West Chester Rehabilitation And Healthcare Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical record review, and staff interviews, it was determined that the facility failed to follow physician's order regarding pre dialysis and post dialysis weight monitoring and to maintain ongoing communication with the dialysis center for four of four residents receiving dialysis (Residents 18, 98,161, and Resident 369). Findings include: Review of Resident 18's diagnosis list includes End Stage Renal Disease (ESRD), and dependence on Hemodialysis (process of purifying the blood of a person whose kidneys are not working normally) Review of Resident 18's physician's order dated April 4, 2024, revealed an order for pre and post-dialysis weights, ensured recorded in the communication binder for dialysis did Review of Resident 18's dialysis binder revealed no information on the pre and post-dialysis weights on the following dates: April 10, 15, and April 17, 2024. Review of Resident 98's diagnosis list includes ESRD and dependence on Hemodialysis. Review of Resident 98'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 a review of their job descriptions it was determined that the Nursing Home Administrator (NHA) and the Director of Nursing (DON) did not effectively manage the facility to ensure that Cardio Pulmonary Resuscitation was provided in accordance with the facility policy and procedures to residents that are a full code. Findings include: Review of the job description for the NHA revealed the essential function is responsible for planning and is accountable for all activities and departments of the Center subject to rules and regulations (put into affect) by government agencies to ensure proper healthcare services to residents. Review of the job description for the DON revealed the responsibility of the job position is overall accountability for providing leadership, direction and administration of day-to-day operations associated with direct patient care activities, nursing practice, clinical education and development, including continuing improvement in nursing services and to staff to meet patient/residents and their families' needs and expectations. The findings in this…

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

Based on clinical records review and staff interview, it was determined that the facility failed to notify the physician of the significant weight change of two of the 32 residents reviewed (Resident 18 and 161). Findings include: Review of Resident 18's diagnosis list includes End Stage Renal Disease (ESRD- Where kidney function has declined to the point that the kidneys can no longer function on their own), and dependence on Hemodialysis (A process of purifying the blood of a person whose kidneys are not working normally). Review of Resident 18's weights and vitals dated April 2, 2024, revealed a weight of 182 pounds, and April 7, 2024, revealed a weight of 205.8, a 13.8% significant weight gain in five days. A re-weight was done on April 16, 2024, which revealed a weight of 205 pounds. Review of Resident 18's clinical record failed to reveal that the physician was notified of Resident 18's significant weight change. Review of Resident 161's diagnosis list includes ESRD and Dependence on Hemodialysis. Review of Resident 161's weights and vitals dated March 1, 2024, revealed a…

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Based on clinical records review, facility documentation review, and staff interview, it was determined that the facility failed to comprehensively investigate an injury of unknown origin for one of the 32 residents reviewed (Resident 37). Findings include: Review of Resident 37's diagnosis list includes Dementia (term used to describe a group of symptoms affecting memory, thinking, and social abilities severely enough to interfere with daily life), Cancer of the Larynx, Acute Respiratory Failure, and generalized muscle weakness. Review of the Significant Change Minimum Data Set (MDS- standardized assessment tool that measures health status in long-term care residents) dated June 30, 2023, revealed that the resident had a severe cognitive impairment and required extensive with one-person assistance with bed mobility and transfers. Review of the physician notes dated July 28, 2023, revealed worsening bilateral hip pain despite conservative measures with pain medications, an X-ray was ordered. Review of the nursing progress notes dated July 29, 2023, at 4:15 a.m., revealed a call was…

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Based on clinical record review and interview with staff, it was determined that the facility failed to notify the State Long-Term Care (LTC) Ombudsman's office of residents transferred or discharged for one of six residents reviewed (Residents 369). Findings include: Review of Resident 369's clinical record revealed a nursing progress note dated March 21, 2024, revealed that the resident had a new order to be sent to the hospital due to being unresponsive. Further review of Resident 369's clinical record failed to reveal documented evidence of the State Ombudsman's office notified of Resident 369's transfers from the facility to the hospital. Interview with the Nursing Home Administrator (NHA) on April 29, 2024, at 10:40 a.m. confirmed that the facility did not notify the State Ombudsman's office when Resident 369 was transferred to the Hospital. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(a) Management 28 Pa. Code 201.18(b)(3) Management 28 Pa. Code 201.29(a) Resident rights

