Embassy Of Tunkhannock

Based on review of facility documents and staff interview, it was determined the facility failed to ensure the Medical Director or designee participated in the facility's Quality Assurance and Performance Improvement (QAPI) Committee meetings on a quarterly basis for two of four quarters (Quarter 1 and Quarter 2 of 2025). Findings include:: A review of the facility policy titled Quality Assurance Performance Improvement (QAPI) last reviewed by the facility on January 23, 2026, revealed the would develop and maintain an effective, comprehensive, data-driven QAPI program. However, the policy did not clearly identify required QAPI committee membership, did not specify required participation of the Medical Director or a designated physician representative, and did not outline attendance expectations or accountability for participation in quarterly meetings. A review of QAPI committee meeting sign-in sheets for the period of March 2025 through January 2026 revealed that although QAPI meetings were conducted quarterly, the Medical Director or the Medical Director's designated physician…

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

Based on staff interviews and review of facility training and orientation records, it was determined that the facility failed to ensure that all employees received required annual education on the facility's abuse prohibition policy and procedures. Findings include: A review of the facility's policy entitled Abuse, Neglect, Exploitation and Misappropriation of Resident Property last reviewed by the facility on January 23, 2026, indicated the facility would educate its staff upon hire and annually thereafter regarding the facility's policy concerning abuse, neglect, exploitation and misappropriate of resident property and how to handle resident-to-resident abuse and injuries of unknown sources. During an interview with the Nursing Home Administrator (NHA) on January 30, 2026, at 12:45 PM, the NHA reported that the Human Resources Director position was eliminated in mid-December 2025 due to budgetary reductions and that the responsibilities of the position were reassigned to administration. The NHA provided the educational content intended for the facility's annual abuse prevention…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy and clinical record review and staff interview, it was determined the facility failed to ensure that a resident's comprehensive care plan was reviewed and revised as needed to accurately reflect their current needs and services required for one of 23 residents sampled (Resident 45).Findings include: A review of the facility policy entitled Comprehensive Care Planning last reviewed on [DATE], revealed the facility will develop a comprehensive person-centered care plan for each resident that includes measurable goals and timetables to meet the resident's medical, nursing, mental, and psychosocial needs identified in the comprehensive assessment. A clinical record review revealed Resident 45 was admitted to the facility on [DATE], with diagnoses to include Diabetes Mellitus (a metabolic disorder in which the body has high sugar levels for a prolonged period.) and cerebral infarction (a type of stroke where the blood flow to the brain is blocked or reduced). A review of Resident 45'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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, clinical record review, facility policy review and staff interview, it was determined the facility failed to ensure that nursing services met professional standards of quality according to the Pennsylvania Code Title 49, Professional and Vocational Standards, by failing to ensure Licensed Practical Nurses (LPNs) were properly trained and validated as competent prior to administering intravenous (IV) medications through a central venous catheter for one of twenty-three residents reviewed (Resident 52). Findings include: According to the Pennsylvania Code Title 49, Professional and Vocational Standards Department of State, Chapter 21 State Board of Nursing, Chapter 21.145 Functions of the LPN (Licensed Practical Nurse) require the following:The LPN is prepared to function as a member of the health care team by exercising sound nursing judgement based on preparations, knowledge, skills, understandings and past experiences in nursing situations. The LPN participates in the planning,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, clinical record review, and resident and staff interviews, it was determined the facility failed to ensure that residents with limited mobility received the necessary services, equipment, and assistance to maintain or improve mobility for one of 18 residents reviewed (Resident 1).Findings Include: Review of the clinical record revealed that Resident 1 was admitted to the facility on [DATE], with diagnoses which include cerebral ischemia (a condition in which reduced blood flow to the brain limits oxygen and nutrients needed for brain function) and flaccid hemiplegia to the right dominant side (a condition where there is complete paralysis or weakness of the muscles on one side of the body). These conditions affected Resident 1's ability to move and use the right hand and arm. A review of a quarterly Minimum Data Set assessment (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) dated December 22, 2025, revealed that Resident 1 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, select facility policy, and staff interviews, it was determined the facility failed to timely identify changes in nutritional parameters, implement appropriate nutritional interventions, and notify the attending physician and the resident's responsible party of a significant weight loss for one of 18 sampled residents (Resident 5).Findings included: A review of a facility policy entitled Weight Policy, last reviewed by the facility January 23, 2026, indicated resident weights would be obtained in a timely and accurate manner, and documented and responded to appropriately. Upon admission or readmission weights will be obtained and documented. The resident will be weighed every week for the following three (3) weeks, then monthly unless ordered otherwise by the medical doctor (MD) or nurse practitioner (NP) or the registered dietitian (RD). If a weight showed the same or greater variance, a nurse would verify the weight was obtained correctly. Significant weight losses of 5…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of clinical records, select facility policy, observation, and staff interview, it was determined that the facility failed to implement procedures to maintain records of controlled drugs and ensure accurate drug administration for two out of the 23 residents sampled (Resident's 4 and 58).Findings include: A review of the facility policy titled Medication Administration, last reviewed by the facility on January 23, 2026, revealed that medications are to be administered by licensed nurses or other staff authorized to do so by the state, as ordered by the physician, and in accordance with professional standards of practice to prevent contamination, infection, and medication errors. The policy further requires that the licensed nurse administering a medication immediately document the resident's name, date and time of administration, dose, route of administration, and the signature of the nurse on the medication administration record. The policy also requires that medications classified as controlled…

