Edenbrook South

Based on clinical record review and staff and resident interview, it was determined that the facility failed to implement a comprehensive, person-centered care plan regarding a diagnosis for PTSD (Post-Traumatic Stress Disorder, a mental health condition triggered by experiencing or witnessing a traumatic event, leading to severe anxiety, flashbacks, and emotional distress) for one of 19 residents reviewed (Resident 9).Findings Include: During an interview with Resident 9 on February 8, 2026, at 1:38 PM, the resident stated he was diagnosed with PTSD related to a history of childhood sexual trauma. Clinical record review for Resident 9 revealed that the resident was diagnosed with PTSD on March 8, 2025. Review of Resident 9's current comprehensive plan of care (a summary of a resident's personal health, nursing, and psychological well-being needs and how they can be met) included two stated goals; I will remain comfortable and safe in my environment, and I will not have episodes of crisis. There were two listed interventions including, Discuss feelings of anger with resident, and I…

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

Based on observation, clinical record review, and resident family and staff interview, it was determined that the facility failed to provide a dependent resident with activities of daily living assistance for one of four residents reviewed (Resident 11).Findings include: Observation of Resident 11 on February 8, 2026, at 12:58 PM revealed he was sleeping in bed and his hair appeared long (shoulder length) and disheveled. Interview with Resident 11 on February 9, 2026, at 1:52 PM revealed that he wished to have his hair cut. Concurrent interview with Resident 11 on February 10, 2026, at 10:15 AM revealed Resident 11 again stated a desire to have his hair cut, indicating he was not sure why it was taking so long. The findings for Resident 11 were reviewed with the Nursing Home Administrator and Director of Nursing on February 9, 2026, at 2:30 PM. They were unable to provide an explanation as to why Resident 11 has not received a haircut for an extended period. Review of social service documentation dated February 9, 2026, at 6:00 PM revealed social worker asked Resident 11 if he would…

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

Based on clinical record review, observation, review of select facility policies and procedures, and staff interview, it was determined that the facility failed to provide appropriate treatment and services for a resident who is fed by enteral (feeding tube) means to prevent potential complications for one of one resident reviewed for tube feeding concerns (Resident 36).Findings include: Review of facility policy titled Policy & Procedure Tube Feeding: Continuous Tube Feeding last reviewed on September 9, 2025, states under step 7 of the procedure to elevate the head of the bed at least 30 degrees during feeding and for 30 to 60 minutes after feeding unless contraindicated. Observation of Resident 36 on February 8, 2026, at 12:20 PM revealed the presence of a feeding tube (G-tube, a tube that is placed directly into the stomach through an abdominal wall incision for administration of food, fluids, and medications; also known as a PEG tube) connected to a feeding pump (a mechanical device used to pump fluids and a specialized liquid nutrition source referred to as feed, through a…

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

Based on clinical record review, observation, and staff interview, it was determined that the facility failed to store respiratory care equipment in a sanitary manner on one of four nursing units (South, Resident 33) and provide respiratory care consistent with professional standards of practice for one of two residents reviewed for respiratory concerns (Resident 4).Findings include: Observation of Resident 33's bedside table on February 8, 2026, at 12:24 PM revealed a nebulizer machine (a compressor device that converts liquid medication into a fine mist, allowing for easier inhalation into the lungs) with nebulizer tubing (a removable, flexible hose that connects the nebulizer machine to the liquid medication cup, allowing air to flow through and convert liquid medication into a mist for inhalation) and a nebulizer mask with a medicine cup (a breathing mask worn over the nose and mouth connected to the medicine cup, which ensures that the aerosolized medicine is adequately inhaled) on the table. The mask appeared to be coated in a slightly opaque white colored film, and the…

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

Based on review of facility documentation and staff interview, it was determined that the facility failed to ensure that nursing staff possessed the appropriate competencies and skill sets related to the care and assessment of residents with wound vacs for four of four employees reviewed (Employees 4, 5, 6, and 7). Findings include: Clinical record review revealed the facility admitted Resident 3 on November 20, 2025. A physician order dated January 13, 2026, revealed nursing staff are to apply a wound vac (a therapy that uses a device to decrease air pressure on a wound) to Resident 3's sacral area wound using black foam and setting to 125 mmhg (millimeters of mercury). A request for nursing staff competencies for Resident 3's wound vac revealed the facility was unable to provide any competencies related to wound vacs for Employees 4 and 5 (licensed practical nurses) and Employees 6 and 7 (registered nurses). The findings were reviewed with the Nursing Home Administrator and Director of Nursing on February 11, 2026, at 9:44 AM. They confirmed the facility could provide no…

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

Based on clinical record review and staff interview, it was determined that the facility failed to obtain and provide medications for one of 19 residents reviewed (Resident 20). Findings include: Clinical record review for Resident 20 revealed that the facility admitted her on June 16, 2017. Further clinical record review revealed that she had diagnoses of bipolar disorder (a mental health disorder characterized by intense mood swings, ranging from extreme highs to deep lows), psychotic disorder with hallucinations (a loss of contact with reality, characterized by hearing voices, seeing things, or feeling sensations that are not there), restlessness and agitation, generalized anxiety disorder (a mental health condition characterized by chronic, excessive, uncontrollable worry), and vascular dementia with agitation (triggered by brain damage from reduced blood flow to the brain causing cognitive decline with behaviors of increased motor activity, restlessness, irritability, and aggression). Review of Resident 20's medication administration record (MAR) for December 2025, 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.

