Perry Health & Rehab Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, review of clinical records, observations and staff interview, it was determined that the facility failed to determine whether it was safe to self-administer medications for two of three residents (Resident R42 and R62).Findings include: Review of the facility policy Resident Self-Administration of Medications dated 3/14/25, indicated residents in the facility who wish to self-administer their medications may do so if the interdisciplinary team has determined that this practice is clinically appropriate. Assessments will include addressing the following and documenting in the care plan: storage of the medication, responsible party for storage of medication, documenting the administration of drugs, and location of where the drugs will be administered. Review of the admission record indicated Resident R42 was admitted to the facility on [DATE]. Review of Resident R42's Minimum Data Set (MDS- a periodic assessment of care needs) dated 10/2/25, indicated the diagnoses of anemia…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, observations, and staff interview, it was determined that the facility failed to accommodate the call bell needs for one of five residents (Resident R91).Findings include: Review of facility policy Resident Rights dated 3/14/25, indicated call light or bell access will be within reach of the resident as one method to communicate needs to staff. Review of the clinical record indicated Resident R91 was admitted to the facility on [DATE]. Review of Resident R91's Minimum Data Set (MDS - a periodic assessment of care needs) dated 8/24/25, indicated diagnoses of high blood pressure, hemiplegia (paralysis on one side of the body), and anemia (too little iron in the blood). Review of Resident R91's care plan, dated 4/24/24, indicated to place touch pad call bell in reach of resident at all times. During an observation on 10/20/25, at 10:57 a.m. Resident R91 was observed laying in their bed. Resident R91's touch pad call bell was observed on the resident's dresser, out of 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 interviews, it was determined that the facility failed to ensure the physician was appropriately notified of missed medication doses for one of five residents reviewed (Resident R1).Findings include: Review of the clinical record indicated Resident R1 was admitted to the facility on [DATE]. Review of Resident R1's Minimum Data Set (MDS - a periodic assessment of care needs) dated 9/10/25, indicated diagnoses of high blood pressure, left knee pain, and difficulty in walking. Review of a physician order dated 9/8/25, indicated to provide Resident R1 with levothyroxine (medication used to treat an underactive thyroid) 100 micrograms, 1 tablet by mouth in the morning every Tuesday, Wednesday, Thursday, Friday, Saturday, and Sunday. Review of Resident R1's September 2025 Medication Administration Record revealed the scheduled medication was not administered on the following dates:- Tuesday 9/9/25-Wednesday 9/10/25 During an interview on 10/23/25, at 2:27 .m. the Assistant…

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 staff interview it was determined that the facility failed to provide in a timely manner, notice of Skilled Nursing Facility Advance Beneficiary Notice (SNF-ABN), Form CMS - 10055 for one of two residents reviewed (Resident R142).Findings include: Review of the clinical documentation indicated Resident R142 was discharged from skilled services on 5/11/25. Review of facility documentation failed to include a SNF-ABN form prior to discharge from skilled services. During an interview on 10/24/25, at 12:32 p.m. Business Office Employee E16 confirmed that the facility failed to provide in a timely manner, SNF-ABN form CMS-10055 for Resident R142. 28 Pa. Code 201.14(a) Responsibility of licensee.

Based on review of facility policy, observation, and staff interview it was determined that the facility failed to maintain the confidentiality of residents' medical information on one of eight medication carts (second floor cart).Findings include: Review of the facility's Health Insurance Portability and Accountability Act (HIPAA) dated 3/14/25, indicated HIPAA requires providers and others to implement security measures to guard the integrity and confidentiality of medical information. During an observation on 10/21/25, at 11:16 a.m. a medication cart by the nurse's station was left unattended with a paper nursing report sheet with identifiable information any passerby could see resident personal and confidential information. During an interview on 10/22/25, at 8:51 a.m. Registered Nurse Employee E5 confirmed the above observation and that the facility failed to maintain the confidentiality of residents' medical information as required. 28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa. Code: 201.29(c.3) Resident Rights.28 Pa. code: 211.5(b) Medical records.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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical records, facility documents, observations, and staff interviews, it was determined that the facility failed to identify the use of bolsters (a long, thick cushion) on a bed as a possible restraint, failed to obtain a physicians order, failed to develop a person-centered plan of care for the use of physical restraints, and failed to provide ongoing re-evaluation of the need for physical restraints for one of two residents reviewed (Residents R15).Findings include: Review of facility policy Restraint- Use and Management dated 3/14/25, indicated physical restraint refers to any manual method or physical or mechanical device, material, or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body. Before a resident is restrained, the facility will determine the presence of a specific medical symptoms that would require the use of restraints, and determine:a. How the use…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to make certain that the necessary resident information was communicated to the receiving health care provider for one of two residents sampled with facility-initiated transfers (Residents R1).Findings include: Review of the clinical record indicated Resident R1 was admitted to the facility on [DATE]. Review of Resident R1's Minimum Data Set (MDS - a periodic assessment of care needs) dated 9/10/25, indicated diagnoses of high blood pressure, left knee pain, and difficulty in walking. Review of the clinical record indicated Resident R1 was transferred to the hospital on 9/10/25. Review of Resident R1's clinical record revealed no documented evidence that the facility had communicated specific information to the receiving health care provider for the residents transferred and expected to return, which included the resident's care plan goals, advanced directive information, specific…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policies, clinical records, and staff interviews, it was determined that the facility failed to develop comprehensive care plans to meet resident care needs for one of five residents (Resident R119).Findings include: Review of facility policy Plan of Care Overview dated 3/14/25, indicated the Plan of Care, also Care Plan is the written treatment provided for a resident that is resident-focused and provides for optimal personalized care. Review of the clinical record indicated Resident R119 was admitted to the facility on [DATE]. Review of Resident R119's Minimum Data Set (MDS - a periodic assessment of care needs) dated 10/7/25, indicated diagnoses of high blood pressure, unsteadiness on feet, and malnutrition (lack of sufficient nutrients in the body). Question B0300 Hearing Aid was coded 1 for yes, hearing aid or other hearing appliance used. Review of a physician order dated 7/1/25, indicated bilateral (both sides) hearing aids. Remove at HS (night) and place in container. Insert…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a resident's interview, clinical record review and review of the facility policy, it was determined that the facility failed to provide assistance with application of a stump shrinker resulting in a resident's inability to attend therapy for ambulation for one of three residents (Resident R46). Findings include: Review of the facility policy Routine Resident Care dated 3/14/25, indicated routine daily care by a certified nursing assistant with specialized training in rehabilitation/restorative care including but not limited to assisting with special devices such as prosthesis (denoting an artificial body part) and eating devices. Providing an environment that contributes to a positive self-image preserves dignity and promotes privacy. Review of the admission record indicated Resident R46 was admitted to the facility on [DATE]. Review of Resident R46's Minimum Data Set (MDS- a periodic assessment of care needs) dated 8/21/25, indicated the diagnoses of anemia (the blood doesn't have enough healthy red…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of facility documentation, resident and staff interview it was determined that the facility failed to provide an on-going program of activities to meet the interests of and support the physical, mental, and psychosocial and well-being of residents for one of seven residents (Resident R128).Findings include: Review of facility documentation Activities Program dated 3/14/25, indicated: It is the policy of this facility to provide resident centered care that meets the psychosocial, physical and emotional needs and concerns of the residents. The activity program is: Designed to encourage restoration to self -care and maintenance of normal activity that is geared to the individual resident's needs. Review of Resident R128 Was admitted on [DATE]. Review of facility documentation dated 4/29/25 indicated: Review of the expert report also indicated diagnosis - anxiety disorder. During an interview on 10/20/25, at 9:45 a.m. Resident R128 indicated that they have no relevant activities to do. Per 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 facility policy, clinical record review, observations, and staff interviews, it was determined that the facility failed to ensure a resident with limited mobility receives appropriate services, equipment, and assistance to maintain or improve mobility for two of four residents (Residents R56 and R57).Findings include: Review of the facility policy Routine Resident Care dated 3/14/25, indicated routine daily care by a certified nursing assistant with specialized training in rehabilitation/restorative care including but not limited to maintaining proper body position and alignment for all residents, encouraging maximum function for each resident, and assisting with special devices such as prosthesis (denoting an artificial body part) and eating devices. Review of the clinical record indicated Resident R56 was admitted to the facility on [DATE]. Review of Resident R56's Minimum Data Set (MDS - a periodic assessment of care needs) dated 7/24/25, indicated diagnoses of high blood pressure, stroke…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy review, clinical record review, and staff interview, it was determined that the facility failed to provide colostomy care and services consistent with professional standards of practice for two of two residents reviewed (Resident R13 and R77).Findings include: Review of facility policy Colostomy Appliance Bag Change dated 3/14/25, indicated that staff should position appropriately sized appliance to fit well around stoma (a surgically created opening in the abdomen that allows waste to exit the body) to prevent leakage. Measure the stoma with a stoma measuring guide. [NAME] the paper backing. Check the opening in the new pouch to ensure that it is large enough to fit the diameter of the stoma. Review of the clinical record revealed that Resident R13 was admitted to the facility on [DATE]. Review of Resident R13's MDS (Minimum Data Set, periodic assessment of resident care needs) dated 9/26/25, indicated diagnoses of high blood pressure, muscle wasting, and colostomy (surgery to divert…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, resident clinical records, and staff interview it was determined the facility failed to provide consistent and complete communication with the dialysis center for two of two residents reviewed (Residents R17 and R65). Findings include: Review of the facility policy Hemodialysis Care and Monitoring dated 3/14/25 indicated the facility will provide a method for on-going communication and collaboration. Review of the clinical record indicated that Resident R17 was admitted to the facility on [DATE]. Review of Resident R17's Minimum Data Set (MDS- a periodic assessment of care needs) dated 10/14/25, indicated with the diagnoses of end stage kidney disease (a condition where the kidney reaches advanced state of loss of function), dependance on renal dialysis and high blood pressure. Review of R17's physician order dated 10/8/25, indicated the resident has dialysis one time a day every Monday, Wednesday, and Friday. Review of Resident R17's Dialysis Communication Records from…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on 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 four residents reviewed (Residents R111 and R119). Findings include: Review of facility policy Dementia Care Resident Rights and Privileges dated 3/14/25, indicated residents with dementia (a group of symptoms that affects memory, thinking and interferes with daily life) and/or dementia-related diagnosis will be treated with the same respect and dignity and afforded the same resident rights regardless of diagnosis, severity of condition or payment source including but not limited to visual privacy for bathing, ADL (activities of daily living) care and toileting. Individual goals will be addressed on the care plan that meet the needs of the resident for quality of life and quality of care including safety and maximize independence and functioning. Review of the Resident Assessment Instrument 3.0…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, facility documentation, clinical record review, resident and staff interview it was determined that the facility failed to provide medically related social services to help a resident reach their highest practicable psych-social needs for addressing the recommendations of a psychologist report for one of two residents (Resident R128).Findings include: Review of facility policy Social Services dated [DATE], indicated: The department, shall as necessary, help and support residents in addressing concrete service needs, including but not limited to: A. Educating residents about state and federal benefits and how to apply. B. Management of trust fund, as necessary. E. Mental Health information and referral services. The social service staff shall document progress pertaining to adjustment, quality of life and general behavioral manifestations. The social service worker shall provide follow up evaluation and intervention as necessary. The social service staff shall be responsible…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, observations, and staff interview, it was determined that the facility failed to properly secure medications on one of eight medication carts (Dover Medication Cart), failed to properly label medications upon opening on one of eight medication carts (Royal Pavilion Back Hall Medication Cart), and failed to properly secure a medication cart while not in use for one of eight medication carts ([NAME] Gardens Medication Cart).Findings include: Review of the facility policy Storage of Medications dated 3/14/25, indicated medications and biologicals are stored safely, securely and properly. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel. or staff members lawfully authorized to administer medications. During an observation on 10/21/25, at 11:16 a.m. the Dover Medication Cart indicated a prefilled injection (Lovenox - a medication used to thin the blood), and two clear nebulizer solution ampules on top of the cart and unattended. Interview…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, resident observations, resident and staff interviews, it was determined that the facility failed to have sufficient nursing staff to provide nursing and related services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for three of five residents (Resident R2, R3, and R4).Findings include: Review of the facility policy Routine Resident Care indicated unlicensed staff provide routine daily care by a nurse aide (NA) under the supervision of a licensed nurse. Routine daily care by a NA includes but is not limited to assisting or provides for personal care: bathing, dressing, eating and hydration, and toileting. During an interview on 9/26/25, at 10:24 a.m. when asked if they felt the facility maintained enough staff to care for resident needs, NA Employee E1 indicated on the second and third floors, there's not enough help. The residents are not getting the care they deserve. Showers? That all depends on how many staff we have, we need…

