Cedarwood Rehabilitation & Healthcare Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the Resident Assessment Instrument User's Manual and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that comprehensive admission Minimum Data Set assessments were completed in the required time frame for four of 32 residents reviewed (Residents 6, 39, 43, 97). Findings include:The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which provides instructions and guidelines for completing required Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2025, indicated that an admission MDS assessment was to be completed no later than 14 days (admission date + 13 calendar days) following admission.An admission MDS assessment for Resident 6 revealed that the resident was admitted to the facility on [DATE], and the resident's admission MDS assessment was dated as completed on December 27, 2025, which was 2 days after admission.An annual MDS assessment for Resident…

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

Based on review of facility policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that the environment remained as free of accident hazards as possible for two of 46 residents reviewed (Residents 88, 114). Findings include:The facility's policy regarding falls, dated January 27, 2026, revealed that resident's identified as fall risks will have interventions in place to prevent further falls.A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 88, dated January 21, 2026, indicated that the resident was cognitively intact and required assistance for daily care. Resident 88's care plan, dated December 14, 2025 indicated that the resident was at risk for falls. Fall interventions included keeping her personal belongings within reach, and that she would have a reacher tool (used to grab objects that are beyond your reach).Observations of Resident 88 on February 5, 2026 at 10:30 a.m. revealed that she was sitting in her wheelchair beside her…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policies, as well as observations and staff interviews, it was determined that the facility failed to properly date medications after they were opened in one of three medication carts reviewed (second floor cart), failed to discard expired medical supplies, and failed to permanently affix a narcotic storage box to the refrigerator.Findings include: The facility's policy regarding medication storage and labeling, dated [DATE], revealed that the facility stores all medications and biologicals in locked compartments under proper temperature, humidity and light controls. Multi-dose vials that have been opened or accessed are dated and discarded within 28 days unless the manufacturer specifies a shorter or longer date for the open vial.Observations in the second floor medication cart on February 4, 2026 at 10:32 a.m. revealed that there was one Insulin Lispro Subcutaneous Solution pen (medication used for diabetes) that had expired on [DATE], and there was one Novolog injection Solution…

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

Based on review of the facility's plans of correction for previous surveys, and the results of the current survey, it was determined that the facility's Quality Assurance Performance Improvement (QAPI) committee failed to correct and/or maintain compliance with quality deficiencies and ensure that plans to improve the delivery of care and services effectively addressed recurring deficiencies. Findings include:The facility's deficiencies and plans of corrections for State Survey and Certification (Department of Health) for the annual survey ending January 10, 2025 and a complaint survey ending March 5, 2025, revealed that the facility developed plans of correction that included quality assurance systems to ensure that the facility maintained compliance with cited nursing home regulations. The results of the current survey, ending February 5, 2026, identified repeated deficiencies related to safety/accidents, labeling and storage of medications, palatable food, and sanitary food practices. The facility's plans of correction for deficiencies regarding safety/accidents, cited during 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 review of established infection control guidelines, facility policies, and clinical records, as well as observations and staff interviews, it was determined that the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one of 46 residents reviewed (Resident 103).Findings include:CDC guidance on suspected or confirmed Clostridioides (C. diff, a germ that causes infectious diarrhea and colitis). Facilities were to isolate and initiate contact precautions (infection control measures designed to prevent the spread of germs transmitted through direct or indirect contact with a patient or their environment).The facility's policy regarding isolation and initiating transmission based precautions, dated January 27, 2026, indicated that the transmission based precautions would be utilized when a resident meets the criteria for…

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 personnel files as well as interviews with staff, it was determined that the facility failed to ensure that the required In-Service Training was completed for one of four nurse aides reviewed (Nurse Aide 6).Findings include:Review of Nurse Aide 6's personnel file revealed that she was hired on March 28, 2017. Review of her continuing education transcript revealed that she did not have the required 12 hours of Nurse Aide training per year.Interview with the Director of Nursing on February 4, 2026 at 3:33 p.m. confirmed that Nurse Aide 6 failed to complete the necessary 12 hours of training. 28 Pa. Code: 201.14(a) Responsibility of Licensee28 Pa. Code: 201.20(a) Staff Development

Based on a review of facility policy and observations, as well as staff interviews, it was determined that the facility failed to ensure that a safe and comfortable environment was maintained for three of nine residents reviewed (Residents 7, 8, 9) who were in the day room with temperatures above 81 degrees Fahrenheit (F). Findings include: Review of the facility policy Homelike Environment, last reviewed January 30, 2024, indicated that the facility reflected a homelike setting to provide comfortable and safe temperatures between 71 degrees F and 81 degrees F. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 7, dated June 9, 2025, indicated that the resident was severely cognitively impaired, was sometimes understood and was sometimes able to understand others, was dependent of staff for care needs, and had diagnoses that included dementia. A quarterly MDS assessment for Resident 8, dated March 24, 2025, indicated that the resident was severely cognitively impaired, was rarely understood and was rarely able…

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 and staff interviews, it was determined that the facility failed to ensure that essential equipment was in safe operating condition in the residents' rooms. Findings include: Manufacturer's instructions for the Packaged Terminal Air Conditioner (PTAC - a heating and cooling system designed to be mounted through a wall to control room temperature) indicated that the air filters are to be cleaned every two weeks, or more often if necessary. Observations in resident room [ROOM NUMBER], on May 15, 2025, at 10:22 a.m. revealed that the room had a PTAC unit. The Maintenance Director was able to remove the filter from the unit and it was covered with a gray-brown layer of removable debris. Observations in resident room [ROOM NUMBER] on May 15, 2025, at 11:51 a.m. revealed that the room had a PTAC unit. The Maintenance Director was able to remove the filter from the unit and it was covered with a thick, gray-brown layer of removable debris. Interview with the Maintenance Director at May 15, 2025,…

