Seneca Place

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical records and staff interview, it was determined that the facility failed to provide documentation that medication regimen reviews (MRR) were completed and reviewed by the resident's attending physician monthly for one of five residents (Resident R3). Findings include: Review of the facility policy Medication Regimen Review dated 5/21/26, indicated the consultant pharmacist performs a comprehensive medication regimen review (MRR) at least monthly. Within twenty-four hours of the MRR, the Consultant Pharmacist provides a written report to the attending physicians for each resident identified as having a non-life threatening medication irregularity. Review of the admission record indicated Resident R3 was admitted to the facility on [DATE]. Review of Resident R3's Minimum Data Set (MDS- a periodic assessment of care needs) dated 5/9/26, indicated the diagnoses of anemia (the blood doesn't have enough healthy red blood cells), atrial fibrillation (irregular heart rhythm), and high…

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 documents, clinical record reviews and staff interview it was determined that the facility failed to initiate a thorough investigation for a burn for one of three residents reviewed (Resident R2). Findings include:Resident R2 was admitted to the facility on [DATE]. Review of Resident R2's Minimum Data Set (MDS - a periodic assessment of care needs) dated 4/17/26 indicated diagnoses of mood disorder, brain injury without loss of consciousness and dysphagia (trouble moving food or liquids from the mouth to the stomach). Review of documentation provided by the facility dated 2/17/26, stated Resident R2 burned his hands on hot coffee during the 3-11 shift, it caused a red area and blister. On call physician was contacted and recommended Resident R2 be sent to the hospital for evaluation and treatment, Resident R2 refused. During an interview 6/2/26 at 1:30 p.m. Dietary Manager Employee E1 stated they do not take temperatures of their coffee or hot water before or during tray line service…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of clinical records and staff interview, it was determined that the facility failed have physician orders for colostomy supplies and care for one of six residents (Resident R1). Findings include: A review of the clinical record indicated Resident R1 was admitted to the facility on [DATE], with diagnoses that included malignant neoplasm vulva, colostomy and anxiety. A review of Resident R1's a MDS 5-Day assessment (minimum data assessment)- periodic assessment of resident care needs) dated 5/6/26, indicated the diagnosis remained current. A review of Resident R1's physician orders dated 5/26/26 indicated:Colostomy Appliance Change Q 7 days and prn- written 5/12/26Conva Tec Natura Plus Pouch Lot #5E013743. 1 1/4- 1 3/4 (33-45mm) [NAME]-Fit-written 5/12/26Colostomy Care-every shift, written 5/12/25 During an interview on 6/2/26, at 2:30 p.m. the Director of Nursing confirmed the facility failed to write colostomy orders on admission for Resident R1 as required. 28 Pa. Code: 211.12 (d)(1)(3)(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 record review, facility provided documents, and staff interviews, it was determined that the facility failed to ensure a safe environment resulting in a burn for one of three residents (Resident R2). Findings include:Review of the clinical record Resident R2 was admitted to the facility on [DATE]. Review of Resident R2's Minimum Data Set (MDS - a periodic assessment of care needs) dated 4/17/26 indicated diagnoses of mood disorder, brain injury without loss of consciousness and dysphagia (trouble moving food or liquids from the mouth to the stomach). Review of documentation provided by the facility dated 2/16/26, stated Resident R2 burned his hands on hot coffee during the 3-11 shift, it caused a red area and blister. Intact Blister on the second finger knuckle to the top of the right hand measuring approximately 2cm x2cm (centimeters). Review of facility provided investigation dated 2/17/26 indicated coffee temperature from the kitchen approximately 172-178 at time of tray set up…

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 documents, facility policy, clinical records, and staff interviews, it was determined that the facility failed to implement written policies and procedures to ensure a complete and thorough investigation of an incident involving the potential for neglect for two of five residents (Resident R5, and R119), and failed to conduct a criminal background check prior to the start of employment for two of five staff ( Licensed Practical Nurse (LPN) Employee E10, and Registered Nurse (RN) Employee E11). Findings include: Review of the facility Abuse, Neglect, Exploitation and Misappropriation Prevention Program policy last reviewed 5/1/25, indicated residents have the right to be free from abuse, neglect, misappropriation of resident ' s property and exploitation. The resident abuse, neglect and exploitation prevention program consists of a facility-wide commitment and resource allocation to support the following objectives that include but not inclusive to developing and implementing policies…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical records, facility documents, and staff interview, it was determined that the facility failed to identify and investigate an incident of possible abuse and/or neglect for three of five incidents reviewed (Residents R5, R54 and R119). Findings include: The facility Accidents and Incidents-Investigating and Reporting policy dated 5/1/25, indicated all accidents or incidents occurring on our premises must be investigated and reported to the administrator. Regardless of how minor an accident or incident, injuries of unknown origin, it must be reported to the nursing supervisor and included on the facility 24- hour report. Review of the clinical record indicated that Resident R5 was admitted to the facility on [DATE]. Review of Resident R5's Minimum Data Set (MDS - a periodic assessment of care needs) dated 4/1/25, indicated the diagnosis of hypertension (high blood pressure) diabetes (high sugar in the blood) and hyperlipidemia (high fats in the blood). Review of 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility documents, facility policy, clinical records, and staff interviews, it was determined that the facility failed to ensure that a resident's care plan was updated and revised to reflect the resident's specific care needs for three of six residents (Residents R62, R118, and R292). Findings include: Review of facility policy Care Plans, Comprehensive Person-Centered dated 5/1/25, indicated assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. Review of the clinical record indicated Resident R62 was admitted to the facility on [DATE]. Review of Resident R62's Minimum Data Set (MDS - a periodic assessment of care needs) dated 5/7/25, indicated diagnoses of anemia (too little iron in the blood), high blood pressure, and muscle wasting. Review of a physician progress note dated 3/13/25, stated, Patient seen and evaluated today for diarrhea and vomiting. 2 episodes of diarrhea and 2 episodes of vomiting this…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical records, resident and staff interview it was determined that the facility failed to have a physician orders for intravenous catheter (IV- a catheter placed into a vein for a medical need of fluids or antibiotics) dressing changes for one of two residents (Resident R56), failed to follow physician orders for wound care for one of five residents (Resident R124), failed to ensure timely follow up physician appointments were ordered for two out of four residents (Residents R2, and R97), and failed to ensure that residents received treatment and care in accordance with standards of practice and physician orders by failing to label a medicated patch with the date and time prior to application for one of three residents (Resident R133) as required. Findings include: Review or the facility policy Central Venous Catheter Care and Dressing Change dated 5/1/25, indicated the purpose of this procedure is to prevent complications associated with intravenous therapy, including…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical records, and staff interview it was determined that the facility failed to provide appropriate respiratory care relating to CPAP/BIPAP (a continuous positive airway pressure machine used to keep airways open while you sleep/a positive airway pressure machine when breathing in and breathing out) for three of three residents (Residents R19, R50, and R93). Findings include: Review of the facility policy CPAP/Bipap Support dated 1/2/25, indicated Bipap delivers continuous positive airway pressure, but allows separate pressure settings for expiration (EPAP -breathing out) and inspiration (IPAP- breathing in). Document in the resident's medical record how the resident tolerated the procedure. Review the physician's order to determine the oxygen concentration and flow, and the pressure measurement for the machine. Review of the admission record indicated Resident R19 was admitted on [DATE]. Review of Resident R19's Minimum Data Set (MDS - a periodic assessment of care needs)…