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, review of clinical records, facility policies and procedures and staff and resident interviews, it was determined that the facility failed to ensure that one of three residents (Resident R1) received the correct medications upon admission to the facility.Findings include: Review of the facility policy Physician Orders dated 3/14/25, indicated medical order transcription can be written, may be entered as an electronic order, and the provider may send a signed and dated fax medical order. The nurse who takes the order will be responsible for executing the order. Review of the facility policy Missed Medication/Medication Error dated 3/14/25, indicated the purpose of the policy is to provide guidance for the process for providing monitoring that all medications are received and administered in a timely manner. In the event the medication is not available from the emergency kit the nurse will notify the physician immediately and receive guidance on how to proceed. Review of the clinical record…

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

Based on review of facility policy, observation, and staff interview, it was determined that the facility failed to maintain a clean, safe, and homelike environment for one of one coffee area (first-floor lobby). Findings Include: Review of the facility policy Resident Rights last reviewed 3/14/25, indicated it is the policy of this facility to provide resident care that meets the psychosocial, physician and emotional needs and concerns of the resident. Safety of residents, visitors and employees is a top priority of care During an observation completed on 7/1/25, at 9:08 a.m. the first-floor lobby coffee area revealed the following: · The ice machine with white substance on catch tray, the counter area under the ice machine had white substance and debris. · The microwave revealed brown splatter debris on inside. · The sinks plastic shield located over faucet with yellow and brown substances. · The area under sink contained a basket, a washcloth and debris to the left corner as well as scattered on the base of cabinet. · The area under the coffee machine revealed white fuzzy…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical records, resident interviews and staff interview it was determined that the facility failed to provide assistance with Activity of Daily Living (ADL) involving consistent shower or baths for two out of seven residents (Closed Record (CR) Resident R1 and Resident R3). Findings include: The facility Routine Resident Care last reviewed 3/14/25, indicated it is the policy of this facility to promote resident centered care by attending to the total medical, nursing, physical, emotional, mental, social and spiritual needs and honor resident lifestyle preferences while in the care of this facility. Providing routine daily care by a nursing assistant with specialized training including but not limited to maintaining a program for skin care. Routine care includes bathing, dressing, eating and toileting. Review of the clinical record indicated CR Resident R1 was admitted to the facility on [DATE]. Review of CR Resident R1's Minimum Data Set (MDS - a periodic assessment of 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility documents, clinical records, and staff interviews, it was determined that the facility failed to fully investigate an incident to eliminate possible neglect for one of two residents (Resident R1). Review of the facility policy Abuse, Neglect and Misappropriation, dated 4/18/24, with a previous review date of 8/21/23, indicated that the facility will provide resident centered care and the intent of the facility is to prevent the abuse, mistreatment or neglect of residents. The accurate and timely identification of any event which would place our residents at risk for potential abuse is the primary concern. Each occurrence of resident incident, bruise, etc., will be identified and reported to the supervisor and investigated immediately. In the event a situation is identified as abuse, neglect, etc., an investigation by the executive leadership will follow. Review of the clinical record revealed Resident R1 was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS -…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, personnel records and staff interview it was determined that the facility failed to complete annual performance evaluations for five out of five nurse aide personnel records Nurse Aide (NA) Employee E26, E27, E30, E31, and E33). Findings include: Review of facility Wexford Employee Handbook dated 10/24/24, indicated section 3.5 Job Description and Performance Evaluations states it's important to understand what is in your job description. It forms the basis for the annual performance evaluation that you will receive from your supervisor. You and your supervisor will meet at least once a year to review your job performance. Review of NA Employee E26's personnel record indicated she was hired to the facility on 7/28/21. Review of NA Employee E27's personnel record indicated she was hired to the facility on 6/21/22. Review of NA Employee E30's personnel record indicated she was hired to the facility on [DATE]. Review of NA Employee E31's personnel record indicated she was hired…

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

Based on a review of facility policies, observations and staff interviews it was determined that the facility failed to properly label and date food products in the Main Kitchen (Main Kitchen) and failed to properly label and date food in one of two nursing unit pantries (Third Floor Unit Pantry) which created the potential for food borne illness. Findings Include: Review of the facility policy Food Storage: Cold Foods last reviewed 10/24/24, and previously reviewed 9/9/23, indicated that all foods will be wrapped or stored in covered containers, labeled, and dated, and arranged in a manner to prevent cross contamination. During an observation and interview in the Main Kitchen walk-in freezer, on 10/27/24, at 9:30 a.m., an open bag of chicken breast was found to be unsealed, unlabeled and undated, and an open package of ravioli was found to be opened, unlabeled, and undated. Assistant Food Service Supervisor Employee E16 confirmed that the facility failed to properly store, label, and date opened food packages to prevent foodborne illness. During an observation on 10/27/24, at 12:30…

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 staff interview it was determined that the facility failed to maintain and implement an effective Quality Assurance and performance improvement program that focuses on outcome by failing to implement a QAPI for 11 previously cited citations. Findings include: Review of Plan of Correction from Full Health Survey ending 10/27/23, indicated the following citations: F550 F565 F585 F600 F677 F684 F686 F689 F693 F760 F880 Facility indicated that the above citations: results of the audits would be forwarded to the facility QAPI committee for further review and recommendation until substantial compliance is maintained. During an interview on 10/31/24, at 2:51 p.m. Nursing Home Administrator confirmed that the facility had multiple repeat deficiencies and failed to maintain and implement an effective QAPI program that focuses on outcome. 28 Pa. Code 201.14(a)Responsibility of licensee. 28. Pa. Code 201.18(a)(b)(3)e(1)(3)(4)Management.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility documentation, observations, resident and staff interviews it was determined that the facility failed to offer residents the opportunity to vote for the May 2024 election and the facility failed to provide a dignified dining experience for one of three Residents (Resident R43). Findings include: Review of the facility policy Resident Rights dated 10/24/24, and previously dated 9/9/23, indicated that residents' care will be provided in a safe and respectful manner. Review of resident council meeting minutes for six months failed to include information of the facility asking the residents about voting. During a resident group on 10/30/24, at 11:40 a.m. residents indicated that they were not offered the ability to vote in this election (November 2024), and in past elections four residents indicated they wanted to vote. During an interview on 10/31/24, at 8:54 a.m. Activity Director Employee E9 confirmed that the facility failed to have documentation showing that all residents in the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policies, observations, resident and staff interviews, it was determined that the facility failed to determine the ability to self-administer medications for three of 10 residents (Residents R17, R50, and R71). Findings include: Review of facility policy Medication Administration dated 10/24/24, indicated a resident-centered, individualized approach to medication administration will be used for administering medications as possible. Safety and avoiding adverse effects are considered a high priority for medication administration and may preclude some preferences. Remain with resident until the medication is swallowed. Do not leave medication at bedside. Review of the clinical record revealed that Resident R17 was admitted to the facility on [DATE]. Review of Resident R17's MDS (Minimum Data Set, periodic assessment of resident care needs) dated 8/28/24, indicated diagnoses of high blood pressure, respiratory failure (when the lungs cannot get enough oxygen), and low back pain. Review…

