Watsontown Rehabilitation And Nursing Center

Based on clinical record review and resident and staff interview, it was determined that the facility failed to obtain routine services from an eye care professional for one of one resident reviewed for vision concerns (Resident 31).Findings include: Interview with Resident 31 on September 10, 2025, at 10:34 AM revealed that she used eyeglasses only for reading. Resident 31 stated that she could not recall when the last time was she saw a doctor or eye care professional for vision services. Resident 31 stated, I need stronger ones (glasses). Clinical record review for Resident 31 revealed that the facility admitted her on February 17, 2022. Resident 31's diagnoses list included diagnoses known to create the potential for eye health concerns as follows: Diabetes (high blood sugar)Long-term use of non-steroidal anti-inflammatories (long term use of medications that can cause complications of the cornea, or outer surface of the eye)Hypertension (high blood pressure)Hyperlipidemia (high levels of fats/cholesterol in the blood) Documentation by the facility's contracted eye care…

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

Based on clinical record review, observation, and resident and staff interview, it was determined that the facility failed to obtain professional podiatry services for one of two residents reviewed for skin conditions (Resident 76).Findings include: Clinical record review for Resident 76 revealed her diagnoses list included diabetes (high blood sugar) and polyneuropathy (nerve damage that can include pain, numbness, weakness, and coordination issues, often affecting the hands and feet). Documentation by the facility's contracted podiatry provider dated January 16, 2025, revealed that the practitioner assessed Resident 76's nails as thickened, that she had complaints of burning in both of her feet, and that her diagnoses included peripheral angiopathy (diseased blood vessels) and diabetes. Documentation by the facility's contracted podiatry provider dated May 27, 2025, revealed that the practitioner continued to assess Resident 76's nails as thickened, that she had complaints of burning in both of her feet, and that her diagnoses included peripheral angiopathy and diabetes. The…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and resident and staff interview, it was determined that the facility failed to assess and implement interventions to maintain a resident's continence status for one of one resident reviewed (Resident 19).Findings include: In an interview with Resident 19 on September 10, 2025, at 10:21 AM the resident indicated she was admitted to the facility without any history of being incontinent of her bowel or bladder and knows when she needs go to the bathroom but has since had several instances of being incontinent of bladder since her admission to the facility. Resident 19 indicated she has to wait a long time for staff at times on the evening or night shift to assist her to the bathroom and even started to ring her bell early to give the staff more time to get to her, but they don't always make it to her in time. Resident 19 also stated sometimes the staff come in and shut off her bell and say they will be back, but they don't come back and she pees the bed because of waiting. Resident…

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

Based on clinical record review, observation, and staff interview, it was determined that the facility failed to provide respiratory and tracheostomy care consistent with professional standards of practice for one of two residents reviewed with a tracheostomy (Resident 42).Findings include: Review of the policy titled, Tracheostomy Care Policy, last reviewed without changes on June 4, 2025, revealed a purpose to guide tracheostomy care and the cleaning of reusable tracheostomy findings. Under the section titled, General Guidelines, the policy noted that a replacement tracheostomy tube must be available at the bedside at all times. Clinical record review for Resident 42 revealed a diagnosis list that included a tracheostomy (trach, an artificial opening through which a medical tube is placed through the front of the neck into the airway to facilitate breathing). Review of the current physician orders for Resident 42 revealed orders for daily and as needed tracheostomy care that included changing the inner cannula. Further review of the physician orders revealed an order that…

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

Based on a review of financial accounting records, clinical record review, and resident and staff interview, it was determined that the facility failed to provide medically-related social services to assist a resident with financial matters for one of 24 residents reviewed (Resident 22).Findings include: Interview with Resident 22 on September 9, 2025, at 12:49 PM revealed that he did not believe that he had any money in a personal account, that he did not receive a statement, and that he did not know where any personal allowance funds were maintained. An interview with the Nursing Home Administrator on September 10, 2025, at 2:30 PM confirmed that Resident 22 entered the facility following his release from prison, and the facility determined that he had no resources. The surveyor requested Resident 22's financial accounting (e.g., monthly charges and payments for those charges) since his admission to the facility. The interview confirmed that Resident 22 had no designated responsible party. Resident 22 was his own responsible party; therefore, there would be no other individual…

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

Based on clinical record review and staff interview, it was determined that the facility failed to ensure accurate clinical documentation for one of 24 residents reviewed for clinical documentation issues (Resident 44; Residents 34 and 122).Findings include: Review of Resident 44's clinical record revealed a section of the electronic health record (EHR) where various documents are uploaded to the medical record for staff to review as needed. Further review of this section for Resident 44 revealed that scans for two other residents, Residents 34 and 122, were uploaded to Resident 44's clinical record. The following documents were erroneously uploaded to Resident 44's medical record: A POLST (Physician Orders for Life-Sustaining Treatment) form for Resident 122 that had an upload and effective date of July 21, 2025. A medication clarification notice for Resident 34 that was dated July 25, 2025. The Nursing Home Administrator and Director of Nursing were informed of the findings on September 10, 2025, at 2:30 PM. The facility failed to ensure an accurate clinical record for Resident…

