Riverstreet Manor

Based on observation, select facility policy review, and staff interviews, it was determined the facility failed to implement and adhere to procedures to ensure acceptable storage and use-by dates for multi-dose medications in two of two medication rooms (Station 1 Medication Room, and Station 2 Medication Room).Findings include: A review of the facility policy titled Medication Labeling and Storage last reviewed by the facility on May 1, 2025, revealed it is the policy of the facility that if a multidose vial ( container of medication intended for use in more than one dose for multiple administrations, which contains a preservative to reduce bacterial growth and requires labeling with the date opened and adherence to manufacturer storage and beyond-use guidelines) of injectable medication has been opened or accessed (e.g., needle puncture) the vial should be dated and discarded within 28 days unless the manufacturer specifies a shorter or longer date for the opened vial. An observation of the medication room in Station 2 Med Room on April 15, 2026, at 8:53 AM, in the presence 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 select facility policies, clinical records, grievances filed with the facility, and staff interviews, it was determined that the facility failed to make prompt and adequate efforts to resolve a resident grievance in accordance with facility policy, for one of ten residents sampled (Resident 1).Findings Include: A review of facility policy entitled Grievance Process Procedure last reviewed by the facility on May 2, 2025, revealed it is the policy of the facility to make prompt efforts to resolve resident grievances to the satisfaction of the resident and or resident representative. The policy indicated a resolution of the concern is desired within five (5) working days from the date the concern was filed. The policy indicated routine follow up on concerns that are outstanding will be completed through the morning process meeting. The policy further identified the grievance official as the Nursing Home administrator (NHA). A grievance is defined as a formal or informal complaint or concern…

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 resident clinical records, select facility policy, and staff interview it was revealed that the facility failed to assure that one of 10 residents reviewed were free of significant medication errors. (Resident 1)Findings include: A review of a facility policy, entitled Reconciliation of Medications on Admission last reviewed by the facility on May 2, 2025, defined the medication reconciliation process as the process of comparing pre-discharge medications to post-discharge medications by creating an accurate list of both prescriptions. The policy further detailed the steps in completing a medication reconciliation which included gathering the information needed to reconcile the medication list by using the approved medication reconciliation form, the discharge summary from the referring facility, the admission order sheet, and all prescription and supplement information obtained from the resident/family during the medication history. The policy further explained that the medication…

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

Based on observation and staff interview, it was determined that the facility failed to maintain a clean and sanitary environment for 2 of 2 resident shower areas in the facility and maintain a clean and safe outdoor smoking area Findings include: On October 21, 2025, at 1:00 P.M., observations of the Area 145 shower/bathroom revealed multiple items stored inappropriately within resident bathing areas, including two shower chair buckets, a mechanical lift sling, a pair of sneakers, and an open plastic bag of briefs placed inside the bathtub. The bathtub's waterspout was coated with a thick layer of dried white residue. In the first shower stall, the perimeter of the floor was coated with a black, sticky substance. The floor surface showed visible soil and buildup. A stainless-steel soap dispenser on the wall exhibited visible streaks and brown discoloration, and the ceiling vent was layered with lint. The air conditioning/heating ceiling unit also had visible accumulations of dust and debris. The shower bed in the second shower stall was observed with a white powdery film and areas…

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 policy, and resident and staff interviews, it was determined the facility failed to implement its established smoking policy to ensure resident safety. The facility failed to post the smoking policy in a conspicuous and legible manner, failed to ensure that required smoking safety equipment was available in the designated smoking area, and failed to ensure smoking materials were properly secured for nine residents who smoke (Residents 2, 3, 4, 5, 6, 7, 8, 9, and 10).Findings include: A review of the facility's policy titled Facility Smoking Policy, last reviewed May 2, 2025, revealed that smoking be permitted only in designated areas that are separate from resident care areas, well ventilated, and equipped with portable fire extinguishers. The policy identified the designated smoking location as the courtyard accessible through the door near the laundry and outside the Station 1 dayroom, prohibited oxygen use in smoking areas, and required that residents…