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

Based on review of facility policy, resident council minutes, group and staff interview it was determined that the facility failed to respond to resident concerns and grievances identified during resident council meeting for six of six months reviewed (May 2024 to October 2024). Findings include: Review of facility policy dated 10/24/24, Resident Grievance indicated: Grievance: an official statement of a complaint over something believed to be wrong or unfair. Review of Resident Council minutes from May 2024 to October 2024 indicated the following concerns: 5/7/24: call bells, 3/11 staff not giving good care, and staff not wearing name tags. 6/4/24: agency aides don't know residents and are rude, want to know staff to resident ratio, why don't wear name tags and introduce themselves, and staff don't wear name tags. 7/2/24: shortage in linens not smelling fresh, not enough oxygen on nursing unit, agency aides not answering call bells. 8/6/24: shortage in linen, vending machine that accepts credit cards, staff not wearing name tags. 9/3/24: vending machine that accepts credit cards,…

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

Based on review of facility policy, observations, and staff interview it was determined that the facility failed to maintain the confidentiality of residents' medical information for three out of six resident rooms (Resident R12, R75, and R83), and one out of four medication carts (100 RP Wing Med cart). Findings include: The facility Health Insurance Portability and Accountability Act (HIPAA) policy dated 10/2424, indicated that the facility requires providers and others to implement security measures to guard the integrity and confidentiality of medical information. During a tour on 10/27/24, at 9:45 a.m. the following was observed: At 9:47 a.m. Resident R12's room was observed with a sign beside his bed which stated Float heels when in bed with use of heel boots and wedge/pillow to maintain heels off bed at all times. At 9:55 a.m. Resident R75's room was observed with a sign above her bed which stated Upright for all oral intake, open all containers, cut food into bite size pieces, put straws in liquids, make sure food is within reach, remove garbage from tray, go in during meal…

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 staff interview, it was determined that the facility failed to make certain that the necessary resident information was communicated to the receiving health care provider for six of six residents with facility-initiated transfers (Residents R20, R36, R41, R42, R48, and R101). Findings include: Review of facility policy Transfer and Discharge Policy dated 9/19/23, last reviewed 10/24/24, indicated information provided to the receiving provider must include a minimum of the following: contact information of the practitioner responsible for the care of the resident, resident representative information including contact information, advance directive information, all special instructions or precautions for ongoing care as appropriate, comprehensive care plan goals, and all other necessary information, including a copy of the residents discharge summary, as applicable, and any other documentation, as applicable, to ensure a safe and effective transition of 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.

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 notify the resident or resident's representative of the facility bed-hold policy (an agreement for the facility to hold a bed for an agreed upon rate during a hospitalization) for six of six resident hospital transfers (Residents R20, R36, R41, R42, R48, and R101). Findings include: Review of facility policy Bed Hold Policy dated 9/19/23, and last reviewed 10/24/24, indicated it is the intent of the facility to obtain the proper authorization to hold a resident bed when the resident returns to the hospital or goes on a leave. The bed hold authorization form may be signed prior to the patient leaving the building, or within 24 hours of the resident leaving the facility or the following business day if the resident leaves on the weekend or a holiday. If applicable according to state law if the bed hold authorization form cannot be signed prior to the resident leaving and needs to be…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of clinical records and observations, as well as staff and resident interviews, it was determined that the facility failed to provide Activity of Daily Living (ADL) assistance for four out of nine sampled residents (Resident R27, R46, R48, and R87). Findings include: The facility Routine resident care policy dated 9/19/23, indicated that routine resident care is not necessarily clinical, but is necessary for quality of life. Provide routine daily care by a certified nursing assistant. Routine care includes but is not limited to the following: bathing, dressing and toileting. Review of Resident R27's admission record indicated he was originally admitted on [DATE], and readmitted on [DATE]. Review of Resident R27's MDS assessment (MDS-Minimum Data Set assessment: periodic assessment of resident care needs) dated 6/18/24, indicated that he had diagnoses that included diabetes (a metabolic disorder impacting organ function related to glucose levels in the human body), peripheral vascular disease…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of the clinical record and staff interviews, it was determined that the facility failed to provide an ongoing program of activities to meet the interests of and support the physical, mental, and psychosocial well-being of each resident for six of six residents (Residents R1 and R112 and Residents R200, R201, R202, and R203). Findings include: Review of facility policy Activities Program dated 9/19/23, and last reviewed 10/24/24, indicated the facility is to provide resident centered care that meets the psychosocial, physical and emotional needs and concerns of the residents. The activity program is designed to encourage restoration to self-care and maintenance of normal activity that is geared to the individual resident's needs. The activity program consists of individual and small and large group activities which are designed to meet the needs and interests of each resident and includes social activities, indoor and outdoor activities, activities away from the facility, religious programs,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to ensure appropriate treatment and services were provided for residents with an indwelling urinary catheter (a tube inserted in the bladder to drain urine) for three of four residents reviewed (Residents R42, R48, and R107). Findings include: Review of facility policy Catheter Care dated 9/19/23, and last reviewed 10/24/24, indicated catheter care at the bedside is performed to promote cleanliness and dignity and is performed by the nursing staff twice daily for residents who have an indwelling catheter. Check that collection bag is not on the floor and is draining properly and secured allowing for no reflux of urine back to the bladder. Review of the clinical record indicated Resident R42 was admitted to the facility on [DATE]. Review of Resident R42's Minimum Data Set (MDS- a periodic assessment of care needs) dated 10/15/24, indicated the diagnosis of anemia (low iron in 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, observation and staff interview, it was determined that the facility failed to make certain that refrigerated medications are stored at proper temperatures for one of four medication rooms (Third Floor Medication Room), failed to store medications properly and securely in medication carts, failed to secure treatment carts on two out of five treatment carts (Second Floor C1-Nursing unit, and D Unit Treatment carts), failed to ensure a medication room was properly locked (Second Floor D Wing Medication Room), failed to properly store medical supplies and biologicals in one of two medication rooms (Second Floor D Wing Medication Room), failed to store treatments for residents properly to prevent cross contamination for three of four medication carts (First floor RP Medication cart and Second Floor D Wing Medication cart, Third floor East medication cart), failed to store all biologicals in a safe, secure manner for one of three residents (Resident R104) failed to label open…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, observations, and staff interviews, it was determined that the facility failed to properly monitor resident's personal refrigerators to ensure that food is properly stored and maintained for four of four residents (Resident R7, R47, R77, and R101) failed to maintain proper infection control practices related to care of indwelling urinary catheters (tube inserted in the bladder to drain urine) for two of three residents reviewed (Residents R48 and R113) and failed to provide a safe and sanitary environment to help prevent the potential for cross contamination for one of two medication rooms (Third Floor Medication Room). Findings include: Review of facility policy Storage of Resident Food dated 10/24/24, indicated it is the policy of the facility to provide resident centered care that meets the psychosocial, physical and emotional needs and concerns of the residents. Residents have the option of bringing food into the facility or have family or friends bring into the facility…