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 statement of deficiencies from the survey ending January 30, 2026, it was determined the facility's Quality Assurance Performance Improvement (QAPI) committee failed to develop and implement corrective action plans to prevent continued quality deficiencies related to the facility's food and nutrition services department and implement effective plans to correct and prevent further quality deficiencies related to timely identification of changes in nutritional parameters, implementation of appropriate nutritional interventions, and notification of the attending physician and the resident's responsible party of a significant weight.Findings included: A review of a facility policy entitled Quality Assurance Performance Improvement, last reviewed by the facility January 23, 2026, indicated the facility developed and maintains an effective, comprehensive, data-driven quality assurance and performance improvement program that focuses on indicators of the outcomes of care and quality of life and will utilize the best available evidence to design and measure…

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 resident clinical records, facility policies, and staff interviews, it was determined the facility failed to ensure one of ten sampled residents (Resident 1) was free of a significant medication error resulting in the administration of incorrect doses on multiple occasions. Findings include:A review of facility policy titled Coumadin Monitoring Procedure revealed it is the responsibility of the nurse to update the MAR (Medication Administration Record) with the new Coumadin dose order, and the PT/INR (Prothrombin Time/International Normalized Ratio, blood tests used to measure how quickly blood clots) laboratory draw orders.A review of a facility policy titled Medication Administration revealed it is the responsibility of the nurse to compare the medication with the MAR to verify the right resident, medication name, form, dose, route and correct time of administration. A clinical record review revealed Resident 1 was admitted to the facility on [DATE], with diagnoses that included dementia (a…

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

Based on review of clinical records, select facility policy review, and staff interview it was determined that the facility failed to ensure that one resident out of five sampled was free of chemical restraints used to most readily control the resident's behavior and not required to treat the resident's medical symptoms (Resident 1). Findings include: A review of the Facility's Policy labeled Restraint Free Environment last reviewed by the facility on June 1, 2024, reviewed on April 15, 2025, at approximately 1:30PM defines a chemical restraint as any medication that is used for discipline or staff convenience, and not required to treat medical symptoms. The policy further revealed the resident's medical record must include documentation that less restrictive alternatives were attempted to treat the medical symptom but were ineffective, ongoing re-evaluation of the need for the restraint and the effectiveness of the restraint in treating the medical symptom. A review of Resident 1's clinical record revealed admission to the facility on March 4, 2024, 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.