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 maintain food delivery equipment in a clean and sanitary condition to prevent potential food contamination for four of four food delivery carts observed (Pine, Oak, Willow, and Spruce hallways).Findings include: Safe food handling and sanitation standards established by the United States Department of Agriculture (USDA) and Food and Drug Administration (FDA) require all equipment and utensils used in the storage, preparation, and delivery of food to be kept clean and in good repair. Equipment must undergo a two-step process consisting of cleaning (removal of visible soil and debris) and sanitizing (application of heat or chemical solution to reduce microorganisms that may cause illness). Harmful bacteria that cause foodborne illness cannot be seen, smelled, or tasted; therefore, strict adherence to cleaning and sanitizing procedures is required to prevent contamination. On October 21, 2025, the following observations were made during meal service: At 11:45 AM, the stainless-steel food delivery cart on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of clinical records, resident and staff interviews, and facility documentation, it was determined the facility failed to ensure that residents who were dependent on staff for assistance with activities of daily living (ADLs) consistently received necessary care and services to maintain personal hygiene and dignity for two residents out of 24 sampled residents (Residents 25 and 60). Findings include: A review of Resident 25's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses to include Parkinson's Disease (a movement disorder of the nervous system that cause symptoms of tremors, rigidity, and postural instability), and muscle weakness. A quarterly Minimum Data Set Assessment (MDS - a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated May 12, 2025, indicated the resident required substantial/maximal assistance from staff for showering/bathing. The resident was cognitively intact with a BIMS score of 14…

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, select facility policy and staff interviews it was determined the facility failed to develop and implement individualized pain management programs, consistent with professional standards of practice, to meet the pain management needs and attempt non-pharmacological interventions to alleviate pain prior to the administration of a narcotic pain medication prescribed on an as needed basis for two residents out of 24 reviewed (Resident 37 and Resident 98). Findings include: According to the US Department of Health and Human Services, Interagency Task Force, Executive Summary Draft Final Report May 6, 2021, for Pain Management Best Practices the development of an effective pain treatment plan after proper evaluation to establish a diagnosis with measurable outcomes that focus on improvements including quality of life (QOL), improved functionality, and Activities of Daily Living (ADLs). Achieving excellence in acute and chronic pain care depends on the following: An emphasis on an…

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

Based on a review of the facility's scheduled mealtimes, select facility policy, and resident and staff interviews, it was determined the facility failed to consistently provide snacks as desired by residents, including experiences reported by seven of seven residents participating in a group interview (Residents 8, 11, 80, 67, 37, 44, and 50). Findings include: A review of facility policy titled Snacks, last reviewed by the facility on May 2, 2025, revealed it is the facility policy that snacks and beverages will be provided as identified in residents' individual plans of care. Bedtime (HS- hour of sleep) snacks will be provided for all residents. Additional snacks and beverages will be available upon request for all residents who want to eat at non-traditional times. Nursing services is responsible for delivering the individual snacks to the identified residents and for offering evening snacks to all other residents. During a resident group interview conducted on June 25, 2025, at 10:00 AM, seven residents in attendance (Residents 8, 11, 80, 67, 37, 44, and 50) stated that snacks…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of clinical records, select facility policy, observations, and resident and staff interviews, it was determined that the facility failed to implement enhanced barrier infection control procedures and failed to ensure the proper use of personal protective equipment (PPE) for one resident out of 23 residents sampled (Resident 93). Findings include: A review of facility policy titled Enhanced Barrier Precautions, last reviewed by the facility on May 2, 2025, revealed it is the facility policy to expand the use of personal protective equipment and refer to the use of gowns and gloves during high-contact resident care activities when contact precautions do not otherwise apply. The policy indicated gown and gloves are applied prior to performing the high contact resident care activity. A clinical record review revealed Resident 93 was admitted to the facility on [DATE], with diagnoses including chronic kidney disease (a condition in which the kidneys are damaged and cannot effectively filter waste…