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

Based on clinical record review and staff interview, it was determined that the facility failed to notify the physician of a resident's change in condition requiring interventions for one of five residents reviewed (Resident CR1). Findings include: Closed clinical record review for Resident CR1 revealed nursing documentation dated March 1, 2025, at 9:35 PM that indicated he was unable to swallow. A nursing progress note dated March 2, 2025, at 10:11 AM indicated that Resident CR1's medications were not given because it was not safe due to him not responding. A nursing progress note dated March 2, 2025, at 11:32 AM revealed that Resident CR1's daughter called and wanted updates on the resident. The resident was assessed by the documenting nurse and indicated his vital signs were within normal limits, his heart rate (HR) was regular, and he had no edema. His feet were cool to touch, and he had coarse lung sounds. He was mouth breathing. His HR was 98 beats per minute, his temperature was 96.6 degrees Fahrenheit, and his blood pressure was unable to be obtained. The daughter declined…

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

Based on clinical record review and staff interview, it was determined that the facility failed to ensure complete and accurate clinical records for one of five residents reviewed (Resident CR1). Findings include: Clinical record review revealed the facility admitted Resident CR1 on February 14, 2025, for a respite (a short stay to give his caregiver a break from their responsibility) stay. Review of the admission orders provided by Resident CR1's physician from the community, revealed that he was to have his blood sugar monitored four to five times a day. Review of Resident CR1's physician orders revealed that the order for his blood sugar checks never got transcribed to his physician orders on admission and his blood sugars were not being monitored. Interview with the Nursing Home Administrator on March 6, 2025, at 12:30 PM confirmed the above noted findings related to Resident CR1's order to monitor his blood sugars. The facility failed to ensure a complete and accurate clinical record for Resident CR1. 28 Pa. Code 211.12(d)(1)(5) Nursing services

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of select facility policies and procedures, clinical record review, observations, and resident and staff interview, it was determined that the facility failed to provide a clean, comfortable, homelike environment on two of two nursing units (upper level nursing unit and lower level nursing unit; Resident 53) and failed to exercise reasonable care for the protection of the resident's property from loss for two of 20 residents reviewed (Residents 60 and 102). Findings include: Observation of the upper-level nursing unit shower room on October 25, 2024, at 8:30 AM revealed the following: A shower gurney had a build-up of a dry, white substance and a used resident brief underneath the layer of padding. A handrail located in a resident shower stall was loose and the wall tile was cracked where the handrail met the wall. The above information for the upper-level nursing unit shower room was reviewed with the Nursing Home Administrator on October 25, 2024, at 12:06 PM. Observation of the lower-level…

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

Based on clinical record review and staff interview, it was determined that the facility failed to provide a written notice of the facility's bed-hold policy to residents or the residents' responsible parties for five of 13 residents reviewed for hospitalization concerns (Residents 17, 65, 62, 80, and 83). Findings include: Clinical record review revealed that Resident 17 was transferred to the hospital on September 28, 2024, after she had a change in condition. There was no documentation available that the facility provided written notice regarding a bed hold to the resident and the resident's responsible party upon transfer out to the hospital. Clinical record review revealed that Resident 65 was transferred to the hospital on September 8, 2024, after he had a change in condition. There was no documentation available that the facility provided written notice regarding a bed hold to the resident and the resident's responsible party upon transfer out to the hospital. The Nursing Home Administrator and Director of Nursing confirmed these findings for Residents 17 and 65 on October…

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

Based on clinical record review and staff interview, it was determined that the facility failed to provide the highest practicable care regarding physician ordered weights and medications for three of 20 residents (Residents 22, 72, and 75). Findings include: Clinical record review for Resident 22 revealed physician orders for staff to administer and complete the following: From August 4, 2023, to September 14, 2024, daily weight every night shift for weight monitoring. Notify physician if given or if weight was greater than 213 (pounds). On September 14, 2024, daily weight every night shift for weight monitoring. Notify physician if given or if weight was greater than 186 (pounds). Both of Resident 22's weight orders indicated that if there was a weight change of greater than 2 pounds in 24 hours or greater than 5 pounds in a week staff were to refer to Resident 22's as needed (PRN) Bumex order for administration. Further review of Resident 22's physician orders revealed the following: From June 13, 2024, to August 12, 2024, Bumex 2 mg (milligrams) PO every 24 hours PRN for weight…

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

Based on clinical record review, observation, and staff interview, it was determined that the facility failed to ensure the application of physician ordered supplemental oxygen consistent with professional standards of practice and the resident's plan of care, for two of two residents reviewed for supplemental oxygen concerns (Residents 47 and 83). Findings include: Clinical record review for Resident 47 revealed an active physician order dated September 12, 2023, for staff to apply supplemental oxygen at 5 liters per minute (lpm) via a cool mist trach collar (air compressor pushes room or oxygenated air through a bottle of sterile water to add moisture to the administered air that is administered through the collar over the tracheostomy tube (artificial opening through which a tube is placed through the front of the neck into the airway to facilitate breathing) to help thin secretions and improve the ability to breathe), titrate (adjust the liter flow) for SPO2 (pulse oximeter, or pulse ox, works by shining a light through the skin and determining the amount of oxygen based on 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.