Based on observation, select facility policy review, review of clinical records, and staff and resident interview, it was determined the facility failed to consistently provide timely and necessary foot care for one of eight residents sampled (Resident 1). Findings include: A review of the Facility's Ancillary Staff Policy last reviewed January 1, 2025, revealed it is the facility's responsibility to assist resident in obtaining routine and emergency ancillary services as needed including Podiatry. The policy then explains podiatry services include everything from toenail trimming to foot exams. A review of Resident 1's clinical record revealed admission to the facility on March 4, 2024, with diagnoses to include vascular dementia with behavioral disturbance (a condition caused by impaired blood flow, characterized by poor judgement and memory impacting daily functioning) and anxiety disorder (a disorder characterized by excessive worry and fear that can significantly impact daily life.) A Quarterly Minimum Data Set assessment (MDS- a federally mandated standardized assessment…

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 surety bond, resident fund accounts, and staff interviews, it was determined the facility failed to ensure the amount of the surety bond was sufficient to cover the total amount of resident funds held by the facility. Findings include: A review of the Resident Fund Trust bank account revealed average daily balances of: September 13, 2024, $155,582.09 September 18, 2024, $159,603.09 September 24, 2024, $155,907.09 September 25, 2024, $158,032.09 October 11, 2024, $149,969.76 October 15, 2024, $149,904.76 October 16, 2024, $153,880.76 October 17, 2024, $135,222.66 October 22, 2024, $133,642.76 October 28, 2024, $133,529.76 October 30, 2024, $133,487.42 November 1, 2024, $150,497.22 November 4, 2024, $133,493.62 November 5, 2024, $139,259.84 November 6, 2024, $140,624.84 November 7, 2024, $139,194.84 November 8, 2024, $140,194.84 November 12, 2024, $140,955.42 November 13, 2024, $143,050.22 December 12, 2024, $141,922.79 January 13, 2024, $130,801.51 A review of the facility's surety bond in place since June 11, 2024, revealed the coverage amount 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 staff interview, a review of personnel files, employee credentials, and facility documentation it was determined the facility failed to provide sufficient staff with the necessary skill set and competencies to ensure appropriate nutritional oversight for residents. The facility also failed to ensure that the full-time Director of Food and Nutrition Services, who was not a qualified dietitian or other clinically qualified nutrition professional, received frequent consultations from a qualified dietitian or other clinically qualified nutrition professional. Findings include: Federal regulations require the facility to employ sufficient staff with the appropriate competencies and skill sets to meet the nutritional needs of residents, considering resident assessments, individual plans of care, and the facility assessment. In the absence of a full-time qualified dietitian, the Director of Food and Nutrition Services must meet minimum qualifications and receive frequent consultations from a qualified…

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

Based on observations, resident and staff interviews, a review of the facility's 4-week menu cycle, and Food Committee meeting minutes, it was determined that the facility failed to ensure the menu was periodically reviewed and updated to reflect reasonable consideration of resident food preferences, thereby failing to enhance meal variety for six out of 20 sampled residents (Residents 26, 42, 30, 59, 65, and 15). Findings include: During a group meeting conducted on March 19, 2025, at 10:15 AM, Residents 26, 42, 30, 59, 65, and 15 reported concerns regarding the repetitiveness of the facility's menu and snack options. They stated that meal variety was lacking, side dishes were often unfamiliar, and portion sizes, particularly for meat-based dishes such as casseroles and tacos, were insufficient. Additionally, they expressed frustration that condiments such as sour cream and salsa were inconsistently available due to the facility running out due to the food order not arriving yet. Resident 26, the elected Resident Council President, stated, You get a teaspoon of meat when casseroles…

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, resident staff interviews and direct observations, it was determined that the facility failed to routinely offer snacks to six of six residents interviewed (Residents 15, 26, 30, 42, 59, and 65). Findings include: Review of the facility policy titled Snack Policy indicated that snacks will be provided between meals if ordered and in the evening for residents who desire them. Furthermore, the policy indicated HS snacks will be delivered to the nurse's station. Nursing staff will offer residents the snack and will be responsible for making sure the snack intakes are recorded. Resident Council minutes dated December 30, 2024, indicated Residents were not receiving snacks. A grievance was filed December 30, 2024, by Resident 26 which stated, No snacks readily available, or if snacks are available the bowl of snacks are on top of the fridge - unreachable. Resident Council minutes dated February 25, 2025, revealed that residents must ask for a snack or retrieve it themselves. On February 25, 2025, Resident Council members filed a second grievance…

