Majestic Oaks Rehabilitation And Nursing Center

Based on observations in the main kitchen and staff interview it was determined that the facility failed to ensure that food was stored, prepared, and served in accordance with professional standards for food service safety. Findings include: A tour of the Food Service Department conducted on March 17, 2025, at 9:22 a.m. with Employee E5, Food Service Director, revealed the following concerns: Observations of the walk-in freezer revealed two tortillas loosely wrapped in plastic wrap with no dates. Observations of the dry storage room revealed the juices used for the juice machine were stored in this room. Two juice bags (fruit punch and orange juice) were taken out of the box and placed directly on a visibly dirty/dusty metal wrack. One juice was not hooked up (cranberry juice) and the tubing was on the floor and backed up with stagnant juice in the tubing. Observations revealed the drainpipe behind the ice machine was placed directly into the floor drain with no air gap. To prevent sewer water backup, all ice machine drains require an air gap of a few inches between the ice machine…

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

Based on observations and interviews with staff, it was determined that the facility did not ensure that that trash was properly disposed of in the receiving and dumpster area. Findings Include: A tour of the main kitchen was conducted on March 17, 2025, at 9:22 a.m. with the Food Service Director, Employee E5. Observations revealed double doors adjacent to the main kitchen where food deliveries are accepted and lead out to where the dumpsters are stored. Observations in the receiving area outside revealed trash, food, and debris on the ground surrounding the dumpsters. On one dumpster, the lid was open, and trash was exposed. 28 PA Code: 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(3) Management

Based on observations, review of facility documentation, and staff interviews it was determined that the facility failed to establish an effective pest control program in the main kitchen. Findings Include: Review of pest control report dated March 4, 2025, revealed pest control inspected and treated the kitchen areas, storage areas, and dishwasher room for occasional invaders. Per the pest control report, mice droppings were observed in the kitchen food storage room. Pest control recommended a door sweep in the kitchen doors and replacing doors to the small room outside, next to the dumpster, as te doors are rotten. A tour of the main kitchen was conducted on March 17, 2025, at 9:22 a.m. with the Food Service Director, Employee E5. Observations revealed double doors adjacent to the main kitchen where food deliveries are accepted and lead out to where the dumpsters are stored. There was a visible gap located at the bottom of the door allowing easy access to the main kitchen for common household pests (mice, roaches, flies, ants). Observations on March 19, 2025, at 12:15 p.m. in the…

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

Based on a review of the facility policy, observations, and an interview with staff, it was determined that the facility failed to ensure that the most recent Department of Health Survey results were readily accessible to residents and visitors in three of three nursing floors and lobby (Second Floor, Third Floor, and Fourth Floor). Findings include: The facility's policy titled Examination of Survey Results, dated April 27, 2017, states, Survey reports and plans of correction are readily accessible to residents, family members, resident representatives, and the public. It further specifies under Bulletin 2: A copy of the most recent survey report and any plans of correction are kept in a binder in the resident's day room. During a resident council meeting held on March 18, 2025, at 10:30 a.m., with 12 residents (R62, R13, R35, R129, R70, R49, R6, R4, R96, R92, R93), who were identified as alert and oriented, it was revealed that the residents were unaware of the recent Department of Health Survey results. On March 19, 2025, at 9:31 a.m., a facility tour was conducted with the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews with residents and staff, and review of the facility policy, it was determined that the facility failed to provide a clean, safe, comfortable and homelike environment in three of the three nursing units observed (2nd, 3rd, 4th floor Nursing Units). Findings include: A review of the facility policy titled Homelike Environment revised February 2021, revealed Residents are provided with a safe, clean and comfortable and homelike environment and encouraged to use their personal belongings to the extend possible. It further states, these characteristics include clean, sanitary and orderly environment, clean bed, bath linens that are in good condition, pleasant, neutral scents. On March 17, 2025, at 11:47 a.m., an interview with Resident R146 who lives in room [ROOM NUMBER] revealed that his mattress is peeling, and he collects the peeling material in a cup. Additionally, observation showed that there are five ceiling tiles with large brown stains. On March 17, 2025, at 11:51 a.m., an…