Based on review of facility documentation, employee files, and staff interviews, it was determined that the facility failed to ensure that nursing staff possessed the appropriate competencies and skill sets related to the care and assessment of resident tracheostomy, peg tube, and catheter care for four of five employees reviewed (Employees 12, 13, 14, and 15). Findings include: A review of the facility documentation revealed that the facility had five residents with urinary catheters (insertion of a tube into the bladder to remove urine), one resident with a tracheostomy (a surgical airway management procedure that consists of making an incision on the anterior aspect of the neck and opening a direct airway through an incision in the trachea), and two residents with peg tubes (medical procedure in which a tube is passed into resident's stomach through the abdominal wall, most commonly to provide a means of feeding). A request for staff competencies for tracheostomy, peg tube, and catheter care revealed the facility was unable to provide them. Further interview with 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and staff interview, it was determined that the facility failed to ensure an environment free from the potential spread of infection for two of two nursing units (Upper and Lower nursing units, Residents 5, 22, 31, 77, 54, 80, 85, and 47) Findings include: Review of the Centers for Medicare and Medicaid Services (CMS) Quality, Safety, and Oversight Group memo QSO-24-08-NH dated March 20, 2024, entitled Enhanced Barrier Precautions (EBP) in Nursing Homes (NH), revealed the following: EBP refers to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident activities, EBP are indicated for residents with an infection or colonization with a CDC (Centers for Disease Control) targeted MDRO (multi-drug resistant organism) when contact precautions do not otherwise apply or any wounds and/or indwelling medical devices (a pathway of pathogens in the environment to enter the body and cause…

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 employee education records and staff interview, it was determined that the facility failed to ensure that nurse aides received 12 hours of in-service training annually for three of three nurse aides reviewed (Employees 2, 3, and 4). Findings include: During a meeting with the Nursing Home Administrator and Director of Nursing on October 23, 2024, at 2:21 PM the surveyor asked for training records to indicate that nurse aides had received at least 12 hours of in-service training in the last year for Employees 2, 3, and 4 (nurse aides). Interview with the Nursing Home Administrator on October 25, 2023, at 11:41 AM confirmed there was no documented evidence that the above employees received the required 12 hours of annual in-service training. 483.95(g) Required in-service training for nurse aides. Previously cited deficiency 11/17/23 28 Pa. Code 201.19 (7) Personnel policies and procedures

Based on clinical record review and staff interview, it was determined that the facility failed to ensure a resident's right to refuse or discontinue advance directive treatment for one of four residents reviewed for advance directive concerns (Resident 80). Findings include: Clinical record review for Resident 80 revealed a POLST (Physician Orders for Life-Sustaining Treatment, portable medical order form that records patients' treatment wishes so that emergency personnel know what treatments the patient wants in the event of a medical emergency) signed by a physician on August 18, 2022, that indicated Resident 80 wanted comfort measures only and should not have hydration or nutrition via a tube. The form did not include a resident or resident representative signature but indicated that verbal consent was obtained via telephone conversation with Resident 80's responsible party. A living will document scanned into Resident 80's electronic medical record signed by Resident 80 on December 1, 2005, designated his responsible party as the agent to carry out his wishes as necessary. The…

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

Based on clinical record review and staff interview it was determined that the facility failed to provide the required notification timely to a resident whose payment coverage changed for one of three residents reviewed (Resident 65). Findings include: A review of the form Instructions for the Notice of Medicare Non-Coverage (NOMNC) CMS-10123, (a notice that informs the recipient when care received from the skilled nursing facility is ending; and how to contact a Quality Improvement Organization (QIO) to appeal) revealed instructions that a Medicare provider must ensure that the notice is delivered at least two calendar days before Medicare covered services end. The provider must ensure that the beneficiary or their representative signs and dates the NOMNC to demonstrate that the beneficiary or their representative received the notice and understands the termination of services can be disputed. If the provider is personally unable to deliver a NOMNC to a person acting on behalf of an enrollee, then the provider should telephone the representative to advise him or her when the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff and resident interview, it was determined that the facility failed to implement a comprehensive person-centered care plan to maintain the highest practicable well-being for two of 20 residents reviewed (Residents 68 and 98). Findings Include: Observation and concurrent interview of Resident 68 on [DATE], at 2:10 PM revealed the resident had an indwelling foley catheter (a device that is inserted into the bladder and drains urine to an external collection bag). The resident's foley catheter drainage collection bag was observed hanging off the dresser located next to the resident's bed. Physician documentation for Resident 68 dated [DATE], revealed the resident had chronic retention of urine with a foley catheter. Current physician orders for Resident 68 revealed the following orders related to the foley catheter: Change the foley catheter and drainage bag monthly and as needed every night shift every one month starting on the 18th and as needed for leaking 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 clinical record review, observation, and staff interview, it was determined that the facility failed to provide shaving support for residents requiring staff assistance for two of two residents sampled for activities of daily living (Residents 65 and 85). Findings include: Observation of Resident 85 on October 22, 2024, at 10:19 AM and October 23, 2024, at 11:21 AM revealed he had several days of facial hair growth on his face. Resident 85 was unable to be interviewed related to his shaving preference due to his current cognitive status. Clinical record review for Resident 85 revealed his admission MDS (Minimum Data Set, an assessment completed at specific interval to determine care needs) dated September 24, 2024, revealed nursing staff assessed him as dependent on staff for his personal hygiene (including shaving). The facility failed to provide Resident 85 shaving assistance. Interview with the Nursing Home Administrator on October 25, 2024, at 11:13 AM confirmed the findings for Resident 85.…