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 facility documentation, it was determined the facility failed to comprehensively review and update its facility-wide assessment to ensure it accurately reflected the specific needs of its resident population and the personnel resources necessary to meet those needs for 24 of 71 residents. Findings Include: A review of the facility-wide assessment provided to the survey team on February 19, 2025, indicated that the facility had last reviewed its assessment on January 14, 2025. The document was intended to evaluate the specific and unique needs of the resident population, along with the available and accessible resources to meet those needs on a daily basis and during emergent situations. At the time of the survey ending March 21, 2025, the facility census was 71 residents, including 24 residents with a documented diagnosis of dementia. The facility-wide assessment stated that the facility provided a more structured environment with additional diversional activity hours on the secured Memory Care Unit (MCU), along with food-related activities and snacks as a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, clinical record review and staff interview, it was determined the facility failed to provide meal service in an environment that maintains each resident's dignity for two residents of 20 sampled residents (Residents 52 and 6). Findings include: On March 18, 2025, at approximately 11:55 AM, in the [NAME] Unit dining/game room, Resident 31, who is independent with eating, was observed seated at a table with Residents 52 and Resident 6. At 11:56 AM, staff placed Resident 31's lunch tray in front of her, and she began eating. However, Residents 52 and 6, who require assistance with feeding, did not receive their trays or staff assistance until approximately 30 minutes later. On March 19, 2025, at approximately 12:10 PM, in the [NAME] Unit dining/game room, Resident 31 was again observed eating her lunch while seated at a table with Residents 52 and 6. However, staff did not provide Residents 52 and 6 with their lunch trays or initiate feeding assistance until approximately 20 minutes later. A…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff interview, it was determined the facility failed to ensure that a residents' comprehensive care plans were reviewed and revised as needed to accurately reflect their current needs and services required by three of 20 residents sampled (Residents 25, 49, and 64). Findings include: A clinical record review revealed Resident 25 was admitted to the facility on [DATE], with diagnoses to include acute and chronic respiratory failure with hypoxia (a condition where there is inadequate supply of oxygen to the body's tissues) and 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). A physician's order dated February 10, 2025, at 8:19 PM, directed oxygen administration at 2 liters (L) via nasal cannula continuously. A review of Resident 25's comprehensive plan of care, last revised on January 6, 2025, failed to reflect these updated medical treatment goals 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 a review of the facility's activities programming, clinical records, staff and resident interviews, and observations, it was determined the facility failed to provide an ongoing program of activities designed to meet the needs, interests, preferences, and functional abilities of its residents, including those diagnosed with dementia for six of six residents sampled (Residents 26, 42, 30, 59, 15, and 65). Findings include: A review of the facility census at the time of the survey ending March 21, 2025, revealed that the facility had 71 residents, including 24 residents with a documented diagnosis of dementia residing across both open resident units. A review of the facility's March 2025 activity calendar revealed a lack of variety in scheduled activities. The only dementia-specific activity, labeled as a Sensory Group, was scheduled three times during the month. Additionally, evening activities were scheduled only once per week (Thursdays at 6:00 PM), and weekend activities remained unchanged week to week, lacking variety or engagement. During a resident group interview on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on 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 4 residents out of 20 residents sampled (Resident 12, 24, 42, 64). Findings include: 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 restore the well-being of individuals. The Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.145 Functions of the Licensed Practical Nurse (LPN) (a) The LPN is prepared 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 clinical record reviews, staff interviews, and facility policy reviews, it was determined that the facility failed to ensure the provision of pharmacy services necessary to assure the timely receipt and administration of physician-prescribed medications for two of twenty residents sampled (Residents 28 and 127). The facility also failed to maintain oversight of its medication dispensing system, including ensuring emergency medication availability and routine pharmacy audits. Findings include: Review of clinical record revealed that Resident 28, was admitted to the facility on [DATE], with diagnoses to include to dementia and cerebral infarction (stroke) with hemiplegia (weakness on one side of the body). A physician order dated October 18, 2024, prescribed Oxycodone 5 mg (an opioid narcotic medication), one tablet by mouth every six hours as needed for moderate to severe pain. A review of the November and December 2024 Medication Administration Records (MARs) revealed that Oxycodone was signed out on…