Based on clinical records review and staff interview, it was determined that the facility failed to develop a comprehensive care plan for one of 32 residents reviewed (Resident 95) Findings include: Review of Resident 95's diagnosis list includes Dementia (term used to describe a group of symptoms affecting memory, thinking and social abilities severely enough to interfere with daily life), Bpolar Disorder (condition associated with episodes of mood swings ranging from depressive lows to manic highs), and Anxiety disorder. Review of Resident 95's Quarterly Minimum Data Set (MDS- standardized assessment tool that measures health status in long-term care residents) dated February 22, 2024, revealed that the resident had a severe cognitive impairment. Review of the Psychiatry notes dated January 10, 2024, revealed resident was previously on another facility with history of at least four prior psychiatry hospitalizations and previous attempts of hurting self. Resident on medication management. Review of Resident 95's care plan revealed no plan of care developed for resident's behavior…

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 records review and staff interview, it was determined that the facility failed to ensure wound treatment was consistently completed and wound recommendation from a wound consultant was followed for a surgical wound for one of 32 residents reviewed. Finding include: Review of the Nurse Practitioner's (NP) progress notes dated March 11, 2024, revealed Resident 18 was re-admitted to the facility on [DATE], with a surgical wound post incision and drainage of a hematoma (pool of mostly clotted blood that forms in an organ, tissue, or body space) to the left lateral leg. A wound treatment order to cleanse the wound with cleanser, apply Collagen to the base of the wound then cover with dressing daily and as needed was ordered. Review of Resident 18's April 2024, Treatment Administration Record revealed that wound treatment to Resident 18's left lateral surgical wound was not done on April 7, 14, 16, 20, and 21, 2024. Review of the wound NP's notes dated April 18, 2024, revealed Resident 18's surgical…

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, it was determined that the facility failed to ensure one of 32 residents reviewed was free of unnecessary psychotropic medication (Resident 42). Findings include: Review of Resident 42's clinical record revealed a physician's order dated November 7, 2023, for trazodone (antidepressant medication) 50 milligrams (mg) 1 tablet by mouth at bedtime. Review of Resident 42's Consultant Pharmacist Report dated November 8, 2023, revealed the pharmacist questioned if the resident's trazodone was still needed, with the physician responding Defer to psych. Review of Resident 42's psychiatrist note from January 24, 2024, revealed that the resident is currently on 3 antidepressants. Trazodone previously ineffective. Recommend taper off trazodone by reducing the dose to 25mg 1 tablet by mouth at bedtime. Review of Resident 42's January, February, and March 2024 Medication Administration Records revealed the resident continued to receive Trazodone 50 mg until March 28, 2024. Review of Resident 42's progress notes revealed a nurse's note dated February 10, 2024,…

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, clinical record review, and staff interview, it was determined that the facility failed to obtain and monitor weights for two of three residents reviewed for nutrition (Residents 3 and 4). Findings include: Review of facility policy Weight Policy revised December 2022 revealed that each resident will be weighed monthly. Any resident displaying a significant change in weight of greater than or equal to 5%, gain/loss in one month will be reported to the Registered Dietitian and reweighed. The Registered Dietitian will review the medical record of residents with significant weight changes (i.e. 5% loss/gain in one month, 7.5% loss/gain in 3 months, 10% loss/gain in 6 months). Dietary interventions will be recommended as needed. Review of Resident 3's clinical record revealed a weight of 227.3 pounds on December 29, 2023 and 227.3 pounds on January 10, 2024. Weight obtained on February 27, 2024, was 192.6 pounds (loss of 34.7 pounds or 15.3% in one month) with no reweigh obtained. Review of the weights and vitals summary revealed a weight of 188.4 pounds on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based review of the facility's policy, clinical records review, and staff interviews, it was determined that the facility failed to accurately assess a sacral wound, inform the physician regarding the wound condition, and accurately assess weekly skin wounds resulting in an advanced wound stage with undermining for one of two residents reviewed (Resident R1). Findings include: Review of the facility's policy titled Pressure Ulcers/Skin Breakdown - Clinical Protocol, revised in April 2018, revealed that the nurse shall describe and document a full assessment of pressure sore including location, stage, length, width, and depth, presence of exudates or necrotic tissue. Review of Resident R1's clinical records revealed resident was admitted to the facility on [DATE], with a diagnosis of Parkinson's Disease (disorder of the central nervous system that affects movement, often including tremors). Resident R1's admission skin assessment dated [DATE], revealed resident skin was intact. Review of Resident R1's Braden…