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

Based on clinical record review, observation, and staff interview, it was determined that the facility failed to apply a physician ordered splint for one of two residents reviewed for range of motion concerns (Resident 47). Findings include: Clinical record review for Resident 47 revealed an active physician order dated June 28, 2024, that instructed staff to apply a left grip splint in the morning and remove the splint in the evening. A plan of care initiated by the facility on July 22, 2019, to address Resident 47's inability to perform activities of daily living independently related to intellectual disabilities, cerebral palsy (a group of conditions that affect movement and posture caused by brain damage that occurs most often before birth), and impaired mobility, indicated that Resident 47 had contractures (abnormal positioning of a joint) of the left wrist and fingers for which staff were to apply a left grip splint with morning care and remove with evening care. Observation of Resident 47 on the following dates and times revealed that staff did not apply the left-hand splint.…

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

Based on review of select facility policies and procedures, clinical record review, observation, and staff interview, it was determined that the facility failed to assess a residents' need for bed rails, assess risk for entrapment from bed rails, and obtain informed consent before installation of bed rails for two of five residents reviewed for potential accident hazards (Residents 60 and 80). Findings include: The surveyor requested the facility's policies and procedures related to the use of bed rails during an interview with the Nursing Home Administrator and the Director of Nursing on October 24, 2024, at 2:15 PM. The two-page information provided by the facility on October 25, 2024, included a Bed Safety Audit procedure that indicated nursing and maintenance are responsible for conducting Bed Safety Audits. Nursing will follow policy and associated procedures to determine if side rails are clinically indicated. A Bed Entrapment Grid document indicated that the facility identified seven zones of potential resident entrapment as follows: Zone 1, within the rail Zone 2, between…

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 develop and implement individualized person-centered care plans to address dementia and cognitive loss displayed by two of three residents reviewed (Residents 45 and 65). Findings include: Clinical record review for Resident 45 revealed the facility admitted her on July 26, 2022, with a diagnosis of Alzheimer's dementia (loss of memory, language, problem-solving, and other thinking abilities that interfere with daily life). A review of Resident 45's most recent significant change Minimum Data Set Assessment (MDS, a form completed at specific intervals to determine care needs) dated December 1, 2023, indicated that the facility assessed Resident 78 as having a diagnosis of dementia. The facility determined that a care plan for dementia and cognitive loss would be developed. A review of Resident 45's care plan revealed that there was no indication that the facility had developed and implemented a person-centered care…

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

Based on clinical record review and staff interview, it was determined that the facility failed to ensure an appropriate response to consultant pharmacist recommendations for one of five residents reviewed for potentially unnecessary medications (Resident 65). Findings include: Clinical record review for Resident 65 revealed a consultant pharmacist report dated December 4, 2023, requesting the facility evaluate if Resident 65's as needed (PRN) Atarax (antihistamine medication) could be discontinued due to nonuse. Resident 65's physician agreed to the recommendation and staff noted the change on December 6, 2024. Review of Resident 65's physician orders revealed an active order since January 30, 2023, for Atarax 25 milligrams(mg), one tablet every eight hours as needed for itching. Interview with the Director of Nursing on October 25, 2024, at 9:08 AM confirmed the facility failed to respond appropriately to Resident 65's December 4, 2023, pharmacy recommendation, and discontinued his Atarax only after surveyor's questioning. 28 Pa. Code 211.9 (k) Pharmacy services 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 observation and resident and staff interview, it was determined that the facility failed to properly secure and account for resident medications and biologicals on one of two nursing units (Upper Level Nursing Unit, Resident 68). Findings include: Observation of Resident 68's room on October 22, 2024, at 2:06 PM revealed the resident was sitting on the edge of the bed. A white, round pill was observed on the floor next to the resident's bed. The resident was unsure where the pill had come from. An interview with Employee 5, licensed practical nurse (LPN), on October 22, 2024, at 2:14 PM revealed the LPN was unable to identify the pill other than the pill was scored. The LPN proceeded to dispose of the medication found on Resident 68's floor. The facility failed to properly secure resident medications as evidenced by an unknown pill found on Resident 68's floor. The above information was reviewed in a meeting with the Nursing Home Administrator and Director of Nursing on October 23, 2024, at 3:16 PM. Observation of a medication administration pass with Employee 5 on October…