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

Based on review of facility documentation, resident and staff interview it was determined that the facility failed to maintain an effective pest control program for two of three floors ( first and second floors). Findings include: During an interview on 10/30/24, at 9:02 a.m. Resident R73 stated that she/he had a mouse in her room in June of 2024. During an interview on 10/30/24, at 11:00 a.m. County Ombudsman confirmed that during a visist with resident R73 they observed mouse droppings around the room of Resident R73. Review of facility documentation resident concerns, showed residents from 2nd floor having multiple concerns regarding seeing mice. During observations on 10/31/24, at 12:10 p.m. Director of Maintenance Employee E36 showed an outside door that has rusted out on the bottom coroner of the door where they believe the mice are coming in. During an interview on 10/31/24, at 12:20 p.m. Director of Maintenance Employee E36 confirmed that Resident R73 did have a hole in an outside wall and mouse droppings were in the room. Director of Maintenance Employee E36 confirmed 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy, resident representative and staff interview it was determined that the facility failed to provide medical record access for one of four residents (Closed Resident Record R177). Findings include: Review of Resident Rights dated 10/24/24, indicated: Residents have the right to access all resident records, including clinical records (medical records and reports) promptly. The residents legal guardian has the right to look at all of the residents medical records and make important decisions on the residents behalf/ Facility documentation indicated Closed Record Resident R177 was admitted on [DATE]. Facility documentation indicated Closed Record Resident R177 had diagnosis of unspecified dementia, anxiety disorder, and cognitive communication deficient. Which remained current as of the MDS (minimum data set a periodic assessment of basic needs) on 8/13/24. Review of Closed Resident Record R177 progress notes indicated contact with the financial POA for medical decisions on the following…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of facility policy, clinical records, and staff interview it was determined the facility failed to notify the physician of a change of condition for one of eight residents (Resident R173). Findings include: Review of facility policy Notification of Change in Condition, dated 10/24/24, indicated Compliance Guidelines: The center must inform the resident, consult with the residents physician when there is a change requiring notification. Resident R173 was admitted to the facility on [DATE]. Review of Resident R173 admit sheet indicated diagnosis of type II Diabetes Mellitus (chronic disease that occurs when the body doesn't use insulin properly, resulting in high blood sugar levels), and end stage real dependence (permanent condition that occurs when the kidneys are no longer able to function). Review of clinical progress notes dated 10/19/24, indicated Trulicity Subcutaneous Solution Pen-injector ( a type 2 diabetes medication that helps your body release own insulin - given weekly) 0.75MG/0.5ML…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, resident council interview, observations of resident areas and nursing units, and staff interviews it was determined that the facility failed to ensure anonymous grievance forms are readily accessible for resident use on one of three floors (Second floor). Findings include: The facility Resident grievance policy dated 2/20/24, indicated that the facility will maintain a secure box, in an area accessible to residents and visitors, for reporting grievances in writing and anonymously. Multiple boxes may be required in the facility to ensure that all residents are able to exercise their right to file grievances anonymously. During a resident group interview on 10/30/24, at 11:45 a.m the residents stated they do not know where the grievance box is, where the concern forms are or who the grievance officer is. During observations on 10/31/24, at 9:42 a.m. observations of the Second floor D-wing lounge was observed locked. A sign was observed on the outside of the door and it 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility documents, facility policy, clinical records, resident representative interview, and staff interviews, it was determined that the facility failed to provide appropriate goods and services to prevent physical neglect for two of four residents (Resident R87 and R107). Findings include: Review of facility Abuse, Neglect and Misappropriation policy dated 9/9/23 and 10/24/24, indicated it is the policy of the facility to provide resident centered care that meets the psychosocial, physical and emotional needs and concerns of the residents. It is the intent of the facility to prevent abuse, mistreatment, or neglect of residents or the misappropriation of their property, corporal punishment and involuntary seclusion and to provide guidance to direct staff to manage any concerns or allegations of abuse, neglect or misappropriation of their property. Review of the clinical record indicated Resident R87 was admitted to the facility on [DATE]. Review of Resident R87's Minimum Data Set (MDS - a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical record review, reports submitted to the State, and resident and staff interviews, it was determined that the facility failed to report allegations of neglect in the required timeframe one of three residents (Resident R48). Findings include: Review of facility policy Abuse, Neglect and Misappropriation dated 10/24/24, indicated neglect is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. For alleged violations of neglect, exploitation, misappropriation of resident property, or mistreatment that do not result in serious bodily injury, the facility must report the allegation no later than 24 hours. Review of the clinical record indicated Resident R48 was admitted to the facility on [DATE]. Review of Resident R48's MDS dated [DATE], indicated diagnoses of neurogenic bladder (bladder problems due to disease or injury of 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 facility policy, clinical records, and staff interviews, it was determined that the facility failed to notify physicians of increased and decreased Capillary Blood Glucose (CBG) levels as per physician's order for two of three sampled residents (Residents R5 and R88) and failed to document appropriate interventions for a resident with hypoglycemia (low blood glucose) for one of three sampled residents (Resident R5). Findings include: The facility Blood glucose point of care policy dated 9/19/23, indicated that point of care testing for blood glucose levels is a lab test that is performed at the bedside by a nurse. Record results and contact provider per physician orders if out of range. The Centers for Disease Control defines diabetes as: Diabetes Mellitus is a chronic (long-lasting) health condition that affects how your body turns food into energy. Most of the food you eat is broken down into sugar (also called glucose) and released into your bloodstream. When your blood sugar goes up, it…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and resident and staff interviews, it was it was determined that the facility failed to obtain physician orders for negative pressure wound therapy devices (NPWT or wound vac - used to draw out fluid and infection from a wound to help it heal) for one of three residents (Resident R107), and failed to obtain physician treatment orders for an as needed dressing for one of three residents (Resident R64). Findings include: Review of facility policy Skin Care and Wound Management dated 9/19/23, last reviewed 10/24/24, indicated residents admitted with or develop skin integrity issues will receive treatment and as indicated. Review of facility policy Physician Orders dated 9/19/23, last reviewed 10/24/24, indicated it is the policy of this facility to provide resident centered care that meets the psychosocial, physical and emotional needs and concerns of the resident. Review of the admission record indicated Resident R107 was re-admitted to the facility on [DATE]. Review of Resident R107'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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, resident clinical records, resident and staff interview, it was determined that the facility failed to provide adequate and timely podiatry care for one of three sampled residents (Resident R27). Findings include: The facility Foot care policy dated 9/19/23, indicated that it is the policy to provide resident centered care. Foot care will be provided by nursing personnel for those residents unable to perform the task. Diabetic residents and those with chronic circulatory problems will be treated by licensed professionals Review of Resident R27's admission record indicated he was originally admitted on [DATE], and readmitted on [DATE]. Review of Resident R27's MDS assessment (MDS-Minimum Data Set assessment: periodic assessment of resident care needs) dated 6/18/24, indicated that he had diagnoses that included diabetes (a metabolic disorder impacting organ function related to glucose levels in the human body), peripheral vascular disease (PVD- a narrowing of the blood vessels…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to perform timely and accurate post-fall documentation and failed to ensure that a resident received neurological assessments after an incident involving a fall for one of five residents (Resident R50). Findings include: Review of facility policy Fall Prevention and Management dated 9/19/23, and last reviewed 10/24/24, indicated after a resident fall, staff should complete the Post Fall Assessment. If the resident hit their head or the fall was unwitnessed, complete Neuro Checks per policy. Complete the Fall Follow Up at least twice each day for three days unless the resident's condition is such that it should be continued longer. Review of the clinical record indicated Resident R50 was admitted to the facility on [DATE]. Review of Resident R50's MDS dated [DATE], indicated diagnoses of high blood pressure, anxiety (a feeling of worry, nervousness, or unease), and Alzheimer's Disease (a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, observations, and staff interview, it was determined the facility failed to provide to provide appropriate care and services to residents receiving tube feedings for one of two residents reviewed (Residents R85). Findings Include: A review of the facility policy Medication Administered by Enteral Tube (surgically placed device through an artificial opening in the abdominal wall) dated 10/24/24, indicates this policy addresses guidance for the clinical administration of medications through a G-tube (surgically placed device used to give direct access to the stomach). Equipment needed but no inclusive to 60cc piston syringe, the syringe is dated upon opening and changed daily. Review of the clinical record indicated Resident R85 was admitted to the facility on [DATE]. Review of Resident R85's Minimum Data Set (MDS- a periodic assessment of care needs) dated 10/11/24, indicated the diagnosis of hypertension (high blood pressure), diabetes (high sugar in the blood), and dysphagia…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical records, observations and staff interviews, it was determined that the facility failed to provide appropriate respiratory care and maintain oxygen equipment for two of two residents (Resident R71 and Resident R113). Findings include: The facility Oxygen therapy: using concentrators policy dated 9/19/23, indicated that a concentrator is a medical device used for oxygen supplementation. A physician's order is required for residents on oxygen concentrators. Filters and machines are to be cleaned weekly. Review of the clinical record indicated Resident R71 was admitted to the facility on [DATE]. Review of Resident R71's Minimum Data Set (MDS - a periodic assessment of care needs) dated 8/14/24, indicated diagnoses of high blood pressure, anxiety (a feeling of worry, nervousness, or unease), and unsteadiness on feet. Review of a physician order dated 9/25/23, indicated to change oxygen tubing every week and as needed every Saturday night shift. During an observation on…