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

Based on observation, clinical record review, facility policy review, and staff interviews, it was determined the facility failed to ensure that licensed nurses provided nursing services in accordance with professional standards of practice by not adhering to medication administration standards for 4 of 4 residents observed during the administration of medications. (Resident 30, 31, 37, and 44). Findings included: According to the Pennsylvania Code, Title 49, Chapter 21, Professional and Vocational Standards, State Board of Nursing, 21.11 (a)(1)(2)(4) indicates the registered nurse was to carry out nursing care actions that promote, maintain, and restore the well-being of individuals. The Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, Chapter 21 section 21.11 Responsibilities of the Registered Nurse (RN) (a) The RN assesses human responses and plans, implements and evaluates nursing care for individuals or families for whom the nurse is responsible. In carrying out this responsibility, (4) the registered nurse carries out nursing 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 a review of clinical records and resident and staff interviews, it was determined the facility failed to provide nursing services consistent with professional standards of practice by failing to follow physician orders for the prescribed bowel protocol intended to promote normal bowel activity for one of 24 sampled residents (Resident 49). Findings include: According to the American Academy of Family Physicians (The American Academy of Family Physicians is one of the largest medical organizations in the US founded to promote the science and art of family medicine) the primary goal of constipation management should be symptom improvement, and the secondary goal should be the passage of soft, formed stool without straining at least three times per week. The facility was unable to provide a written policy regarding bowel elimination management. A review of the clinical record revealed that Resident 49 was admitted to the facility on [DATE], with diagnoses to include congestive heart failure (weakness 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 clinical records, facility policy, and resident and staff interviews, it was determined the facility failed to provide colostomy care and services consistent with professional standards of practice for one of 24 sampled residents (Resident 81). Findings include: Review of the facility Colostomy/Ileostomy Care Policy last reviewed May 2, 2025, indicated it is the policy of the facility to ensure that residents who require colostomy services receive care consistent with professional standards of practice, and to provide guidelines that will aid in preventing exposure of the resident's skin to fecal matter. A review of Resident 81's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses which included peritoneal abscess (a localization of pus or infected material within the peritoneal cavity) Chronic Kidney Stage 5(also known as end stage renal failure when the kidneys are no longer functional to support the body's needs) , Dependence on Renal dialysis ( 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 a review of clinical records and staff interview, it was determined the facility failed to develop and implement an individualized person-centered plan to render trauma informed care to a resident with a diagnosis of Post-Traumatic Stress Disorder for one out of 24 residents reviewed (Resident 50). Findings include: A review of Resident 50's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses that included major depressive disorder, anxiety, malignant neoplasm of lung (cancerous tumors that form in lung tissue) and post-traumatic stress disorder (PTSD a mental health condition that's caused by an extremely stressful or terrifying event, either being part of it or witnessing it. Symptoms may include flashbacks, nightmares, severe anxiety, and uncontrollable thoughts about the event). The resident's current care plan, in effect at the time of review on June 24, 2025, did not identify the resident's PTSD triggers related to this diagnosis and resident 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 clinical records and select facility policy, and staff interviews, it was determined the facility failed to ensure that the physician medication orders were signed in a timely manner, resulting in medication administration delays for one resident out of 24 reviewed (Resident 46). Findings include: Review of the facility policy titled Physician Services last reviewed by the facility on May 2, 2025, indicated that the medical care of each resident is supervised by a licensed physician. Supervising the medical care of resident incudes providing consultation or treatment when called by the facility, prescribing medications and therapy, and overseeing a relevant plan of care for the resident. A review of the clinical record revealed that Resident 46 was admitted to the facility on [DATE], with diagnoses to include polyneuropathy (medical condition where multiple peripheral nerves throughout the body become damaged or dysfunctional, resulting in numbness, tingling, burning sensations, weakness, 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 clinical record reviews and resident and staff interviews, it was determined the facility failed to ensure the provision of pharmacy services to assure the timely receipt and administration of physician-prescribed medications for one resident of 24 reviewed (Resident 49). Findings include: A review of the clinical record revealed that Resident 49 was admitted to the facility on [DATE], with diagnoses to include congestive heart failure (weakness of the heart that leads to build-up of fluid in the lungs and surrounding body tissues), chronic obstructive disease (lung disease that blocks airflow and makes it difficult to breathe), and Type 2 diabetes (body has trouble controlling blood sugar and using it for energy). During an interview on June 24, 2025, at 10:48 AM, Resident 49 reported ongoing constipation and described a recent incident of significant straining that led to the development of hemorrhoids and rectal bleeding. The resident stated, They're supposed to do suppositories or cream or something…