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 policy and staff interview it was determined the facility failed to provide consistent and complete communication with the dialysis center for two of three residents reviewed (Residents R4 and R44), failed to have physician orders for access device care and management for two of three residents (Resident R4, and R109) and failed to have appropriate care plans for two of three resident's (Resident R4 and R109). Findings include: Review of the facility policy End-Stage Renal Disease (ESRD), Care of Resident With dated 5/1/25, indicated the nature and clinical management of ESRD, the care of grafts and fistulas, and agreements between the facility and the contracted ESRD facility include all aspects of how the resident's care will be managed including how the care plan will be developed and implemented, and how information will be exchanged between facilities. Review of the clinical record indicated that Resident R44 was admitted to the facility on [DATE].…

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, observations, and staff interviews, it was determined that the facility failed to store medications and biologicals properly and securely in three of five medications carts (Third floor North Hall, Third floor [NAME] Hall, and Fourth floor East Hall medication carts). Findings include: Review of the facility policy Storage of Medications last reviewed 5/1/25, indicated the facility stores all drugs and biologicals in a safe, secure, and orderly manner. Drugs and biologicals are stored in the packaging, containers or other dispensing systems in which they are received. Only the issuing pharmacy is authorized to transfer medications between containers. Review of the facility policy Administering Medications last reviewed 5/1/25, indicated the expiration/beyond use date on the medication label is checked prior to administering. When opening a multi-dose container, the date opened is recorded on the container. Insulin pens are clearly labeled with the resident's name or other identifying information. During an observation on 6/10/25, at 9:00 a.m.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical record review, observations, and staff interviews, it was determined that the facility failed to follow enhanced barrier precautions for two of three residents (Residents R49 and R109), failed to implement appropriate transmission-based precautions for four of five residents (Residents R62, R118, R142, and R143), and failed to implement an infection control program that included a system of surveillance to identify possible communicable diseases or infections for two of ten months (September 2024, and February 2025) and failed to prevent cross contamination during a medication pass for one of three resident's (Resident R133). Findings include: Review of the facility policy Enhanced Barrier Precautions (EBP) dated 5/1/25, indicated EBP's are used as an infection prevention and control intervention to reduce the spread of multi-drug-resistant organisms (MDRO) to residents. EBP's are indicated for residents with wounds and/or indwelling medical devices regardless of MDRO…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy and clinical records and staff interview, it was determined that the facility failed to notify the physician or resident representative of a change in condition/status for three of six residents (Resident R54, R119 and R124). Findings include: Review of the facility policy Change in a Resident's Condition or Status dated 5/1/25, indicated the facility promptly notifies the resident, his, or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status. Review of the clinical record indicated that Resident R54 was admitted to the facility on [DATE]. Review of Resident R54's Minimum Data Set (MDS - a periodic assessment of care needs) dated 3/12/25, indicated the diagnoses of diabetes mellitus(a chronic metabolic disease characterized by high blood sugar levels), post-traumatic stress disorder and hypotension (medical condition characterized by low blood pressure). Review of Resident R54's progress notes 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 review of facility policies, clinical record reviews and staff interviews, it was determined that the facility failed to report one of five neglect allegations (Residents R5) to the State Department of Health as required. Findings include: Review of facility Abuse, Neglect, Exploitation and Misappropriation Prevention Program last reviewed 5/1/25, indicated residents have the right to be free from abuse, neglect, misappropriation of resident ' s property and exploitation. The resident abuse, neglect and exploitation prevention program consists of a facility-wide commitment and resource allocation to support the following objectives that include but not inclusive to developing and implementing policies and protocols to prevent and identify abuse or mistreatment and neglect of residents. Conduct employee background checks. Provide staff orientation and training programs that include topics such as abuse prevention, identification and reporting of abuse. Identify and investigate all possible incidents 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 facility policy review, clinical and facility record review, facility provided documents and staff interviews, it was determined that the facility failed to provide adequate supervision resulting in elopement (resident exited to an unsupervised and unauthorized location without staff's knowledge) for two of five residents (Resident R54 and R119). Findings include: The facility Wandering and Elopements policy dated 5/1/25, indicated the facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents. Review of the clinical record indicated that Resident R54 was admitted to the facility on [DATE]. Review of Resident R54's MDS dated [DATE], indicated with the diagnoses of diabetes mellitus (a chronic metabolic disease characterized by high blood sugar levels), post-traumatic stress disorder and hypotension (medical condition characterized by low blood pressure). Review of the Resident Assessment Instrument 3.0…

