Meadowview Rehabilitation And Nursing Center

Based on observations, resident and staff interviews, and a review of facility documentation, it was determined that the facility failed to provide food and drink that was palatable and served at palatable temperatures for eight of 35 residents reviewed (Residents R169, R91, R178, R25, R131C, R45, R199 and R110). Findings include: A review of the Food and Nutrition Services Test Tray and Accuracy Evaluation form Revised November 19, 2019, revealed that the standard for cold food is 45 degrees or less and for hot food 135 degrees or more. Interview with Resident R169 on April 7, 2025, at 10:35 a.m. revealed that he thinks that the food sucks, that it is not always hot, you should try it. Interview with Resident R91 on April 7, 2025, at 10:41 a.m. revealed that he does not like the food, that it is too soft and mushy. Interview with Resident R178 on April 7, 2025, at 10:50 a.m. revealed the meals are bad, the food is never right, doesn't taste right, it's the kitchen not the nursing staff. Interview with Resident R131 on April 7, 2025, at 11:05 a.m. revealed that the food here tastes…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 the review of closed clinical records, facility policies and interview with staff, it was determined that the facility failed to ensure that an appropriate discharge was documented in the resident's clinical record for one of four closed records reviewed. (Resident R523) Findings Include: Review of Resident R523's Minimum Data Set (MDS - federally mandated resident assessment and care screening) assessment dated [DATE] revealed that the resident was discharged from the facility and the resident was not anticipated to return to the facility. It was revealed that the discharge was unplanned and the resident was discharged to the hospital. Review of clinical record for Resident R523 on April 8, 2025 revealed that there was no documentation available in the clinical record to indicate a reason for residents discharge. Review of a discharge summary completed by the nurse practitioner dated March 3, 2025 but signed as completed on April 9, 2025 revealed that resident was not seen within the 72 hours from…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility documentation, review of clinical records, and interviews with staff, it was determined that the facility failed to notify the Office of the State Long-Term Care Ombudsman of facility-initiated transfers to the hospital and that a resident's representative was made aware of a facility-initiated transfer in writing, for one of four clinical records reviewed. (Residents R136) Findings Include: Review of Minimum Data Set (MDS - federally mandated resident assessment and care screening) assessment dated [DATE] revealed that the resident was discharged from the facility and the resident was not anticipated to return to the facility. It was revealed that the discharge was unplanned and he was discharged to the hospital. Review of clinical record for Resident R523 on April 8, 2025 revealed that there was no documentation available in the resident's clinical record to indicate a reason for residents discharge. Review of a discharge summary completed by the nurse practitioner dated March 3,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, review of facility policies and staff interview, it was determined that the PASRR (Preadmission Screening and Resident Review) was not appropriately completed according to the resident assessment for one of five residents reviewed (Residents R184). Findings include: The PASRR (Preadmission Screening Resident Review) was created in 1987 through language in the Omnibus Budget Reconciliation Act (OBRA) and it has three goals: to identify individuals with mental illness and/or intellectual disability, to ensure they are placed appropriately, whether in the community or in a nursing facility, and to ensure they receive the services they require for their mental illness or intellectual disability. The PASRR Level 1 must be completed on all persons who are considering admission to a Medicaid certified nursing facility. A Level II PASRR evaluation must be completed if the Level 1 PASRR determined that the person is a targeted person with mental illness or an intellectual disability. 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 review of facility documentation, it was determined that the facility failed to developed a comprehensive care plan with measurable objectives for a resident who exhibited aggressive behaviors towards other residents for one of 35 clinical records reviewed. (Resident R325) Findings include: Review of Resident R325's clinical record revealed that the resident was admitted to the facility on [DATE] with the diagnosis of history of transient ischemic attack (mini stokes), cerebral infraction, depression (major loss of interest in pleasurable activites), schizophrenia (mental disease characterized by loss of reality), and bipolar disorder (condition in which a person has periods of depression and periods of being extremely happy). Review of Resident R325's admission Minimum Data Set (MDS- assessment of resident needs) dated February 12, 2025 revealed that the resident had a BIMS (Brief Interview of Mental Status) score 11, which indicated moderate impairment. The resident was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policies, clinical record reviews and interviews with staff, it was determined that the facility failed to revise a resident's care plans, related to accuracy of information, for one of 35 residents reviewed (Resident R184). Findings include: Review of facility policy, Care Planning Process and Care Conference dated revised March 19, 2025, revealed, Care plan development, renewal and revision will be based upon the results of the resident assessment. Review of Resident R184's care plan, dated April 3, 2024, revealed that the resident had an indwelling suprapubic catheter (a tube that has been surgically inserted into the bladder to drain urine). Review of Resident R184's Significant Change MDS (Minimum Data Set - a mandatory periodic resident assessment tool), dated January 6, 2025, revealed that the resident was admitted to the facility on [DATE]. Continued review revealed that the resident did not have a urinary catheter. Continued review of Resident R184's care plan, dated April 3,…