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, review of select facility policy, clinical records, and staff interviews, it was determined the facility failed to store and label multi-dose medications in accordance with professional standards of practice and manufacturer instructions for one of three medication carts observed (Pine Hall). Findings Include: Review of the facility policy titled Storage of Medications last reviewed by the facility May 2,2025, indicated that multi-use medication vials/bottles are labeled accordingly. The policy further revealed it is the nursing staff responsibility to maintain medication storage including proper labeling. An observation of the medication cart located on the Pine Hall unit, conducted on June 25, 2025, at 8:22 AM in the presence of Employee 2 (Registered Nurse), revealed one multi-dose insulin pen of Insulin Lispro (a fast-acting insulin medication used to lower blood sugar) and three multi-dose insulin pens of Insulin Glargine (a long-acting insulin medication used to lower blood sugar) that were opened and available for use but were not labeled with the date…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of clinical records, resident council meeting minutes, and resident and staff interviews, it was determined the facility failed to provide care in a manner that promotes each resident's quality of life by failing to respond timely to residents' requests for assistance, including experiences reported by two out of the 27 residents sampled (Residents 97 and 159) and experiences reported by five out of the seven residents during a resident group interview (Residents 38, 49, 53, 91, and 94). Findings include: A review of the clinical record revealed that Resident 97 was admitted to the facility on [DATE], with diagnoses to include hypertension and lymphedema (swelling caused by a build-up of lymph fluid in the body, usually in an arm or leg). An admission Minimum Data Set assessment (MDS- standardized assessment completed at specific intervals to plan care) dated, August 21, 2024, indicated the resident had a BIMS score of 11 (Brief Interview for Mental Status-a tool to assess the resident's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, select facility policy, and resident and staff interviews, it was determined the facility failed to ensure comprehensive care plans were developed and revised with the participation of the resident and the resident's representative for two residents out of 27 residents sampled (Residents 62 and 79) and five out of seven residents during a resident council interview (38, 49, 94, 91, and 53). Findings include: A review of facility policy titled Care Plans, Comprehensive Person-Centered, last reviewed by the facility on August 1, 2024, revealed that a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs is developed and implemented for each resident. The policy indicates that residents are informed of their right to participate in his or her treatment and provided advance notice of care planning conferences. Also, the policy indicates if the participation of the resident 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 staff interview, it was determined the facility failed to maintain acceptable practices for the storage and service of food to prevent the potential for contamination and microbial growth in food, which increased the risk of food-borne illness in two of two resident pantries (Station 1 and Station 2). Findings include: Food safety and inspection standards for safe food handling indicate that everything that comes in contact with food must be kept clean, and food that is mishandled can lead to foodborne illness. Safe steps in food handling, cooking, and storage are essential in preventing foodborne illness. You cannot always see, smell, or taste harmful bacteria that may cause illness, according to the USDA (The United States Department of Agriculture, also known as the Agriculture Department, is the U.S. federal executive department responsible for developing and executing federal laws related to food). Observation of the Station One resident pantry on September 4, 2024, at 12:00 PM and September 5, 2024, at 1:45 PM revealed the interior of the microwave 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 clinical record review and resident interview and staff interview, it was determined the facility failed to ensure that in preparation for room change, a resident and resident representative received written notice, including the reason for the change, before the resident's room was changed for one of 27 residents reviewed (Resident 62). Findings Include: Federal regulatory guidelines note that moving to a new room or changing roommates is challenging for residents. A resident's preferences should be taken into account when considering such changes. When a resident is being moved at the request of facility staff, the resident, family, and/or resident representative must receive an explanation in writing of why the move is required. The resident should be provided the opportunity to see the new location, meet the new roommate, and ask questions about the move. Review of the clinical record of Resident 62 revealed the resident was admitted to the facility on [DATE], with diagnoses to include cerebral…

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, resident interview, and staff interview it was determined the facility failed to accurately identify a resident's wishes for future health care and advance directives (a written instruction such as a living will or durable power of attorney for health care for when the individual is incapacitated) as evidenced by one resident (Resident 62) out of 27 residents sampled. Findings include: A review of the clinical record of Resident 62, revealed the resident was cognitively intact and admitted to the facility on [DATE], with diagnoses that included cerebral infarction (stroke- damage to tissues in the brain due to loss of oxygen to the area) with right side hemiparesis (partial paralysis on one side of the body). A POLST a medical order signed by a doctor (Pennsylvania Orders for Life-Sustaining Treatment- is not intended to replace an advance health care directive document or other medical orders. The POLST process and health care decision-making works best when the person has…