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 facility polices, observations, clinical records, and staff interviews it was determined that the facility failed to make certain that appropriate treatments and services were provided for the use of an indwelling urinary catheter as required for one of three residents (Resident R292). Findings include: Review of facility policy Catheter Care, Urinary dated 5/1/25, indicated to review and document the clinical indications for catheter use prior to inserting. Nursing and the interdisciplinary team should assess and document the ongoing need for a catheter that is in place. Review of the clinical record indicated Resident R292 was admitted to the facility on [DATE]. Review of Resident R292's Minimum Data Set (MDS - a period assessment of care needs) dated 5/29/25, indicated diagnoses of high blood pressure, hyperlipidemia (high levels of fat in the blood), and muscle weakness. Review of the clinical record revealed Resident R292 had a physician's order dated 6/2/25, for an indwelling urinary…

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, personnel records and staff interviews it was determined that the facility failed to complete annual performance evaluations for four of five nursing staff (Employees E15, E16, E17, and E18). Findings include: Review of facility provided document Performance Evaluators Instructions dated 1/1/25, indicated to rate the employee on the observations listed. Check the rating that best describes the employee's performance. List those skills, qualities or habits that have enabled the employee to perform the duties and responsibilities of the job with strength. List areas that have demonstrated the need for attention or improvement. File the original in the personnel file and provide a copy to the employee. Place on the performance evaluation for annual or other. Review of Nurse Aide (NA) Employee E15's personnel record indicated a hire date of 10/16/95. Review of NA Employee E16's personnel record indicated a hire date of 10/2/17. Review of NA Employee E17's personnel record indicated a hire date of 11/20/23. Review of Licensed Practical Nurse (LPN)…

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 and staff interviews, it was determined that the facility failed to provide food in a form to meet individuals' needs in one of six residents (Resident R13). Findings include: Review of the clinical record revealed that Resident R13 was admitted to the facility on [DATE]. Review of Resident R13's MDS (Minimum Data Set, periodic assessment of resident care needs) dated 5/3/25, indicated diagnoses of anoxic brain damage, cerebral infarction (a condition where a part of the brain is deprived of blood supply, leading to the death of brain tissue) and chronic obstructive pulmonary disease (group of lung diseases that cause long-term breathing problems) . During a review of Nutrition assessment dated [DATE] indicated Resident R13 had a crab allergy. During a review of Nutrition assessment dated [DATE] indicated Resident R13 had a crab allergy. Review of Resident R13 Progress notes dated 5/13/25 indicated while passing 7 p.m. meds , resident called out and stated he has vomited. when assessed,…

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 documents, resident clinical records and staff interviews it was determined that the facility failed to ensure residents had the capacity to understand the terms of a binding arbitration agreement (A binding agreement by the parties to submit to arbitration all or certain disputes which have arisen or may arise between them in respect of a defined legal relationship, whether contractual or not). for one of five residents (Resident R11) and failed to ensure an arbitration agreement was signed for one of five residents (Resident R28). Findings include: Review of the facility form arbitration and limitation of liability agreement completed on 6/11/25, indicated this agreement sets forth a dispute resolution procedure by which the parties intend to resolve all disputes which may arise between them concerning the residents stay in the facility. The procedure is intended to be a speedy and economic alternative to court litigation which is often slow, time consuming and expensive. By using…

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

Based on facility policy review, review of Quality Assurance attendance records, and staff interview, it was determined that the facility failed to conduct Quality Assessment and Assurance (QAA) meetings at least quarterly with all the required committee members for one of four quarterly meeting (Quarter One of 2025). Findings Include: The facility Quality Assurance and Performance Improvement (QAPI) Program policy dated 5/1/25, indicated that the facility shall develop, implement, and maintain an ongoing, facility-wide, date-driven QAPI program that is focused on indicators of the outcomes of care and quality of life for our residents. Review of Quality assurance and Performance Improvement sign in sheets and attendance records for Quarter One of 2025, failed to reveal the Infection Preventionist was in attendance. During an interview on 6/10/25, at 2:29 p.m. the Director of Nursing confirmed that the facility failed to conduct Quality Assessment and Assurance (QAA) meetings at least quarterly with all the required committee members for one of four quarterly meeting (Quarter One of…

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

Based on review of the facility's infection control policies and procedures and staff interview, it was determined that the facility failed to implement an antibiotic stewardship program for one of ten months (September 2024). Findings include: Review of facility policy Antibiotic Stewardship dated 5/1/25, indicated the purpose of the Antibiotic Stewardship Program is to monitor the use of antibiotics in our residents. Review of the Quality Assurance/Infection Control Preventionist job description indicated responsibility includes oversees the community's antibiotic stewardship program. Review of the facility's Infection Control surveillance for August 2024 through May 2025, failed to include documentation to indicate that antibiotic monitoring was completed for September 2024. During an interview on 6/11/25, at 2:40 p.m. the Director of Nursing confirmed that the facility failed to implement an antibiotic stewardship program for one of ten months (September 2024). 28 Pa. Code: 211.10(c)(d) Resident care policies. 28 Pa. Code: 211.12(d)(1)(2)(3)(5) Nursing services.

Based on a review of select facility policy and staff interview, it was determined the facility failed to designate a qualified individual(s) onsite, who is responsible for implementing programs and activities to prevent and control infections (2/10/25 to 3/5/25). Findings included: During an interview on 6/10/25, at 1:24 p.m. the Director of Nursing (DON) stated, Infection Preventionist Employee E12 sent an email on a Saturday saying she quit effective immediately. That's when we put Infection Preventionist Employee E13 into the role. Review of facility documents indicated Infection Preventionist Employee E12 worked from 7/15/24, to 2/9/25. Review of facility documents indicated Infection Preventionist Employee E13 worked from 2/12/25, to 4/21/25. Infection Preventionist Employee E13 did not complete specialized training in infection prevention and control and become certified until 3/6/25. During an interview on 6/11/25, at 2:40 p.m. the DON confirmed that the facility failed to designate a qualified individual(s) onsite, who is responsible for implementing programs and activities…