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, pharmacy record review, and staff and resident interview it was determined the facility failed to ensure medications were available for resident for one of the two residents reviewed (Resident CL1). Findings include: Review of Resident CL1's physician order dated January 26, 2024, revealed an order for Gabapentin Oral Capsule 300mg Give 300mg orally at bedtime for neuropathy (numbness and pain from nerve damage, usually in the hands and feet). Review of the January 2024 Medication Administration Record (MAR) revealed Gabapentin was not administered to the resident until January 31, 2024, four days after the medication was ordered by the physician. The resident missed four doses of the Gabapentin 300mg medication. Review of the pharmacy records revealed the medication was not delivered by the pharmacy until January 31, 2024. Interview conducted with the Director of Nursing on February 28, 2024, confirmed that Resident CL1 was not administered with Gabapentin due to medication not being available from the pharmacy. The facility failed to ensure…

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, it was determined that the facility failed to ensure the call bell alerts were answered in a timely manner on one of two floors. (First Floor) Findings include: Observation conducted on January 17, 2024, at approximately 12:15 p.m., of the call bell alert unit at the first-floor nursing station, responsible for monitoring room [ROOM NUMBER], revealed that the room's call bell was on for 17 minutes. Continued observation on January 17, 2023, from 12:15 p.m. through 1:00 p.m. revealed the call bell alert system continued to be activated for room [ROOM NUMBER]. Interview conducted on January 17, 2024, at approximately 1 p.m., with Resident R2, revealed that he/she pushed the call bell for staff assistance. R2 confirmed the call bell remained activated at time of the interview. R2 could not confirm the exact time call bell was initiated but stated it had been a while. R2 stated his/her bed was broken and was the reason he/she pushed the call bell for assistance. R2 stated that he/she informed…

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

Based on clinical record reviews and resident and staff interviews, it was determined that the facility failed to implement the comprehensive care plan interventions to prevent pressure ulcer healing and discomfort for one of three resident reviewed (Resident R1). Findings include: Review of R1's records revealed a care plan dated December 24, 2023, documenting the resident has a pressure ulcer or has potential for pressure ulcer development related to disease process, immobility, sacral wound. Interventions documented the need for staff to elevate/offload heels when in bed as tolerated using pillows, bootie, heel protectors or heel cushions. Observation of R1 on January 17, 2024, at 12:30 p.m., revealed the resident lying in bed with resident's heels contacting a pillow. Observations also revealed resident wearing socks, with no heel booties, heel protectors or heel cushions. Further observation of resident's room revealed heel booties sitting on air conditioner unit. Interview on January 17, 2024, at 12:35 p.m., with E3 revealed that R1 often refused to wear the heel booties…

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 clinical record review, it was determined that the facility failed to ensure adequate supervision during a transfer for one of four residents reviewed (Resident 1). This was identified as a past noncompliance situation. Findings include: Review of Resident 1's Quarterly Minimum Data Set (MDS - periodic assessment of resident care needs) revealed under Section G - Functional Status, that the resident was totally dependent on two staff persons for transfers. Review of Resident 1's progress notes revealed a nurse's note on August 22, 2023, which stated: resident alert, at 5:50 am, resident said, when [nurse aide Employee E2] put her in her [wheelchair] while still on the Hoyer Lift, [Employee E2] try to pull her Hoyer pad up and the Hoyer tip hit her left neck. Further review of Resident 1's progress notes revealed an x-ray was obtained same day and revealed there were no injuries. Review of phone interview by the Director of Nursing (DON) with Employee E2 on August 24, 2023, revealed Employee E2 confirmed she Hoyer lifted [Resident 1] into…

