the bed pan. The grievance form did not indicate whether this current…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of clinical records and select facility policy and staff interview it was determined that the facility failed to provide nursing services consistent with professional standards of practice by failing to timely obtain physician orders to assure timely medication administration to one resident out of 10 reviewed (Resident 43). Findings include: A review of Section 21.14(a) of the Pennsylvania Code Title 49 Pa. Code §21.14, relating to the administration of drugs by registered nurses provides: (a) A licensed registered nurse may administer a drug ordered for a patient in the dosage and manner prescribed. The Board recognizes that practitioners other than physicians, such as nurse practitioners, physician assistants and institutional pharmacists, are authorized by law and/or regulations to issue orders for drugs and therefore the RN and LPN may accept and execute such orders. A review of the facility policy entitled Medication orders dated as revised by the facility July 2023 revealed the following…

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.