Based on observation and staff interview, it was determined that the facility failed to ensure a medication error rate below five percent on one of four nursing units (North Nursing Unit; Residents 75 and 94). Findings include: The facility's medication error rate was 11.54 percent based on 26 medication opportunities with three medication errors. Review of Resident 75's current physician orders revealed an order dated September 24, 2025, for Potassium Chloride (potassium supplement) ER (extended release) oral tablet 20 mEq (milliequivalent); give 1 tablet by mouth two times a day, dissolve in small amount of fluid for slurry. Observation of Resident 75's medication administration on February 8, 2026, at 8:37 AM revealed that Employee 10, licensed practical nurse, crushed the Potassium Chloride ER tablet and placed it in pudding with additional crushed medications to administer to Resident 75. Employee 10 did not prepare the Potassium Chloride ER as ordered. Drugs.com (an online comprehensive source of drug information) states do not chew, break, or crush the medication. Review of…

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

Based on a review of select facility policies and procedures, observation, and staff and resident interviews, it was determined that the facility failed to ensure an environment free from the potential spread of infection on one of eight residents reviewed for infection control (Resident 22).Findings include: The facility policy entitled Isolation Precautions, last reviewed without changes September 9, 2025, revealed contact precautions will be implemented for residents suspected or confirmed to be infected with a communicable disease/infection that can be transmitted by direct contact with the resident or indirect contact with environmental surfaces/equipment in the resident's environment. Residents should be placed in a private room when available. Prior to entering the isolation room, the following steps are required: perform hand hygiene and apply gloves and gown prior to entering room, while providing direct resident care, wear gloves and wash hands after coming into contact with infectious material, remove gloves and perform hand hygiene before leaving room. Clinical record…

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

Based on a review of employee personnel and education records and staff interviews, it was determined that the facility failed to ensure that each nurse aide received 12 hours of in-service training annually for one of three nurse aides reviewed (Employee 1).Findings include: Review of Employee 1's, nurse aide, personnel record revealed that the facility hired her on September 21, 2022. The surveyor requested training records for Employee 1 during an interview with the Nursing Home Administrator and the Director of Nursing on February 9, 2026, at 2:38 PM. Review of training records provided by the facility for Employee 1 on February 10, 2026, revealed that Employee 1 completed only 3.35 hours of in-service education in the last year. Interview with the Director of Nursing and the Nursing Home Administrator on February 11, 2026, at 9:44 AM confirmed the above findings for Employee 1, and were unable to provide any further documentation indicating Employee 1 received 12 hours of in-service training annually. 28 Pa. Code 201.19(7) Personnel policies and procedures 28 Pa. Code…

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

Based on a review of facility documents, clinical record review, and resident and staff interviews, it was determined that the facility failed to ensure care and services were provided in accordance with professional standards of quality for three of six residents reviewed (Residents 1, 2, and 3).This deficiency is cited as past non-compliance.Findings Include: Review of facility reportable events and an abuse investigation report revealed that on October 2, 2025, Employe 2, NA (nurse aide), administered medications and completed medical treatments on behalf of Employee 1, LPN (licensed practical nurse), for Residents 1, 2, and 3. An interview with the DON (Director of Nursing) and the NHA (Nursing Home Administer) on December 23, 2025, at 11:30 AM revealed that on October 8, 2025, it was reported to the DON that Employee 2, NA, had administered medications. Review of Employee 2's statements revealed that on October 2, 2025, she had administered prescribed medications by oral (by mouth), PEG tube (Percutaneous Endoscopic Gastrostomy tube, is a tube surgically inserted through the…

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

Based on clinical record review and staff interview, it was determined that the facility failed to obtain and provide medications for one of six residents reviewed (Resident 1). Findings include: Review of Resident 1's clinical record revealed that the facility admitted him on April 29, 2025. Review of Resident 1's hospital discharge records dated April 29, 2025, indicated that Resident 1 has a history of schizoaffective disorder and was to continue his Ingrezza (can be used off label for schizoaffective disorder, a chronic mental health condition) 40 mg (milligrams) nightly. A nursing progress note dated April 29, 2025, at 2:51 PM indicated that Resident 1's sister will be bringing in his Ingrezza on April 30, 2025, and that the pharmacy will not be providing. Resident 1 did not receive his nightly dose of Ingrezza on April 29, 2025. There was no indication why the pharmacy was not providing the medications, or why Resident 1's sister was expected to bring in the medication. The Ingrezza was the only medication that was not being obtained through the facility's pharmacy. Review of…