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, the facility's abuse prohibition policy, select facility incident reports, and resident and staff interviews, it was determined the facility failed to timely and thoroughly investigate an incident to rule out neglect and identify planned fall interventions not in place which resulted in a resident who requires the assistance of two staff for bed mobility and transfers to sustain a fall with a minor injury for one of 27 residents sampled (Resident 10). The findings include: A review of the facility's Abuse Prohibition Policy last revised May 1, 2021, and last reviewed August 2024, indicated the facility will do all that is within their control to prevent occurrences of abuse, mistreatment, neglect, misappropriation of resident property, and exploitation for all residents. Abuse is defined as 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…

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, a review of clinical records and staff interviews it was determined the facility failed to provide nursing services consistent with professional standards of practice by failing to follow physician orders for the consistent application of prescribed therapeutic devices and or preventative measures, neck positioning pillow, when in bed and chair, for one resident out of 27 sampled (Resident 69) to assure the provision of person-centered care. Findings include: A review of the clinical record revealed that Resident 69 was admitted to the facility on [DATE], with diagnoses to include traumatic subdural hemorrhage (blood collects between the layers of tissue that surround the brain) with loss of consciousness, lack of coordination, abnormal posture, muscle disorder, and fracture of the base of the skull and occiput (flat bone that forms the back of the skull). A quarterly Minimum Data Set assessment (MDS-standardized assessment completed at specific intervals to identify specific resident 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 observations, review of clinical records and staff interviews it was determined the facility failed to provide person-centered care as prescribed to meet the current clinical needs, failed to ensure the ready availability of prescribed emergency supplies, and failed to follow physician orders for management of a midline catheter (long, thin, flexible tube that is inserted into a large vein in the upper arm. It is used to deliver medications or fluid into the bloodstream) for one resident out of 27 sampled (Resident 100). Findings include: A review of clinical records revealed Resident 100 was admitted to the facility on [DATE], with diagnoses to include urinary tract infection, and Extended Spectrum Beta Lactamase Resistance (ESBL- a bacteria resistant to most antibiotics) in the urine. Review of Resident 100's hospital record Peripherally Inserted Central Catheter (PICC) Midline Insertion Documentation dated August 1, 2024, revealed the resident underwent a procedure for a single lumen midline catheter…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, review of clinical records, select facility policy, staff, and resident interviews, it was determined that facility failed to implement pain management interventions when a resident suffered pain without relief for one resident out of 27 sampled (Resident 92). Findings include: A review of the policy title Pain-Clinical Protocol, last reviewed by the facility on August 1, 2024, revealed the physician and staff will identify individuals who have pain or who are at risk for having pain. This includes reviewing known diagnoses and conditions that commonly cause pain. It also includes a review of any treatments that the resident is currently receiving for pain, including pharmacological and non-pharmacological treatments. The policy also indicates staff will identify any situations or interventions where an increase in the resident's pain may be anticipated. With input from the resident to the extent possible, the physician and staff will establish goals for pain treatment. A 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of clinical records and staff interview, it was determined the facility failed to provide therapeutic social services to promote the mental and psychosocial well-being of one resident out of 27 sampled (Resident 69) Findings include: A review of the clinical record revealed that Resident 69 was admitted to the facility on [DATE], with diagnoses to include major depressive disorder, and intermittent explosive disorder. The resident's care plan, initiated August 5, 2020, indicated he is at risk for distressed/fluctuating mood symptoms related to anxiety. A review of a nursing note dated April 9, 2024, at 1445 at 2:45 PM indicated the nurse entered the residents' room to give Prednisone (a medication that reduces inflammation and suppresses the immune system) and to start his J tube feeding (a soft, plastic tube placed through the skin of the abdomen into the midsection of the small intestine used to administer liquid nutrition). Resident 69 refused, and an attempt was made by a different nurse…