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

Based on observations, staff interviews, and review of facility practices, it was determined that the facility failed to provide adequate dining space to accommodate the number of dependent residents requiring staff assistance during meals in one of two occupied resident units (Blue Unit). Findings include: An observation of the Blue Unit dining room on March 18, 2025, at 12:15 PM revealed that five dining tables were occupied by thirteen residents in wheelchairs, while two additional residents in Geri reclining chairs were seated with mobile bedside tables in front of them. The dining area was congested, making it difficult for staff to pass through, set up meal trays, and assist residents effectively. The limited space also restricted residents' ability to maneuver safely within the room. A subsequent observation of the same dining area on March 19, 2025, at 12:35 PM revealed fifteen residents in wheelchairs seated among the five dining tables, along with two residents in Geri reclining chairs using mobile bedside tables. Due to the number of residents requiring assistance and the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of the facility's abuse policy, investigative reports, clinical records, and staff interviews, it was determined that the facility failed to ensure that residents were free from misappropriation of property, specifically resident medications, for one of 20 sampled residents (Resident 28). Findings included: A review of the facility policy titled Abuse, Neglect, and Exploitation, last reviewed in January 2025, revealed that the facility is responsible for ensuring the health, welfare, and rights of each resident by implementing written policies and procedures prohibiting and preventing abuse, neglect, exploitation, and misappropriation of resident property. Misappropriation of property is defined as the deliberate misplacement, exploitation, or wrongful, temporary or permanent use of a resident's belongings or money without the resident's consent. Review of clinical record revealed that Resident 28, was admitted to the facility on [DATE], with diagnoses to include to dementia and cerebral…

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 resident and staff interviews, it was determined the facility failed to ensure that residents dependent on staff for assistance with activities of daily living consistently received showers as planned to maintain good personal hygiene for two of 20 residents sampled (Residents 30 and 65). Findings include: During a resident group meeting conducted on March 19, 2025, at 10:15 AM, two out of six residents in attendance (Residents 30 and 65) stated they had not been showered as scheduled. Resident 65 stated I have not had a shower in a week because they do not have the help. Resident 30 stated she had not had her showers as scheduled. A review of Resident 30's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses to include intrahepatic bile duct carcinoma (a cancer that originates in the bile ducts within the liver) and vascular dementia (a type of dementia caused by reduced blood flow to the brain). A quarterly Minimum Data Set…

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 and staff interview, it was determined the facility failed to ensure documented evidence of clinical necessity for administration of an antibiotic drug for one resident (Resident CR1) out of 20 residents reviewed for unnecessary medications. Findings include: A review of the clinical record revealed that Resident CR1 had a physician's order dated January 27, 2025, for Ciprofloxacin HCL (an antibiotic medication) 500 mg, one tablet to be administered one tablet twice a day for seven days for the treatment of a urinary tract infection (UTI). A review of a urine and a culture and sensitivity (C & S a urine culture is a method to grow and identify bacteria that may be in the urine. The sensitivity test helps select the best medicine to treat the infection) report dated January 28, 2025, revealed that it was positive for Escherichia coli a type of bacteria commonly found in the intestines, some strains of which can cause infections. The C&S report indicated that E. coli was resistant to Ciprofloxacin HCL, making the prescribed medication ineffective against 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 staff interview, it was determined the facility failed to ensure coordination of care and services between the facility and the Hospice agency for one resident (66) out of 20 sampled. Findings include: A review of facility policy titled Coordination of Hospice Services, last reviewed by the facility on June 1, 2024, revealed it is the facility policy to coordinate a plan of care and implement interventions in accordance with the resident's needs, goals, and recognized standards of practice in consultation with the resident's attending physician/practitioner and resident's representative, to the extent possible. The policy indicates the plan of care will identify the care and services that each entity will provide in order to meet the needs of the resident and his/her expressed desire for hospice care. A review of Resident 66's clinical record revealed she was admitted to the facility on [DATE], with diagnoses to include peripheral vascular disease (a condition 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 implement enhanced barrier infection control procedures for one resident out of the 20 residents sampled (Resident 12). Findings include: A review of facility policy titled Enhanced Barrier Precautions, last reviewed by the facility on June 1, 2024, revealed it is the facility policy to expand the use of personal protective equipment and refer to the use of gowns and gloves during high-contact resident care activities that provided opportunities for transfer of multi-drug-resistant organisms (MDROs) to staff hands and clothing. The policy indicates nursing home residents with wounds are especially high risk for both the acquisition of and colonization with MDROs. The policy indicates that the facility will make gowns and gloves available immediately outside of the resident's room for those who require enhanced barrier precautions, and that clear signage will be…