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

Based on clinical record, review of select facility policies, and staff interview, it was determined that the facility failed to provide the highest practical care related to bowel management for one of four residents reviewed (Resident 1) Findings include: The current facility policy entitled Standing Orders for Skilled Nursing Facility, revealed the following orders are initiated from standing orders. The bowel and gastrointestinal (organs that help with digestion) protocol includes nursing staff will administer residents Milk of Magnesia (MOM) 30 milliliters (mL) by mouth on the day shift of day three without a bowel movement. Nursing staff are to administer a Dulcolax Suppository 10 milligram (mg) on the evening shift of day three if the Milk of Magnesia is ineffective. Nursing staff are to administer a Fleet's enema as needed on day four without a bowel movement if no results from the suppository. Nursing staff can administer 15 to 30 mL every two hours for as needed gastrointestinal distress. Clinical record review for Resident 1 revealed the facility initiated a plan 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.

Based on clinical record review, review of select facility policies and procedures, and staff interview, it was determined that the facility failed to implement interventions to promote acceptable parameters of nutrition for one of nine residents reviewed (Resident 1). Findings include: The facility policy entitled Resident Height and Weight, last reviewed without changes on January 7, 2025, revealed nursing department staff and the facility dietician will cooperate to prevent, monitor, and provide interventions for undesirable weight variances for residents. A significant weight change is defined as a 5 percent weight change over 30 days, 7.5 percent weight change over 90 days, or a 10 percent weight change over 180 days. Upon admission, and two days following, the nursing department staff will weigh the resident, weekly thereafter for four weeks, and then monthly unless otherwise ordered by the physician, or recommended by the dietitian. Any weight change of five pounds or greater within 30 days will be retaken within 72 hours for verification, and the reweight will be documented…

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 store food and maintain food service equipment in accordance with professional standards for food service safety in the facility's main kitchen. Findings include: Observation of the facility's main kitchen on January 21, 2025, at 8:58 AM with Employee 1, dietary director, revealed the following: Two large bulk clear plastic containers were observed on a lower shelf of a production table with a white substance in each container. One container was labeled as flour and the other sugar, but there was no date to indicate when the products were placed in the containers or when they needed used by. Several white potholders were observed sitting on top of the convection oven. The potholders were soiled with dried foods and significantly stained. The bottom shelf of the steamer and prep table had dried food debris. The bottom shelf of the steamer and lower shelf of the production table across from the steamer contained dust and dried food debris. The flooring under and behind the steamer and the table beside…

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

Based on clinical record review and staff interview, it was determined that the facility failed to provide activities of daily living (ADL) for two of five residents reviewed (Resident 65 and 89). Findings include: Clinical record review for Resident 65 revealed that the facility completed a significant change MDS assessment (Minimum Data Set, an assessment tool completed at specific intervals to determine resident care needs) on November 25, 2024, which indicated that it was somewhat important that they choose between a tub bath, shower, bed bath, or sponge bath. The MDS also identified that they were dependent on staff for a shower and to bathe themself. Review of Resident 65's task documentation (documentation where staff indicate completion of ADL care) revealed that since June 29, 2023, staff was to complete ADL - Bathing (bed bath) during the day shift on Tuesdays and Saturdays. Review of Resident 65's task documentation revealed that there was documentation that indicated staff provided the following showers to Resident 65: October 5 and 29, 2024 November 12, 19, 26, and 30,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff interview, it was determined that the facility failed to provide services to maintain or improve a resident's range of motion (ROM) and mobility for three of seven residents reviewed (Residents 42, 65, and 70). Findings include: Clinical record review for Residents 65 revealed a current therapy restorative referral dated November 29, 2024. Therapy staff indicated nursing staff should provide seated AROM/AAROM (active and active assisted range of motion, movement of the body to maintain a resident's ability) one to two times daily for their LAQ's (bilateral anterior quadriceps, upper leg muscles) marches, heel to toes, hip abduction (legs move away from the body's midline), adduction (legs move towards the body's midline), and pillow squeezes. Review of Resident 65's task documentation revealed that nursing staff did not implement the AROM/AAROM the restorative nursing program until December 6, 2024, day shift. There was no documentation that staff completed or indicated…

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

Based on review of facility documentation and staff interview, it was determined that the facility failed to ensure that nursing staff possessed the appropriate competencies and skill sets related to the care and assessment of residents with enteral tube feeding, tracheostomy care, catheter care, medication administration, and dressing changes for four of four employees reviewed for competencies (Employees 4, 5, 6, and 7). Findings include: A review of the facility documentation revealed that the facility had a total of 121 residents receiving medications, 10 residents with indwelling catheters (insertion of a tube into the bladder to remove urine), five residents with pressure ulcers, five residents with enteral tube feedings (device that allows liquid food to enter your stomach or intestine through a tube), and one resident with a tracheostomy (a surgical airway management procedure that consists of making an incision on the anterior aspect of the neck and opening a direct airway through an incision in the trachea). A request for nursing staff competencies for enteral tube…