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 during dining and resident interviews it was determined that the facility failed to serve food that was palatable and attractive to meet resident needs for 20 of 20 residents reviewed (Resident R62, R13, R35, R129, R70, R49, R6, R4, R96, R92, R93, R30, R9, R120, R122, R81, R108, R83, R58, and R139). Findings Include: During a Resident Council meeting on March 18, 2025, at 10:30 a.m. with 11 alert and oriented residents (R62, R13, R35, R129, R70, R49, R6, R4, R96, R92, R93) residents reported that the chicken being served is dry. Review of the facility menu revealed chicken was on the menu for lunch on March 18, 2025. Observations on March 18, 2025, at approximately 12:30 p.m. on the 2nd floor nursing unit during the lunch time meal revealed the following: Observations and interview at 12:38 p.m. revealed Resident R30 refused to eat the chicken served for lunch because it was dry. Observations and interview at 12:50 p.m. revealed Resident R9 and R120 refused to eat the chicken because it was served cold. Observations and interview at 12:51 p.m. revealed 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 protocol, observations, interview ,and review of clinical records, it was determined that the facility failed to implement proper use of personal protective equipment (PPE) for one resident on enhanced barrier precautions during morning care and wound observation of 31 resident records reviewed (Resident R102). Findings include: Review of the facility policy for Enhanced Barrier Precautions (EBP) revised December 2024 states it is used as an infection prevention and control intervention to reduce the spread of multi-drug-resistant organisms to residents. EBP employ targeted gown and glove use during high contact resident care activates EBP are indicated for residents with wounds and or indwelling medication devices. Resident R102 was initially admitted to the facility on [DATE], diagnosed with spastic quadriplegic cerebral palsy, major depressive and anxiety disorder, dysphagia (difficulty swallowing) , and had a gastrostomy (a surgical tube place in the abdominal wall and into the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a resident group interview, resident interview, review of facility policy and staff interview, it was determined that the facility failed to ensure that prompt efforts were made to resolve grievances for one of thirty-one residents (Resident R30) and effectively communicate the resolutions of grievances for 11 of thirty-one residents (R4, R6, R13, R35, R49, R62, R70, R92, R93, R96, R129) Findings include: A review of the facility policy titled Grievances/Complaints, Filing, revised on April 2023, stated under Policy Statement The administrator and staff will make prompt efforts to resolve grievances to the satisfaction of the resident and/or representative. Further review, in section Policy Interpretation and Implementation, part 12, it states that The resident, or person filing the grievance and/or complaint on behalf of the resident, will be informed (verbally and in writing) of the finding of the investigation and the actions that will be taken to correct any identified problems 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 facility policy, clinical record review, observations, and staff interviews, it was determined that the facility failed to identify the placement of beds against the wall as a restraint and failed to assess the functional status of an individual resident to determine the use of the restraint for one of 31 residents reviewed. (Residents R5). Findings Include: Review of facility policy titled Use of Restraints, revised 2017, revealed the definition of a restraint is based on the functional status of the resident and not the device. If the resident cannot remove a device in the same manner in which staff applied it given that resident's physical condition (i.e, side rails are put back down, rather than climbed over), and this restricts his/her typical ability to change position or place, that device is considered a restraint. Clinical record review revealed Resident R5 was admitted to the facility May 24, 2022 with a diagnosis that included but not limited to hemiplegia and hemiparesis affecting left non-dominant side (muscle weakness on one side of the body), acute…

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, personnel file review, and staff interview, it was determined that the facility failed to perform Elder Abuse and Resident Rights training upon hire for one of five personnel files reviewed (Employee E4). Findings Include: Review of the personnel file for Cook, Employee E4 on March 20, 2025 at 12:02 pm revealed employee hire date on December 5, 2024. Further review indicated that there was no documented evidence for completion of Elder Abuse training upon hire. An interview was conducted with Business Office/ HR, Employee E5, on March 20, 2025 at 12:13 pm, confirmed Employee E4's Elder Abuse training incomplete. 28 Pa. Code 201.18(b)(1)(e)(1) Management 28 Pa. Code 201.19(8) Personnel policies and procedures

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, it was determined that the facility failed to notify the representative of the Office of the State Long Term Care Ombudsman for one of 31 residents sampled who were transferred to the hospital. (Resident R102). Finding includes: Resident R102 was initially admitted to the facility on [DATE], diagnosed with spastic quadriplegic (partial or complete paralysis of all limbs), cerebral palsy (condition that affect movement and posture), major depressive and anxiety disorder, dysphagia (difficulty swallowing). On July 7, 2024, Resident R102 had an unplanned transfer to the hospital and a surgical gastrostomy (a surgical tube place in the abdominal wall and into the stomach used to provide nutrients and medications when a person cannot eat or drink adequately) was performed. Further review of the resident's clinical record revealed on December 18, 2024 Resident R102 had an unplanned transfer to the hospital due to stomach pain. On March 20, 2025, at 11:43 a.m., the Nursing Home…