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

Based on clinical record review and resident and staff interview, it was determined that the facility failed to assist a resident in obtaining routine dental services for two of five residents reviewed for dental concerns (Residents 65 and 80). Findings include: Observation of Resident 65 on October 22, 2024, at 11:20 AM revealed that Resident 65 had several broken teeth. Resident 65 was unable to be interviewed due to his current cognitive status. Clinical record review revealed the facility admitted him November 18, 2022, with payment sources that included the state Medicaid benefit. Further review of Resident 65's clinical record revealed that he last saw a dentist on January 10, 2024. A review of this progress note revealed that Resident 65's broken teeth were asymptomatic at that time, and he would be due for his next visit for prophylactic dental cleaning in six months. An interview with Employee 8 (social worker) on October 25, 2024, at 10:46 AM confirmed these findings for Resident 65 and had no further information to indicate that Resident 65 was offered routine dental…

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 select facility policies and procedures, clinical record review, and staff interview, it was determined that the facility failed to ensure a resident received the pneumococcal immunization for one of five residents reviewed for immunization concerns (Resident 96). Findings include: Review of the policy entitled Pneumococcal Vaccine Guidelines, last reviewed without changes in August 2024, revealed that the facility will offer residents the pneumococcal vaccine to aid in preventing pneumococcal infections as applicable per physician order. The procedure noted that previous immunization information will be requested during the pre-admission process. A representative from the admissions office/designee will obtain and forward copies of the immunization records to the admitting nurse. Verify the data with the resident and/or authorized representative when applicable. The pre-admission immunizations will be added to the electronic immunization record/EMR. The immunization record/EMR will be updated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, review of select facility policies and procedures, and staff interview, it was determined that the facility failed to offer, or provide education regarding the benefits, risks, and potential side effects with the COVID vaccine for one of five residents reviewed for immunizations (Resident 96). Findings include: Review of the policy titled COVID-19 Vaccination Administration, last reviewed in August 2024, indicated that, The facility will offer and administer COVID-19 vaccinations in accordance with state and federal guidelines. The vaccination schedule in the policy noted, The COVID vaccination schedules for people who are not moderately or severely immunocompromised and people who are moderately or severely immunocompromised should be consulted for age-specific information. Clinical record review for Resident 96 revealed the resident was admitted to the facility on [DATE]. Review of the immunizations for Resident 96 revealed no evidence of a COVID vaccination for 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.

Based on observation and staff interview, it was determined that the facility failed to ensure a safe and clean environment in the facility main laundry area located on the lower level. Findings include: Observation of the facility's main laundry area on October 25, 2024, between 8:40 AM to 8:55 AM revealed the following: A soiled linen room that contained a large laundry bin on wheels with an extensive build-up of debris in the bottom that included paper products, dirt, balled up gloves, and at least two washcloths. An active vent blowing air into the soiled area had an extensive build-up of dust on it. A commode with no lid on the bowl had debris and paper products discarded in the bowl. Three pillows and other items were set on top of the lidless bowl. There were multiple cobwebs hanging from the ceiling at the perimeter where the ceiling met the wall. The clean linen area of the laundry had a ceiling tile missing next to a fluorescent light fixture that was powered off. There were multiple pipes and wires visible. At least three ceiling tiles had large brown colored water stains…

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 documentation and resident responsible party and staff interview, it was determined that the facility failed to resolve resident grievances related to respect, incontinence issues, and resident safety for one of five residents reviewed (Resident 1). Findings include: Review of the facility Concern Forms for the month of December 2023, revealed the Log for December 2023, had 5 concern forms submitted related to Resident 1. Review of the Resident Concern reports related to Resident 1 revealed that all 5 were filed by her daughter/responsible party. Review of the concern forms for Resident 1, filed by her daughter/responsible party revealed the following: December 12, 2023, Concern form filed related to the resident being in pants all day that had a dried urine mark on them suggesting that they did not put her in dry pants all day. The form indicated the findings and disposition that a toileting program would be evaluated, and a family meeting scheduled. The investigation was completed by Employee 1 (Social services) on December 14, 2023. The form was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and resident and staff interview, it was determined that the facility failed to provide a clean, comfortable, and homelike environment on two of two nursing units reviewed (Upper and Lower Nursing Units; Residents 18, 25, 35, 47, 63, 68, 72, 85, 86, 97, 101, 102, and 112). Findings include: Observation of the Upper Nursing Unit on November 14, 2023, at 9:50 AM in the hallway where north and south halls intersect revealed the floor had gray and tan stains. The lower section of north hall revealed the walls had scuff marks. A build-up of debris was on the floor edges and continued there when observed at 11:30 AM. Observation and interview with Resident 63 on November 14, 2023, at 11:11 AM revealed the resident reporting having the coldest room in the home. There was a draft from his window. The surveyor informed Employee 3, nurse aide, who put a sweatshirt on Resident 63. Employee 3 indicated that this room is often colder. Concurrent observation of Resident 63's nightstand revealed the side…