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

Based on observation and staff interview, it was determined that 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 and two of three resident pantries. 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). Review of a facility policy titled Food Storage that was provided by the facility on May 20, 2024, indicated that food storage…

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

Based on staff interviews, it was determined that the facility failed to conduct a facility wide assessment that reflected the personnel and specific resources presently available and to identify those that are necessary to care for its current resident population. Findings include: At the time of the survey ending May 21, 2024, the facility failed to provide evidence that a facility assessment to determine the specific and unique needs of its resident population and the available and accessible resources to meet these needs on a daily basis and during emergent situations had been developed. During an interview with the Nursing Home Administrator on May 19, 2024, at 1:00 PM, the NHA had indicated that the facility assessment was provided in the survey readiness binder. Additional interview with the NHA on May 21, 2024, at 1 PM indicated that the facility assessment had recently been updated yet failed to provide the survey team with the required document. There was no facility assessment presented to the survey team by survey ending May 21, 2024. 28 Pa. Code 201.14(a) Responsibility…

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 staff interview, it was determined that the facility failed to maintain documentation and demonstrate evidence of its ongoing QAPI (Quality Assurance Performance Improvement - a framework utilized to guide an organization's performance improvement efforts) program. Findings include: Review of the facility policy entitled Quality Assurance and Performance Improvement last revised August 29, 2022, revealed, the company is committed to developing, implementing, and maintaining an effective, comprehensive, data-driven QAPI program that focuses on indicators of the outcomes of care and quality of life. The facility will: 1. Maintain documentation and demonstrate evidence of its ongoing QAPI program which may include but is not limited to: a. systems and reports demonstrating systematic identification, reporting, investigation, analysis, and prevention of adverse events; and b. documentation demonstrating the development, implementation, and evaluation of corrective actions or performance improvement activities; 2. Present its QAPI plan to the…

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

Based on information provided by the facility, and staff interview it was determined that the facility failed to implement a quality assurance program to identify problems that are opportunities for improvement. Findings include: According to federal regulatory requirements at 42 CFR §483.75 (g)(2) the QAPI committee must: §483.75 (g)(2)(ii) Develop and implement appropriate plans of action to correct identified quality deficiencies; §483.75 (g)(2)(iii) Regularly review and analyze data, including data collected under the QAPI program and data resulting from drug regimen reviews, and act on available data to make improvements. Interview with the Nursing Home Administrator on May 21, 2024, at 10:36 AM revealed there was no evidence the facility had taken actions aimed at performance improvement since last annual survey completed April 21, 2023. 28 Pa. Code 201.18 (b)(1)(3)(e)(1)(2)(4) Management

Based on review of facility documents and staff interviews, it was determined that the facility failed to maintain a Quality Assurance Process Improvement (QAPI) Committee. Findings include: During review of QAPI committee on May 21, 2024, the Nursing Home Administrator was unable to provide evidence of any staff, administration, or Medical Director attendance to meetings. The NHA failed to provide evidence of QAPI Committee meeting sign-in sheets for the period of April 2023 through April 2024. Interview with the NHA on May 21, 2024, at 10:36 AM confirmed that the facility failed to maintain a QAPI committee. 28 Pa. Code 211.2(d)(5)(6)(7)(8)(10) Medical director 28 Pa. Code 201.18 (e)(2)(3)(4) Management.