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, interview with staff and review of facility policy, it was determined that the facility did not ensure revisions were made to the PASRR (Pre-admission Screening and Resident Review) application to include mental health diagnoses for 2 out of 2 residents reviewed. (Resident R71, R98) Findings include: Review of the facility policy titled Preadmission Screening and resident Review (PASRR) policy last revised October 2023 revealed New admissions and readmissions are screened for mental disorders (MD), intellectual disability (ID) or related disorders (RD) per the Medicaid Pre-admission Screen for all potential admission, regardless of payer source, to determine if the individual meets the criteria for a MD, IM, RD. Review of Resident R71's PASRR completed on July 27, 2023, indicated that Resident R71 only had a mental health condition of Mood Disorder and Major Depressive Disorder. Review of R71's clinical record revealed on August 31, 2023, obtained a medical diagnosis Psychosis (is a mental health condition characterized by a disconnection from…

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 documents, clinical records, and interview with staff, it was determined the facility failed to develop a comprehensive care plan and interventions to address resident care needs for Resident R37's diagnosis of diabetes, Resident R115 respiratory care, Resident R97 mood, R75 and R136 psychotropic medication, for five of 31 residents reviewed (Resident R37, R115, R136, R97, and R75). Findings include: Review of facility policy titled Care Plan, Comprehensive Person-Center revised March 2022, revealed the a comprehensive, person-center care plan that includes measurable objectives and timetable to meet the resident's physical psychosocial and functional needs is developed and implemented for each resident. Review of Resident R37's clinical record revealed the resident was admitted to the facility on [DATE], diagnosed with Diabetes (failure of the body to produc insulin) with orders for insulin and Accu-Cheks three times a day at 8:00 a. m., 12:00 p.m. and 5:00 p.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 staff interviews, and review of resident records determined the facility failed to document to ensure one resident (Resident R102) received treatment and care in accordance with professional standards of practice when the facility failed to properly assess and document a change of condition per physician orders for one of 31 records reviewed. (Resident R102) Findings include: Review of Resident R102's clinical record revealed that the resident was initially admitted to the facility on [DATE], with the diagnoses of spastic quadriplegic cerebral palsy, major depressive and anxiety disorder, dysphagia (difficulty swallowing), and had a gastrostomy (a surgical tube place in the abdominal wall and into the stomach used to provide nutrients and medications when a person cannot eat or drink adequately). Review of Resident R102 quarterly MDS (an assessment of residents' needs) dated December 29, 2024, indicated Resident R102 was completely dependent on staff for all activities of daily needs including bed…

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, review of clinical record, and staff interview it was determined that the facility failed to provide pressure ulcer treatment, consistent with professional standards of practice, for one of three residents reviewed for pressure ulcers (Resident R18). Findings Include: Review of facility policy Pressure Ulcers/Skin Breakdown revised April 2018 revealed the nurse should describe and document/report a full assessment of the pressure ulcer including location, stage, length, width, and depth. The staff and practitioner will examine the skin of newly admitted residents for evidence of existing pressure ulcers or other skin conditions. Review of Resident R18's quarterly Minimum Data Set (MDS - federally mandated resident assessment and care screening) dated February 18, 2025, revealed the resident had diagnoses of peripheral artery disease (narrowing of arteries which results in reduced blood flow to head, arms, stomach and legs), diabetes mellitus (metabolic disorder that affect how…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of clinical records and facility policies and procedures, observations of care and services, and interviews with staff, it was determined that the facility failed to consistently provide respiratory care and supplemental oxygen as ordered by the physician for two of 31 residents reviewed. (Resident R115 and R63). Findings included: A review of the facility policy titled Oxygen Administration dated October 2023, stated The purpose of this procedure is to provide guidelines for safe oxygen administration. Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration. Review the resident's care plan to assess for any special needs of the resident. A review of a clinical record for Resident R115 revealed an admission on [DATE], with a diagnosis of diffuse traumatic brain injury. A review of the physician order dated February 17, 2025, oxygen as needed to maintain O2 level above 92% at 2 Liter per min via nasal cannula, PRN…