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, review of facility documentation, and staff interviews, it was determined that the facility failed to make certain that equipment was in safe operating condition for two of two crash carts (First and Second floor). Findings include: Review of the facility's Crash Cart Daily Signature Log dated 5/1/25, indicated the purpose of the form completed daily is to ensure that the emergency crash cart is in order and ready to use in case of emergency. During an observation of the first-floor crash cart (a cart maintained with equipment used in cardiac emergencies) on 6/12/25, at 8:04 a.m. revealed a Crash Cart Daily Signature Log dated June 2025. The last completed entry was conducted on 6/9/25, three days overdue. Interview on 6/12/25, at 9:09 a.m. the Director of Nursing verified the last entry was 6/9/25, and that the audit had not been conducted in three days. During an observation of the second-floor crash cart on 6/12/25, at 8:15 a.m. revealed a Crash Cart Daily Signature Log dated June 2025. The audit was not conducted on 6/9/25, and the signature line 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 facility policy, facility documents and staff interviews, it was determined that the facility failed to provide Communication training to five of five direct care facility staff reviewed (Employees E15, E16, E17, E18, and E19). Findings include: Review of the facility policy In-Service Training dated 5/1/25, indicated all staff must participate in initial orientation and annual in-service training. The primary objective of the in-service training is to ensure that staff are able to interact in a manner that enhances the resident ' s quality of life and quality of care and can demonstrate competency in the topic areas of the training. Required training topics include the following: - Effective Communication with residents and family - Resident Rights - Preventing Abuse, neglect, exploitation, and misappropriation of resident's property - Quality Assurance and Performance Improvement (QAPI) - Infection Prevention - Behavioral Health - Compliance and Ethics During an interview on 6/11/25, at 9:00 a.m. Human Resources Director Employee E6 stated that education is…

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, facility documents, and staff interview, it was determined that the facility failed to provide training on Quality Assurance and Performance Improvement (QAPI) for five of five staff members (Employees E15, E16, E17, E18, and E19). Findings include: Review of the facility policy In-Service Training dated 5/1/25, indicated all staff must participate in initial orientation and annual in-service training. The primary objective of the in-service training is to ensure that staff are able to interact in a manner that enhances the resident ' s quality of life and quality of care and can demonstrate competency in the topic areas of the training. Required training topics include the following: - Effective Communication with residents and family - Resident Rights - Preventing Abuse, neglect, exploitation, and misappropriation of resident's property - QAPI - Infection Prevention - Behavioral Health - Compliance and Ethics During an interview on 6/11/25, at 9:00 a.m. Human Resources Director Employee E6 stated that education is conducted by calendar year…

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, facility documents, and staff interview, it was determined that the facility failed to provide training on Infection Control for two of five staff members (Employees E18, and E19). Findings include: Review of the facility policy In-Service Training dated 5/1/25, indicated all staff must participate in initial orientation and annual in-service training. The primary objective of the in-service training is to ensure that staff are able to interact in a manner that enhances the resident's quality of life and quality of care and can demonstrate competency in the topic areas of the training. Required training topics include the following: - Effective Communication with residents and family - Resident Rights - Preventing Abuse, neglect, exploitation, and misappropriation of resident's property - QAPI - Infection Prevention - Behavioral Health - Compliance and Ethics During an interview on 6/11/25, at 9:00 a.m. Human Resources Director Employee E6 stated that education is conducted by calendar year running January through December. Review of facility…

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

Based on review of clinical records and staff interview, it was determined that the facility failed to inform a resident's representative in advance of the proposed care, including the risk and benefits of the prescribed medication for one of five sampled residents (Resident R1). Findings include: Review of Resident R1's MDS assessment (MDS-Minimum Data Set assessment: periodic assessment of resident care needs), dated 12/3/24, indicated she had diagnoses included end stage renal disease (permanent condition in which the kidneys are no longer able to filter waste from the blood), dementia (progressive decline in cognitive abilities, such as memory, thinking, problem-solving, and judgment) and chronic kidney disease. Further review of the MDS indicated the resident's BIMS (Brief Interview for Mental Status assessment was 10 indicating moderately impairment. Review of the Resident Assessment Instrument 3.0 User's Manual effective October 2019, indicated that a Brief Interview for Mental Status (BIMS) is a screening test that aides in detecting cognitive impairment. The BIMS total…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff interview, it was determined that the facility failed to make certain that the necessary resident information was communicated to the receiving health care provider for two of two residents sampled with facility-initiated transfers (Residents R1, and R2). The findings include: Review of facility policy Transfer Form dated 5/12/24, indicated that the facility provides a completed and accurate transfer form to a resident transferred or discharged from our facility. A copy of the transfer form will be filed in the resident ' s medical record. Review of Resident R1's clinical record indicated the resident was admitted to the facility on [DATE]. Review of Resident R1's MDS (Minimum Data Set, periodic assessment of resident care needs) dated 1/19/25, indicated diagnoses of high blood pressure, diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time), and cerebral infarction (necrotic tissue in the brain resulting loss of blood and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical records, and staff interviews, it was determined that the facility failed to notify the resident or resident's representative of the facility bed-hold policy (an agreement for the facility to hold a bed for an agreed upon rate during a hospitalization) for two of two resident hospital transfers (Residents R1, and R2). Findings Include: Review of the facility policy Bed Holds and Returns, dated 5/12/24, indicated that residents or representatives are informed (in writing) of the facility bed hold policies. All residents or representatives are provided information regarding the facility bed hold policies, which address holding or reserving residents bed during periods of absence (hospitalization or therapeutic leave). Residents are provided information about these policies at least twice: admission packet, and at the time for transfer. Review of Resident R1's clinical record indicated the resident was admitted to the facility on [DATE]. Review of Resident R1's 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of clinical records, staff, and resident interviews, it was determined that the facility failed to provide Activity of Daily Living (ADL) assistance for two out of four residents (Resident R1, and R3). Findings include: The facility Activities of Daily Living policy dated 5/12/24, indicated that residents will be provided with care, treatment, and services to maintain or improve their ability to carry out ADL's. Care and services will be provided for residents who are unable to carry out ADL's independently including bathing, dressing, grooming, and oral care. Review of Resident R1's admission record indicated resident was admitted to facility on 1/13/25. Review of Resident R1's MDS assessment (MDS-Minimum Data Set assessment: periodic assessment of resident care needs) dated 1/19/25, indicated diagnoses of high blood pressure, diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time), and cerebral infarction (necrotic tissue in the brain resulting loss…