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

Based on the review of clinical records, interviews with staff, it was determined that the facility failed to administer medication as ordered by the physician for one of 35 residents reviewed. (Resident R175). Findings Include: Review of Resident R175's nursing notes dated March 7, 2025 revealed that unit manager spoke to resident regarding his low hemoglobin, in the past was on Epoetin alfa injection which the resident was refusing. Per resident, he would take the shot if it prevented him from going to emergency for transfusions. Physician was aware and had new order to place injection. Review of physician order for Resident R175 dated March 9, 2025 revealed an order for Epoetin Alfa-epbx Injection Solution 10000 UNIT/ML, inject 1ML subcutaneously one time a day every Tuesday Thursday and Sunday for anemia. Review of medication administration record for Resident R175 revealed that the resident did not receive the medication on March 16, 2025 and March 23, 2025. Review of practitioner progress note dated March 20, 2025 revealed that the resident was seen for discussion of lab…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, a review of facility policies and resident and staff interviews, it was determined that the facility failed to make certain the highest practicable level of pain management was maintained for two of 35 residents reviewed (Resident R9 and R132). Findings include: Review of facility policy Administering Medications revealed that Medications must be administered within one (1) hour of their prescribed time, unless otherwise specified (for example, before and after meal orders). Review of Resident R9's clinical record revealed the resident was admitted to the facility on [DATE], with diagnosis to include but not limited to chronic ulcer to the left ankle with fat layer exposed. Continued review of medical records for Resident R9 including the quarterly assessment MDS (an assessment of care needs) dated March 9, 2025, revealed a Brief Interview for Mental Status evaluation which revealed that resident had a BIMS score of 15 indicating he was cognitively intact. Interview with Resident…