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, facility policy and procedure review and staff interview it was determined the facility failed to provide proper dialysis services for four of 5 residents reviewed. (Residents 20, 29, 51, and 117) Findings Include: Review of facility policy and procedure titled Hemodialysis Access Care revealed under the section for care of AVFs (Aterio-Venous fistula- device surgically connected to an artery and a vein in a person's arm for dialysis treatment) and AVGs (synthetic or animal derived tubing to connect the artery and vein) to prevent infection and/or clotting check the patency of the site at regular intervals. Palpate the site to feel the thrill or use a stethoscope to hear the bruit of blood flow through the access. An admission Minimum Data Set (MDS) assessment (mandated assessment of a resident's abilities and care needs) for Resident 20, dated May 18, 2023, revealed that Resident 20 had diagnoses that included Kidney Failure requiring Hemodialysis (process of cleaning the blood…

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 and resident interviews it was determined the facility failed to ensure mediations were available for resident for three of 5 residents reviewed (Residents 68, 73, 137). Findings Include: Interview with Resident 68 on June 14, 2023, at 1:25 p.m. revealed that there are times the facility will run out of the resident's Latuda (antipsychotic medication). Review of Resident 68's clinical record revealed a physician's order dated February 10, 2023 for Latuda 80 mg (milligrams) twice daily for schizoaffective disorder (mental health disorder that is marked by a combination of schizophrenia symptoms, such as hallucinations or delusions, and mood disorder symptoms, such as depression or mania). Review of Resident 68's April 2023 Medication Administration Record (MAR) revealed the resident did not receive Latuda 80 mg from April 1, 2023 through April 3, 2023, with nursing coding the medication as not being given due to awaiting delivery from the pharmacy. Review of Resident 68's progress notes revealed a nurse's note on April 3, 2023 which stated,…

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 resident council interview and staff interviews, it was determined that the facility failed to ensure a nourishing snack is provided when 14 hours are between a substantial evening meal and breakfast the following day. Findings include: Reveal of the facility meal times revealed that dinner is served at 4:45 p.m. in the 2 central dining room. The breakfast meal is offered at 7:55 a.m. to those same residents. This is 15 hours and 10 minutes from one meal to the next. An interview conducted during the resident council interview on June 14, 2023, at 11:00 a.m. revealed that were not offered snacks at bed time. An interview with the Nursing Home Administrator was conducted on June 16, 2023 at approximately 1:00 p.m. confirmed that the residents were not being offered a snack at bedtime and confirmed if the residents are eating at 4:45 p.m. there is more than 14 hours before the 7:55 a.m. meal. The facility failed to serve a nourishing snack at bedtime with meals being spaced more than 14 hours apart. 28 Pa. Code: 201.14(a) Responsibility of license

Based on facility policy and procedure review, observation, and resident and staff interviews it was determined the facility failed to ensure the privacy of resident's mail for one of one resident reviewed and residents during a group interview. (Resident 73) Findings Include: Review of Facility Policy and Procedure titled Mail and Electronic Communication, undated; revealed mail will be delivered to residents unopened. Staff members of this facility will not open mail for the resident unless the resident request them to do so. Observation on June 14, 2023 at 11:03 a.m. revealed Certified Nursing Employee E4 handing a package to Resident 73 that was opened. Interview with Resident 73 at the time of the observation revealed this was the first he/she was seeing the package and had not asked staff to open it. Further interview revealed he/she had received other packages in the past that had been opened before they were given to resident. Interview with Employee E13 on June 16, 2023 at 9:45 a.m. confirmed she had been holding the package at the front desk because the first name on the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of clinical records and staff interview, it was determined that the facility failed to develop a care plan for ascites for one out of 33 residents (Resident 69). Findings include: Review of Resident 69's clinical record revealed that they were admitted to the facility on [DATE], with the diagnosis of ascites (abnormal build-up of fluid in the abdomen). Further review of the clinical record revealed that the careplan did not address the diagnosis. An interview with the Nursing Home Administrator on June 14, 2023, at 11:50 a.m. revealed that the resident did not have a care plan for ascites. 28 Pa Code 211.10(d) Resident care policies 28 Pa Code 211.11(d) Resident care plan 28 Pa. Code 211.12(c) Nursing services