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 interview with resident and staff and review of clinical records and facility policy it was determined that the facility failed to appropriately assess residents for use of bedrails and failed to ensure correct installation, use and maintenance of bed rails were maintained for two of 31 resident records reviewed (Resident R37 and R77). Findings include: Review of Resident R37 medical diagnosis revealed the resident was admitted to the facility on [DATE], identified lacking coordination, reduced mobility, abnormal posture and a need for assistance with personal care. Resident R37 was assessed as a fall risk and care planned to encourage the resident to use handrails/ siderails or assistive devices properly and to maintain the call bell within the resident's reach for preventing falls and accidents, dated January 10, 2025. During an interview on March 18, 2025, at 1:00 p.m. Resident R37 stated he did not like his bedrails and moved the bedrails to show how loose they were attached to his bed.…

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 The facility failed to ensure that one resident, who displayed mental disorder or psychosocial adjustment difficulty, received treatment and services to correct the assessed problem or to attain the highest practicable mental and psychosocial well-being for one of four residents reviewed for mood/behavior (Resident R97). Findings Include: Review of Resident R97's comprehensive Minimum Data Set (MDS - federally mandated resident assessment and care screening) dated February 6, 2025, revealed the resident was admitted to the facility on [DATE], had moderate cognitive impairment, and diagnoses of non-Alzheimer's dementia and depression. Further review of Resident R97's MDS dated [DATE], revealed the resident scored a 17 under section D Mood which can be interpreted as moderately severe depression. Review of Resident R97's clinical record revealed a psychiatry assessment dated [DATE], by Psychiatric Mental Health Nurse Practitioner (PMHNP), Employee E8, that revealed Resident R97 expressed feeling anxious and…

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

Based on review of clinical records, facility policy, and staff and resident interviews, it was determined that the facility failed to ensure the timely acquisition and administration of a prescribed medication to meet the needs of one of 31 residents reviewed (Resident R16). Findings include: A review of Resident 16's clinical record revealed Resident R16 was admitted to the facility September 1, 2022 , with diagnoses that included but not limited to congestive heart failure (condition that happens when your heart can't pump blood well enough you meet the body's needs), alcoholic polyneuropathy (damage to the nerves caused by excessive alcohol consumption), and generalized anxiety disorder. On March 18, 2025 at 12:10 p.m. interview with Resident R16 revealed Resident R16 was experiencing anxiety due to a recent event that occurred in his personal life. Resident R16 stated the physician ordered Ativan and he did not receive it for 3 days due to the medication not being available. Review of Resident R16's nursing progress note, dated February 11, 2025 at 1:25 p.m., revealed 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 observations and staff and resident interviews it was determined that the facility failed to provide a substitute for a resident who requested a meal alternative and failed to serve foods that accommodate a residents allergies for two of 26 residents reviewed during dining (Resident R97 and R6). Findings Include: Review of Resident R97's comprehensive Minimum Data Set (MDS - federally mandated resident assessment and care screening) dated February 6, 2025, revealed the resident was admitted to the facility on [DATE], had moderate cognitive impairment, and had a diagnosis of malnutrition (deficiencies, excesses, or imbalances in a person's intake of energy and/or nutrients). Observations on March 17, 2025, revealed an always available menu dated February 18, 2025, posted on the wall on the 2nd floor nursing unit located next to the elevators. For the lunch and dinner meal, a hamburger was listed as an alternative option that could be requested by calling the kitchen. Observations on March 17, 2025, at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews with staff and residents and review of facility policy, it was determined that the facility failed to ensure that call bells were within reach for five of 31 residents reviewed. (Resident R37, R115, R153, 109, R88 ). Findings include: A review of the policy titled Answering Call light last revised March 2021 revealed The purpose of this procedure is to ensure timely responses to the resident's requests and needs. Its further states under General Guideline bulletin 4. Be sure that the call light is plugged in and always functioning. 5. When the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident. Review of Resident R37's medical diagnosis revealed the resident was admitted to the facility on [DATE], identified lacking coordination, reduced mobility, abnormal posture and a need for assistance with personal care. Resident R37 was assessed as a fall risk and care planned to encourage the resident to use handrails/ siderails 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.