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 policy and clinical records, and staff interviews, it was determined that the facility failed to ensure that a dental appointment was scheduled for one of eight residents reviewed (Resident 6). Findings include: A facility policy for dental care, dated January 30, 2025, revealed that the facility is to provide routine and emergency dental care for residents including follow-up dental appointments. A quarterly MDS assessment for Resident 6, dated May 5, 2025, revealed that the resident was cognitively intact, required staff supervision with care, and had her own natural teeth. A physician's order for Resident 6, dated October 10, 2024, revealed that the resident was to see the oral surgeon for tooth extraction. An interview with Resident 6 on May 15, 2025, at 11:44 a.m. revealed that she has an extremely sensitive tooth on her right side, and she believed that she was to have a tooth pulled and has not had it pulled. As of May 15, 2025, there was no documented evidence that Resident 6 saw the oral surgeon to have her tooth pulled. An interview with the…

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

Based on review of clinical records, as well as resident and staff interviews, it was determined that the facility failed to maintain clinical records that were complete and accurately documented for one of eight residents reviewed (Resident 1). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandatory assessment of a resident's abilities and care needs) for Resident 1, dated April 18, 2025, revealed that the resident was understood, could understand others, and had diagnoses that included diabetes. A dental summary note, dated August 2, 2024, revealed that Resident 1 was present for the insertion of lower complete denture. Denture care and wearing instructions were given to the resident. Observations and interview with Resident 1 on May 15, 2025, revealed that he had no natural teeth and was not wearing any dentures. He said he did not have any dentures right now, because they broke. He said he wanted dentures because some of the foods are difficult to chew. Review of nurse aide task documents for February, March, April and May 2025 revealed that the resident 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.

Based on review of policies, as well as observations and staff interviews, it was determined that the facility failed to store food in accordance with professional standards for food service safety for three of three resident refrigerators. Findings include: The facility's policy regarding food and snacks kept on nursing units, dated January 30, 2025, revealed that all foods stored in the refrigerator or freezer will be labeled with the resident's name and use-by dates, and all food items are to be kept at or below 41 degrees Fahrenheit (F). Observations of the second floor resident refrigerator on March 5, 2025, at 9:30 a.m. revealed a white plastic bag dated February 17, 2025, with Resident 1's name, that contained a piece of fried chicken between two paper plates and a plastic container of barbequed ham. Interview with Nurse Aide 1 on March 5, 2025, at 9:43 p.m. confirmed that the food should have been discarded within three days. Observations of the resident refrigerator on the third floor on March 5, 2025, at 9:47 a.m. revealed a salad in a plastic bowel with lid and pizza 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.

Based on review of clinical records, as well as staff interviews, it was determined that the facility failed to ensure that physician's orders for medications were followed for one of 46 residents reviewed (Resident 99). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 99, dated November 25, 2024, indicated that the resident was cognitively intact, required assistance from staff for daily care needs, and had a diagnosis of renal failure requiring dialysis (a procedure that removes waste products and excess fluid from the blood when the kidneys are no longer functioning properly). Physician's orders from the dialysis center for Resident 99, dated December 24, 2024, included an order for the resident to receive 210 milligrams (mg) of Auryxia (treats anemia) five times a day with meals and snacks. Review of Resident 99's Medication Administration Record (MAR), dated January 2025, revealed that the resident was receiving Auryxia three times per day and not the ordered five times per day.…

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 policy and clinical records, and staff interviews, it was determined that the facility failed to ensure that physician's orders for enteral feedings were followed for three of 46 residents reviewed (Residents 16, 54, 67). Findings include: The facility's policy regarding enteral nutrition, dated January 25, 2024, revealed that adequate nutritional support through enteral nutrition is provided to residents as ordered, and is monitored the by the dietician who makes recommendation for interventions for nutritional adequacy. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 16, dated November 18, 2024, indicated that the resident was cognitively intact, required maximum assistance from staff for care, and had an enteral feeding tube (feeding through a tube inserted directly into the stomach). Physician's orders for Resident 16, dated January 6, 2025, included an order for the resident to receive Jevity 1.5 (a type of enteral feeding) at a rate of 60 milliliters (ml)/hour. 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 a review of facility policies and observations, as well as resident and staff interviews, it was determined that the facility failed to serve food that was palatable. Findings include: A facility policy for food preparation and service, dated January 25, 2024, revealed that food should be distributed and served in a manner that complies with safe food handling practices with hot foods above 130 degrees Fahrenheit (F). Interview with a group of residents on January 8, 2025, at 1:30 p.m. revealed that the food delivered to the resident rooms was served cold. Observations in the kitchen for the lunch meal service on January 10, 2025, at 11:31 a.m. revealed that a test tray left the kitchen and arrived on the fourth floor at 11:32 a.m. The lunch meal on January 10, 2025, consisted of ground sausage and noodles, broccoli, rootbeer float dessert cup, milk, and coffee. Trays were passed to the residents in their rooms and the last resident was served and eating at 11:50 a.m. The test tray on January 10, 2025, at 11:52 a.m. revealed that the temperature of the ground sausage 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 review of policies, as well as observations and staff interviews, it was determined that the facility failed to store and prepare food in accordance with professional standards for food service safety. Findings include: The facility's policy regarding food and snacks kept on nursing units, dated January 25, 2024, revealed that all foods stored in the refrigerator or freezer will be labeled with the resident's name and use-by dates, and that beverages are dated when opened and discarded after 24 hours. Observations in the kitchen on January 7, 2025, at 9:27 a.m. revealed a box of frozen 1.5 ounce egg patties that were open to air and dated December 31, 2024. Interview with the Dietary Manager on January 7, 2025, at 9:40 p.m. confirmed that the box of egg patties were open to air. Observations of the resident refrigerator on the second floor on January 7, 2025, at 12:33 p.m. revealed two opened and undated one-pint containers of 2 percent milk labeled with a resident's first name, one opened half-gallon of 1 percent milk that was three quarters full, without a name, and a…