Based on clinical record review and staff and resident interview it was determined the facility failed to provide ADL care for a resident unable to complete on their own for one of 32 resident reviewed (Resident 73). Findings Include: Interview with Resident 73 on June 14, 2023 at 11:00 a.m. revealed they had not received a shower in three weeks time. Review of Resident 73's Quarterly Minimum Data Set (MDS-periodic assessment of resident needs), dated April 20, 2023 revealed the resident only needed supervision while bathing. Review of Resident 73's physician orders revealed an order dated March 9, 2021 for every Tuesday, Thursday, and Saturday please make sure CNA (certified Nursing Assistant) takes the resident to the shower room. Review of Resident 73's CNA task documentation from May 17, 2023 until June 15, 2023 revealed the resident had received only one shower during the 30-day period. Interview with the Director of Nursing and Nursing Home Administrator on June 16, 2023 at 10:45 a.m. confirmed Resident 73 did not receive showers as ordered by the physician. 28 Pa. Code 211.5…

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

Based on clinical records review and staff interview, it was determined that the facility failed to ensure treatment and services necessary to monitor bladder functioning were implemented for one of the 33 residents reviewed (Resident 137). Findings include: Review of Resident 137's diagnosis list revealed acute Kidney Failure, and Obstructive Uropathy (disorder of the urinary tract that occurs due to obstructed flow). Review of Resident 137's attending physician progress notes dated May 24, 2023, revealed resident was seen by a Urologist (A medical doctor specializing in conditions that affect the urinary tract), foley catheter (flexible tube that a clinician passes through the urethra and into the bladder to drain urine) was removed. Review of the physician order dated May 24, 2023, revealed an order for a bladder scan every six hours if greater than 350 ccs, and a straight catheter for the resident every six hours for urinary retention. Review of Resident 137's May 2023, Treatment Administration Record (TAR) revealed that the bladder scan procedure to determine urinary retention…

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 and procedure review, clinical record review and staff interview it was determined the facility failed to monitor the nutritional status for 2 of five residents reviewed, (Residents 18 and 29) Findings Include: Review of facility policy and procedure titled Weight Assessment and Interventions revealed Residents are weighed upon admission and at intervals established by the interdisciplinary team and/or as ordered by the physician. The threshold for significant unplanned and undesired weight loss will be based on the following criteria. 1 month- 5% weight loss is significant, greater than 5% is severe. 6 months- 10% weight loss is significant; greater than 10% is severe. Review of Resident 18's physician orders revealed an order dated October 25, 2023 for daily weights. Review of Resident 18's weights revealed on December 17, 2023 the resident weighed 155.0 pounds and on June 6, 2023 the resident weighed 137.2 pounds which is an 11.48% loss. Review of Resident 18's Nutritional Risk Assessment, dated June 6, 2023 revealed under the Evaluate and Summary section…

