Lutheran Home At Topton, The

Based on clinical record review and staff interview, it was determined that the facility failed to ensure physicians' orders were implemented for two of 21 sampled residents. (Residents 8, 10)Findings include: Clinical record review revealed that Resident 8 had diagnoses that included congestive heart failure and hypertension (high blood pressure). On November 21, 2024, a physician ordered that staff weigh the resident daily because of her congestive heart failure. There was no documented evidence that staff weighed the resident on August 12 and 20, and September 2, 4, 12, 14, and 16, 2025. Clinical record review revealed that Resident 10 had diagnoses that included heart failure and atrial fibrillation (irregular heart rhythm). On May 22, 2025, the physician ordered that staff administer a blood pressure medicine (metoprolol succinate) once a day. Staff was not to administer the medication if the resident's heart rate was less than 55 beats per minute. Review of the Medication Administration Record for August and September 2025, revealed that staff administered the medication when…

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 employee personnel files and staff interviews, it was determined that the facility failed to follow Centers for Disease Control and Prevention (CDC) recommendations for baseline tuberculosis (TB) screening and testing for three of five newly hired employees. (Employee 2, 3, and 5)Findings include: According to the CDC's recommendations entitled, Baseline Tuberculosis Screening and Testing for Health Care Personnel, last updated December 19, 2023, all United States health care personnel should be screened for TB upon hire. This process includes a risk assessment, symptom evaluation, and TB blood test or TB skin test. If the tuberculin skin test is used to test health care personnel upon hire, the two-step testing should be used. A review of Employee 2's personnel file revealed a facility used a tuberculin skin test to screen for tuberculosis on August 18, 2025, and the result was read on August 22, 2025. There was no documented evidence that a second PPD test (step 2) was done. A review of Employee 3's personnel file revealed a facility used a tuberculin skin…

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 facility documentation, and staff interview, it was determined that the facility failed to implement safety interventions for one of three sampled residents at risk for falls. (Resident 5) Findings include: Clinical record review revealed that Resident 5 had diagnoses that included neurocognitive disorder with Lewy body dementia (a progressive brain disorder that can cause cognitive decline, motor problems, sleep disturbances, and visual hallucinations) and seizures. The Minimum Data Set (MDS) assessment dated [DATE], revealed the resident was cognitively impaired and dependent on staff for care. Review of the care plan revealed that the resident was at risk for falls, exhibited resistance to care, and required the assistance of two staff members for care. On June 6, 2025, a nurse noted that the resident was being changed by a single nurse aide (NA) and that the resident jerked her legs while on her side, causing her to roll out of bed. Review of the facility…

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 review, clinical record review, and staff interview, it was determined that the facility failed to ensure physician's orders were implemented for one of 29 sampled residents. (Resident 99) Findings include: Review of the policy entitled, Administering Medication, last reviewed January 25, 2024, revealed staff were to obtain vital signs if necessary and document physician indicated medication administration information. Clinical record review revealed that Resident 99 had diagnoses that included hypertension (high blood pressure) and cardiomyopathy (the heart muscle is no longer able to pump blood efficiently). On June 8, 2024, the physician ordered staff to administer a blood pressure medicine (losartan potassium) once a day. Staff were not to administer the medication if the resident's systolic blood pressure (the first measurement of blood pressure when the heart beats and the pressure is at its highest) was less than 100 millimeters of mercury (mmHg). Review of Resident 99's September and October 2024 Medication Administration Records revealed that staff…