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

Based on review of facility policies, investigative reports, and clinical records, as well as staff interviews it was determined that the facility failed to ensure that residents were free from neglect for one of 46 residents reviewed (Resident 95). Findings include: The facility's current policy regarding abuse, neglect, exploitation, and misappropriation indicated that the residents are to be protected from abuse, neglect, exploitation, or misappropriation of property by anyone, including facility staff. An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 95, dated December 12, 2024, revealed that the resident was cognitively intact, required maximum assistance from staff for transfers, and had diagnoses that included arthritis (a chronic condition that causes joint inflammation, pain, stiffness, and swelling), and had a total knee arthroplasty (a surgical procedure that replaces the knee joint with artificial parts). The resident's activities of daily living care plan, revised on December 6, 2024, indicated…

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 reviews and staff interviews, it was determined that the facility failed to notify the resident, responsible party, and Ombudsman, in writing, regarding the reason for hospitalization for two of 46 residents reviewed (Residents 19, 67). Findings include: A annual Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 19, dated November 2, 2024, indicated that the resident was cognitively intact and required assistance from staff for daily care needs. A nursing note for Resident 19, dated June 6, 2024, at 12:59 p.m., revealed that the certified registered nurse practitioner (CRNP) reviewed lab results and wrote an order to send Resident 19 to the hospital for evaluation. The resident's responsible party was also notified and was agreeable for the resident to be transported to the hospital. There was no documented evidence that a written notice of Resident 19's transfer to the hospital was provided to the resident's responsible party and the Ombudsman regarding the reason for transfer. A quarterly MDS…

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

Based on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that appropriate parties were notified about the facility's bed-hold policy upon transfer to the hospital for two of 46 residents reviewed (Residents 19, 67). Findings include: A facility policy for Bed Holds, dated January 25, 2024, included that residents and/or representatives are informed in writing of the facility and state bed-hold policies. An annual Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 19, dated November 2, 2024, indicated that the resident was cognitively intact and required assistance from staff for daily care needs. A nursing note for Resident 19, dated June 6, 2024, at 12:59 p.m., revealed that the certified registered nurse practitioner (CRNP) reviewed lab results and wrote an order to send Resident 19 to the hospital for evaluation. The resident's responsible party was also notified and was agreeable for the resident to be transported to the hospital. There…

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 reviews and staff interview, it was determined that the facility failed to develop comprehensive care plans that included specific and individualized care regarding the use of an anti-coagulant (blood thinner) for one of 46 residents reviewed (Resident 99). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 99, dated November 25, 2024, revealed that the resident was cognitively intact and that she was medicated with an anti-coagulant. Physician's orders for Resident 99, dated January 2, 2025, included an order for the resident to take 5 milligrams (mg) Eliquis (anti-coagulant) every 12 hours. Review of Resident 99's Medication Administration Record, dated January 2025, revealed that the resident was medicated with Eliquis twice daily. There was no documented evidence that Resident 99's care plan included a care plan for the use of an anti-coagulant. Interview with the Director of Nursing on January 10, 2025, at 1:14 p.m. confirmed that Resident 99's care plan was not…

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 observations, as well as resident and staff interviews, it was determined that the facility failed to ensure that care plans were updated to reflect changes in care needs for one of 46 residents reviewed (Resident 91). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 91, dated November 6, 2024, revealed that the resident was cognitively intact, required substantial assistance with care needs, and was receiving an intravenous antibiotic (when the antibiotic is given through the vein). Review of Resident 91's intravenous access care plan, dated November 24, 2024, indicated that the resident had a peripherally inserted central catheter (PICC) in her right upper arm for administration of antibiotics. Physician's orders for Resident 91, dated December 10, 2024, included an order for the PICC line to be removed. Observations on January 7, 2025, at 10:30 a.m. revealed that the resident did not have a PICC line in her right upper arm. Interview with the…

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

Based on review of the Pennsylvania Nurse Practice Act and clinical records, as well as staff interviews, it was determined that the facility failed to clarify physician's orders for one of 46 residents reviewed (Resident 59). Findings include: The Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.11 (a)(1)(2)(4) indicated that the registered nurse was to collect, complete, and review 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. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 59, dated November 15, 2024, indicated that the resident was understood, could understand others, and was cognitively impaired. Physician's orders, dated January 8, 2024, included orders for the resident to receive 10 mg of Lexapro (a medication used to treat depression 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 review of facility policy and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that residents receive adequate supervision and assistance to prevent accidents for two of 46 residents reviewed (Residents 79, 95). Findings include: The facility's policy for using a lifting machine, dated January 25, 2024, revealed that staff must be competent in the use of mechanical lifts per manufacturer's instructions. Manufacturer's instructions for the Maxi Move mechanical lift revealed that the breaks were to be engaged when lifting and lowering a patient. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 79, dated October 11, 2024, revealed that the resident was cognitively intact, required extensive assistance with daily care needs including transfers, and had diagnoses that included spondylosis (a chronic condition that involves the breakdown of the spine's joints and disks). A care plan, dated September 26, 2024, revealed that the resident was to 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of manufacturer's instructions, facility policies, and clinical records, as well as observations and staff interviews, it was determined that the facility failed to discard expired insulin pens in two of three medication carts reviewed (second and third floor long hall medication carts). Findings include: A facility policy regarding medication labeling and storage, dated [DATE], indicated that multi-dose vials that have been opened or accessed, are dated and discarded within 28 days unless manufacturer specifies a shorter or longer date for the open vial, and discarded according to the manufacturer's expiration date. Manufacturer's directions for use of Lantus Solostar u100 Insulin pen (a long acting insulin), dated [DATE], indicated to discard Solostar Lantus after 28 days out of cool storage. Manufacturer's directions for use of Humalog u100 Insulin pen (a short acting insulin), dated 2023, indicated to discard a 3 milliliter single patient use Humalog pen after 28 days once opened and in use.…