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

Based on clinical record review and staff interview, it was determined that the facility failed to maintain pharmacy recommendations or evidence pharmacy recommendations were addressed by the physician for three of five residents reviewed (Residents 23, 42, and 49). Findings include: Clinical record review for Resident 23 revealed a pharmacist monthly medication review note dated June 10, 2024, which indicated a medication review was completed for the resident and to see report for recommendation. There was no evidence of the pharmacist report of recommendations or a physician's response to a pharmacy recommendation for the date indicated. Interview with the Nursing Home Administrator and Director of Nursing on January 24, 2025, at 8:52 AM revealed the pharmacy recommendation for June 10, 2024, could not be located to determine if the physician addressed the recommendation. Clinical record review for Resident 49 revealed that the consultant pharmacist completed a medication review on November 10, 2024. There was no documentation what the consultant pharmacist recommended or that the…

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

Based on clinical record review and staff interview, it was determined that the facility failed to ensure a resident's medication regime was free from potentially unnecessary medications for two of five residents reviewed for medication regime review (Residents 9 and 65). Findings include: Clinical record review revealed the facility admitted Resident 9 on January 16, 2023. Review of the consultant pharmacist's recommendation dated July 13, 2024, revealed Resident 9 has been receiving Buspar (medication used to treat anxiety) 10 milligrams (mg) three times a day and Cymbalta (antidepressant medication) 90 mg every day. The consultant pharmacist requested the facility consider an attempted dose reduction or trial discontinuation. Resident 9's physician agreed to change her Cymbalta to 60 mg every day on July 24, 2024. Further review of Resident 9's clinical record revealed the facility never decreased her Cymbalta to 60 mg until January 17, 2025. Interview with the Nursing Home Administrator and Director of Nursing on January 24, 2025, confirmed these findings indicating the facility…

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

Based on observation and staff interview, it was determined that the facility failed to prevent the potential spread of infection during medication administration pass for two of five residents observed (Residents 10 and 60), during a dressing change for one of one resident observed for a dressing change (Resident 50), and failed to adhere to enhanced barrier precautions for one of one resident observed during observation of a dressing change (Resident 50). Findings include: Observation of Employee 8 (Licensed Practical Nurse, LPN) during a medication administration pass on January 23, 2025, at 8:35 AM revealed she prepared the following medications for Resident 10, Famotidine (a medication used to treat ulcers of reflux disease) 20 milligrams (mg) two capsules; Mucinex (a medication used to treat cough caused by the common cold) 600 mg one tablet; One daily with minerals (a multi vitamin) one tablet; Vitamin D3 (used to supplement vitamin D in the body) 1000 units, one capsule; Colace (a medication used to treat or prevent constipation) 100 mg one capsule; and Fexofenadine (a…

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

Based on observation and staff interview, it was determined that the facility failed to ensure that care and services were provided in a manner that enhanced resident dignity for one of 21 residents sampled (Resident 61). Findings include: Observation on January 21, 2025, at 10:42 AM revealed Resident 61 was sleeping in bed. Observation from the hallway revealed Resident 61's catheter bag was full of urine, not covered, and laying on the floor. Observation on January 22, 2025, at 10:36 AM revealed Resident 61 was sleeping in bed. Observation from the hallway revealed Resident 61's catheter bag was again not covered and laying on the floor. The surveyor reviewed the above findings during a meeting with the Director of Nursing on January 24, 2025, at 9:34 AM. CFR 483.10(a) Resident Rights/Exercise of Rights. Previously cited deficiency 2/16/24. 28 Pa. Code 201.18(b)(1) Management

Based on observation and staff interview, it was determined that the facility failed to provide adequate housekeeping and maintenance services to maintain a clean and safe environment on four of four nursing units (North, South, East and West, Residents 85, 56, 68, 14, 39, and 50 ). Findings include: An observation of Resident 85 on January 21, 2025, at 10:28 AM revealed the resident was in bed. An enteral feeding pump was observed hanging from the pole beside the resident's bed, not in use. The feeding pump was observed to have several spots of dried brown liquid splatter/spills on the exterior of the feeding pump. There was no enteral feeding bag/container hanging at the time of the observation. Resident 85's observation of the feeding pump was reviewed with the Director of Nursing on January 22, 2025, at 2:30 PM. An observation of Resident 56 on January 21, 2025, at 11:01 AM revealed the resident was in bed. An enteral feeding pump and bag was observed hanging from a pole beside the resident's bed. The feeding pump was observed to have several spots of dried brown liquid…