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 ensure that the Minimum Data Set (MDS) assessment was completed to accurately reflect the resident's status for one of 36 sampled residents. (Resident 157) Findings include: Clinical record review revealed that Resident 157's MDS assessment dated [DATE], Section C (Brief Interview for Mental Status) was incomplete and Section H (Appliances) inaccurately indicated that the resident had an indwelling catheter. There was no documented evidence or physician's order to reflect that the resident had an indwelling catheter. In an interview on November 15, 2023, at 9:45 a.m., the Registered Nurse Assessment Coordinator (RNAC) confirmed that the MDS sections were not completed accurately during the assessment period to reflect the resident's current status.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, review of incident reports and staff interview, it was determined that the facility failed to provide adequate supervison and interventions in order to prevent falls for one of six sampled residents who were at risk for falls. (Resident 131) Findings include: Clinical record review revealed that Resident 131 had diagnoses that included dementia, anxiety, insomnia and a lack of coordination. The Minimum Data Set assessment dated [DATE], indicated that the resident had memory impairment and experienced behaviors that occurred daily including pacing and rummaging. The assessment also indicated that the resident required supervision to walk in the corridor and on the unit and required limited assistance for transfers and that the resident had experienced two or more falls during the assessment period. A review of the care plan revealed that the resident was at risk for falling related to frequent falls, cognitive loss, a desire to ambulate frequently, wandering, a recent history 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 staff interview, it was determined that the facility failed to ensure that the pharmacist's recommendations were acknowledged by the physician for one of 36 sampled residents. (Resident 20) Findings include: Clinical record review for Resident 20 revealed multiple recommendations from the consultant pharmacist on July 27, August 18, and September 28, 2023. These included recommendations regarding seizure medications and bowel stimulants. There was no documented evidence that Resident 20's physician acknowledged or acted upon the pharmacist's recommendations. In an interview on November 14, 2023, at 3 p.m., the Assistant Director of Nursing confirmed that there was no documented evidence that the physician acknowledged Resident 20's recommendations from the pharmacist. 28 Pa. Code 211.12(d)(5) Nursing services.

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 document the rationale for the continued use of as needed (PRN) anti-anxiety medications for three of five sampled residents. (Residents 128, 134, 168) Findings include: Clinical record review revealed that Resident 128 had diagnoses that included Alzheimer's disease, dementia, psychosis, anxiety and depression. Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated that the resident had memory impairment and had taken an anti-anxiety medication three days of the assessment period. A review of the care plan revealed that the resident had increased behaviors. There was an intervention for the primary care physician to monitor drug use. On September 8, 2023, a physician ordered for staff to administer an anti-anxiety medication (Ativan) every four hours PRN for anxiety and/or behaviors. Review of the Medication Administration Records (MAR's) for September, October, and November 2023, 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 clinical record review, observation, and staff interview, it was determined that the facility failed to ensure that adaptive equipment was provided to one of three sampled residents who utilized adaptive equipment for meals. (Resident 131) Findings include: Clinical record review revealed that Resident 131 had diagnoses that included dementia, anxiety and a lack of coordination. The Minimum Data Set assessment dated [DATE], indicated that the resident had memory impairment and required extensive assistance from staff for eating. A review of the care plan revealed that the resident had a nutrition problem related to dementia and significance weight loss. There was an intervention for staff to provide adaptive equipment including Kennedy cups (spill proof drinking cups that included a lid and a straw), for all drinks. Review of an occupational therapy Discharge summary dated [DATE], revealed that upon discharge from therapy services, the resident was able to consistently drink by herself after staff…

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 implement physician's orders to obtain therapy services for one of three sampled residents who were referred to therapy. (Resident 1) Findings include: Clinical record review revealed that Resident 1 had diagnoses that included depression, pain, dementia, osteoarthritis, lack of coordination, and difficulty walking. Review of the Minimum Data Set assessment dated [DATE], revealed that the resident required extensive assistance from staff for activities of daily living. On April 14, 2023, staff documented that the resident had decreased strength and endurance and that the resident's family had requested physical therapy for ambulation. A physician's order dated April 14, 2023, referred the resident for therapy services per the resident's family's request. There was no evidence that the resident was evaluated for therapy services, per the physician's order. In an interview on August 21, 2023, at 1:41 p.m., 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 provide treatment for pressure ulcers for one of three sampled residents with pressure ulcers. (Resident 3) Findings include: Clinical record review revealed that Resident 3 had diagnoses that included anemia and weakness. Review of a wound evaluation dated August 15, 2023, revealed that Resident 3 had a stage three pressure ulcer to the left upper back. The treatment plan recommendation was for staff to apply hydrogel and gauze island once daily for 30 days. There was no evidence that staff entered the recommended treatment into the resident's clinical record or provided treatment to the pressure ulcer until August 21, 2023, six days after the evaluation. In an interview on August 21, 2023, at 3:42 p.m., the Assistant Director of Nursing confirmed staff should have entered the treatment into the resident's clinical record and there was no evidence that any wound treatment was provided to the resident's pressure ulcer prior to August 21, 2023. 28 Pa. Code 211.12(d)(1)(3)(5) 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.