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 policies and written menus, as well as observations and staff and resident interviews, it was determined that the facility failed to follow their planned menu. Findings include: A facility policy, dated January 24, 2024, indicated that menus shall be written in advance and posted in resident areas. Any menu substitutions or deviations from the posted menu shall be made in an emergency situation only and recorded on the substitution log. An interview with a group of residents on January 7, 2025, revealed that they do not always get what is on the menu. The facility's written and printed menu for the lunch meal on January 7, 2025, indicated that the residents were to receive chunky cheeseburger casserole, glazed sweet carrots, garlic bread, a lemon brownie, and choice of beverage. Observations in the kitchen on January 7, 2025, at 9:17 a.m. revealed a yellow cake in the walk-in cooler for the lunch meal. Observations of the lunch meal in the Third floor dining room on January 7, 2025, at 12:30 p.m. revealed that the facility served a blonde brownie 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 review of the facility's plans of correction for previous surveys, and the results of the current survey, it was determined that the facility's Quality Assurance Performance Improvement (QAPI) committee failed to correct quality deficiencies and ensure that plans to improve the delivery of care and services effectively addressed recurring deficiencies. Findings include: The facility's deficiencies and plans of corrections for a State Survey and Certification (Department of Health) survey ending February 8, 2024, and complaint investigation surveys ending June 4, 2024; July 22, 2024; September 17, 2024; and December 11, 2024, revealed that the facility developed plans of correction that included quality assurance systems to ensure that the facility-maintained compliance with cited nursing home regulations. The results of the current survey, ending January 10, 2025, identified repeated deficiencies related to creating and implementing care plans, revision of care plans, quality of care, meeting professional standards, free of accidents, menus made in advance and followed,…

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 and staff interviews, it was determined that the facility failed to provide comfortable temperatures for one of three dining rooms in the facility (fourth floor Dining Room). Findings include: Observations in the fourth floor dining room on January 7, 2025, at 11:40 a.m. revealed that there were five residents waiting for lunch. The temperature in the dining room was 64 degrees Fahrenheit. Observations in the fourth floor dining room on January 9, 2025, at 12:16 p.m. revealed that there were five people eating there and the temperature ranged from 60 to 70 degrees Fahrenheit. Interview with the Maintenance Director on January 7, 2025, at 11:40 a.m. revealed that the doors to the fourth floor dining room were closed and the heat was not circulating into the dining room from the hallways. He indicated that when the doors were open, the dining room was warm. At 2:20 p.m. the temperature in the fourth floor dining room was 73.4 degrees Fahrenheit. Interview on January 9, 2025, at 2:18 p.m. with the owner of the heating, ventilation, and air conditioning (HVAC…

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

Based on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that a resident's representative was notified about the need to alter treatment/new physician's orders for one of nine residents reviewed (Resident 1). Findings include: The facility's policy regarding a Change in a Resident's Condition or Status, dated January 25, 2024, indicated that unless otherwise instructed by the resident, a nurse would notify the resident's representative when there was a significant change in the resident's physical, mental or psychosocial status. A significant change of condition was a major decline or improvement in the resident's status that would not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions. An annual Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated November 3, 2024, indicated that the resident was cognitively impaired, was incontinent of urine, and had diagnoses…

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

Based on review of policies, as well as observations and staff interviews, it was determined that the facility failed to maintain a clean and homelike environment for one of nine residents reviewed (Resident 6). Findings include: The facility's policy regarding cleaning and disinfecting, dated January 25, 2024, indicated that housekeeping was to remove visible debris from surfaces and that proper cleaning was necessary to reduce infection. A quarterly Minimum data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 6, dated November 18, 2024, revealed that the resident was cognitively intact and had diagnoses that included coronary artery disease, heart failure, and asthma. Observations on December 10, 2024, at 11:02 a.m. revealed that the resident was lying in his bed with a stand-up fan blowing directly on him. The fan was noted to have a very heavy amount of visible dirt and debris accumulated on the blade cover. There were approximately four tendrils of dirt/debris flowing from the fan cover as the fan was blowing toward 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 facility policies and clinical records, as well as resident and staff interviews, it was determined that the facility failed to ensure that residents received the appropriate treatment and services to maintain or improve their abilities to ambulate and perform activities of daily living for one of nine residents reviewed (Resident 2). Findings include: A facility policy regarding supporting activities of daily living, dated January 25, 2024, indicated that residents will be provided with care, treatment, and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Interventions to improve or minimize a resident's functional abilities will be in accordance with the resident's assessed needs, preferences, stated goals, and recognized standards of practice. The resident's response to interventions will be monitored, evaluated, and revised as appropriate. A significant change Minimum Data Set (MDS) assessment (a mandated assessment of 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 review of the facility's investigation documents and residents' clinical records, as well as staff interviews, it was determined that the facility failed to ensure that safe transfer techniques were used in accordance with their care plans for one of nine residents reviewed (Resident 5) resulting in a fall. This deficiency was cited as past non-compliance. Findings include: An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 5, dated September 26, 2024, revealed that the resident was cognitively intact and had a diagnosis of a fracture, anxiety, and depression. A [NAME] report (a nursing worksheet that includes a summary of patient information, such as devices/interventions, activities of daily living, behaviors/mood, mobility, bathing, bladder/bowel, positioning and toileting) for Resident 5, dated October 14, 2024, revealed the following safety measures for staff to follow: transfer with a stand-up lift (mechanical lift used to…