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

Based on clinical record review, staff interview, and review of facility investigation documentation, it was determined that the facility failed to thoroughly investigate a resident's injury of unknown origin for one of two residents reviewed for abuse (Resident 42). Findings include: Clinical record review for Resident 42 revealed a progress note dated December 30, 2024, at 1:16 PM that indicated the nurse was made aware of Resident 42 having a bruise on the right side of her face that measured 3 centimeters (cm) x 2 cm and was dark bluish and purplish in color. The bruise was on the outside of the right eye. The note indicated that Resident 42 is combative with care and staff were educated to walk away when performing care if the resident becomes combative to avoid self-inflicted wounds. Further clinical record review revealed that there was no follow-up progress notes related to the event until January 22, 2025, at 5:49 PM after the surveyor inquired about event reports related to Resident 42 in a meeting on January 22, 2025, at 3:01 PM with the Director of Nursing. The note…

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

Based on clinical record review and staff interview, it was determined that the facility failed to ensure assessments accurately reflected a resident's status for one of 21 residents reviewed (Resident 52). Findings include: Clinical record review for Resident 52 revealed a quarterly MDS (Minimum Data Set, an assessment tool completed at specific intervals to determine resident care needs) dated November 6, 2024, that facility staff assessed Resident 52 as receiving an anticoagulant medication during the last seven days in the assessment period. Further clinical record review revealed no evidence that Resident 52 received an anticoagulant medication during the assessment period for the MDS noted above. Interview with the Director of Nursing on January 23, 2025, at 2:31 PM confirmed that Resident 52's November 6, 2024, MDS was coded in error regarding receiving an anticoagulant medication. 28 Pa. Code 211.5(f)(ix) Medical records 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on clinical record review, observation, and resident and staff interview, it was determined that the facility failed to ensure the highest practical care related to consultant recommendations for one of 21 residents reviewed (Resident 93). Findings include: Observation and interview with Resident 93 on January 21, 2025, at 10:51 AM revealed Resident 93 complained of a cold hand. Observation of his right hand revealed he had no grasp, and his fingers were partially contracted. He stated that he sits on his hand to try and warm up his hand and straighten his fingers. Resident 93 stated that he went to see a specialist about his hand. Review of Resident 93's clinical record indicated he saw a plastic surgeon on January 13, 2025, due to pain and stiffness in his right hand. The physician progress note indicated with some exercise Resident 93's range of motion improved. The physician noted that the facility stopped doing occupational therapy even though he was improving. The physician recommended warm soaks twice a day and a need to resume hand therapy. Further review of Resident…

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

Based on observation, clinical record review, and staff interview, it was determined that the facility failed to provide appropriate respiratory care and services for one of three residents reviewed (Resident 43). Findings include: According to the American Association for Respiratory Care proper cleansing of respiratory (nebulizer) equipment reduces infection risk. The longer a dirty nebulizer sits and is allowed to dry, the harder it is to clean thoroughly. Parts of the aerosol drug delivery device should be rinsed and then washed with soap and hot water after each treatment. Once completely dry, store the nebulizer cup and mouthpiece in a zip lock bag. Clinical record review for Resident 43 revealed a current physician's order for staff to provide oxygen at 5 liters per minute (LPM) via NC (nasal canula, tubing to deliver oxygen to the nose) continuously every day and evening shift for supplementary oxygen and BiPAP (pressurized non-invasive air ventilation via mask): oxygen 6 to 7 LPM at bedtime and as needed (PRN) for sleep apnea. Observation of Resident 43's oxygen…

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 secure treatments on one of four nursing hallways (North Hall, Resident 56). Findings include: Observations of Resident 56's room on January 21, 2025, at 10:02 AM, January 22, 2025, at 10:19 AM, and January 23, 2025, at 10:52 AM, revealed two open bottles of Dakin's solution (an antiseptic used to treat and prevent infections in wounds), and a bottle of Derma wound cleanser (antiseptic for skin and wounds) on the windowsill. The label on the bottle read to keep out of reach of children, and if swallowed to get medical help, or call poison control. The above findings for Residents 56 and were reviewed with the Nursing Home Administrator and Director of Nursing during a meeting on January 23, 2025, at 2:29 PM. The Director of Nursing confirmed the above-mentioned items should not be stored on Resident 56's windowsill. 483.45(g)(h)(1)(2) Label/store Drugs and Biologicals Previously cited deficiency 2/16/24 28 Pa. Code 211.9 (a)(1)(k) Pharmacy services 28 Pa. Code 211.12 (d)(1)(3)(5) Nursing services