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 documents, facility policy, clinical records, facility tour, and staff interviews, it was determined that the facility failed to make certain each resident received adequate supervision that resulted in an elopement (leaving an area without permission) for one of six residents (Resident R1). Findings include: Review of facility policy Wandering and Elopements last reviewed 5/18/24, indicated that the facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents. Review of the clinical record revealed that Resident R1 was admitted to the facility on [DATE]. Review of Resident R1's MDS (Minimum Data Set, periodic assessment of resident care needs) dated 11/5/24, indicated diagnoses of high blood pressure, dementia (neuro-cognitive disorder impacting reasoning, judgment, and memory), and psychotic disorder (a mental disorder characterized by a disconnection from reality). 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of clinical records, staff, and resident interviews, it was determined that the facility failed to provide Activity of Daily Living (ADL) assistance for one of two residents (Resident R1). Findings include: The facility Activities of Daily Living policy dated 5/12/24, indicated that residents will be provided with care, treatment, and services to maintain or improve their ability to carry out ADL ' s. Care and services will be provided for residents who are unable to carry out ADL's independently including bathing, dressing, grooming, and oral care. Review of Resident R1's admission record indicated he was originally admitted on [DATE]. Review of Resident R1's MDS assessment (MDS-Minimum Data Set assessment: periodic assessment of resident care needs) dated 10/23/24, indicated that she had diagnoses that included high blood pressure, hip fracture, and dementia (a group of symptoms that affects memory, thinking and interferes with daily life). Review of Resident R1's MDS assessment dated [DATE],…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, closed clinical records and staff interview, it was determined that the facility failed to notify a medical provider of a change in condition for one out of five closed resident records (Closed Resident Record CR1). Findings include: Review of facility policy Change in a resident's condition or status dated 5/18/24, indicated that the facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical, mental condition or status. Policy Interpretation and Implementation includes: The nurse will notify the resident's physician when there has been: a. accident or incident involving the resident. b. discovery of injuries of an unknown source. c. adverse reaction to medication. d. significant change in the resident's physical/emotional/mental condition. A significant change of condition is a major decline or improvement in the resident's status that will not normally resolve itself without intervention by…

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, job descriptions, documents, clinical records, and staff interviews, it was determined that the facility failed to protect residents from physical neglect for one of three residents reviewed (Resident R1). Findings include: Review of the facility policy Abuse, Neglect, Exploitation and Misappropriation Prevention Program dated, 5/12/24, indicated residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. The objective is to protect residents from abuse, neglect, exploitation, or misappropriation of property by anyone to include facility staff. Review of the facility Nurse Aide Job Description dated May 2024, indicated the Nurse Aide (NA) will provide routine Activities of Daily Living (ADL - personal care activities like bathing, dressing, eating, mobility, and toileting) care in a manner conducive to the comfort and safety of residents and will be responsible for performing person centered care. Review of admission…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of clinical records and facility provided documents, and staff interviews, it was determined that the facility failed to ensure that residents were free from misappropriation (the act of stealing something that you have been trusted to care of and using it for yourself) of medications for two of five residents reviewed (Residents R2 and Resident R3). Findings include: Review of the facility policy Abuse, Neglect, Exploitation and Misappropriation Prevention Program dated, 5/12/24, indicated residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. The objective is to protect residents from abuse, neglect, exploitation, or misappropriation of property by anyone to include facility staff. Review of the facility policy Controlled Substances dated 5/12/24, indicated controlled substances are reconciled upon receipt, administration, disposition, and at the end of each shift. The nurse administering the medication must record it and sign.…

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, observations and staff interview, it was determined the facility failed to properly store food products in a manner to prevent foodborne illness in the Main Kitchen. Findings include: Review of facility policy Food Receiving and Storage dated 5/18/24, indicated foods shall be received and stored in a manner that complies with safe food handling practices. Opened containers must be dated and sealed or covered during storage. During an observation on 7/8/24, at 9:36 a.m. in the Main Kitchen Dry storage area, an open box contained a plastic bag of rice that was not sealed, and an additional open box that contained a plastic bag of pureed bread mix that also was not sealed. During an interview on 7/8/24, at 9:45 a.m. Dietary Director Employee E13 confirmed that the facility failed to properly store products in a manner to prevent foodborne illness. 28 Pa. Code: 201.14(a) Responsibility of licensee 28 Pa. Code: 201.18(b)(1) Management. 28 Pa. Code: 211.6(c) Dietary services.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of facility policy, clinical record review, observations, and resident, family and staff interviews, it was determined that the facility failed to provide privacy during medication administration for one of five residents (R51), failed to provide an environment that maintained and enhanced each resident's quality of life for one of two residents (Resident R75), and failed to treat resident with respect by failing to address a resident by their preferred name for one of three residents (Resident R93). Findings include: Review of facility policy Dignity dated 5/18/24, indicated that each resident shall be cared for in a manner that promotes and enhances his or her sense of well- being, level of satisfaction with life, and feelings of self-worth and self-esteem. Residents are treated with dignity and respect at all times. Demeaning practices and standards of care that compromise dignity is prohibited. Staff are expected to promote dignity and assist residents. Review of facility policy 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policies, resident records and staff interview, it was determined that the facility failed to acquire and document a physician's discharge order for one out of three resident records (Resident R133) reviewed, and failed to make certain that the necessary resident information was communicated to the receiving health care provider for five out of six residents sampled with facility initiated transfers (Residents R28, R43, R64, R75, and R83). Finding include: The facility Discharge Summary and Plan policy dated 5/18/24, indicated that when a resident's discharge is anticipated, a discharge summary and post-discharge plan will be developed to assist the resident to adjust to his/her new living environment. The discharge summary will include a recapitalization of the resident's stay at this facility and a final summary of the resident's status at the time of discharge in accordance with established regulations governing release of resident information and as permitted by the 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical record review, and staff interviews, it was determined that the facility failed to make certain that resident assessments were accurate for seven of 23 residents (Resident R2, R6, R21, R38, R64, R68, and R285). Findings include: Review of facility policy Certifying Accuracy of the Resident Assessment, dated 5/18/24, indicated the information captured on the assessment reflects the status of the resident during the observation (look-back) period for that assessment. Review of the clinical record indicated Resident R2 was admitted to the facility on [DATE]. Review of Resident R2's Quarterly Minimum Data Set (MDS - a periodic assessment of care needs) dated 5/26/24, indicated diagnoses of high blood pressure, hemiplegia (paralysis on one side of the body), and muscle weakness. Review of Section GG - Functional Abilities and Goals indicated Resident R2 was coded as 1 dependent upon staff for roll left and right. Review of a physician order dated 2/22/24, indicated 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 clinical records, facility policy, observations, and staff interviews, it was determined that the facility failed to provide prescribed treatment and services related to the care of pressure ulcers for four of six residents (Resident R4, R9, R83, R243) that resulted in worsening and new pressure area for one resident (Resident R83) and failed to prevent avoidable pressure ulcer development that of a new pressure ulcer for two of six residents (Resident R9). Findings include: Review of facility policy Prevention of Pressure Injuries, dated 5/18/24, indicated that the facility will conduct a comprehensive skin assessment upon (or soon after) admission with each risk assessment, as indicated according to the resident's risk factors, and prior to discharge. Use a standardized pressure injury screening tool to determine risk factors. Inspect skin on a daily basis when performing or assisting with personal care. Identify any signs of developing pressure injuries. Inspect pressure points sacrum…