Based on interviews with residents and staff, and review of temperature logs, it was determined that the facility failed ensure that essential mechanical equipment ws maintain in working function to provide comfortable bathing temperatures on two of three nursing floors. (Second and Fourth floor) Findings include: Review of the policy titled bathing, showering and use of tub dated February 2018 revealed that it was the responsibility of the nursing staff to promote cleanliness and provide a comfortable bathing experience for the residents. Review of the policy titled safe water temperatures dated December, 2009 revealed that it was the responsibility of the facility to provide a water temperatures used by the residents at safe levels to prevent burns. The maintenance staff was responsible for checking thermostats and temperature controls in the facility to ensure safe and comfortable bathing, showering and sink use for the residents. Interview with the Nursing Home Administrator, Employee E1, at 1:00 p.m., on October 17, 2024 revealed that the facility has been having water…

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

Based on a review of clinical records, facility policies, and interviews with staff and residents, it was determined that the facility failed to implement comprehensive, person-centered care plans for one out of the seven records reviewed (Resident R1). Findings include: Facility policy titled Care Plans, Comprehensive Person-Center last revised December 2022 revealed A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. It further states Each resident's comprehensive person-center care plan is consistent with the resident's right to participate in the development and implementation of his or her plan of care. Review of Resident R1's clinical record revealed admission date on August 8, 2023, with diagnoses of cerebral infarction (typically caused by a blood clot or plaque buildup in the arteries, depriving brain cells of oxygen and nutrients, resulting in cell death), hemiplegia and hemiparesis, lack of coordination, adjustment…

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 personnel files, facility documentation and interviews with staff, it was determined that the facility failed to ensure that nursing staff possessed the required skills to properly care for residents' needs for three of three personnel files reviewed related to skills competencies evaluations (Employees E5). Findings include: Review of Employee E5's personnel file revealed that the employee was agency employee worked on September 9, 2024, hired, as a nursing aid. A review of the internal investigation included a written statement for Employee E5, which revealed that Employee E5 failed to follow the care plan for Resident R1, leading to an escalation of the situation. On September 16, 2024, at approximately 1:41 p.m. an interview with Administrator, Employee E1 and Director of Nursing, Employee E2 confirmed that agency staff nursing aid, Employee E5, was not being evaluated on their competency to ensure nursing employees possess the required skills to properly care for resident's needs and are oriented to the facility practices and care plans. 28 Pa. Code 201.19(7)…

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 procedures, review of clinical records, and staff interview, it was determined that the facility failed to allow a resident to return to the facility following a hospitalization for one of eight residents reviewed. (Resident R1) Findings Include: Review of the facility policy titled, Admissions Policies undated states, Policy Statement- Written policies and procedures governing admissions to the facility will be maintained on a current basis to ensure fair and impartial admission practices. The objectives of our admission policies are to: a. Provide uniform guidelines in the admission of residents to the facility; b. Admit residents who can be adequately care for by the facility; c. Reduce the fears and anxieties of the resident and family during the admission process; d. Review with the resident, and/or his/her representative (sponsor), the facility's policies and procedures relating to resident rights, resident care, financial obligations, visiting hours, etc; and e.…

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 policy and staff and resident interviews, it was determined that the facility failed to maintain a clean and homelike environment in the main dining room and two of three nursing units (Second floor and Third Floor). Findings Include: Review of facility policy titled Bath, Shower, Tub revised February 2018 revealed the purpose of the procedures are to promote cleanliness, provide comfort to the resident and observe skin conditions. This policy included instructions including: to be sure the tub or shower is clean, the bath area is a comfortable temperature for the resident, if using a shower regulate the temp and the flow of the water warm water is 105 degrees Fahrenheit. Observation on May 21, 2024, at 11:00 a.m., accompanied with Nursing Home Administrator Employee E1 (NHA), Director of Nursing, Employee 2 and Maintenance Director, Employee E11 of Third floor's resident shower, displayed a deteriorated malfunctioning shower. The shower floor was observed with noticeable fragmented broken concrete, sharp, shattered pieces. The showers wall…

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

Based on staff interviews, review of facility policy and the review of the clinical record, it was determined that the facility failed to ensure that a complete and thorough investigation was conducted to rule out abuse/neglect for a bruise of an unknown original for 1 out of 30 residents reviewed (Resident R39) Findings include: Review of the facility policy, Abuse and Neglect-Clinical Protocol with a revised date of March 2018, indicated that management and staff with physician support will address situation of suspected or identified abuse and report them in a timely manner to appropriate agencies, consistent with applicable laws and regulations. Continued review of the policy indicated that if resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law. The policy also indicated that upon receiving any allegations of abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source,…