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

Based on a review of select facility policies and procedures, employee personnel records, and staff interview, it was determined that the facility failed to implement its abuse prohibition policy pertaining to screening for five of five newly hired employees reviewed (Employees 1, 6, 7, 8, and 9). Findings include: A review of the facility policy entitled Employment Screenings for Potential Hires: Pennsylvania, last reviewed July 21, 2023, revealed for applicants who have not resided in Pennsylvania for the two years prior to the application or who currently live in another state, the facilty will obtain a report from the FBI using the FBI fingerprint card criminal history check process. This will be completed within 90 days of hire. A review of Employee 1's, maintenance director, personnel record revealed that the facility hired him on July 25, 2023. There was no documented evidence in Employee 1's personnel record that the facility obtained an attestation of Pennsylvania residency or completed an FBI check. A review of Employee 6's, activities, personnel record revealed that 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 closed clinical record review and staff interview, it was determined that the facility failed to ensure a discharge summary for two of three discharged residents reviewed (Residents 114 and 117). Findings include: Closed clinical record review for Resident 114 revealed nursing documentation dated [DATE], at 9:08 AM that indicated she was discharged to the hospital as of [DATE]. Further clinical record review revealed that Resident 114 was discharged to the hospital because she returned from a leave of absence with family on [DATE], at 3:21 PM and they indicated that she had a fall and complained of right hip pain. A new order was received at 3:47 PM for an X-ray to be completed as soon as possible on the right hip and pelvis. A progress note dated [DATE], at 11:29 PM indicated that the X-ray results revealed an acute right femoral neck fracture. An order was received to transfer her to the ER. Interview with the Director of Nursing on [DATE], at 2:45 PM revealed that Resident 114 was discharged to the…

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

Based on observation and staff interview, it was determined that the facility failed to store food items in a safe and sanitary manner and maintain equipment in a safe and sanitary condition in the main kitchen and lower level pantry. Findings include: An observation of the facility's main kitchen on November 14, 2023, at 9:12 AM with Employee 10 (food service director) revealed the following: The floor in the kitchen was dirty with numerous black sticky spots from spillage, dried food messes, and trash on the floor. The sink in the food prep area had the following items stored underneath: a tub of peanut butter, a box of potato pearls, a container of jelly, a jug of vinegar and Worcestershire sauce, a container of vanilla, and two trays of spices. The jug of Worcestershire sauce expired on August 26, 2023. There was no date on the container of vanilla. There was a dirty towel on the floor in the dish room. There was a tray with dirty oatmeal bowls in the food prep area. The trash can by the paper products was overflowing and had no lid on it. The above findings were reviewed with…

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

Based on observation and staff interview, it was determined that the facility failed to implement proper infection control practices during medication administration to prevent potential spread of infection on one of three residents observed for medication administration (Resident 113) Findings include: Observation of a medication administration pass on November 16, 2023, at 8:35 AM with Employee 12, Licensed Practical Nurse, revealed her administering Systane ophthalmic drops (eye drops used to treat dry eyes) 0.6%, one drop in each eye to Resident 113. Employee 12 administered Resident 113's oral medications and then proceeded to administer the eye drops. She administered the eye drops with no gloves on. Concurrent interview with Employee 12 confirmed the above noted findings that she did not don gloves prior to administering Resident 113's eye drops. Interview with the Director of Nursing on November 16, 2023, at 12:50 PM confirmed that Employee 12 should have donned gloves to administer Resident 113's eye drops. The facility failed to implement proper infection control practices…

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 complete a significant change Minimum Data Set assessment for one of two residents reviewed (Resident 85). Findings include: Interview with Employee 14, Registered Nurse assessment Coordinator (RNAC), on November 16, 2023, at 2:37 PM confirmed that the facility follows the guidelines from the Centers for Medicare and Medicaid's (CMS) Resident Assessment Instruction (RAI) for completing the Minimum Data Set assessment (MDS, an assessment tool utilized to determine resident care needs). Review of the Resident Assessment Instrument 3.0 User's Manual (reference used to complete an MDS) revealed that the facility must conduct a comprehensive assessment of a resident within 14 days after the facility determines, or should have determined, that there has been a significant change in the resident's physical or mental condition. Clinical record review for Resident 85 revealed a quarterly MDS dated [DATE], that indicated she…