Based on observation, clinical record review, and interviews with staff and residents, it was determined that the facility failed to provide dependent residents with activities of daily living assistance for three of five residents reviewed (Residents 2, 3, and 4). Findings include: Clinical record review for Resident 2 revealed a plan of care developed by the facility to address his deficits with performing activities of daily living (initiated October 14, 2022). Interventions included in the plan of care noted that Resident 2 requires supervision/cueing for personal hygiene. Observation of Resident 2 on September 12, 2024, at 10:53 AM revealed several days of beard growth on his face. Interview with Resident 2 on the date and time of the observation revealed that staff shave him because he cannot see what he is doing to do it well. Resident 2 stated that he could not remember, but he may have had shaving assistance with his shower on Monday. Resident 2 stated that although his showers are scheduled for Mondays and Thursdays, he had a shower yesterday (Wednesday). Resident 2 stated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff and resident interview, it was determined that the facility failed to provide services for mobility deficits for two of five residents reviewed (Residents 2 and 4). Findings include: Review of Resident Council meeting minutes dated July 10, 2024, revealed that Resident 2 had concerns regarding, walking. A Resident Concern Report dated July 10, 2024, revealed that Resident 2 wanted an evaluation for walking. Findings recorded on the form indicated that physical therapy evaluated Resident 2 on July 11, 2024, and began physical therapy services. Clinical record review for Resident 2 revealed a physical therapy Discharge summary dated [DATE], that indicated staff discharged Resident 2 from skilled physical therapy services. The documentation indicated that the skilled physical therapy staff did not indicate a restorative program at that time. Clinical record review for Resident 2 revealed a plan of care developed by the facility to address his need for a restorative program…

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

Based on observation and resident and staff interview, it was determined that the facility failed to provide food that accommodated resident preferences for one of five residents reviewed (Resident 5). Findings include: Interview with Resident 5 on September 12, 2024, at 11:11 AM revealed that she rated the facility's meals a seven on a one to 10 scale (10 being very good). Resident 5 stated that her strongest complaint was that she either received food that she is allergic to (strawberries, occurred approximately one month ago) or food that is on her dislike list of foods that she would prefer she not receive. She stated that she repeatedly receives rice, which she claims that she has reported that she does not like. Resident 5 stated that staff do not offer to obtain an alternative when she reports errors in her provided meal. Resident 5 claimed that staff often respond, .well, that's what they (dietary staff) put on your tray. Observation of the lunch meal on September 12, 2024, at 12:05 PM revealed Resident 5 was in the [NAME] Hall dining room talking to Employee 2 (activities…

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 provide a clean, comfortable, and homelike environment on four of four nursing units reviewed (North, East, South, and [NAME] Nursing Units, Resident 1). Findings include: Observations on the [NAME] Nursing Unit on August 6, 2024, between 9:05 AM and 9:15 AM revealed the following: The main dining room revealed three vents on the center of the ceiling that had an accumulation of what appeared to be moisture related dark colored spots on the majority surface of the vents. A smaller vent on the ceiling located near the perimeter of the ceiling with the wall had a significant accumulation of a dust-like substance. A nourishment ice cart at the South/West nurse station revealed a drip tray underneath the ice chest that had a slimy, black colored substance accumulated on the entire perimeter of the drip tray. There was a brown moisture stain on the ceiling tile near the exit sign. A vent on the ceiling in the hallway in front of the South/West nurse's station was noted to have a significant…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on closed clinical record review and staff interview, it was determined that the facility failed to ensure each resident's medication regimen was free from unnecessary medications for one of five residents reviewed (Resident CR1). Findings include: Closed clinical record review for Resident CR1 revealed that she resided in the facility from [DATE], to May 10, 2024. Diagnoses for Resident CR1 did not indicate a history of cancer or radiation treatments. A verbal physician order dated April 10, 2024, instructed staff to administer Temozolomide (medication is used to treat certain types of brain cancer) 140 mg (milligrams) by mouth one time a day, give med for duration of radiation NPO (nothing by mouth) for 90 min (minutes) prior to administration. There was no appropriate diagnosis included with the Temozolomide medication order as the resident did not have cancer and was not prescribed radiation therapy. Employee 5 (certified registered nurse practitioner, CRNP) electronically signed the order on April 15,…