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

Based on review of facility policy, observation and staff interview it was determined the facility failed to dispose or reconcile discontinued medication in a timely manner for one of two medication rooms reviewed (Second floor D Wing Medication room). Findings: Review of facility Storage of Medications policy dated 10/24/24, indicated that medications and biologicals are stored safely, securely, and properly, following manufacturer ' s recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel or staff members lawfully authorized to administer medications. This includes medication rooms, carts, and medication supplies are locked when they are not attended. Review of facility Returning Medications to the Pharmacy policy dated 10/24/24, indicated unused medication are returned to the provider pharmacy for credit whenever possible. For each medication returned, the medication is scanned in the Return for Credit application available in the pharmacy ' s customer portal. Once all scanning is complete, 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, facility policy review, and staff interviews, it was determined that the facility failed to ensure Medication Regimen Reviews were completed by the facility after the consultant pharmacist recommendations were made for three out of 12 months (November 2023, March 2024, and April 2024). Findings include: The facility Medication Regimen Review policy last reviewed 9/9/23 and 10/24/24, indicated that monthly medication review will be performed by a licensed pharmacist. The pharmacist will report any irregularities to the attending physician, the facilities medical director and director of nursing, and these reports must be acted upon in a timely manner that meets the needs of the residents. Review of Resident R47's admission record indicated he was admitted to the facility on [DATE]. Review of Resident R47's MDS assessment (Minimum Data Set assessment: MDS -a periodic assessment of resident care needs) dated 8/26/24, indicated his diagnoses included high blood pressure, depression,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy, clinical record review, and staff interview it was determined the facility failed to identify a diagnosed specific condition for treatment for one of three residents receiving psychotropic medication reviewed (Resident R93) Findings Include: Review of facility policy Resident Rights dated 9/19/23, last reviewed 10/24/24, indicated to provide resident centered care that meets the psychosocial, physical and emotional needs and concerns of the resident. Review of the admission record indicated that Resident R93 was admitted to the facility on [DATE]. Review of Resident R93's care plan revised on 8/27/24, indicated resident R93 uses anti-psychotic medication due to behaviors: verbal outburst, violently shoving items or throwing items, tearful. Observe for side effects of anti-psychotic medications. Review of Resident R93's Minimum Data Set (MDS- a periodic assessment of care needs) dated 8/7/24, indicated the diagnoses of hypertension (high blood pressure), viral hepatitis (inflammation of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical record review and staff interview it was determined that the facility failed to make certain that residents are free from significant medication errors for two of eight residents (Resident R73 and R173). Findings include: Review of facility policy Missed Medication/Medication Error dated 10/24/24, indicated the following: Medication error/incident - any physician/provider prescribed medication that is not administered to the resident as prescribed regardless of the category or the reason for not providing the medication. Review of manufactures of guidelines for Trulicity (a type 2 diabetes medication that helps your body release own insulin - given weekly) indicated: Recommendations regarding missed dose - If a dose is missed, instruct patients to administer the dose as soon as possible if there are at least 3 days (72 hours) until the next scheduled dose. Review of the clinical record indicated Resident R73 was admitted to the facility on [DATE]. Review of Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, resident clinical records, and resident and staff interviews, it was determined that the facility failed to provide routine and emergency dental services for one of two residents (Resident R27). Findings include: The facility Dental services policy dated 9/19/23, indicated that the facility will assist the resident in obtaining routine and 24-hour emergency dental services. Review of Resident R27's admission record indicated he was originally admitted on [DATE], and readmitted on [DATE]. Review of Resident R27's MDS assessment (MDS-Minimum Data Set assessment: periodic assessment of resident care needs) dated 6/18/24, indicated that he had diagnoses that included diabetes (a metabolic disorder impacting organ function related to glucose levels in the human body), peripheral vascular disease (PVD- a narrowing of the blood vessels in the legs), hypertensive heart disease (a condition characterized by long term heart conditions and high blood pressure), anxiety disorder (a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy, observation, and staff interviews, it was determined that the facility failed to provide food in a form to meet individuals' needs in one of two residents ordered an NPO (nothing by mouth) diet. Findings include: Review of the facility policy Resident Rights last reviewed 10/24/24, and previously reviewed 9/9/23, indicated that the facility will provide resident centered care that meets the psychosocial, physical and emotional needs and concerns of the residents. Safety of residents, visitors, and employees is a top priority of care. Review of the clinical record revealed that Resident R107 was admitted to the facility on [DATE]. Review of Resident 107's MDS (Minimum Data Set, periodic assessment of resident care needs) dated 10/7/24, indicated diagnoses of high blood pressure, Intracerebral hemorrhage (when a ruptured blood vessel causes bleeding inside the brain), and dysphagia (difficulty swallowing). Section K0520 indicated that Resident 107 received nutrition through a feeding tube…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and staff interview it was determined that the facility failed to maintain essential equipment heating units for three rooms on the second floor (238, 239, and 251). Findings include: During observations on the second floor the following was observed: 10/27/24: 1:01 p.m. rooms [ROOM NUMBERS] heater removed from wall area open to outside. 10/27/24: 1:12 p.m. room [ROOM NUMBER] heater removed from wall area open to outside. During an interview on 10/27/24, at 1:30 p.m. Nursing Home Administrator (NHA) confirmed that the facility failed pulled the heaters from the above rooms for other rooms in the facility,. During an interview on 10/27/24, at 1:30 p.m. NHA confirmed that the facility failed to maintain essential equipment with heating units being removed from 3 resident rooms, for other rooms that heating units weren't working. 28 Pa. Code 207.2 (a)Administrator's responsibility.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, and staff interview, it was determined that the facility failed to maintain a safe, clean and homelike environment in resident public areas. (Front entrance outside walkways). Findings Include: Review of the facility policy Resident Rights dated 4/18/24, indicated - Dignity: a state worthy of honor or respect; includes but not limited to speaking respectfully to resident, providing privacy for care and treatment, providing safe and secure housing, sanitary food and hydration; respecting resident choice and attending to needs in a timely fashion. Review of the admission record indicated Resident R1 was admitted to the facility on [DATE]. Review Resident R1's Minimum Data Set (MDS- a periodic assessment of care needs) dated 9/5/24, indicated the diagnoses of traumatic spinal cord dysfunction (physical damage to the spinal cord which interfere with normal motor, sensory or autonomic function), quadriplegia (a symptom of paralysis that affects all of a person ' s limbs and body from the neck…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, resident clinical records, facility documents, resident and staff interviews, it was determined that the facility failed to report an allegation of physical abuse for one of three sampled residents (Resident R3). Findings include: The facility Abuse, neglect and misappropriation policy dated 4/18/24, indicated that abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental and psychosocial well-being. For alleged violations of abuse or if there is resulting serious bodily injury, the facility must report the allegation immediately, but no later than two hours after the allegation is made. For alleged violations of neglect, exploitation, misappropriation of resident property, or mistreatment that do not result in serious bodily…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical record review, and staff interview it was determined that the facility failed to make certain that residents are free from significant medication errors for two of five residents (Resident R2 and Resident R4). Findings include: Review of facility policy Missed Medication/Medication Error dated 4/18/24, indicated Medication error/incident: any physician/provider prescribed medication that is not administered to the resident as prescribed regardless of the category or the reason for not providing the medication. Review of manufactures guidelines for Pregabalin indicated: Increased seizure frequency or other adverse reactions may occur if Pregabalin is rapidly discontinued. Review of Resident R2's admission record indicated she was admitted on [DATE]. Review of Resident R2's MDS assessment (minimum data set - a periodic assessment of resident care needs) dated 7/27/24, indicated she had diagnoses that included chronic obstructive pulmonary disease (COPD: a disease…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, observations, resident council minutes, resident and staff interview it was determined that the facility failed to maintain a clean and safe, homelike environment in one of two community bathrooms (across from room [ROOM NUMBER]), one of six resident rooms (Resident R1), and failed to have an ample linen supply available for two of six residents (Resident R1 and Resident R2). Findings Include: Review of the facility policy Resident Rights dated 4/18/24, indicated dignity is a state worthy of honor or respect; includes but not limited to speaking respectfully to residents, providing privacy for care and treatment, providing safe and secure housing, sanitary food, and hydration; respecting resident choice and attending to needs in a timely fashion. Observation on 7/23/24, at 9:15 a.m. the community bathroom across from Resident room [ROOM NUMBER] was adorned with an Out of Order sign. Survey Agency (SA) opened the door, that was not locked, and revealed a hole in the ceiling, a…

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

Based on observation and staff interview, it was determined the facility failed to ensure that essential equipment was in operating condition for one resident common area (Second floor D-lobby ) and two out of 11 resident rooms (Resident R1 and Resident R2). Findings include: The facility Failure of HVAC system policy dated 4/18/24, indicated that in the event of failure of part of system, check the unit control panel, electrical problem, air restriction in the cooling tower, and operation of the condenser. During observations on 6/25/24, at 10:42 a.m. the Second floor D-lobby was found with two air conditioner units with ice build up on the top of each one. A white towel was observed under one of the air conditioner units to collect dripping water. During an interview on 6/25/24, at 10:43 a.m. Housekeeper Employee E3 stated: I have been here for one month. These air condition units have been dripping water for a few weeks. During observations on 6/25/24, at 11:38 a.m. Resident R1's air conditioner unit was observed not working when set on cool. During an interview on 6/25/24, at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical record review, reports submitted to the State, and staff interview, it was determined that the facility failed to identify and report an allegation of neglect in the required timeframe for three of three abuse allegations (Resident R1, R2, and R3). Findings include: The facility Pennsylvania Abuse, Neglect, and Misappropriation policy last reviewed 4/18/24, indicated in the event a situation is identified as abuse, neglect, or misappropriation, an investigation by the executive leadership will immediately follow. The Executive Director, Director of Nursing, or designee will report immediately to the appropriate agencies, and document the time and date of that report on the investigation report. Review of Title 42 Code of Federal Regulations (CFR) §483.12(c) states in response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of…

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

Based on review of facility policy, observations, review of grievances, resident and staff interviews it was determined that the facility failed to have sufficient nursing staff to provide nursing and related services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of seven of 13 residents (Resident R1, R2, R3, R4, R5, R6 and R7). Findings Include: Review of facility's Nurse Aide job description last revised dated June 2019, previously reviewed 4/18/24, indicated the nurse aides provide routine nursing and personal care for residents to assure that the highest degree of quality resident care is maintained at all times. This position must work effectively with team members ensuring that work is accomplished and quality care delivered. Review of the facility's Resident Rights, ICF Policy last reviewed 4/18/24, indicated it is the facility policy to provide resident centered care that meats the psychosocial, physical, and emotional needs and concerns of residents. The purpose of the policy is to guide employees in the general principles of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of facility policy, clinical records, grievance logs, and Concern Forms it was determined that the facility failed to perform a thorough and complete investigation for grievances that were submitted in the facility related to resident care and call bell times for three of three residents (Resident R1, R2, and R3). Findings include: Review of facility policy, Abuse, Neglect and Misappropriation, dated 4/18/24, indicated that the facility will provide resident centered care that meets the psychosocial, physical, and emotional needs and concerns of the residents. Definition of Neglect: the failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid harm, pain, mental anguish, or emotional distress. Review of Resident R1's clinical record indicated the resident was admitted [DATE]. Review of Resident R1's Minimum Data Set (MDS- a periodic assessment of resident care needs) dated 5/11/43, indicated he had diagnoses 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policies, clinical records, facility's grievances, resident and staff interviews, it was determined that the facility failed to provide services to create an environment free from neglect for two of four residents (Resident R1 and Resident R3). Findings include: The facility Abuse prohibition policy last reviewed on 4/18/24, indicated that it is the facility's policy to provide resident centered care that meets the psychosocial, physical, and emotional needs and concerns of residents. It is the intent of the facility to prevent abuse, mistreatment, or neglect of residents, and to provide guidance to direct staff to manage any concerns or allegations of abuse and neglect. Review of Resident R1's clinical record indicated the resident was admitted [DATE]. Review of Resident R1's Minimum Data Set (MDS- a periodic assessment of resident care needs) dated 5/11/43, indicated he had diagnoses that included hypertension (a condition impacting blood circulation through the heart related to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on an abbreviated survey in response to a complaint completed on June 4, 2024, it was determined that Quality Life Services- [NAME] was in compliance with the requirements of 42 CFR Part 483, Subpart B, Requirements for Long-Term Care Facilities and the 28 PA Code, Commonwealth of Pennsylvania Long-Term Care Licensure Regulations. Based on a review of the facility's policies, plans of corrections and the results of the current survey, it was determined that the facility's Quality Assurance Performance Improvement (QAPI) committee failed to correct quality deficiencies and make certain that plans to improve the delivery of care and services effectively addressed recurring deficiencies. Findings include: A review of the facility policy QAPI (Quality Assurance Performance Improvement Plan last reviewed on 4/18/24, indicated it is the facility's policy to provide resident centered care that meets the psychosocial, physical, and emotional needs and concerns of the residents. It was indicated that the facility…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, resident clinical record, investigation documentations, family interview and staff interviews, it was determined that the facility failed to report an allegation of neglect within 24 hours for four out of five residents (Residents R1, R3, and R12) Findings include: The facility Pennsylvania Abuse, Neglect, and Misappropriation policy last reviewed 4/18/24, indicated in the event a situation is identified as abuse, neglect, or misappropriation, an investigation by the executive leadership will immediately follow. The Executive Director, Director of Nursing, or designee will report immediately to the appropriate agencies, and document the time and date of that report on the investigation report. Review of the facility report submitted to the Department of Health on 4/21/24, indicated on 4/18/24, it was discovered Licensed Practical Nurse (LPN) Employee E1 did not chart his morning and early afternoon medications/treatments for (Resident R1 and R3). The facility failed to report…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical records, reports submitted to the state, and staff interviews, it was determined that the facility failed to conduct a thorough investigation to rule out abuse for four of five residents (Residents R1, R3, R12, and R19). Findings include: The facility Pennsylvania Abuse, Neglect, and Misappropriation policy last reviewed 4/18/24, indicated in the event a situation is identified as abuse, neglect, or misappropriation, an investigation by the executive leadership will immediately follow. Statements will be obtained in writing from staff related to the incident, including victim, person reporting incident, accused perpetrator, and witnesses. The executive Director, Director of Nursing, or designee will report immediately to the appropriate agencies, and document the time and date of that report on the investigation report. Review of Resident R1's clinical record indicated she was admitted to the facility on [DATE]. Review of Resident R1's MDS (Minimum Data Set, periodic…