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 facility polices, observations, clinical records, and staff interviews it was determined that the facility failed to make certain that appropriate treatments and services were provided for the use of a urinary catheter as required for three of four residents (Resident R53, R93, and R129). Findings include: Review of facility policy Catheter Care, Urinary dated 5/18/24, indicated that the facility should ensure that the catheter tubing and drainage bag are kept off the floor. Review of facility policy Resident Rights dated 5/18/24, indicated that residents have the right to a dignified existence. Review of facility policy Dignity dated 5/18/24, indicated that each resident shall be cared for in a manner that promotes and enhances his or her sense of well- being, level of satisfaction with life, and feelings of self-worth and self-esteem. Residents are treated with dignity and respect at all times. Demeaning practices and standards of care that compromise dignity is prohibited. Staff are expected…

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, medical record review, observations, and staff interviews, it was determined that the facility failed to provide necessary services and properly monitor and assess weight and nutrition status for five of seven residents reviewed (Resident R28, R83,R91, R129, and R243). Findings include: Review of facility policy Weight Assessment and Intervention dated 5/18/24, indicated that residents are to weighed upon admission and at intervals established by the interdisciplinary team. Any weight change of 5% or more since the last weight assessment is retaken the next day for confirmation. If the weight is verified nursing will immediately notify the dietitian in writing. Unless notified of significant weight change, the dietitian will review the unit weight record monthly to follow individual weight trends over time. The threshold for significant unplanned and undesired weight loss will be based on the following criteria: a) 1 month: 5% weight loss is significant; greater than 5% is severe. b) 3…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, observations, interviews, and clinical record review, it was determined that the facility failed to provide appropriate respiratory care for three of three residents (Residents R68, R285, and R334). Findings include: Review of facility policy Oxygen Administration dated 5/18/24, indicated prior to administering oxygen verify there is a physician's order and review the resident's care plan to assess for any special needs of the resident. It was indicated to check the mask, tank, and humidifying jar to be sure they are in good working order. Be sure there is water in the humidifying jar and the water level is high enough that the water bubbles as oxygen flows through. Review of the clinical record indicated Resident R68 was admitted to the facility on [DATE]. Review of Resident R68's Minimum Data Set (MDS - a periodic assessment of care needs) dated 6/2/24, indicated diagnoses of high blood pressure, asthma (a condition where the airways narrow and swell), and Post-Traumatic…

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, review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to maintain accurate resident care plans and conduct ongoing accurate assessments to ensure that bedrails were used to meet residents' needs and the risks associated with bedrail usage for five of five residents (Residents R2, R6, R21, R28, and R64). Findings include: Review of Title 42 Code of Federal Regulations (CFR) §483.25(n) - Bed Rails states that the facility must assess the resident for risk of entrapment from bed rails prior to installation. Additionally, there should be evidence in the resident's records that the facility performed ongoing assessments to assure that the bed rail is used to meet the resident's needs and that there is an ongoing evaluation of risks associated with bed rail usage. Review of facility policy Bed Safety and Bed Rails dated 5/18/24, indicated the use of bed rails or side rails (including temporarily raising the side rails for episodic 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff interview, it was determined that the facility failed to maintain complete and accurate documentation for three of 16 residents (Resident R4, R9, and R38). Findings include: Review of facility policy Charting and Documentation dated 5/18/24, indicated all services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate. Review of Title 42 Code of Federal Regulations (CFR) §483.709(i) Medical records. In accordance with accepted professional standards and practice, the facility must maintain medical records that are complete, accurately documented, readily accessible, and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, resident records, observations and staff interview it was determined that the facility failed to implement an infection control program that included a system of surveillance to identify possible communicable diseases or infections for four of 11 months (March 2024, April 2024, May 2024, and June 2024), failed to prevent cross contamination during a dressing change for one of two residents (Resident R9), and failed to make certain that appropriate treatments and services were provided for the use of a urinary catheter as required for one out of five residents (R53). Findings include: Review of facility policy Surveillance for Infections dated 5/18/24, indicated the Infection Preventionist will conduct ongoing surveillance for Healthcare-Associated Infections (HAIs) and other epidemiologically significant infections that have substantial impact on potential resident outcomes and that may require transmission-based precautions and other preventative interventions. The purpose of…