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 controlled medication records, and staff interview, it was determined the facility failed to implement procedures to promote accurate accounting and administration of controlled medications and maintenance of accurate controlled substance records as evidenced by one resident of 27 sampled (Resident 99). Finding include: A review of the clinical record revealed that Resident 99 had a physician order initially dated June 24, 2024, at 4:15 PM for Oxycodone HCl oral tablet 5 MG (an opioid pain medication used to treat moderate to severe pain), give 5 mg by mouth every 6 hours as needed for pain 4-10 (numeric pain scale 1-10, 1 least pain, 10 most pain). A review of the Controlled Drug Administration Record accounting for the above narcotic medication revealed that on the following dates nursing staff signed for the removal of a dose from the resident's supply of Oxycodone 5 mg: August 21, 2024, at 6:00 PM, August 25, 2024, (time illegible), August (date illegible) at 11:45 PM, and August 28, 2024, at 8:00 PM, However, 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 the facility failed to ensure the presence of current documented clinical necessity for use of an antipsychotic medication for one of five residents reviewed for unnecessary medications (Resident 68). Findings include: A clinical record review revealed Resident 68 was admitted to the facility on [DATE], with diagnoses that included dementia (a condition characterized by the loss of cognitive functioning such as thinking, remembering, and reasoning, to such an extent that it interferes with a person's daily life and activities). A review of a quarterly Minimum Data Set assessment (MDS - a federally mandated standardized assessment process conducted periodically to plan resident care) dated August 8, 2024, revealed that Resident 68 is moderately cognitively impaired with a BIMS score of 8 (Brief Interview for Mental Status- a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of clinical records and select facility policy and staff interviews it was determined that the facility failed to provide emergency care consistent with a resident's advanced directives for one resident out of 14 residents reviewed (Resident CR1). Findings include: According to the national library of medicine, irreversible death is classified as a person having the following: rigor mortis (stiffening of the joints and muscles of a body a few hours after death), dependent lividity (pooling of blood to dependent areas resulting in a red/purple coloration), decapitation (total separation of the head from the body), transection (cut in half), and decomposition (the state or process of rotting) A review of Resident CR1's clinical record revealed admission to the facility on [DATE], with multiple diagnoses including cancer of the right lung, type 2 diabetes, heart disease, and anxiety. A review of Resident CR1's clinical record revealed a physician order dated [DATE], identifying the resident was 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 observation and staff interview, it was determined the facility failed to maintain an environment free of potential accident hazards and obstacles for safe mobility and use of mobility assistance devices on one of two resident units (Station 2). Findings include: An observation on August 11, 2024, at 8:50 AM of the hallway leading to the therapy department from the main entrance of the facility revealed 4 large reclining/wheelchairs lined up against the right-hand side of the wall. The hallway leading down the resident care area revealed multiple high back chairs setting outside of resident rooms, causing congestion in the hallways. These items obstructed continued access to the handrails which are to be used for resident ambulation or mobility assistance and did not create a homelike environment. During an interview August 11, 2024, the Nursing Home Administrator stated that resident care areas should be maintained in a clean and orderly manner. 28 Pa. Code 201.18 (e)(2.1) Management 28 Pa. Code 205.9 (c) Corridors

Based on observation, review of select facility policy and staff interview, it was determined the facility failed to implement procedures to ensure acceptable storage for medications on one of two nursing units observed (Station 1). Findings include: A review of facility policy titled Discontinued Medications, provided by the facility on August 11, 2024, revealed that discontinued medications are destroyed or returned to the issuing pharmacy in accordance with facility policy and state regulations. This policy refers to the policy entitled Discarding and Destroying Medications. A review of facility policy titled Discarding and Destroying Medications provided by the facility on August 11, 2024, revealed that individual resident medications supplied in sealed unopened containers may be returned to the issuing pharmacy for disposition provided that all such medications are identified as to lot or control number and the receiving pharmacist and a registered nurse employed by the facility sign a separate log that lists the resident's name; the name, strength, prescription number, and…

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

Based on review of clinical records, observation and staff interview it was determined the facility failed to maintain accurate and complete clinical records for three out of 14 residents reviewed. (Residents 7, 11, and 14) Findings included: The Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.145 Functions of the Licensed Practical Nurse (LPN) (a) The LPN is prepared to function as a member of the health-care team by exercising sound judgement based on preparation, knowledge, skills, understandings, and past experiences in nursing situations. The LPN participates in the planning, implementation, and evaluation of nursing care in settings where nursing takes place. 21.148 Standards of nursing conduct (a) A licensed practical nurse shall: (5) Document and maintain accurate records. According to the American Nurses Association Principles for Nursing Documentation, nurses document their work and outcomes and provide an integrated, real-time method of informing the health care team about the patient status. Timely documentation 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.