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

Based on facility policy, job descriptions, and staff interviews, it was determined that the facility failed to provide care and services to meet the accepted standards of practice for one of five units (E Wing.) Findings Include: Review of facility's Nurse Aide job description last revised dated June 2019, previously reviewed 4/18/24, indicated the nurse aides provide routine nursing and personal care for residents to assure that the highest degree of quality resident care is maintained at all times. This position must work effectively with team members ensuring that work is accomplished and quality care delivered. Review of the facility's Nurse Shift Change and Walking Rounds policy dated 4/18/24, indicated the nurse will provide reports and changes to on-coming nurse assistants. During an interview on 5/22/24, at 10:36 a.m. Nurse Aide (NA) Employee E3 stated she works daylight, and when she gets to the unit at 7:00 a.m. there are no nurse aides there. NA Employee E3 stated the nurse aides who work overnight are bolting before we even get to the unit and nurse aides on daylight…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy and clinical records, and staff interview, it was determined that the facility failed to make certain medications were administered as ordered by the physician for one of three residents (Resident R12). Findings include: A review of the facility policy Medication Administration dated 4/18/24, indicated to administer medications as prescribed by the provider. It was indicated medications will be administered within the time frame of one hour before up to one hour after time ordered. Review of Resident R12's clinical record indicated she was admitted to the facility on [DATE]. Review of Resident R12's Minimum Data Set (MDS - periodic assessment of resident care needs) dated 4/12/24, indicated diagnosis of osteoarthritis (degeneration of the joint causing pain and stiffness), diabetes (a disease that occurs when your blood glucose, also called blood sugar, is too high), and high blood pressure. Review of a physician order dated 1/19/23, indicated to give 10 units of Humalog…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical records, and staff interview it was determined that the facility failed to notify family of a change in condition of a resident for one of three residents (Resident R1). Findings include: Review of the Notification of Change in Condition policy dated 10/17/23, indicated the facility must inform the resident's authorized family member when there is a change in condition requiring such notification. Circumstances requiring such notification include but not limited to a significant change in the resident's physical, mental or psychosocial condition such a deterioration of health, life threatening conditions, or circumstances that require a need to alter treatment. Review of the clinical record indicated that Resident R1's was admitted to the facility on [DATE]. Review of Resident R1's Minimum Data Set (MDS - a periodic assessment of care needs) dated 1/25/23, indicated diagnoses constipation, depression, and high blood pressure. Section C-Cognitive Patterns indicated the…

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

Based on review of facility policy, resident observations, clinical record review and staff interviews, it was determined that the facility failed to develop a plan of care to include a focus and interventions to maintain a resident's highest practicable physical well-being as required for two of three residents. (Resident R1 and Resident R44) Findings include: Review of the facility Plan of Care Plan Overview policy dated 10/17/23, indicated care plan documents are resident specific and resident focused. It was indicated nurses are expected to participate in the resident plan of care for reviewing and revising the care plan of residents they provide care for as the resident condition warrants. Review of Resident R1's clinical record indicated an admission date of 9/3/23, with diagnoses of constipation, depression, and high blood pressure. Resident R1's Minimum Data Set (MDS-periodic assessment of care needs) dated 1/25/24, indicated the diagnosis were current. Review of Resident R1's physician order indicated to administered two tablets of 5mg Bisacodyl (a laxative used to treat…

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

Based on review of clinical records, facility policy, and staff interview, it was determined that the facility failed to obtain physician admission orders for one of three residents (Resident R2). Findings include: Review of the facility policy Resident Rights dated 10/17/23, indicate to provide resident centered care that meets the psychosocial, physical, and emotional needs and concerns of the residents. Review of Resident R2's clinical record indicates a readmission to facility on 2/2/24, with the diagnosis of fracture of first lumbar vertebra (backbone), chronic obstructive pulmonary disease (makes it hard to breath), asthma (respiratory condition that causes difficulty in breathing). Review of clinical records indicate Resident R2 readmitted to facility 2/2/24, 3:11 p.m. Review of physician orders 2/3/24, 7:00 a.m. indicate orders for oxygen at 2 liters per minute via nasal canula every shift. Interview 2/15/23, 3:34 p.m. Regional Clinical Director of Operations. Employee E1 confirmed the facility failed to obtain physician orders upon readmission to facility for one of three…

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

Based on review of clinical records, facility policy, and staff interview, it was determined that the facility failed to obtain physician admission orders for one of three residents (Resident R). Review of the facility policy Resident Rights dated 10/17/23, indicate to provide resident centered care that meets the psychosocial, physical, and emotional needs and concerns of the residents. Review of the facility policy Enteral General Nutrition (tube feeding) guidelines indicate to verify physician orders for type of enteral formula, amount, frequency, flush volume, and method of delivery. Review of Resident R1 clinical records indicated readmission to facility on 1/23/2024, with the diagnosis of osteomyelitis (infection of bone), pressure ulcer of sacral area (bone at bottom of spine) stage four (deep wound that may impact muscle, tendon, ligaments, and bone) gastrostomy status (surgical procedure that creates an artificial external opening into the stomach for nutritional support). Review of hospital discharge summary of care indicated Gastrostomy Tube (G-tube) placed on January…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of facility policy, clinical records and staff interviews it was determined that the facility failed to ensure that a resident's drug regimen was free of unnecessary medication and medication was provided as per order for one of three closed records (Closed Resident Record CR1) Findings include: The facility Medication administration policy last reviewed 10/17/23, indicated to administer medication only as prescribed by the provider, observed the five rights in giving each medication (right resident, right time, right medicine, right dosage, and right route). Review of Closed Resident Record CR1's admission record indicated she was admitted on [DATE], with diagnoses that included diabetes (metabolic disorder impacting organ function related to glucose levels in the human body), hypertension (high pressure in arteries impacting blood flow), asthma, and paroxysmal atrial fibrillation (irregular heart rhythm that may lead to stroke or dizziness). Review of Closed Resident Record CR1's MDS…

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

Based on a review of facility policies, observations and staff interviews it was determined that the facility failed to properly label and date food products, properly restrain hair and perform hand washing and verify the sanitizing temperature of the dish machine in the Main Kitchen (Main Kitchen), which created the potential for food borne illness. Findings Include: Review of the facility policy Cold Foods last reviewed 10/17/23, indicated that all foods will be stored wrapped or in covered containers, labeled and dated, and arranged in a manner to prevent cross contamination. Review of the facility policy Staff Attire, last reviewed 10/17/23, indicated that all staff members will have their hair off the shoulders, confined in a hair net or cap, and facial hair properly restrained. Review of the facility policy Ware Washing, last reviewed 10/17/23, indicated that all dish machine water temperatures will be maintained in accordance with manufacturer recommendations. During an observation in the Main Kitchen walk-in refrigerator, on 10/23/23, at 9:55 a.m., a metal bin that contained…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, observations and staff interviews it was determined that the facility failed to provide a clean, safe, comfortable, and homelike environment for one of five resident rooms (Resident R81). Findings include: Review of The Resident's [NAME] of Rights, indicated the resident has the right to a safe, clean comfortable and homelike environment, including but not limited to ensuring that the physical layout of the facility maximizes resident independence and is sanitary, orderly and comfortable. Review of admission record indicated Resident R81 was admitted to the facility on [DATE]. Review of Resident R81's Minimum Data Set (MDS - a periodic assessment of care needs) dated 9/13/23, indicated the diagnoses of dementia (a progressive disease that destroys memory and other important mental functions), alcoholism, and anemia (the blood doesn ' t have enough healthy red blood cells). Observation on 10/24/23, at 10:51 a.m. Resident R81's room indicated a large trash can with a dirty brief…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical record review, and staff interviews, it was determined that the facility failed to develop and implement comprehensive care plans to meet care needs for four of twelve residents (Residents R1, R3, R62, and R71). Findings include: Review of facility policy Plan of Care Overview last reviewed 10/17/23, indicated the care plan is the written treatment provided for a resident that is resident-focused and provides for optimal personalized care. It is the policy of this facility to provide resident centered care that meets the psychosocial, physical, and emotional needs and concerns of the residents. Review of the clinical record indicated that Resident R1 was admitted to the facility on [DATE]. Review of Resident R1's Minimum Data Set (MDS - a periodic assessment of care needs) dated 8/17/23, indicated diagnoses of hypertension (high blood pressure), diabetes (too much sugar in the blood), and unsteadiness on feet. Review of a current physician order dated 1/17/20,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy, clinical record review, resident interviews, resident representive interview, and staff interviews, it was determined that the facility failed to make certain that showers and assistance for activities of daily living were consistently provided for two of ten Residents (R7 and R67). Review of the facility policy Routine Resident Care, last reviewed 10/17/23, indicated that routine care by a nursing assistant includes assisting or providing for personal care including bathing. Review of Resident R7's admission record indicated he was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS-periodic assessment of care needs) dated 8/26//23, included diagnoses of paraplegia (paralysis of the legs and lower body), stage four pressure ulcer (pressure injury with full thickness skin loss with extensive destruction; tissue necrosis: or damage to muscle, bone or supporting structure) of the buttocks, and muscle weakness. Section G0120 stated that resident requires physical help…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and resident and staff interviews, it was it was determined that the facility failed to provide sufficient wound care equipment for negative pressure wound therapy devices (NPWT or wound vac - used to draw out fluid and infection from a wound to help it heal) for two of two residents (Resident R121 and R118 ) and failed to follow physician treatment order for one of two residents (Resident R118). Findings include: Review of facility policy Skin Care and Wound Management, dated 10/17/23, indicated residents admitted with or develop skin integrity issues will receive treatment and care as indicated. Review of the admission record indicated Resident R121 was admitted to the facility on [DATE]. Review of Resident R121's Minimum Data Set (MDS - a periodic assessment of resident care needs) dated 10/8/23, indicated diagnoses of diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time), wound infection, and high blood pressure. Review of Resident R121'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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to conduct ongoing accurate assessments to ensure that bedrails were used to meet residents' needs and the risks associated with bedrail usage for five of five residents (Resident R1, R3, R29, R55, and R62). Findings include: Review of facility policy Side Rail Assessment and Consent Policy last reviewed 10/17/23, indicated a side rail assessment will be completed for residents who desire to use side rails as an assistive or transfer device. This assessment is completed on admission, on initial use, and reviewed quarterly. Review of the clinical record indicated that Resident R1 was admitted to the facility on [DATE]. Review of Resident R1's Minimum Data Set (MDS - a periodic assessment of care needs) dated 8/17/23, indicated diagnoses of hypertension (high blood pressure), diabetes (too much sugar in the blood), and unsteadiness on feet. Review of Resident R1's MDS dated…