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

Based on review of the facility's infection control policies and procedures and staff interview, it was determined that the facility failed to implement an antibiotic stewardship program for three of 11 months (March 2024, April 2024, May 2024, and June 2024). Findings include: Review of facility policy Antibiotic Stewardship dated 5/18/24, indicated the purpose of the Antibiotic Stewardship Program is to monitor the use of antibiotics in our residents. Review of the Quality Assurance/Infection Control Preventionist job description indicated responsibilities include overseeing the community's antibiotic stewardship program. Review of the facility's Infection Control surveillance for August 2023 through June 2024, failed to include documentation to indicate that antibiotic monitoring was completed for March 2024, April 2024, May 2024, and June 2024. During an interview on 7/12/24, at 8:50 a.m. the Director of Nursing confirmed that the facility failed to implement an antibiotic stewardship program for four of 11 months (March 2024, April 2024, May 2024, and June 2024). 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 review of facility in-service documentation, personnel records, and staff interviews it was determined that the facility failed to ensure that all nurse aide staff received a minimum of twelve hours of in-service education training each year, within 12 months of their hire date anniversary, as required for five out of five personnel records (Nurse Aide Employee E17, Nurse Aide Employee E18, Nurse Aide Employee E19, Nurse Aide Employee E20, and Nurse Aide Employee E21). Findings include: Review of facility policy titled Staffing, Sufficient and Competent Nursing, dated 5/18/24, indicated that the facility provides sufficient numbers of nursing staff with the appropriate skills and competency necessary to provide nursing and related care and services for all residents in accordance with resident care plans and the facility assessment. Review of Nurse Aide Employee E17's personnel record indicated she was hired on 1/30/06. Review of Nurse Aide Employee E17's personnel record failed to include a minimum of 12 hours of nurse aide training per year as required under…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, observations, and staff interview, it was determined that the facility failed to accommodate the call bell needs for one of five residents (Resident R38). Findings include: Review of facility policy Call System, Resident dated 5/18/24, indicated residents are provided with a means to call staff for assistance through a communication system that directly calls a staff member or a centralized work station. Each resident is provided with a means to call staff directly for assistance from his/her bed, from toileting/bathing facilities and from the floor. The resident call system remains functional at all times. Review of the clinical record indicated Resident R38 was admitted to the facility on [DATE]. Review of Resident R38's Minimum Data Set (MDS - a periodic assessment of care needs) dated 4/7/24, indicated diagnoses of high blood pressure, muscle wasting, and dementia (a group of symptoms that affects memory, thinking and interferes with daily life). During an observation 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 review of facility policy, clinical records, and staff interview, it was determined that the facility failed to provide the opportunity to formulate an advance directive (a written instruction such as a living will or durable power of attorney for health care for when the individual is incapacitated) for one of three residents reviewed (Resident R43). Review of the facility policy Advanced Directives, dated 5/18/24, indicated that upon admission, the resident will be provided with written information concerning the right to refuse or accept medical or surgical treatment and to formulate an advanced directive if he or she chooses to do so. Information about whether or not the resident has executed an advanced directive shall be displayed prominently in the medical chart. Review of the clinical record revealed that Resident R43 was admitted to the facility on [DATE]. Review of Resident 43's MDS dated [DATE], indicated diagnoses of quadriplegia (paralysis of all four limbs), high blood pressure, and dry…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, observation, and staff interview it was determined that the facility failed to maintain the confidentiality of residents' medical information on one of three nursing units (Third Floor) and two of nine residents (Resident R9 and R285). Findings include: Review of facility policy Confidentiality of Information and Personal Privacy dated 5/18/24, indicated the facility will safeguard the personal privacy and confidentiality of all resident personal and medical records. Access to resident personal and medical records will be limited to authorized staff and business associates. During an observation on 7/8/24, at 12:21 p.m. the Third Floor [NAME] Medication Cart at the nurse's station was left unattended with the computer screen open with identifiable information any passerby could see resident personal and confidential information. During an interview on 7/8/24, at 12:24 p.m. Licensed Practical Nurse (LPN) Employee E2 confirmed the above observation. During an 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 review of facility policy, grievance records, reports submitted to the state, and staff interviews, it was determined that the facility failed to implement the facility abuse and neglect policy for two of four allegations (Resident R15 and Resident R38). Findings include: Review of facility policy Abuse, Neglect, Exploitation or Misappropriation- Reporting and Investigating dated 5/18/24, indicated all reports of resident abuse, neglect, exploitation, or theft, misappropriation of resident property are reported to local, state, and federal agencies and thoroughly investigated by facility management. Findings of all investigations are documented and reported. If abuse or neglect is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law. Immediately is defined as: * within two hours of an allegation involving abuse or results in serious bodily injury; or * within 24 hours of an allegation that does not involve abuse or result in serious…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, facility grievances, reports submitted to the State, and staff interviews, it was determined that the facility failed to report an allegation of abuse or neglect for one of four residents (Resident R38). Findings include: Review of facility policy Abuse, Neglect, Exploitation or Misappropriation- Reporting and Investigating dated 5/18/24, indicated all reports of resident abuse, neglect, exploitation, or theft, misappropriation of resident property are reported to local, state, and federal agencies and thoroughly investigated by facility management. Findings of all investigations are documented and reported. If abuse or neglect is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law. Immediately is defined as: - within two hours of an allegation involving abuse or result in serious bodily injury; or - within 24 hours of an allegation that does not involve abuse or result in serious bodily injury. 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, facility grievances, investigation documentations, and staff interviews, it was determined that the facility failed to conduct a thorough investigation involving an allegation of neglect for one out of four residents (Resident R38). Findings include: Review of facility policy Abuse, Neglect, Exploitation or Misappropriation- Reporting and Investigating dated 5/18/24, indicated all reports of resident abuse, neglect, exploitation, or theft, misappropriation of resident property are reported to local, state, and federal agencies and thoroughly investigated by facility management. Findings of all investigations are documented and reported. If abuse or neglect is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law. Immediately is defined as: - within two hours of an allegation involving abuse or result in serious bodily injury; or - within 24 hours of an allegation that does not involve abuse or result in serious…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to timely recheck and notify the physician of decreased Capillary Blood Glucose (CBG) levels for one of three residents (Resident R284). Findings include: Review of facility policy Management of Hypoglycemia dated 5/18/24, indicated if a resident's blood sugar is less than 70 milligrams per deciliter (mg/dl), but greater than 54 mg/dl then give the resident an oral form of rapidly absorbed glucose (15-20 grams). Notify the provider immediately, remain with the resident, and recheck the resident's blood glucose in 15 minutes. It was indicated to document the resident's blood glucose before intervention, note the blood sugar after each administration of rapid-acting glucose and follow-up blood sugar, record the resident's level of consciousness before and after intervention, document provider instructions. Review of the clinical record indicated Resident R284 was admitted to the facility 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 clinical record review, observations, and staff interview, it was determined the facility failed to provide to provide appropriate care and services to residents receiving tube feedings for two of two residents reviewed (Residents R51 and R83). Finding include: Review of facility policy Enteral Nutrition (nutrition provided via a tube inserted into the stomach) dated 5/18/24, indicated adequate nutritional support through enteral nutrition is provided to residents as ordered. The nurse confirms that orders for enteral nutrition are complete. Complete orders include the enteral nutrition product, and instructions for flushing. Review of the clinical record revealed that Resident R51 was admitted to the facility on [DATE], with diagnoses of high blood pressure, anxiety, depression, and stroke (occurs when the blood supply to part of the brain is blocked or reduced. This prevents brain tissue from getting oxygen and nutrients.) Review of Resident R51's care plan dated 5/3/24, indicated the 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of resident clinical records, facility policy and staff interview it was determined the facility failed to provide consistent and complete communication with the dialysis center for two of two residents reviewed (Residents R4 and R334), and failed to implement a dialysis care plan for one of two resident's (Resident R4). Findings include: Review of the facility policy End-Stage Renal Disease (ESRD), Care of Resident with dated 5/18/24, indicated agreements between the facility and the contracted ESRD facility include all aspects of how the resident's care will be managed including how the care plan will be developed and implemented, and how information will be exchanged between facilities. Review of the clinical record indicated that Resident R4 was admitted to the facility on [DATE]. Review of Resident R4's Minimum Data Set (MDS- a periodic assessment of care needs) dated 5/8/24, indicated with the diagnoses of end stage kidney disease (a condition where the kidney reaches advanced state of loss…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, resident record review, and staff interviews, it was determined that the facility failed to provide a trauma survivor with trauma informed care to eliminate or mitigate triggers that may cause re-traumatization of the resident for two of two residents (Resident R6 and R68). Findings include: Review of facility policy Trauma-Informed and Culturally Competent Care dated 5/18/24, indicated resident assessment involves an in-depth process of evaluating the presence of symptoms, their relationship to trauma, as well as the identification of triggers. The facility will develop individualized care plans that address past trauma in collaboration with the resident and family, identify and decrease exposure to triggers that may re-traumatize the resident, and recognize the relationship between past trauma and current health conditions. Review of the clinical record indicated Resident R6 was admitted to the facility on [DATE]. Review of Resident R6's MDS (Minimum Data Set, periodic…