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

Based on observations,staff interviews and review of facility documentation, it was determined that the facility failed to ensure that the recommended therapeutic diet that she made, was provided to a resident for 1 out of 35 residents reviewed (Resident R210). Findings include Review of the facility policy, Therapeutic diets, with a revision date of January 7, 2025. The policy stated that therapeutic diets are prepared and served according to written orderS from the attending physician. Review of the April 2025 physician orders for Resident R210 indicated that the resident was admitted into the facility on December 19, 2024 from a local hospital with diagnosis that included the following: cerebral infarction (a stroke), hypertension (high blood pressure); aphasia (a disorder that affects how you communicate usually after a stroke or head injury) an dysphagia (difficulty swallowing). Continued review of the physician orders for the resident included a physician's order dated December 19, 2024 and monthly thereafter for the resident to have a mechanical soft texture diet with nectar…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 the review of facility documents and resident clinical record and staff interviews, it was determined that the facility failed to ensure a resident had the capacity to understand the terms of a binding arbitration agreement for one of three residents reviewed (Resident R89). Findings Include: Review of Resident R89's admission Minimum Data Set (MDS - federally mandated resident assessment and care screening) dated September 1, 2022, revealed the resident was admitted to the facility on [DATE], and had a diagnosis of altered mental status. Further review of the MDS, Section C - Cognitive Patterns (items in this section are intended to determine the resident's attention, orientation, and ability to register and recall new information - these items are crucial factors in many care-planning decisions), indicated that Resident R49 scored a 0 on the Brief Interview for Mental Status (BIMS), which indicated the resident had severe cognitive impairment. Review of an admission note dated August 30, 2022 revealed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 determined that the facility failed to maintain a safe, clean, homelike environment on three of five nursing units(A, B, E Nursing Units) E unit shower room. Findings include: Facility Policy titled Bathroom Cleaning unknown date, indicated under option 5 clean and sanitize toilet (including raised toiled seats) using infectable cleaner. Facility Policy titled Resident's Room Cleaning unknown date, indicated to provide a detailed description of the steps that are to be completed daily in the cleaning of a resident room. Daily cleaning will ensure optimum levels of cleanliness and sanitation, prohibit the spread of infections and bacteria, and maintain the outward appearance of the facility. Observation of facility B nurisng unit on June 5, 2024, 10:22 a.m. revealed the following observations, In room B 101 there was CPAP (a respiratory equipment) tubing on the floor. In room B 106 there was dried brown substance on the floor, it appeared like dried…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 upon observations, interviews and review of clinical records and facility policy, determined the facility failed to establish and maintain an infection prevention and control program to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of Multidrug-resistant organism (MDRO) transmission for three residents with indwelling medical devices and hand hygiene for one resident during medication administration (Resident R21, R87 and R129) of 35 residents records reviewed. Findings include: Review of the facility 's policy Transmission Based Precautions revised in April 2024, states Transmission Based Precautions (TBP) will be initiated when there is a reason to believe a resident has a communicable infectious disease, which may include using Enhanced-Barrier Precautions (EBP). EBP are designed to reduce the transmission of multidrug-resistant organisms (MDRO) in facilities by using targeted gown and glove during high contact resident care activities 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.

Based on a review of facility documentation, facility policies and staff interviews, it was determined that the facility failed to maintain an effective antibiotic stewardship program that includes a system that includes antibiotic use protocols and a system to effectively monitor antibiotic usage for three of four months of antibiotic stewardship program data reviewed. (January 2024, February 2024, March 2024 and April 2024). Findings Include: Review of facility policy Antibiotic Stewardship-Surveillance dated February 8, 2024, revealed the Antibiotic usage and outcome data will be collected and documented using a facility: approved antibiotic surveillance tracking form. The data will be used to guide decisions for improvement of individual resident antibiotic prescribing practices and facility-wide antibiotic stewardship. The facility's antibiotic stewardship program will promote the appropriate use of antibiotics and includes a system of monitoring to improve resident outcomes and reduce antibiotic resistance. This development should include leadership support and accountability…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 documentation, clinical record review and interviews with staff, it was determined that the facility failed to ensure a resident was free from misappropriation related to missing medication for one of 35 residents reviewed (Resident R205). Findings include: Review of facility policy, Abuse Policy - Prevention and Management dated reviewed September 2023, revealed, The facility prohibits the mistreatment, neglect, and abuse of residents/patients and misappropriation/exploitation of resident/patient property by anyone including staff, family, friends, visitors, etc. Continued review revealed, Examples of misappropriation of resident property include . Diversion of a resident's medication(s), including, but not limited to, controlled substances for staff use or personal gain. Review of facility policy, Narcotic Management dated revised July 1, 2023, revealed, Control/schedule II-V medication will be counted with two professional nurses at the beginning and end of each shift.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 policies and procedures, and interviews with staff, it was determined that the facility failed to conduct a complete and thorough investigation of an alleged violation for one of 35 residents reviewed. (Resident R81). Findings include: Review of the facility policy titled, Reporting and Investigation dated, September 2023, revealed, . The Administrator, Director of Nursing, and Risk Manager, if applicable are responsible for Investigation and reporting. Upon receiving an incident or suspected incident of resident abuse, Neglect, misappropriation of resident property, or injury of an unknown source, the Administrator/DON/designee will conduct an investigation to include but not limited to the Following: Complete paperwork for investigation of abuse, neglect, misappropriation; Interview the person(s) reporting the incident; Interview any witnesses to the incident; Interview the resident, if able; Interview the resident ' s attending physician and review of the resident ' s record; Interview staff members (on all shifts) having contact with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record reviews, review of facility policies and staff interviews, it was determined that the PASRR (Preadmission Screening and Resident Review) was not appropriately completed according to the resident assessment for two of three residents reviewed related to PASRR assessments (Residents R25 and R208). Findings include: The PASRR (Preadmission Screening Resident Review) was created in 1987 through language in the Omnibus Budget Reconciliation Act (OBRA) and it has three goals: to identify individuals with mental illness and/or intellectual disability, to ensure they are placed appropriately, whether in the community or in a nursing facility, and to ensure they receive the services they require for their mental illness or intellectual disability. The PASRR Level 1 must be completed on all persons who are considering admission to a Medicaid certified nursing facility. A Level II PASRR evaluation must be completed if the Level 1 PASRR determined that the person is a targeted person with mental…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 the review of facility policy, review of clinical records and interview with staff, it was determined that the facility did not develop a baseline care plan for a newly admitted residents with history of drug abuse for one of 35 residents reviewed. (Resident R527) Findings Include: Review of clinical record for Resident R527 revealed that the resident was admitted to the facility on [DATE], with diagnosis including opioid abuse, psychoactive substance abuse and schizophrenia (A disorder that affects a person's ability to think, feel, and behave clearly). Review of a physician progress note for Resident R527 dated March 5, 2024 revealed that the resident had history of opioid( heroin) abuse. A review of baseline care plan for Resident R 527 dated March 4, 2024, revealed that there was evidence that the facility developed a care plan with intervention for drug abuse and behavioral concerns. Continued review of baseline care plan under social service section revealed that the mental health needs, social…