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 clinical records and staff interviews, it was determined that the facility failed to develop and implement an individualized, comprehensive care plan with measurable objectives and interventions to meet the resident's needs for one of 30 residents reviewed (Resident R140). Findings Include: Review of Resident R140's quarterly Minimum Data Set (MDS - federally mandated resident assessment and care screening) dated May 14, 2024, revealed the resident had moderate cognitive impairment, and functional limitation in range of motion to upper and lower extremities. Further review of the MDS revealed Resident R140 had diagnoses of hemiplegia (one-sided paralysis or weakness), muscle weakness, and need for assistance with personal care. Continued review of Resident R140's quarterly MDS dated [DATE], revealed the resident required substantial/maximal assistance (helper does more than half the effort) with personal care. Review of Resident R140's comprehensive care plan revised February 16,…

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 policy, staff interviews and the review of the clinical record, it was determined that the facility did not ensure that services provided met professional standards of practice in regard to a change in a resident's medical condition for 1 out of 30 residents reviewed (Resident R39). Findings include: Review of the facility policy, Change in a Resident's Condition or Status, with a revision date of April 2024 indicated that the facility promptly notifies the resident, his or her attending physician, and the resident's representative of changes in the resident's medical/mental condition and/or status (e.g. changes in level of care, billing payments, resident rights, etc.). Review of the policy also included the following situations in which nursing will notify the resident's attending physician or the physician on call of resident changes: an accident or incident involving the resident; discovery of injuries of an unknown source; refusal of treatment; specific instructions from the physician to notify him/her about changes in a resident's…

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

Based on review of clinical records, observations, and staff interview, it was determined that the facility failed to ensure interventions were implemented for the prevention of pressure ulcers for one of five residents reviewed for pressure ulcers (Resident R1). Findings Include: Review of Resident R1's Quarterly Minimum Data Set (MDS - federally mandated resident assessment and care screening) dated April 25, 2024, revealed the resident was cognitively impaired and had diagnoses of diabetes mellitus (disorder of carbohydrate metabolism) and hemiplegia (one-sided paralysis or weakness). Review of Resident R1's comprehensive care plan revised on January 22, 2024, revealed the resident was at risk for developing wounds related to non-compliance with care. Intervention dated February 16, 2024, included to offload heels as ordered. Review of Resident R1's clinical record revealed a physician order dated February 23, 2024, to apply heel boots (device that pads the heel to relieve pressure and help to prevent skin breakdown) while in bed every shift. Observations on May 22, 2024, at…

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

Based on observations, staff interviews, and review of clinical records, it was determined that the facility failed to ensure that weekly weights were obtained for 2 out of 30 residents reviewed with a history of weight loss (Resident R39 and Resident R454). Findings include: Review of the Resident R39's May 2024 physician orders included the diagnoses of hypertension (high blood pressure); cerebral infarction (a stroke); contracted right elbow and right wrist; dysphagia (difficulty swallowing) and congestive heart failure (a long-term condition that happens when your heart can't pump blood well enough to give your body a normal supply). Review of the nutritional note by the Registered Dietician dated November 15, 2023, at 3:51 p.m. indicated that Resident R39 experienced an 18.3% significant weight loss from October 2, 2023 (weight recorded as 167 pounds) through November 9, 2023 (weight recorded as 136.4). Resident also had a significant weight loss over the past three months of -19. 3 % with August 2, 2023 weight recorded as 169 pounds; September 13, 2023 weight recorded as 164…

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, staff interviews, review of clinical records and review of facility policy, it was determined that the facility failed to ensure that medications were delivered from pharmacy timely for two of 30 resident records reviewed (Resident R133 and Resident R39). Findings include: Review of facility policy titled Pharmacy Services Overview revised April 2029 states, The facility shall accurately and safely provide or obtain pharmaceutical services including the provision of routine and emergency medications and biologicals. Resident R133 was initially admitted to the facility on [DATE], diagnosed with chronic pancreatitis (pancreatis does not produce enzymes or hormones to ensure proper digestion to absorb nutrients) and Tinea Cruris (fungal infection). Review of Resident R133's physician orders revealed an order for Pancrelipase (Lip-Prot-Amyl) Capsule, delayed release particles 12000-38000 UNI (used to help improve food digestion) was instructed to give one capsule by mouth with meals for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of clinical records, interview with staff and review of facility policy, it was determined the facility failed to ensure that as needed psychotropic medication included an end date for stoping the medication for one of 30 resident records reviewed (Resident R25). Findings include: Review of the facility's policy titled, Psychotropic Medication Use revised July 2022 states, Residents will not receive medications that are not clinically indicated to treat a specific condition. The policy defines psychotropic medication as any medication that affects brain activity associated with mental processes and behaviors. The same policy further states that psychotropic medications are not prescribed or given on a PRN (as needed) basis unless that medication is necessary to treat a diagnosed specific condition that is documented in the clinical record. PRN orders for psychotropic medications are limited to 14 days. For psychotropic medications that are NOT antipsychotics (example the benzodiazepines lorazepam…