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 and clinical records, observations and staff interviews, it was determined that the facility failed to maintain a medication error rate of less than five percent for one of three residents (Resident R51). Findings include: The observations listed below revealed seven medication errors out of 26 opportunities resulting in a medication error rate of 25%. Review of facility policy Administering Mediations through an Enteral Tube dated 5/18/24, indicated the purpose of this procedure is to provide guidelines for the safe administration of medications through an enteral tube (a tube inserted through the wall of the abdomen into the stomach and can be used to provide liquid food, medications or liquids). General guidelines include administer each medication separately and flush between medications. . Review of Resident R51's clinical record indicated resident was admitted to the facility on [DATE]. Review of Resident R51's Minimum Data Set (MDS - periodic assessment of care needs)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical record review, observation and staff interview it was determined the facility failed to ensure that residents were free from any significant medication errors for one of three residents. (Resident R51). Findings include: Review of facility policy Administering Mediations through an Enteral Tube dated 5/18/24, indicated the purpose of this procedure is to provide guidelines for the safe administration of medications through an enteral tube (a tube inserted through the wall of the abdomen into the stomach and can be used to provide liquid food, medications or liquids). General guidelines include administer each medication separately and flush between medications. . Review of Resident R51 ' a clinical record indicated resident was admitted to the facility on [DATE]. Review of Resident R51's Minimum Data Set (MDS - periodic assessment of care needs) dated 5/2/24, indicated diagnoses of hypertension (high blood pressure in the arteries), diabetes (a metabolic disorder in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policies, observations, and staff interviews, it was determined that the facility failed to properly store medications in two out of five medication carts (3 East Medication Cart and 4 East Medication Cart), failed to monitor refrigerator temperatures utilized for medication storage in one of two nursing units (Fourth Floor Medication Room), and failed to properly secure a medication cart while not in use for one of five medications carts (2 North Medication Cart). Findings include: Review of facility policy Storage of Medications dated 5/18/24, indicated the facility stores all drugs and biologicals in a safe, secure, and orderly manner. Drugs and biologicals used in the facility are stored in locked compartments under proper temperature, light and humidity controls. Drugs and biologicals are stored in the packaging, containers, or other dispensing systems in which they are received. The nursing staff is responsible for maintaining medication storage and preparation areas in a clean,…

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 policy, resident clinical records, and staff interview, it was determined the facility failed to obtain a diagnosis for hospice services and to ensure the coordination of hospice services with facility services to meet the needs of each resident for end of life care for two of two residents (Resident R38 and R93). Findings include: Review of facility policy Hospice Program dated 5/18/24, indicated it is the responsibility of the facility to meet the resident's personal care and nursing needs in coordination with the hospice representative, and ensure that the level of care provided is appropriately based on the individual resident's needs, including communicating with the hospice provider (and documenting such communication) to ensure that the needs of the resident are addressed and met 24 hours per day. The coordinated care plan will reflect the resident's goals and wishes, as stated in his or her advanced directives and during ongoing communication with the resident or…

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, observation, clinical record review, and staff interviews, it was determined that the facility failed to make certain that residents are free from significant medication errors for three of seven residents (Residents R44, R291, and R287) which caused a pulmonary hypertension (a condition that affects the blood vessels in the lungs and develops when the blood pressure in the lungs is higher than normal) medication not to be administered. This failure resulted in a harm situation for one of seven residents (Resident R287). Review of facility policy Medication Administration: Injectables dated January 2023, indicated that injectable medication will be prepared for administration by verifying medication order on the Medication Administration Record (MAR) for the right resident, right drug, right dose, right route, right time, and any special instructions. Review of the clinical record indicated Resident R44 was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS - 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.