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

Based on facility policy, clinical record review, and staff interview, it was determined that the facility failed to ensure a comprehensive resident care plan was developed and implemented related to adaptive equipment required for swallowing liquids properly (Resident R40) and failed to implement care and services identified on a comprehensive care plan regarding unwanted behaviors and mealtime (Resident R81) for two of 35 residents reviewed. Findings include: Review of facility policy titled Care Planning Process and Care Conference last revised July 2023, indicated that the care plan is a working tool that provides a profile of the needs of the individual resident/patient; the resident/patient care plan will be available for use by staff caring for the resident. The interdisciplinary team will meet within 21 days of admission, readmission, when a change of condition occurs and annually to develop the comprehensive, resident centered plan of care for each resident. Once the initial MDS is completed, the Clinical Reimbursement Specialist will initiate any care plan triggered by 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 review, staff interviews and medication manufacture's medication insert, it was determined the facility failed to ensure care and services were provided in accordance with professional standards of practice for one of 35 residents reviewed (resident R 96) regarding proper medication order. Findingsinclude: The Pennsylvania Code, Title 49, Chapter 21 physician assistant and certified registered nurse practitioners. Profession, and vocational standards, Standards, subpart A Chapter 18 The State Board of Medical Practitioners other than medical doctors, indicates that a CRNP(certified nurse practitioner) with prescriptive authority approval may, when acting in collaboration with a physician as set forth in a prescriptive authority collaborative agreement and within the CRNP's specialty, prescribe and dispense drugs and give written or oral orders for drugs and other medical therapeutic or corrective measures. These orders may include: orders for drugs, total parenteral nutrition and lipids, in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policies, clinical record reviews and interviews with staff, it was determined that the facility failed to ensure that physician orders were followed related to insulin for two residents (Residents R6 and R42) and adaptive equipment for one resident (Resident R40) of 35 residents reviewed. Findings include: Review of facility policy, Diabetes Mellitus, Guidelines for dated reviewed June 2023, revealed, Glucose monitoring guidelines: Blood sugar level and frequency measured when ordered . Facility protocol in place for physician notification with specific parameters for notification. Review of facility policy, Medication Administration/Disposition dated revised September 6, 2023, revealed, If a drug is withheld, refused, or given at a time other than the scheduled time, the individual administering the medication shall initial and use the corresponding code on the EMAR [electronic medication administration record] to indicate the medication was not given and the reason for 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.