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

Based on review of facility policy, resident interviews, resident representative interviews. observations, group resident interviews, grievance review, and Resident Council documentation, it was determined that the facility failed to have sufficient nursing staff to provide nursing and related services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of four of six residents (Resident R8, R16, R67, R230). Findings Include: Review of the policy Resident Rights last reviewed 10/17/23, indicated the dignity includes but is not limited to respecting resident choice and attending to needs in a timely fashion. During an interview on 10/23/23, at 9:23 a.m., Resident R230 stated that she had her call bell on one time for two to three hours and no one came. I peed my pants. During an interview on 10/23/23, at 11:59 a.m., Resident R67 stated that one day last week I put the light on at 10:55 (a.m.), and they didn't answer until 12 (noon), and I just wanted water. During an interview on 10/23/23, at 12:51 p.m., Resident R16 stated that during evening…

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

Based on review of facility policies and clinical records, observations and staff interviews, it was determined that the facility failed to maintain a medication error rate of less than five percent for one of three residents (Resident R89). Findings include: The observations listed below revealed nine medication errors out of 25 opportunities resulting in a medication error rate of 36%. Review of facility policy, Medication Administration dated 10/17/23, indicated that insulin (a medication used to treat sugar in the blood) should not be shaken rather rotate gently between palms. Review of facility policy Medication Administered by Enteral Tube dated 10/17/23, indicated: -follow the pharmacy requirements for pharmacological crushing or altering medication, -mixing medications may result in a drug interaction that may include occlusion of the tube and does not comply with medication administration practices of administering medications separately, -administer medication one at a time and follow with a minimum of 15ml (milliliters) of water between medications unless otherwise…

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, review of facility policy and clinical records and staff interview, it was determined that the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one of three nursing units (first floor nursing unit). The facility failed to provide a safe and sanitary environment to help prevent the potential for cross contamination for one of three medication rooms (E Wing Medication Room). The facility failed to prevent the potential for cross contamination during a dressing change for one of three residents (Resident R34). Findings include: Review of facility policy Medication Administered by Enteral Tube dated 10/17/23, indicated the nurse will observe the standards and protocols for use with enteral drug administration including Enhanced Barrier Precautions (an infection control intervention designed to reduce transmission…

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, resident and staff interviews it was determined that the facility failed offer residents the opportunity to vote for the May 2023 election and the facility failed to provide a dignified dining experience for one five residents reviewed (Resident R9). Findings include: Review of resident council minutes for five months failed to include information of the facility asking the residents about voting. During a resident group on 10/25/23, at 11:00 a.m. residents indicated that they were not offered the opportunity to vote for the previous election in May and had not been asked about the upcoming election in November 2023. Residents stated that they use to be asked about voting, but that hasn't happened for a while. Five residents indicated that they were interested in voting. During an interview on 10/25/23, at 3:02 p.m. Activity director Employee E29 confirmed that facility did not ask residents about voting for each election, and that the facility failed to offer residents the opportunity to vote effort the May 2023 election. During an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, observations, resident interview, and employee interviews it was determined that the facility failed to accommodate the call bell needs of one of six residents (Residents R10). Findings include: The facility policy Resident Rights last reviewed 10/17/23, indicated that the purpose of this policy is to provide resident center care that meets the psychosocial, physical, and emotional needs and concerns of the residents. Residents will be treated with dignity and respect including but not limited to: To have a method to communicate needs to staff. Call light or bell access will be within reach of the resident as one method to communicate needs to staff. Review of Resident R10 ' s admission record indicated she was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS-periodic assessment of care needs) dated 8/24/23, included diagnoses of diabetes (high levels of sugar in the blood), and Cerebral Palsy (disorder that affect a person ' s ability to move and…

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

Based on review of facility policy, resident council minutes, group and staff interviews it was determined that the facility failed to respond to resident concerns and grievances identified during resident council minutes for five of five months (October 2023 To July 2023). Findings include: Review of the facility policy dated 10/17/23, Resident Grievances indicated: Grievance: an official statement of a complaint over something believed to be wrong or unfair, Complaint: knowledge that someone believes they have been wronged or treated unfairly . Review of resident council minutes from October to July 2023 indicated the following concerns: 10/10/23: New Business: evening shift not responsive to resident needs, beds not being made, , aids taking clothes away in sheets, 3-11 arguing about who will answer call bells, beds not being made 9/5/23: new business activities low on snacks, nurse aide staff on phone 3-11 D wing, room smells like mold, aids not picking up garbage bags, halls smell 8/1/23 : New business: residents saying not getting shower when asking about it later staff saying…

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

Based on review of the facility Resident Trust Bond (surety bond), it was determined that the facility failed to identify Residents that had their accounts managed by the facility as the beneficiaries bond. Findings include: The Resident Trust Fund Bond listed the oblige as Commonwealth of Pennsylvania - Department of Aging and not the residents of the facility. During an interview on 10/27/23, at 2:09 p.m. NHA (Nursing Home Administrator) confirmed that the facility failed to identify the oblige as the Residents of the facility. 28 Pa. Code 201.18e(1)Management.

Based on review of facility policy, observations, and staff interviews, it was determined the facility failed to maintain privacy of confidential information during medication administration for two of two residents (first floor nursing unit). Findings include: Review of a facility policy , Routine Resident Care dated 10/17/23, indicated that staff always maintains confidentiality of resident information. Observation on 10/25/23, at 9:10 a.m. indicated Registered Nurse (RN) Employee E8 performed resident medication administration and left the medication cart and the computer screen open with resident information visible to anyone passing by in the corridor. Report sheet with resident information also visible to anyone passing by in the corridor. Interview at the time of the observation, RN Employee E8 acknowledged the lack of privacy with resident information on the computer screen and report sheet. Observation on 10/25/23, at 9:15 indicated Employee E8 performing resident medication administration and left the medication cart and the computer screen open with resident information…

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, observations, and resident and staff interviews it was determined that the facility failed to provide and/or identify where the grievance forms were located, failed to inform the residents of the location, in the grievance policy failed to identify what a reasonable time frame for responding to concerns means in the grievance policy met the regulation. Findings include: Review of facility policy Resident Grievances dated 10/17/23, indicated: The facility will make available to all residents posting in a prominent location in the facility information of the right to file grievances orally or in writing; the right to file grievances anonymously; contact information for the Grievance Official; a reasonable time frame of completing the review of the grievance ; the right to obtain a written decision regarding the grievance. Resident group interview on 10/25/23, at 11:45 a.m. residents indicated that they did not know who the grievance official was, did not know what the grievance procedure was, they were unaware of where the grievance forms were located and did…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, facility documents, clinical record and staff interview it was determined that the facility failed to protect a Resident from sexual abuse, and failed to implement a long term plan to ensure safety of other residents, failed to monitor Residents for any ongoing behaviors, and failed to identify the behaviors for one of three residents reviewed (Resident R71). Findings include: Review of the facility policy Abuse, Neglect, and Misappropriation dated 10/17/23, indicated that: Abuse the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish Serious bodily injury also includes sexual intercourse with a resident who is incapable of declining to participate in the sexual act or lacks the ability to understand the nature of the sexual act. Review of Resident R71 clinical record indicated he was admitted on [DATE]. Resident R71 has diagnosis of unspecified intellectual disabilities (defects in adaptive…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policies, clinical record review, observations and staff interviews, it was determined the facility failed to identify side rails as a possible restraint and failed to assess the functional status of individual residents to determine if the use of bed rails is a restraint for two of five residents (Residents R29 and R55). Findings include: Review of facility policy Physical Restraint and Management last reviewed 10/17/23, indicated a physical restraint is defined as any manual method, physical, or mechanical device, equipment, or material that meets all of the following criteria: is attached or adjacent to the resident's body, cannot be easily removed by the resident (including cognitive abilities to remove), and restricts the resident's freedom of movement or normal access to his/her body. Restraints may be intentional or unintentionally applied based on the residents ability to easily remove or release the device. The facility evaluates whether a device or situation constitutes a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical record review, observation, and staff interviews, it was determined that the facility failed to provide care and services to meet the accepted standards of practice for one of three residents (Resident R34). Findings include: Review of facility policy Standards of Nursing Practice last reviewed 10/17/23, indicated nurses will provide care according to the Standards of Nursing Practice, and will provide care according to their license scope of practice that is defined within their own state board of nursing. Review of facility policy Wound Care last reviewed 10/17/23, indicated residents/patients admitted with or develop skin integrity issues will receive treatment as indicated based on location, stage, and drainage. Review of the clinical record indicated that Resident R34 was admitted to the facility on [DATE]. Review of Resident R34's Minimum Data Set (MDS - a period assessment of care needs) dated 9/20/23, indicated diagnoses of hypertension (high blood pressure),…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical record review, observation, and staff interview, it was determined that the facility failed to provide appropriate care and services to maintain activities of daily living (ADLs) for one of six residents (Resident R101). Findings include: Review of facility policy Routine Resident Care last reviewed 10/17/23, indicated the facility is to promote resident centered care by attending to the total medical, nursing, physical, emotional, mental, social, and spiritual needs and honor resident lifestyle preferences while in care of the facility. Licensed staff will provide services based upon their scope of practice and coordinate and oversee direction and implementation of resident Care Plan with specific accountability for nursing interventions and evaluation. Review of the clinical record indicated that Resident R101 was admitted to the facility on [DATE]. Review of Resident R101's Minimum Data Set (MDS - a periodic assessment of care needs) dated 7/19/23, indicated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical record review, observations, and staff interview, it was determined that the facility failed to provide pressure ulcer treatment consistent with professional standards of practice and failed to prevent worsening of pressure injuries. The facility failed to promote healing and provide treatment according to the physician orders for one of three residents (Resident R34). Findings include: Review of facility policy Wound Care last reviewed 10/17/23, indicated residents/patients admitted with or develop skin integrity issues will receive treatment as indicated based on location, stage, and drainage. Review of facility policy Pressure Ulcer Prevention: High Risk last reviewed 10/17/23, indicated staff are to monitor for consistent implementation of interventions, evaluate the effectiveness or interventions, revise intervention and/or goals as indicated, and communicate changes in interventions to the caregiving staff. Review of facility policy Skin Care and Wound…