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, review of clinical records, and staff interview, it was determined that the facility failed to ensure labs were completed per physician orders for one of 30 residents reviewed (Resident R118). Findings Include: Review of facility policy Lab and Diagnostic Test Results - Clinical Protocol revised November 2018 reveled the physician will identify, and order lab testing based on the resident's diagnostic and monitoring needs. The staff will process test requisitions and arrange for tests. Review of Resident R118's clinical record revealed a physician order dated January 23, 2024, ordered by Nurse Practitioner, Employee E19, for laboratory values to be drawn on January 24, 2024. Continued review of Resident R118's clinical record revealed an assessment dated [DATE], by Nurse Practitioner, Employee E19, which revealed the Nurse Practitioner was unsure if the labs ordered for January 24, 2024, had been drawn. Review of Resident R118's entire clinical record revealed no documented…

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, observations, and staff interview, it was determined that the facility failed to ensure beverages were provided in accordance with resident needs for three of three residents with orders for thickened liquids observed (Resident R1, R140, and R34). Findings Include: Review of Resident R1's Quarterly Minimum Data Set (MDS - federally mandated resident assessment and care screening) dated April 25, 2024, revealed the resident was cognitively impaired and had a diagnosis of dysphagia (difficulty swallowing). Review of Resident R1's clinical record revealed a physician diet order dated January 25, 2024, that indicated Resident R1 was ordered nectar thick fluids (liquids that have been altered to a thicker consistency than water - nectar thick liquids are similar to that of fruit nectar). Review of Resident R1's care plan revised May 22, 2024, revealed the resident had a nutritional problem or potential nutritional problem related, but not limited to, mechanically altered diet and…

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

Based on observations, staff interviews and the review of clinical records, it was determined that the facility failed to maintain complete and accurate clinical records for 1 out of 30 residents (Resident R89). Findings include: Review of the facility policy, Charting and Documentation, with a revision date of July 2017, indicated that all services provided to the resident, progress toward the care plan, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. The policy also indicated that the medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. Continued review of the policy indicated that information documented in the medical record should include, but not limited to: Objective observations; treatments or services performed; changes in the resident's condition, and events, incidents or accidents involving the resident. Review of the Resident R89's May 2024 physician orders included the diagnoses of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, interviews with staff, hospital record reviews and reviews of policies and procedures, it was determined that the facility failed to ensure that the physician was notified of a refusal of a laxative mediation for one of four residents reviewed. (Resident R4) Findings include: Review of the facility policy titled refusal and/or discontinuing care or treatment dated February, 2021 revealed that it was the facility's responsibility to inform each resident of the care that will be furnished or made available to the resident based on his or her assessment and plan of care, the risks and benefits of the proposed care , treatment, treatment alternatives or treatment options and any changes in the resident's care plan. The policy indicated that if a resident refuses treatment, the staff would meet with the resident to determine why he or she is requesting, refusing or discontinuing care and treatment and address the resident's concerns, and offer alternative treatment and care options.…

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 reviews of policies and procedures and interviews with residents and staff, it was determined that the facility failed to address the behavioral health needs and services for one of two residents. (Resident R1) Findings include: Review of the policy titled behavioral health services dated February, 2029 revealed that it was the responsibility of the facility to provide behavioral health services for each resident to maintain their highest practicable physical, mental and psychosocial well-being. The policy indicated that residents having emotional or psychosocial distress would receive services to meet their needs. The policy also indicated that residents having diagnoses of mental, psychiatric or psychosocial adjustment disorders would receive services to meet their needs. The policy said that residents with substance abuse or post traumatic stress disorder would receive services to promote dignity, autonomy, privacy, socialization and safety. The policy titled comprehensive…

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.