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

Based on clinical record reviews and staff interviews, it was determined that the facility failed to ensure that weekly weights were obtained as recommended by the dietician for one of nine residents reviewed (Resident 2) who had a weight loss. Findings include: A significant change Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 2, dated October 11, 2024, revealed that the resident was cognitively impaired, was clearly understood and able to clearly understand others, required substantial assist with care needs, had significant weight loss, and had diagnosis that included protein calorie malnutrition. A care plan for Resident 4, dated July 5, 2024, indicated that the resident had a risk for altered nutrition due to her history of dysphagia (difficulty swallowing), weight loss, and need for a textured diet. A care plan intervention, dated July 5, 2024, indicated to periodically obtain the resident's weight, evaluate, and report to the registered dietician, physician, and family of significant weight changes. A dietician…

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 reviews and staff interviews, it was determined that the facility failed to ensure that laboratory specimens were obtained as ordered for one of nine residents reviewed (Resident 2). Findings include: A significant change Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 2, dated October 11, 2024, revealed that the resident was cognitively impaired, was clearly understood and able to clearly understand others, required substantial assist with care needs, had significant weight loss, received oxygen, and had diagnoses that included pulmonary fibrosis (a lung disease that causing scarring and stiffening of lung tissue, making it harder to breathe), respiratory failure (blood does not have enough oxygen and causes difficulty breathing), asthma, rheumatoid arthritis (chronic inflammatory disorder that affects the joints and organs), and protein calorie malnutrition. Physician's orders for Resident 2, dated October 7, 2024, indicated that the resident was ordered to have bloodwork (calcium level, sed…

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 policy, written menus, observations, and staff interviews, it was determined that the facility failed to follow their planned menu. Findings include: The facility's policy for menus, dated January 25, 2024, revealed that menus are served as written unless changed in response to preference, unavailability of an item, or a special meal. In addition, deviations from the posted menus are recorded, including the reason for the substitution or deviation. The written lunch menu for the day of December 10, 2024, revealed that there was to be chunky cheeseburger casserole, glazed sweet carrots, garlic bread, and lemon brownies. Observations on Tuesday, December 10, 2024, at 12:35 p.m. of Resident 4's lunch tray revealed that the lunch meal consisted of chunky cheeseburger casserole, glazed sweet carrots, a half of a hot dog bun broken in half with butter, and a chocolate brownie. There was no garlic bread or lemon brownie. Interview with Resident 4 on December 10, 2024, at that time revealed that the bread served was not garlic bread and that she never heard of a…

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

Based on review of facility policies, as well as observations and staff interviews, it was determined that the facility failed to serve food in accordance with professional standards for food safety by ensuring the food was served at the appropriate temperatures. Findings include: The facility's policy regarding food preparation and service, dated January 25, 2024, revealed that the facility was to serve food in a manner that complies with safe food handling practices. A test tray was done during the lunch meal on December 10, 2024. The food cart carrying the test tray left the kitchen at 12:49 p.m., arrived on the second floor at 12:50 p.m., and the last resident tray was delivered and the test tray was tested at 1:02 p.m. The test tray consisted of chunky cheeseburger casserole, glazed sweet carrots, bread, brownies, milk, pink lemonade, and coffee. The food was then tasted and the following temperatures were obtained by the Dietary Manager and visualized by the surveyor. The cheeseburger casserole was 129.7 degrees Fahrenheit (F), glazed sweet carrots were 116.1 degrees F, coffee…

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, as well as observations and staff interviews, it was determined that the facility failed to prepare, distribute, and serve food in accordance with professional standards for food service safety by failing to ensure that dietary staff wore appropriate hair coverings. Findings include: The facility's policy regarding hair restraints, dated January 25, 2024, revealed that all kitchen employees prepping or preparing food must wear hair restraints that are designed to effectively keep hair properly restrained. Observations in the kitchen on December 10, 2024, at 11:35 a.m. revealed that the Dietary Manager was stirring, temping, and plating food for residents. It was noted that the she had two to three inches of hair at the back of her head at her hairline and approximately one inch of hair on the side of her face that was not covered. Observations in the main kitchen on December 10, 2024, at 11:50 a.m. revealed that Dietary Worker 4 was placing desserts and lids onto the residents' meal trays, which already contained prepared plates of food. Dietary…