Based on clinical record reviews, observations, and staff interviews, it was determined that the facility failed to implement treatment and services to prevent pressure ulcers for two of 35 sampled residents reviewed. (Resident R59 and Resident R177) Findings include: Review of facility policy Risk assessment and prevention dated October 6, 2023, revealed that The facility will strive to ensure that a resident entering the facility without pressure ulcers/pressure injuries does not develop pressure ulcer/injuries. Unless the clinical condition demonstrates unavoidable skin breakdown. Prevention of pressure ulcer/injuries requires early identification of at-risk residents and the implementation of preventions strategies. Manage pressure. -Use support surface on bed and or wheelchair. -Use turning and positioning plan if indicated -Off load heel pressure Clinical record review revealed that Resident R59 had diagnoses that included cognitive communication deficit and severe protein calorie malnutrition. The Minimum Data Set assessment (Assessment of resident care needs) dated March 28,…

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

Based on the observations, review of clinical records, facility policies, and interview with staff, it was determined that the facility failed to ensure that a resident with limited range of motion, received appropriate services to prevent further decline in range of motion and maintain appropriate positioning for one of 35 resident s reviewed. (Resident R70). Finding Include: Review of facility policy ADL Care, Contractures, Preventative Care and Treatment and Restorative ROM Program, dated March 12, 2024, revealed that A plan of care will be developed based on the resident's individual ADL ROM/impaired joint mobility Needs. -There must be a clearly defined problem statement that identifies the restorative need; -The restorative nursing program is not the problem statement, it is an intervention; -There must be a measurable goal related to the problem; measurable objectives describe what The resident is expected to achieve, such as ROM goals/measurements to be achieved within a Specific timeframe; - There must be individualized Interventions; care plan interventions must include…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 the review of facility records, observations, and interviews with staff, it was determined that the facility failed to ensure accurate accounting of controlled drugs for one of three medication storage rooms reviewed (B unit medication room). Finding Include Observation of facility B unit medication room with Employee E32, Licensed Practical Nurse, on June 6, 2024, at 9:17 a.m., revealed a bottle of lorazepam liquid medication in the refrigerator. The bottle contained 14 ml of medications left in the bottle. Employee E32 confirmed the amount of medication left in the bottle. Review of narcotic count sheet for the lorazepam medication revealed that the amount should have been left should have been 4.5 ml. Employee E32 stated noticed the discrepancy 2 days ago and the amount was almost 10 ml extra that what was accounted for. Interview with Director of Nursing on June 6, 2024, at 12:17 p.m., confirmed that there was discrepancy with Lorazepam liquid on B nursing unit. 28 Pa. Code 211.9(a)(1)(k) Pharmacy Services

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on the review of clinical records, interviews with resident and staff, it was determined that the facility failed to ensure that residents drug regimen was free of unnecessary drugs related to the use of antipsychotic medication without adequate monitoring for one of five resident reviewed for drug regimen. (Resident R207.) Findings Include: Review of physician order for Resident R207 dated April 3, 2024, revealed an order for Quetiapine Fumarate 25 mg, half tablet by mouth at bedtime for schizophrenia. Review of pharmacy review of Resident R207 dated May 19, 2024, revealed that Please watch for ataxia and falls secondary to Seroquel. Seroquel may cause extra pyramidal symptoms ([NAME] effects of some medications, such as antipsychotic drugs, that can affect movement.), tardive dyskinesia (a chronic, drug-induced movement disorder that causes involuntary, repetitive body movements.), akathisia (a neuropsychiatric movement disorder that makes it difficult to sit still and causes an uncontrollable urge 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.