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 interviews, it was determined that the facility failed to provide enteral nutrition (delivery of nutrition by a feeding tube) in accordance with physician's order for one of five residents receiving enteral feeding (Resident 414). Findings include: Clinical record review of Resident 414 revealed the following diagnoses: Parkinson's disease (a progressive disorder that affects the nervous system and the parts of the body controlled by the nerves), Gastro-Esophageal Reflux disease without esophagitis (a disorder where stomach acid repeatedly flows back into the tube connecting your mouth and stomach). During observations conducted on June 13, 2023, approximately 1:15 p.m., Resident 414 was actively receiving nourishment through enteral feeding (tube feed). Review of Resident 414's clinical record revealed the following order in the morning stop feed 0800. restart at 1200 .Glucerna 1.5 64ml/hr x 20 hr or until total nutrient 1280ml is infused. Provides 1920kcal, 105g prot, 2660ml nutrient +flush. AND in the evening start feed 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 observation, clinical record review and staff interview, it was determined the facility failed to provide respiratory care consistent with professional standards of practice, for one of 33 residents reviewed (Resident 20). Findings include: Observation conducted on June 13, 2023, at approximately 10:23 a.m. revealed Resident 20 was receiving oxygen therapy trough via nasal cannula (device that delivers extra oxygen to your nose through soft prongs) Review of Resident 20's clinical record on June 14, 2023, at approximately 9:25 a.m. failed to reveal any active orders for oxygen therapy via nasal cannula. Further review of Resident 20's clinical record revealed a care plan intervention for 2-3 L continuous oxygen via nasal cannula. Interview conducted with LPN E1 on June 14, 2023, at approximately 10:30 a.m. revealed that Resident 20 did not have an active order for oxygen therapy in his clinical records. Interviews conducted with the Director of Nursing (DON) on June 16, 2023, at approximately 12:15 p.m. confirmed that Resident 20 did not have an order for oxygen therapy. 28…

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, and interview, it was determined that the facility failed to provide the necessary psychological services to attain or maintain the highest practicable mental and psychosocial well-being for one of six residents reviewed for mood and behaviors. (Resident 68) Findings include: During interview with Resident 68 on June 14, 2023 at 1:25 p.m., the resident was noted to have a flat affect (lacking emotion). Review of Resident 68's clinical record revealed diagnoses of Schizoaffective Disorder (mental health disorder that is marked by a combination of schizophrenia symptoms, such as hallucinations or delusions, and mood disorder symptoms, such as depression or mania), Bipolar Disorder (mental health condition that causes extreme mood swings that include emotional highs called mania or hypomania and lows such as depression) Anxiety Disorder (excessive, uncontrollable and often irrational worry that can interfere with daily functioning), Major Depressive Disorder (persistent feeling of sadness and loss of interest), and Post-Traumatic Stress…

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 that monthly medication regimen reviews were completed by a licensed pharmacist for one of five residents reviewed for unnecessary medications (Residents 27). Findings include: Clinical records review revealed Resident 27 was receiving multiple medications which include cardiac medication, insulin, anti-anxiety medication, and anti- psychotic medication The facility was requested to provide a medication regimen review report for Resident 27 for the last 12 months. Review of Resident 27's clinical record failed to reveal that a licensed pharmacist conducted a medication regimen review in the months of September and October 2022. Interview with the Director of Nursing on June 6, 2023, at 1:00 p.m., confirmed that Resident 27's medication regimen review was not done on September 2022, and October 2022. The facility failed to ensure monthly medication review was completed by a licensed pharmacist. 28 Pa. Code 211.5(h)Clinical records Previously cited 6/17/22 28 Pa. Code 211.12(d)(5)…

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

Based on clinical record review and staff interview it was determined the facility failed to obtain lab services as ordered by the physician for two of 32 residents reviewed. (Residents 96 and 108) Findings include: Review of Resident 96's progress notes revealed the resident had a fall on April 22, 2023. The provider was notified and ordered a stat (urgent or immediate) UA (urinalysis - analysis of urine by physical, chemical, and microscopical means to test for the presence of disease) C&S (culture and sensitivity - tests for bacteria in the urine and what antibiotics will treat the bacteria). Review of Resident 96's laboratory results from April 24, 2023 revealed the results for the UA were: We were unable to perform the test specified because the specimen was not received. Review of Resident 96's progress notes revealed a nurse's note from April 25, 2023 which stated: resident urine sample noted in refrigerator. improper labeling noted. new sample with correct label placed in refrigerator. [lab] contacted for stat pick up. Review of Resident 96's laboratory results from April…

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.