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

Based on review of Pennsylvania's Nursing Practice Act and clinical records, as well as staff interviews, it was determined that the facility failed to clarify physician's orders for one of six residents reviewed (Resident 5). Findings include: The Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.11 (a)(1)(2)(4) indicated that the registered nurse was to collect complete and ongoing data to determine nursing care needs, analyze the health status of individuals and compare the data with the norm when determining nursing care needs, and carry out nursing care actions that promote, maintain, and restore the well-being of individuals. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 5, dated June 26, 2024, indicated that the resident was cognitively intact, required substantial assistance from staff with personal hygiene care, and had diagnoses that included peripheral vascular disease (a medical condition where blood vessels become blocked, reducing blood flow 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record reviews and staff interviews, it was determined that the facility failed to ensure that admission orders were followed for one of five residents reviewed (Resident 2). Findings include: Resident 2's clinical record indicated that she was admitted to the facility on [DATE], with diagnoses that included frequent falls and congestive heart failure. admission orders for Resident 2, dated June 12, 2024, included orders for the resident to be weighed daily and to notify the physician of a weight gain of 1 to 2 pounds in one day or 5 pounds in one week. admission orders also included for the resident to receive 20 milligrams (mg) Lasix (diuretic) daily. A review of Resident 2's Treatment Administration Record (TAR), dated June 2024, revealed that the resident did not receive the Lasix. Further review revealed that the resident was weighed June 13 at 121.4 pounds, June 14 at 122.4 pounds, and June 20 at 122.4 pounds. She was not weighed daily per the order, and the physician was not notified 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 clinical record reviews and staff interviews, it was determined that the facility failed to ensure that laboratory specimens were obtained as ordered for one of five residents reviewed (Resident 2). Findings include: According to Resident 2's clinical record she was admitted to the facility on [DATE], after being admitted to the hospital for multiple falls and congestive heart failure. Hospital discharge instructions for Resident 2, dated June 12, 2024, included orders for the resident to have repeat lab work in one to two days after discharge from the hospital. There were no labs ordered or obtained for Resident 2 during her stay at the facility. Interview with the Director of Nursing on July 22, 2024, at 1:02 p.m. revealed that the admitting nurse and the nurse that reviewed the admission orders missed the lab order because it was in the narrative of the discharge summary and not included among the discharge orders. She confirmed that the labs should have been obtained and were not. 28 Pa. Code…

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

Based on a review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that insulin was administered timely for two of four residents reviewed (Residents 1, 4), and failed to provide medications as ordered by the physician for one of four residents reviewed (Resident 1). Findings include: The facility's policy for medication administration, dated November 30, 2023, revealed that medications were to be administered within one hour of their prescribed time, unless otherwise specified. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated March 9, 2024, indicated that the resident was cognitively intact, received insulin, and had diagnoses that included diabetes. Physician's orders for Resident 1, dated October 3, 2023, included and order for the resident to receive 15 units of Basaglar (insulin) subcutaneously (tissue just beneath the skin) one time a day and at bedtime, and a physician's order, dated May 7, 2024, included an order for the…

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

Based on review of facility policies, residents' clinical records, and the facility's investigative documents, as well as resident and staff interviews, it was determined that the facility failed to ensure that a professional (licensed) nurse completed a timely assessment when changes in condition occurred for one of five residents reviewed (Resident 1). This deficiency was cited as past noncompliance. Findings include: The facility's policy regarding change in condition, dated January 25, 2024, indicated that a nurse would make detailed observations and gather relevant and pertinent information for the provider when a change in condition has occurred. The facility's investigation, dated March 8, 2024, indicated that Resident 1 rang for the nurse aide around 1:00 p.m. and asked to see the nurse because she was not feeling well. She told Nurse Aide 2 that she was having chest discomfort and that she felt like she was getting COVID or pneumonia again. Nurse Aide 2 went to Licensed Practical Nurse 1 and told him that Resident 1 was not feeling well, that she was having chest pain, 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 review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that advance directives decisions were documented in the clinical record for 10 of 37 residents reviewed (Residents 23, 28, 37, 47, 55, 62, 64, 73, 78, 82). Findings include: The facility's policy regarding advance directives (instructions regarding the provision of health care when the resident is incapacitated), dated January 25, 2024, indicated that the resident has the right to formulate an advanced directive, including the right to accept or refuse medical or surgical treatments. Prior to or on admission of a resident, the social services director or designee inquires of the resident, his or her family members, and/or his or her legal representative about the existence of any written advance directives. The resident or representative is provided with written information concerning the right to refuse or accept medical or surgical treatment and to formulate an advance directive if he or she desires to do so. Copies of these documents are obtained…

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

Based on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to develop and implement comprehensive care plans that included specific and individualized interventions to address specific care needs for two of 37 residents reviewed (Residents 45, 73). Findings include: The facility's policy regarding care plans, dated January 25, 2024, indicated that individualized, comprehensive, person-centered care plans would be developed and implemented based on the resident's assessments. An annual Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 45, dated November 21, 2023, revealed that the resident was cognitively intact, had limited range of motion of one upper extremity, required moderate assistance from staff for dressing, toileting, and bathing, and had diagnoses that included cerebral palsy (disorder that affects movement and balance). A care plan, dated December 6, 2023, for Resident 45 indicated that the resident had a contracture of her hand. Nursing…

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

Based on review clinical records, as well as staff interviews, it was determined that the facility failed to notify the physician that a medication was ineffective for one of 37 residents reviewed (Resident 62). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs), for Resident 62, dated November 7, 2023, revealed that she was cognitively impaired and had diagnoses that included seizure disorder (sudden, uncontrolled body movements and changes in behavior that occur because of abnormal electrical activity in the brain), anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), and psychotic disorder (a mental disorder characterized by a disconnection from reality). Physician's orders for Resident 62, dated December 17, 2023, included orders for the resident to receive 0.5 mg of Xanax (a medication used to treat anxiety) every six hours as needed. The resident's Medication Administration Record (MAR) for…