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 interviews, it was determined that the facility failed to provide appropriate assistance with transfers creating a potential accident and hazards for one of five residents (Resident R30). Findings include: Review of facility policy Routine Resident Care dated 10/17/23, indicated unlicensed staff will provide routine daily care by assisting with ambulation, transfer, repositioning or transport to clinic appointments and activities. Review of admission record indicated Resident R30 was admitted to the facility on [DATE]. Review of Resident R30's Minimum Data Set (MDS - a periodic assessment of care needs) dated 9/5/23, indicated the diagnosis of anemia (the blood doesn't have enough healthy red blood cells), diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time), and high blood pressure. Section G indicated transfer status as needing extensive assistance of two staff members. Review of Resident R30's physician order dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policies, clinical records, and staff interviews, it was determined that the facility failed to make certain that weight loss was identified and addressed in a timely manner for two of five residents (Resident R10, and R118) and to identify needs for increased nutrition for one of five residents (Resident R118). Findings include: Review of facility policy Pressure Ulcer Prevention: High Risk dated 10/17/23, indicated that nutrition status should be monitored to care for and prevent wounds. This should include monitoring the resident ' s weight, and nutritional requirements for calories, minerals, protein, and vitamins. GUIDANCE §483.25(g) Significant weight loss is defined as: 5% or greater in one month 7.5% or greater in three months 10% or greater in six months Altered Nutrient intake, absorption, and utilization: Poor intake, continuing or unabated hunger, or a change in the resident's usual intake that persists for multiple meals, may indicate an underlying condition or illness.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that an enteral feeding (nutrition through a tube in the stomach) was administered in a safe manner to one of two residents (Resident 89) who had a gastrostomy tube (surgically placed tube in the stomach). Findings include: Review of facility policy Medication Administered by Enteral Tube dated 10/17/23, indicated that the staff shall validate tube placement by aspirating 15-30 mls (milliliters) of stomach contents using a 60ml catheter tipped syringe. Replace stomach contents once placement is verified. If placement cannot be validated, do not administer medications and contact the physician. Review of admission record indicated Resident R89 was admitted to the facility on [DATE]. Review of Resident R89's Minimum Data Set (MDS - a periodic assessment of care needs) dated 9/7/23, indicated the diagnoses of stroke (damage to the brain from an interruption of…

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

Based on review of facility education documents and staff interview it was determined that the facility failed to ensure that nurse aides (NA) demonstrate competency and skills necessary to safely transfer a resident according to the resident's assessed needs and care plan for one of five nurse aides (NA Employee E12) and failed to ensure that an enteral feeding (nutrition through a tube in the stomach), and medications were administered in a safe manner (Registered Nurse RN Employee E8 and RN Employee E17). Findings include: Review of facility policy Routine Resident Care dated 10/17/23, indicated unlicensed staff will provide routine daily care by assisting with ambulation, transfer, repositioning or transport to clinic appointments and activities. Review of facility policy Medication Administered by Enteral Tube dated 10/17/23, indicated that the staff shall validate tube placement by aspirating 15-30 mls (milliliters) of stomach contents using a 60ml catheter tipped syringe. Replace stomach contents once placement is verified. If placement cannot be validated, do not administer…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record reviews, observations, and staff interviews, it was determined that the facility failed to provide appropriate, ongoing assessment for two of three residents reviewed (Resident R25 and R98) who had Alzheimer's dementia (a progressive disease that destroys memory and other important mental functions). Findings include: Review of federal guidance §483.40(b)(3) a resident who displays or is diagnosed with dementia, receives the appropriate treatment and services to attain or maintain his or her highest practicable physical, mental, and psychosocial well-being. The regulations associated with medication management include consideration of: o Indication and clinical need for medication; o Dose (including duplicate therapy); o Duration; o Adequate monitoring for efficacy and adverse consequences; and o Preventing, identifying, and responding to adverse consequences. Review of the admission record indicated Resident R25 was admitted to the facility on [DATE]. Review of Resident R25's Minimum…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical record review, facility documents and staff interview it was determined the facility failed to ensure that residents were free from any significant medication errors for one of three residents. (Resident R89). Findings include: Review of facility policy Medication Administration dated 10/17/23, indicated observe the five rights in giving each medication - the right resident, the right time, the right medicine, the right dose, and the right route. Roll suspension as directed. Review of admission record indicated Resident R89 was admitted to the facility on [DATE]. Review of Resident R89's Minimum Data Set (MDS - a periodic assessment of care needs) dated 9/7/23, indicated the diagnoses of stroke (damage to the brain from an interruption of blood supply), high blood pressure, diabetes (too much sugar in the blood), hemiplegia(paralysis of one side of the body), and dysphagia (difficulty swallowing food). Review of Resident R89's physician order dated 8/31/23, indicated…

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

Based on review of facility policy, observations, and staff interviews, it was determined that the facility failed to properly store medical supplies and biologicals in one of three medication rooms (C Wing Medication Room). Findings include: During an observation of the facility medication room on 10/26/23, at 11:47 a.m. the following was observed under the sink: - An open box of individually packaged border gauze dressings (a self-adhering, multi-layer foam dressing) - An open box of individually packaged Medihoney (a wound gel) tubes - An open box of antifungal topical powder - An open box of procedure masks (a loose-fitting mask that covers the mouth and nose) - An open box of oral swabs - A box of hypodermic syringes During an interview on 10/26/23, at 11:47 a.m. Registered Nurse Employee E3 confirmed the above observations. During an interview on 10/26/23, at 12:13 p.m. the Incoming Director of Nursing confirmed the facility failed to properly store medical supplies and biologicals in one of three medication rooms. 28 Pa. Code: 211.10(c) Resident care policies. 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 observations, resident and staff interviews it was determined that the facility failed to provide complete meals/nutrition services for three of six Residents who did not receive a meat and or protein option with their dinner meal (Resident R3, R4, and R5). Findings include: During an observation on 8/31/23, between 6:01 p.m. and 6:10 p.m. the following was observed: Resident R3 and Resident R4 had dinner, but did not have a meat option on their plates. Resident R4 stated that this has happened more than once, Resident R3 agreed. Resident R4 stated they met with the Registered Dietitian regarding not getting a meat and their preferences. Resident R4 said that every time there is meatballs they don't get a meat. During an observation on 8/31/23, between 6:01 p.m. and 6:10 p.m. Resident R5 was observed without a meat/protein selection on their plate. Review of the menu indicated the following: Swedish meatballs, mashed potatoes, and green peas. Alternatives (always) hamburger, cheeseburger, grilled cheese, and peanut butter and jelly. During an interview on 8/31/23, at 6:20…

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

Based on review of facility policy, clinical records, and staff interview it was determined that the facility failed to ensure that residents with limited range of motion receive assessment and treatment to achieve and maintain and/or improve mobility for one of four residents (Resident R2). Finding s include: Review of facility policy dated 3/30/23, Professional Standards of Quality It is the policy of this facility to provide resident centered care that meets the psychosocial, physical, and emotional needs and concern of the residents. The attending physician shall authenticate orders for the care and treatment of assigned residents. The attending physician or physician designee will review and approve all recommendations, orders received from an outside, non-privileged consultant medical provider. Review of Resident R2 admission record indicated that they were admitted to the facility 5/24/23. Review of the Minimum Data Set (MDS - a brief periodic assessment of resident needs) dated 8/2/23, included diagnosis of cerebral palsy ( a condition marked by impaired muscle…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical records and staff interview it was determined that the facility failed to ensure medications were administered per physician order for one of four residents (Resident R2). Findings include: Review of the facility policy Provision of Physician Ordered Services dated 3/30/23, indicated Professional Standards of Quality means services provided according to accepted standards of clinical practice. Review of Resident R2 was admitted to the facility on [DATE]. Review of Resident R2 Minimum Data Set (MDS - a brief periodic assessment of resident needs) dated 8/2/23, included diagnosis of cerebral palsy ( a condition marked by impaired muscle coordination), seizure disorder (brain's electrical rhythms have a tendency to become imbalanced), and anxiety disorder (persistent and excessive worry that interferes with daily activities). Review of Resident R2 clinical record indicated the following : Allegheny Health Network Neurology 6/12/23, To whom it may concern: Please do not…

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