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

Based on review of select facility policies and procedures, review of employee personnel records, and staff interview, it was determined that the facility failed to thoroughly investigate and report to the required agencies an allegation of resident mental abuse for one of five residents reviewed (Resident CR1). Findings include: The CMS State Operations Manual, Appendix PP - Guidance to Surveyors for Long Term Care, revised February 3, 2023, defines abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled by technology. Mental abuse is the use of verbal or nonverbal conduct which causes or has the potential to cause the resident to experience humiliation, intimidation, fear, shame, agitation, or degradation. Mental abuse includes abuse that is facilitated or enabled through the use of technology, such as smartphones and other personal electronic devices. This would 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff interview, it was determined that the facility failed to provide bathing assistance for a dependent resident for one of five residents reviewed (Resident CR1). Findings include: Closed clinical record review for Resident CR1 revealed that she resided in the facility from [DATE], to May 10, 2024. Review of an admission MDS (Minimum Data Set, an assessment tool completed at specific intervals to determine resident care needs) dated April 3, 2024, revealed that staff assessed that Resident CR1 was dependent upon staff to shower or bathe. Review of the Documentation Survey Report (electronic documentation by nurse aides for the completion of tasks related to activities of daily living) dated April 2024, for Resident CR1 revealed that nurse aides were to complete bathing via a bed bath on Tuesdays and Saturdays. Staff documented that Resident CR1 required the physical help of staff or was completely dependent upon the physical performance of the task by staff for bathing. 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 interview, it was determined that the facility failed to ensure that a physician supervised the care of one of five residents reviewed (Resident CR1). Findings include: Closed clinical record review for Resident CR1 revealed that she resided in the facility from [DATE], to May 10, 2024. Diagnoses for Resident CR1 did not indicate a history of cancer or radiation treatments. A verbal physician order dated April 10, 2024, instructed staff to administer Temozolomide (medication used to treat certain types of brain cancer) 140 mg (milligrams) by mouth one time a day for, give med for duration of radiation NPO (nothing by mouth) for 90 min (minutes) prior to administration. There was no appropriate diagnosis included with the Temozolomide medication order as the resident did not have cancer and was not prescribed radiation therapy. Employee 5 (certified registered nurse practitioner, CRNP) electronically signed the order on April 15, 2024, for nursing staff to implement the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on closed clinical record review and staff interview, it was determined that the facility failed to ensure that the consultant pharmacist identified a potential medication irregularity for physician review for one of five residents reviewed (Resident CR1). Findings include: Closed clinical record review for Resident CR1 revealed that she resided in the facility from [DATE], to May 10, 2024. Diagnoses for Resident CR1 did not indicate a history of cancer or radiation treatments. A verbal physician order dated April 10, 2024, instructed staff to administer Temozolomide (medication used to treat certain types of brain cancer) 140 mg (milligrams) by mouth one time a day for, give med for duration of radiation NPO (nothing by mouth) for 90 min (minutes) prior to administration. There was no appropriate diagnosis included with the Temozolomide medication order as the resident did not have cancer and was not prescribed radiation therapy. A Pharmacy Monthly Medication Review dated April 16, 2024, at 10:03 AM…

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 store food and maintain food service equipment in accordance with professional standards for food service safety in the facility's main kitchen and employee breakroom. Findings include: Observation of the facility's main kitchen on February 13, 2024, at 9:30 AM with Employee 1, food service director revealed the following: A large gray garbage can in the food preparation area across from the coolers was observed with visible dried food and dried liquid runs on the exterior of the lid and can, crumbs and debris were observed collected in the grooves of the handles. The coating of shelves in the coolers by the floor mixer was peeled/worn off in several locations exposing rust colored metal. Flooring throughout the kitchen under preparation tables, steam table, and coolers, along with the wall edges in corners and behind equipment was observed with significant debris and black buildup. The lower shelf of the preparation table and steam table contained dried spills and splatter, and dried food debris.…

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, clinical record review, and staff and resident interview, it was determined that the facility failed to provide treatment and services regarding skin assessments and treatments for four of five residents reviewed (Residents 27, 95, 93, and 82). Findings include: Review of Resident 95's clinical record revealed a follow up progress note from a wound care consultant company dated October 17, 2023, that indicated that her sacral area was assessed, and that the treatment plan would be cleaning Resident 95's sacral area with acetic acid (helps kill microorganisms in the wound), applying Santyl (a gel that helps debride wounds), and apply a foam dressing. Review of the facility's physician order dated October 17, 2023, did not contain the recommended acetic acid, nor was there documented evidence to indicate contraindication to its use. The wound care consultant assessed Resident 95's sacral wounds on October 31, 2023, and indicated that the treatment plan should remain the same as on October 17,…

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

Based on observation, clinical record review, and staff interview, it was determined that the facility failed to provide care, consistent with physician orders, for the administration of supplemental oxygen for five of eight residents reviewed for oxygen use (Residents 27, 78, 97, 60, and 93). Findings include: Review of Resident 27's clinical record revealed a physician's order dated January 20, 2024, for nursing staff to administer two Liters of oxygen per minute via nasal cannula continuously (a tubing that connects the flow of oxygen to the resident's nose) every day related to chronic obstructive pulmonary disease. Observation on February 13, 2024, at 12:39 PM revealed Resident 27 was in bed and his oxygen was running at 6 liters per minute. Observation on February 14, 2024, at 9:37 AM and 12:05 PM revealed Resident 27 was in bed with his oxygen running at 6 liters per minute. Observation with Employee 2 (licensed practical nurse) on February 14, 2024, at 12:15 PM confirmed these findings. The facility failed to provide supplemental oxygen as ordered by Resident 27's physician.…

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

Based on clinical record review and staff interview, it was determined that the facility failed to ensure that the resident's attending physician addressed pharmacy recommendations for two of six residents reviewed (Residents 58 and 24) and failed to ensure that the consulting pharmacist identified potential appropriateness for psychoactive medications for one of six residents reviewed (Resident 23). Findings include: Review of Resident 23's clinical record revealed a physician's order dated December 15, 2023, for nursing staff to administer Ativan (used to treat anxiety) 0.5 mg (milligrams) every four hours as needed for restlessness and agitation for three months. There was no documented evidence in Resident 23's clinical record to indicate a rationale for extending the as needed Ativan past 14 days. Review of Resident 23's pharmacy consultation report dated January 10, 2024, did not identify the inappropriateness of Resident 23's Ativan order past 14 days. Review of Resident 58's clinical record revealed a consultant pharmacy recommendation dated July 18, 2023, indicating that…