Based on review clinical records and resident and staff interviews it was determined that the facility failed to provide care in a manner and environment, which promotes each resident's quality of life by failing to respond timely to residents' requests for assistance, as evidenced by experiences reported by six residents out of 15 interviewed (Residents 2, 40, 54, 69, 89, and 92). Findings include: A review of resident clinical records, and a facility provided BIMS (brief interview mental status - to assess cognitive status) report, and random interviews conducted on April 24, 2024, with 15 alert and oriented residents, to include six residents residing on nursing station 1, and nine residents residing on the nursing station 2, revealed that 6 residents' interviewed expressed complaints regarding staff's failure to respond to their requests for assistance and provide requested and needed care and services in a timely manner. During the random interviews, the residents stated that they feel the facility is not adequately staffed because they wait extended periods of time for staff…

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, a review of clinical records and select grievances/complaints lodged with the facility, resident, and staff interviews it was determined that the facility failed to consistently administer oxygen as ordered and maintain sanitary oxygen delivery systems for two out of five sampled residents (Residents 59, and 72). Findings included: According to the American Thoracic Society, oxygen is a medication that requires a prescription from a healthcare provider. The provider will prescribe your oxygen at a specific flow rate and a specific number of hours per day. It is very important that oxygen is used as prescribed. Using too little oxygen may put a strain on the heart and brain, causing heart failure, fatigue, or memory loss. Using too much oxygen can also be a problem. For some patients, using too much oxygen can cause them to slow their breathing to dangerously low levels. It is important to wear oxygen as your provider ordered it. If the patient starts to experience headaches, confusion, or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, a review of the the minutes from Residents' Council meetings and grievances lodged with the facility, resident and staff interviews it was determined that the facility failed to provide food that accommodates resident preferences for 26 residents of 26 resident meal trays observed and as reported by nine residents out of 15 interviewed (Residents 1, 72, 73, 87, 88, 89, 91, 92, and 94). Findings include: A review of the minutes from the Resident Council meeting dated March 4, 2024, revealed that Resident 93 voiced concern that there has not been a good variety of food being offered at meals. A review of the minutes from the Resident Council meeting dated April 1, 2024, revealed that Resident 27 complained that the rice is always hard. Resident 93 voiced concern that the meat served during the St. Patrick's Day meal was tough and food is often hard or under cooked. A review of facility grievance dated February 23, 2024, indicated that Resident 44 complained that the scrambled eggs were…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and staff interview, it was determined that the facility failed to maintain acceptable practices for the storage and service of food to prevent the potential for contamination and microbial growth in food, which increased the risk of food-borne illness in two of two resident pantries. (Station 1 and Station 2) Findings include: Food safety and inspection standards for safe food handling indicate that everything that comes in contact with food must be kept clean and food that is mishandled can lead to foodborne illness. Safe steps in food handling, cooking, and storage are essential in preventing foodborne illness. You cannot always see, smell, or taste harmful bacteria that may cause illness according to the USDA (The United States Department of Agriculture, also known as the Agriculture Department, is the U.S. federal executive department responsible for developing and executing federal laws related to food). Observation of Station 2 resident pantry refrigerator on January 18, 2024, at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of select facility policies and clinical records it was determined that the facility failed to provide nursing services consistent with professional standards of quality by failing to demonstrate that licensed nurses evaluated and recorded the provision of necessary nursing care for a change in condition for one resident out of six sampled residents (Resident 1). Findings included: According to the Title 49, Professional and Vocational Standards, Department of State, Chapter 21 State Board of Nursing Subsection 21.11 (a) The register nurse assesses human responses and plans, implements and evaluates nursing care for individuals or families for whom the nurse is responsible. In carrying out this responsibility, the nurse performs all of following functions: (4) Carries out nursing care actions which promote, maintain, and restore the well-being of individuals (6)(b) The registered nurse is fully responsible for all actions as a licensed nurse and is accountable to clients for the quality 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.