Based on observations, and staff interview, it was determined the facility failed to ensure that essential equipment was in safe operating condition in the facility's kitchen. Findings include: Observation of the dietary department on May 18, 2024, at 8:38 a.m., revealed that the door latch to the facility's walk-in freezer was broken and did not make contact with the latch on the door jamb to secure it closed and left a gap around the perimeter of the door. Additionally, observed that the seal around the freezer door was ill-fitting. Upon entering the walk-in freezer, observed that the air curtain was ill-fitting, covered in frost, and had icicles hanging off the plastic strips and dripping on to the floor. The freezer entry way floor was covered in a thick coating of ice and was slippery. Additionally, observed that the cases of frozen food were encased in ice crystals and the wire metal shelves were encased in ice. At the time of the survey ending May 21, 2024, the Nursing Home Administrator (NHA) could not provide documented evidence that that the facility had acted upon 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 staff interviews, it was determined that the facility failed to afford a resident and their designated representative the right to participate in the development of the resident's plan of care for five residents out of five interviewed during a resident group interview (Residents 19, 30, 37, 61, and 73). Findings include: A clinical record review revealed that Resident 19 was admitted to the facility on [DATE], with diagnoses that included osteoarthritis (a degenerative joint disease in which the tissues in the joint break down over time). A review of the quarterly Minimum Data Set assessment (MDS - a federally mandated standardized assessment process conducted periodically to plan resident care) dated May 7, 2024, revealed that Resident 19 was cognitively intact with a BIMS score of 15 (Brief Interview for Mental Status- a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new…

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

Based on a review of select facility policy, the minutes from resident council meetings, grievance logs, and resident and staff interviews, it was determined that the facility failed to demonstrate timely action to resolve resident grievances raised at resident group meetings and keep the residents apprised of the status of the facility's decisions and efforts toward grievance resolution, including concerns expressed by five of the five residents interviewed during a resident council group interview (Residents 19, 30, 37, 61, and 73). Findings include: A review of facility policy titled Grievance Policy and Guidelines, last reviewed by the facility in July 2023, indicated that all employees are responsible for ensuring customer satisfaction. The policy indicates that when concerns arise, a grievance system is in place to resolve the issues to the satisfaction of all parties involved. The policy also indicates that response to the grievance should be as soon as possible, but within ten working days of receipt of the grievance form. A review of resident council meeting minutes dated…

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, and resident and staff interviews, it was determined that the facility failed to provide housekeeping and maintenance services to maintain a clean and safe resident environment on two of two occupied resident care units. Findings include: An observation on May 18, 2024, at 11:10 AM in resident room [ROOM NUMBER] revealed a ceiling block with a large brown and tan stain above the resident's mirror. In the resident's bathroom, cracks in the floor were observed extending around the edge of the floor. The bathroom wall to the left of the sink, revealed multiple areas of scraped paint, gray and black scuff marks, and exposed drywall. An observation on May 18, 2024, at 11:14 AM in the Nursing [NAME] Hall shower room revealed that the sink faucet continuously flowed water when in the off position. The shower room vent was observed to have a thick layer of gray dust. A gray bucket under a shower chair was observed to contain a brown and black substance. A toilet with…

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

Based on review of the minutes from Resident Council Meetings, scheduled facility mealtimes, and select facility policy, and resident and staff interviews, it was determined that the facility failed to consistently provide snacks as desired by residents including 3 out of the 20 residents sampled (19, 30, and 37) and experiences reported by residents during a group interview (Residents 61 and 73). Findings include: A review of the facility's policy titled Policy: Frequency of Meals, last reviewed in July 2023, indicated that nourishing snacks will be available for residents who need or desire additional food between meals. The policy indicates that residents will be offered nourishing snacks if the time span between the evening meal and the next day's breakfast exceeds fourteen hours. A review of the facility's scheduled mealtimes revealed that the time between dinner and breakfast the next day exceeds fourteen hours. A review of resident council meeting minutes dated April 12, 2024, revealed that all residents in attendance indicated that they were not receiving snacks. The meeting…