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

Based on review of policies, as well as observations and staff interviews, it was determined that the facility failed to provide confidentiality of residents' personal health information during medication administration for one of 37 residents reviewed (Resident 242). Findings include: The facility policy regarding privacy of health information, dated January 25, 2024, indicated that the facility was to protect the confidentiality of a resident's health information. Observations during medication administration on February 7, 2024, at 8:21 a.m. revealed that Licensed Practical Nurse 1 walked away from her medication cart to retrieve a blood pressure cuff without securing her computer screen. Resident 242's personal health information was visible on the computer screen, which was facing the hallway. Observations on February 7, 2024, at 8:29 a.m. revealed that Licensed Practical Nurse 1 entered Resident 242's room to administer medication and again left her computer unsecured on her medication cart with Resident 242's personal health information visible on the screen and facing the…

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

Based on review of clinical records and observations, as well as resident and staff interviews, it was determined that the facility failed to ensure that care plans were updated to reflect changes in care needs for three of 37 residents reviewed (Residents 23, 62, 78). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 23, dated November 13, 2023, revealed that the resident was cognitively impaired, required substantial assistance with care needs, was incontinent of bowel and bladder, was receiving an antibiotic for a urinary tract infection, and had diagnoses that included dementia (loss of cognitive functioning), atrial fibrillation (irregular heart beat), ventricular tachycardia (fast heart rate), congestive heart failure (heart does not pump blood effectively). Review of Resident 23's cardiac care plan, dated December 8, 2022, indicated that the resident was to have pacemaker checks as ordered; however, the resident did not have a pacemaker. Interview with the Director of Nursing 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 review of clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that pressure ulcer treatments were completed as ordered for one of 37 residents reviewed (Resident 48). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 48, dated December 27, 2023, indicated that the resident was cognitively impaired, was dependent on staff for all care needs, and had a Stage 3 pressure area (full-thickness skin loss potentially extending into the subcutaneous tissue layer) to her left buttocks. Physician's orders for Resident 48, dated October 30, 2023, included an order for the resident's left buttocks to be cleansed with soap and water and patted dry, zinc barrier cream applied to the area every shift and as needed, and to leave the wound open to air. Review of the December 2023 Treatment Administration Record (TAR) for Resident 48 revealed no documented evidence that the treatment to her left buttocks was completed on December 17,…

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 reviews, observations, and resident and staff interviews, it was determined that the facility failed to ensure that nutritional supplements were provided as ordered for two of 37 residents reviewed (Residents 11, 29) who were at risk for weight loss. Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 11, dated January 1, 2024, indicated that the resident could rarely or never understand or be understood, and was dependent on staff for eating. The resident's care plan, dated December 22, 2023, indicated that the resident had an impaired metabolic status and to provide the diet as ordered. Physician's orders for Resident 11, dated August 2, 2023, included an order for the resident to be provided a sugar-free healthshake with breakfast, lunch, and dinner related to a risk for malnutrition. Observations of the lunch meal on February 5, 2024, at 11:36 a.m. revealed that Resident 11 was being assisted by Licenced Practical Nurse (LPN) 2 in the dining room. There was 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 review of clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that oxygen therapy was provided as ordered by the physician for one of 37 residents reviewed (Resident 78). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 78, dated November 17, 2023, revealed that the resident was cognitively intact, was using supplemental oxygen, and had diagnoses that included acute and chronic respiratory failure (difficulty breathing) and chronic obstructive pulmonary disease (COPD) (a chronic lung disease making breathing difficult). Physician's orders for Resident 78, dated November 30, 2023, included an order for the resident to receive oxygen at a flow rate of 2 liters per minute by way of a nasal canula (a small tube that delivers oxygen through the nasal passages). Observations of Resident 78 on February 5, 2024, at 10:35 a.m. and February 6, 2024, at 8:45 a.m. revealed that the resident was receiving supplemental oxygen…

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 reviews and staff interviews, it was determined that the facility failed to ensure that residents were assessed and received trauma-informed care to eliminate or mitigate triggers for residents with the diagnosis of Post Traumatic Stress Disorder (PTSD) (a mental and behavioral disorder that develops related to a terrifying event) for one of 37 residents reviewed (Resident 45). Findings include: An annual Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 45, dated November 21, 2023, revealed that the resident was cognitively intact; required moderate assistance from staff for dressing, toileting, and bathing; and had diagnoses that that included depression and PTSD. A review of Resident 45's care plan, dated December 6, 2023, indicated that the resident had a history of PTSD after surviving a traumatic event. Interview with Resident 45 on February 5, 2024, at 11:38 a.m. revealed that a past boyfriend had physically hurt her. There was no documented evidence that a trauma-informed assessment 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.

Based on review of clinical records, as well as staff interviews, it was determined that the facility failed to obtain labs timely for one of four residents reviewed (Resident 62). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 62, dated November 7, 2023, revealed that she was cognitively impaired and had diagnoses that included seizure disorder (sudden, uncontrolled body movements and changes in behavior that occur because of abnormal electrical activity in the brain), anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), and psychotic disorder (a mental disorder characterized by a disconnection from reality). The pharmacist's Medication Regimen Review for Resident 62, dated June 23, 2023, recommended lab tests for Keppra (a medication used for seizures that must be regulated by routine lab testing), Basic Metabolic Panel (a blood test that measures eight different substances 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.