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

Based on observation, clinical record review, review of select facility policies and procedures, and staff interview, it was determined that the facility failed to provide treatment and services, consistent with professional standards of practice, regarding skin assessments, for two of five residents reviewed (Residents 40 and 110). Findings include: The policy entitled Skin Integrity, last reviewed July 21, 2023, revealed the facility will develop a routine to review residents with wounds, or if they are at risk on a weekly basis. Clinical record review for Resident 40 revealed nursing documentation dated November 1, 2023, at 3:30 PM indicating staff noted an open area to her right buttock measuring 1.5 centimeters (cm) by 1.5 cm. There was no documentation that the facility assessed Resident 40's wound weekly until the surveyor questioned them on November 15, 2023. Clinical record review for Resident 110 revealed wound physician documentation dated November 2, 2023, noting Resident 110's pressure wound of the right heel measured 0.6 cm by 1.0 cm. There was no further documentation…

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

Based on review of select facility policies and procedures, clinical record review, and staff interview, it was determined that the facility failed to assess and evaluate interventions to prevent fall reoccurrence for one of nine residents reviewed for falls (Resident 82). Findings include: The facility policy entitled, Resident Accidents and Injuries, last reviewed without changes on July 21, 2023, revealed a purpose to ensure all incidents involving a resident are reported, documented, and an investigation initiated after the incident is identified. An incident is defined in the policy as .any happening that is not consistent with the routine operation of the facility or the routine care of a particular resident. It may be an accident or a situation that could result in an accident. Clinical documentation for Resident 82 dated November 2, 2023, at 2:35 PM revealed a BIMS (Brief Interview for Mental Status) assessment was completed on October 23, 2023, that indicated the resident scored a score of six out of 15 and was not capable. Current care plan review revealed the resident was…

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

Based on clinical record review, observation, and staff interview, it was determined that the facility failed to store supplemental oxygen equipment per professional standards of practice for one of three residents reviewed (Resident 25). Findings include: A review of a current diagnoses list for Resident 25 revealed the resident is dependent on supplemental oxygen. A current physician's order for Resident 25 dated May 10, 2023, instructed staff to administer oxygen via nasal cannula (medical tubing with two nasal prongs used to deliver supplemental oxygen into the nose) continuously at two liters per minute. The current care plan for Resident 25 revealed that the resident is at risk for respiratory failure due to the medical history. Observation of Resident 25 on November 14, 2023, at 11:00 AM revealed the resident's electric wheelchair was in the hallway outside of the resident's room. A nasal cannula was draped over the back of the wheelchair. The nasal cannula was not bagged or protected from the ambient environment. Observation of Resident 25 on November 14, 2023, at 1:33 PM…

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 interview and review of facility documentation, it was determined that the facility failed to ensure that nurse aides received an annual performance review for three of three nurse aides reviewed (Employees 3, 4 and 5). Findings Include: During a meeting with the Nursing Home Administrator and Director of Nursing on November 15, 2023, at 3:00 PM the surveyor asked for annual performance reviews for Employees 3, 4, and 5. The Director of Nursing confirmed that the employees have been employed for at least a year. Interview with the Nursing Home Administrator on November 17, 2023, at 11:15 AM confirmed there was no documented evidence that annual performance reviews were completed for the above employees. 28 Pa. Code 201.19 (2) Personnel policies and procedures

Based on observations, clinical record review, and staff and family interview, it was determined that the facility failed to ensure proper medication storage and labeling for two of two residents reviewed (Residents 40 and 113). Findings include: Observation of a medication administration pass on November 16, 2023, at 8:35 AM revealed Employee 12, Licensed Practical Nurse, administered Vitamin D 50 micrograms (mcg) one tablet to Resident 113. Clinical record review for Resident 113 revealed his current order was for Vitamin D 25 mcg, not 50 mcg. Interview with Employee 12 on November 16, 2023, at 10:09 AM confirmed that Resident 113 should have only received 25 mcg of Vitamin D. She indicated that she did give 50 mcg because the lids on the stock bottles of Vitamin D, the 25 mcg and the 50 mcg, got switched. Observation of both bottles of Vitamin D, at this time, revealed that the bottle of Vitamin D 25 mcg had 1000 written with black marker on the lid of the bottle and the Vitamin D 50 mcg had 2000 written on the lid in black marker. Employee 12 confirmed that staff labeled 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 observation and resident and staff interview, it was determined that the facility failed to arrange for timely podiatry (foot doctor) services for three of four residents reviewed for podiatry services (Residents 35, 63, and 107). Findings include: Observation of Resident 35 on November 15, 2023, at 8:59 AM revealed he was lying in bed. His toenails were of unequal length, discolored, and a nail on the right foot was long. Review of a podiatry consultation for Resident 35 dated August 11, 2023, revealed that the resident has onychomycosis (thickened and discolored nails from a fungal infection, trimming nails is often a treatment). His toenails were trimmed and debrided (removal of diseased toenail bed). The resident was to have a podiatry follow up in nine weeks. There was no documented evidence that another podiatry consultation was completed on or after October 13, 2023 (nine weeks). Observation and interview with Resident 63 on November 15, 2023, at 2:10 PM revealed that his toenails were very long over the edges of his toes. Review of a podiatry consultation for…