Based on observations and staff interviews it was determined that the facility failed to provide accurate meal trays for one of two residents and failed to provide food products based on the resident's food preference for three of 35 residents (Resident R88, 107, R212). Review of facility policy Resident Preferences, last revised January 2024, indicates Residents' individual choices including religious, cultural, and ethnic needs and preferences are obtained. Residents are served meals that offer choices and comply with food preferences. On June 5, 2024, at 12:13 p.m. Resident R212 reported that food preferences are not being honored. His/her ticket is preference for double portions protein, and he/she is not getting them during meals times. On June 5, 2024, at 12:25 p.m. Resident's R212 lunch arrived, and lunch ticket indicated double meat sandwich to meals tray. Lunch tray was missing sandwich. Licensed Dietician, Employee E5 confirmed that resident's preference did not reflet the lunch tray. On June 6, 2024, at 10:21 a.m. Resident Council Meeting was held with 11 alert and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, review of facility documentation, review of clinical records, observations, and staff interview, it was determined that the facility failed to maintain appropriate supervision for two of three residents reviewed (Resident R1 and R6). Findings Include: Review of facility policy Suicide Prevention, reviewed September 2023, revealed it is the policy of the facility to ensure that residents who voice and/or display suicidal ideation actions receive services and interventions to help them manage feelings and maintain their psychosocial wellbeing. Procedure includes implement 1:1 oversight until resident does not exhibit any suicidal ideations. Place resident on close observation as needed after 1:1 observation determined not needed. Review of Resident R1's quarterly Minimum Data Set (MDS - federally mandated resident assessment and care screening) dated April 29, 2024, revealed the resident had a Brief Interview for Mental Status (BIMS - assessment used to monitor cognition) score…

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

Based on a review of clinical records, facility documentation and interviews with staff, it was determined that the Nursing Home Administrator and the Director of Nursing failed to effectively manage the facility to make certain that residents were protected from verbal, physical and psychological abuse from a nursing staff for one of four residents reviewed. (Resident R1) This failure resulted in an immediate jeopardy situation for Resident R1. Findings include: Review of the job description for the Nursing Home Administrator (NHA) state that the NHA is responsible to establish and maintaining systems that are efficient and effective to operate the nursing home in a manner to safely meet residents' needs in accordance with federal,state and local regulations. Develop and enforce a monitoring program to assure compliance with federal, state, and local requirements. Review of the job description for the Director of Nursing (DON) state that the DON functions as the administrative authority for the Department of Nursing. The Director will be responsible for the organization 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 observation and interviews with staff, it was determined that the facility failed to maintain a clean, safe and functional environment for residents and staff in four of five central bathing rooms (A wing, B wing, C wing, D wing) and in the boiler room. Findings include: A tour of the central bathing rooms on the five nursing units at 10:00 a.m. on September 11, 2023, with Employee E12, the Infection Preventionist, revealed the following: Observations in the central bathroom on A Wing revealed a wall mounted heating and air conditioning unit with rust colored corrosion on the lowered vents at the top of the unit and adjacent sheet metal cover. Observations in the central bathroom on B Wing revealed a bariatric shower chair with rust colored corrosion on the white metal pipes on the underside of the chair. Observations in the central bathroom on C Wing revealed a shower chair with build-up of medium brown colored material on the white pipes on the underside of the chair. Observations in the central bathroom on D Wing revealed a wall mounted heating and air conditioning unit…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 interviews with staff, it was determined that the facility did not ensure that the resident was provided needed care and services related to follow up medical appointments for surgery clearance as recommended for one of four clinical records reviewed (Resident R3). Findings include: Review of Resident R3's admission MDS (Minimum Data Set - a mandatory periodic resident assessment tool), dated, revealed that the resident was admitted to the facility on [DATE], with a diagnosis of pyelonephritis (inflammation of the kidney, typically due to a bacterial infection). Review of Resident R3's August 10, 2023, Urology Consult revealed a diagnosis of nephrolithiasis (the presence of stones in the kidney due to a decrease in urine volume or excess of stone-forming substances in the urine, causing back pain, abdominal pain, burning sensation during urination, blood in urine and fever. Urgent medical attention is usually recommended in severe cases by healthcare providers and can 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.