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

Based on observation, review of select facility policy and staff interview, it was determined that the facility failed to ensure that medication was stored at the appropriate temperature according to manufacturer's directions in one of three medication storage rooms reviewed. (Blue Wing) Findings include: Observation of the facility's medication storage refrigerator on May 20, 2024, at 9:41 AM in the presence of Employee 6, Licensed Practical Nurse (LPN) revealed that the thermometer read 26 degrees Fahrenheit (6 degrees below freezing). Observation revealed the following medications stored in the medication refrigerator: Lorazepam Intensol 2mg/mL (oral concentrate), Promethazine 25mg suppositories, and the following insulins; Lantus Solostar 100 units/mL (3 mL) pen, Novolog Flexpen 100 units/mL (3 mL) pen, Victoza 18 mg/3 mL (3 mL) pen, Humalog Kwikpen 100 units/mL (3 mL), and Ozempic. Review of the medication room refrigerator temperature log dated May 2024, revealed that refrigerator temp. must be between 36 and 46 degrees Fahrenheit. The staff are to report any…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, a review of facility's planned meal tickets, and resident and staff interviews it was determined that the facility failed to accommodate residents' food preferences, and provide foods planned for oral gratification for one resident of 20 residents reviewed (Resident 32). Findings included: A review of resident 32's clinical record indicated she was most recently admitted to the facility on [DATE], with diagnoses to include chronic obstructive pulmonary disease (COPD), diabetes, and gastroparesis (a condition which affects the stomach muscles and prevents proper stomach emptying). The resident's care plan, dated August 15, 2016, included a focus area of Nutrition, revealing the resident is dependent on tube feeding related to duodenal stricture, gastroparesis with a planned included that the resident is NPO (nothing by mouth, ice chips, clear Gatorade, coffee, and lemon Italian ice allowed) see orders section of medical chart, date revised December 13, 2022. The resident's care plan, also…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, clinical record review, and staff interview, it was determined that the facility failed to ensure the coordination of hospice services with facility services to meet the resident's needs on a daily basis for one out of 20 residents sampled (Resident 5). Findings include: A clinical record review revealed that Resident 5 was admitted to the facility on [DATE], with diagnoses that included multiple sclerosis (an immune-inflammatory disease that attacks and damages cells in the central nervous system and causes neurological impairment). Further review of the clinical record revealed a physician's order for Resident 5 to be admitted to hospice services related to a malignant neoplasm of the colon initiated on April 26, 2024. A clinical record review revealed a significant change in status comprehensive Minimum Data Set assessment (MDS - a federally mandated standardized assessment process conducted periodically to plan resident care) for Resident 5 dated May 4, 2024. According to the Long-Term…

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

Based on a review of select facility policy and grievances lodged with the facility and and interviews with the facility, 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. The findings include: A review of the facility's Grievance Policy, last revised by the facility January 14, 2019, revealed that This facility has a system in place to ensure the resident's right to prompt efforts to resolve grievances that they may have. The policy noted The reasonable timeframe within which the resident can expect a completed review of the grievance is within 5 to 7 business days. A review of the facility's grievance log dated August 2023, provided by the facility during the survey of January 22, 2024, revealed that there were no grievances lodged during the month of August 2023. However, the facility provided four grievances that were raised on August 24, 2023, through Resident Council, that were not included on the log. These complaints…

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

Based on review of clinical records and staff interview, it was determined that the facility failed to notify the resident's interested representative of the need to alter treatment as the result of the reoccurrence of a pressure sore for one resident out of 8 sampled (Resident CR1). Findings include: A review of the clinical record revealed that Resident CR1 was admitted into the facility on October 17, 2020, with diagnoses which included dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), skin cancer of the left lower limb, and diabetes. A review of Resident CR1's clinical record revealed that on August 31, 2023, a stage 1 pressure area was identified on the resident's coccyx and treatment to the area was initiated. A review of Resident CR1's wound evaluation flow sheet dated October 13, 2023, revealed that the resident's coccyx pressure wound had healed. According to the resident's Treatment Administration Record, treatment to the area with peri-guard continued until October 24, 2023. On October 25, 2023, the treatment…

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.