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

Based on clinical record review and staff interview, it was determined that the facility failed to ensure an integrated care plan that included services provided by Hospice and those provided by the facility for two of two residents reviewed for Hospice concerns (Residents 9 and 30). Findings include: Clinical record review for Resident 9 revealed the facility admitted her to hospice services on October 16, 2023. During an interview with the Nursing Home Administrator and Director of Nursing on November 15, 2023, at 3:00 PM the surveyor was informed that Hospice documentation was located in binders at the nursing stations. During an interview with Employee 13, licensed practical nurse, and Employee 15, nurse aide, on November 16, 2023, at 12:03 PM it was revealed that they never know in advance when Hospice staff visits and provides care for Resident 9 and that the resident could have been washed by facility staff for the day and then the Hospice aide comes in and does it again. Review of the Hospice binder for Resident 9 revealed a calendar in the front of the notebook that 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 employee education records and staff interview, it was determined that the facility failed to ensure that nurse aides received 12 hours of in-service training annually for three of three nurse aides reviewed (Employees 3, 4, and 5). Findings include: During a meeting with the Nursing Home Administrator and Director of Nursing on November 15, 2023, at 3:00 PM the surveyor asked for training records to indicate that nurse aides had received at least 12 hours of in-service training in the last year for Employees 3, 4, and 5. Interview with the Nursing Home Administrator on November 17, 2023, at 11:15 AM confirmed there was no documented evidence that the above employees received the required 12 hours of annual in-service training. 28 Pa. Code 201.20(a)(1-6)(d) Staff development

Based on observation and staff interview, it was determined that the facility failed to accommodate resident needs regarding the accessibility to a call bell for one of 10 residents reviewed (Resident 1). Findings include: Observation on August 8, 2023, at 2:25 PM revealed Resident 1 was sitting in the middle of her room in her wheelchair. The call bell cord was draped across the bed in the opposite direction of Resident 1, with the call bell button facing the window. The call bell was out of Resident 1's reach. Interview with the Director of Nursing on August 8, 2023, at 2:27 PM confirmed the above observation. The Director of Nursing repositioned the call bell in Resident 1's reach and asked her to demonstrate how to use the call bell. Resident 1 was able to grasp the call bell and push the red button, which activated her call light. 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of select facility policies and procedures, review of clinical records, and staff interview, it was determined that the facility failed to implement an abuse prohibition policy pertaining to investigation of potential neglect for one of 10 residents reviewed (Resident 2). Findings include: The policy entitled Freedom from Abuse, Neglect and Exploitation, last reviewed on June 23, 2023, indicates that the facility will conduct a thorough investigation of an allegation. The policy defines neglect as failure to provide goods or services that is required for a resident. Review of Resident 2's clinical record revealed a Minimum Data Set Assessment (MDS, an assessment completed at specific intervals to determine care needs) dated April 25, 2023, indicated that the facility assessed Resident 2 as needing the extensive assistance of two caregivers for transferring. Nursing documentation dated May 9, 2023, at 2:18 PM indicated that Resident 2 is using a stand up lift for transfers. Nursing documentation dated May 12, 2023, at 11:37 AM indicated that nursing staff was heard…

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

Based on observation, clinical record review, review of select facility policies and procedures, and staff interview, it was determined that the facility failed to provide treatment and services, consistent with professional standards of practice, regarding skin assessments, interventions, and treatments for two of 10 residents reviewed (Residents 1 and 2). Findings include: The policy entitled Pressure Injury Prevention Guidelines, last reviewed on June 23, 2023, indicates that the facility will implement evidence-based interventions for residents who are assessed at being at risk of developing pressure sores. Interventions will be documented in the care plan. Review of Resident 1's clinical record revealed that the facility admitted her on June 26, 2023. Nursing documentation dated June 26, 2023, indicated that nursing staff assessed her bilateral heels as being boggy, possibly indicating pressure damage. There was no documented evidence to indicate the facility implemented an intervention to address Resident 1's boggy heels. A Minimum Data Set Assessment (MDS, an assessment…

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

Based on clinical record review and staff interview, it was determined the facility failed to obtain lab services as ordered by the physician for one of 10 residents reviewed (Resident 1). Findings include: Nursing documentation dated July 8, 2023, at 5:47 PM indicated that Resident 1's responsible party wanted Resident 1's urine tested for an infection. The facility contacted Resident 1's physician and obtained an order for a urine culture and for Resident 1 to start an antibiotic while the culture was pending. Review of Resident 1's urine culture dated July 10, 2023, indicated that the lab noted Resident 1's urine was growing multiple organisms and that the culture was most likely contaminated. The laboratory recommended the facility obtain another urine sample from Resident 1 for testing. Resident 1's culture results dated July 10, 2023, had writing on it indicating urine to be collected for culture only today dated July 10, 2023. There was no signature as to who wrote it. A physician's order was obtained and entered into Resident 1's clinical record on July 10, 2023, for nursing…

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