Based on clinical record reviews and staff interviews, it was determined that the facility failed to obtain laboratory studies as ordered by the physician for one of 37 residents reviewed (Resident 37). Findings include: An annual Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 37, dated November 14, 2023, indicated that the resident was cognitively impaired, required substantial assistance from staff for daily care needs, and had diagnoses that included chronic iron deficiency anemia due to blood loss. A Certified Registered Nurse Practitioner's (CRNP) progress note for Resident 37, dated November 3, 2023, at 2:04 p.m. indicated that the resident had recent bloodwork reviewed from October 10, 2023, showing a hemoglobin (measurement of protein in the blood that carries oxygen to body organs) of 7.4 (low) and a hematocrit (measures how much of the blood consists of red blood cells) of 24.7 (low). The results were reviewed by the physician on October 10, 2023, and the physician ordered the bloodwork to be rechecked in one…

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 and staff interviews, it was determined that the facility failed to ensure that food was stored and served under sanitary conditions in accordance with professional standards for food service safety, and failed to ensure that food items were stored in accordance with professional standards for food service safety in three of three nursing unit pantry refrigerators (first, third, fourth floor pantries). Findings include: Observations inside the second floor pantry refrigerator on February 5, 2024, at 10:18 a.m. revealed a large spill of a brown, sticky, removable substance below the draws in the bottom of the refrigerator and several loose pieces of old, dried-up shredded cheese on the door of the refrigerator. Interview with the Director of Nursing on February 5, 2024, at 10:21 a.m. confirmed that the spill and old cheese should have been cleaned up. 28 Pa. Code 211.6(f) Dietary services.

Based on review of clinical records, as well as resident and staff interviews, it was determined that the facility failed to maintain clinical records that were complete and accurately documented for two of 37 residents reviewed (Residents 53, 62). Findings include: A quarterly MDS assessment for Resident 53, dated January 12, 2024, revealed that the resident was cognitively impaired, required assistance with daily care needs, and had diagnoses that included a stroke and a Stage 3 pressure ulcer on the left middle finger. Physician's orders for Resident 53, dated December 22, 2023, included an order for the resident's left middle finger to be cleansed with normal saline and patted dry, Bactroban 2 percent (an antibiotic ointment) applied to the wound base, secured with bordered gauze, and to be changed daily. Review of the January and February 2024 Treatment Administration Record (TAR) for Resident 53 indicated that the resident did not receive the treatment on January 23 and 27, 2024, or February 2, and 5, 2024. A witness statement from Licensed Practical Nurse 5 revealed that she…

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 hospice contracts and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that the designated interdisciplinary team member obtained the required information from the contracted hospice provider for two of two hospice residents reviewed (Residents 32, 48). Findings include: An agreement between the facility and a hospice provider (provider of end-of-life services), dated January 25, 2024, indicated that the hospice provider would provide information to the facility to facilitate coordination of care that included the most recent hospice plan of care specific to each patient and a hospice benefit of elections form (a form signed to indicate that the individual waives all rights to traditional Medicare Part A payments for treatment related to the terminal illness). Physician's orders for Resident 32, dated July 12, 2022, revealed that the resident was to receive hospice services from the facility's contracted hospice provider. As of February 8, 2024, there was no documented evidence in the resident's clinical record,…

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

Based on review of the facility's plans of correction for previous surveys, and the results of the current survey, it was determined that the facility's Quality Assurance Performance Improvement (QAPI) committee failed to ensure that corrective plans to improve and/or correct quality deficiencies effectively addressed recurring deficiencies and ensured that the facility maintained compliance with nursing home regulations. Findings include: The facility's deficiencies and plans of correction for State Survey and Certification (Department of Health) surveys ending December 1, 2023; June 30, 2023; and March 23, 2023, revealed that the facility developed plans of correction that included quality assurance systems to ensure that the facility maintained compliance with cited nursing home regulations. The results of the current survey, ending February 8, 2024, identified repeated deficiencies related to notification of changes, developing comprehensive care plans, updating and revising care plans, providing services to maintain adequate nutrition, ensuring that food was properly stored,…

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 guidance from the Centers for Disease Control (CDC - the national health protection agency) and clinical records, as well as observations and staff interviews, it was determined that the facility failed to follow CDC guidelines to reduce the spread of infections and prevent cross-contamination related to Clostridioides difficile infection for one of 37 residents reviewed (Resident 38). Findings include: The facility's policy regarding isolation and transmission based precautions, dated January 25, 2024, indicated that contact precautions are implemented for residents known or suspected to be infected with microorganisms that can be transmitted by direct contact with the resident or indirect contact with environmental surfaces or resident-care items in the resident's environment. Staff and visitors are to don gloves and disposable gowns (also known as personal protective equipment or PPE) when entering the room and remove the PPE before leaving the room. A quarterly Minimum Data Set (MDS) assessment (required assessment of a resident's abilities and care needs) for…

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

Based on review of facility documents and clinical records, as well as staff interviews, it was determined that the facility failed to accommodate the residents' needs by failing to provide a communication board for one of 11 residents reviewed (Resident 2). Findings include: An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 2, dated October 27, 2023, indicated that the resident wore hearing aides and could hear adequately, had moderately impaired cognition, and was dependent for toileting and transfers. The resident's care plan, dated October 11, 2023, revealed that the resident wore hearing aides in both ears, and staff were to apply them in the morning and remove them at bedtime. An e-mail, dated October 31, 2023, revealed that the family requested a white board (communication board) due to her hearing deficits. However, there was no documented evidence that the resident received a communication board during her stay in the facility. Interview with the Director of Rehabilitation on November 21, 2023, at…

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 policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that a therapeutic diet was provided as ordered by the physician for one of four residents reviewed (Resident 4). Findings include: The facility's policy regarding therapeutic diets, dated February 23, 2023, indicated that therapeutic diets are prescribed by the attending physician to support the resident's treatment and plan of care and in accordance with his or her goals and preferences. A therapeutic diet is considered a diet ordered by a physician as part of treatment for a disease, to modify specific nutrients in the diet, or to alter the texture of a diet. An annual Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 4, dated July 17, 2023, revealed that the resident was cognitively impaired, required extensive assistance for personal care needs and supervision with eating, and had diagnoses that included Alzheimer's dementia. Physician's orders for Resident 4, 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.