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

Based on observation and resident and staff interviews, it was determined that the facility failed to ensure that care and services were provided in a manner that enhanced resident dignity for two of 21 residents sampled (Residents 27 and 56). Findings include: Observation on February 13, 2024, at 10:48 AM and 1:47 PM revealed Resident 56 was in bed with his urinary catheter bag hanging full of urine on the door side of the bed, uncovered. The urinary catheter bag was able to be observed from the hallway. Observation on February 13, 2024, at 12:38 PM revealed Resident 27 was in bed with his urinary catheter bag hanging full of urine on the door side of the bed, uncovered. The urinary catheter bag was able to be observed from the hallway. Resident 27 was in a hospital gown at this time and when questioned, he confirmed that he went to therapy this morning in the hospital gown. Observation on February 14, 2024, at 1:13 PM revealed Resident 27 was in his wheelchair in a hospital gown. Resident 27 confirmed he wears the hospital gown to therapy every day. He stated that he has clothes…

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

Based on clinical record review and staff interview, it was determined that the facility failed to consult a physician for a deterioration in health status for one of seven residents reviewed for hospitalization (Resident 65). Findings include: Review of a nursing progress note for Resident 65 dated December 7, 2023, at 4:30 PM revealed that the resident asked for the nurse and he usually does not. The resident had an emesis (vomited). Resident 65 reported his stomach was upset. He was coughing and wheezing (a high-pitched noise that indicates narrowing and inflammation of the airway in any location, from the throat to the lungs). Resident 65 had a temperature of 100.8 degrees (feverish, possibly indicating an infection). The resident was given Tylenol (medication to reduce fever). With a temperature recheck, the resident was afebrile (no fever). The resident refused tube feeding (nutrition given by way of a tube that is inserted in the stomach). The resident had adventitious breath sounds (abnormal sounds in the lungs). The resident refused the suggestion of going to the emergency…

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 provide a clean and safe environment and maintain resident medical equipment free of disrepair on two of two nursing units (North and South Hall; Residents 60 and 65). Findings include: An observation of Resident 60, north hall, on February 13, 2024, at 11:54 AM revealed the resident sleeping in bed. An enteral feeding pump was observed to be running and attached to the resident. Several spots of a dried brown substance (the same color as the feeding formula hanging in the bag above) were observed on the feeding pump. The head of the resident's bed was elevated. The frame of the resident's bed was very dusty. A suction machine sitting on a tray table near Resident 60's bed was observed with several rusty spots on the machine. The machine contained a maintenance check sticker that indicated the machine was last checked by maintenance in June 2021. The floor of Resident 60's bathroom contained holes in the linoleum. A follow up observation of Resident 60's enteral feeding pump on February 14, 2024,…

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

Based on clinical record review, observation, and resident, family, and staff interview, it was determined that the facility failed to assist with mouth care for residents requiring staff assistance for two of four residents sampled for activities of daily living (Residents 24 and 3) and nail care for one of four residents sampled for activities of daily living (Resident 3). Findings include: Observation and interview with Resident 24 on February 13, 2024, at 10:38 AM revealed a build-up of film on Resident 24's teeth. Resident 24 stated she is afraid of losing her teeth. Resident 24 stated she is not able to brush her own teeth without some help from staff. Clinical record review revealed an annual MDS (an assessment tool completed at specific intervals to determine care needs) dated February 2, 2024, noting staff assessed Resident 24 as requiring supervision or touching assistance for oral hygiene. A follow-up interview with Resident 24, on February 16, 2024, at 10:00 AM revealed she is not able to brush her teeth in the bathroom due to her wheelchair being too low, not able 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 clinical record review and resident and staff interview, it was determined that the facility failed to provide the highest practicable care regarding physician orders for one of three discharged residents reviewed (Resident 107) and care of a mediport for one of 21 current residents reviewed (Resident 56). Findings include: Review of Resident 107's physician orders dated August 29. 2023 through October 2, 2023, revealed that staff was to administer Carvedilol (medication to treat hypertension which is high blood pressure) 12.5 milligrams tablet by mouth twice daily for hypertension. If Resident 107's heart rate was less than 60 beats per minute staff was to not administer the medication. Review of the Medication Administration Record for Resident 107 revealed the following times when Carvedilol was documented as being administered for a heart rate under 60 beats per minute: September 22, 2023, at 9:00 AM, heart rate 58 beats per minute September 23, 2023, at 9:00 AM, heart rate 57 beats per minute September 28, 2023, at 9:00 AM, heart rate 58 beats per minute September 29,…

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

Based on clinical record review and staff interview, it was determined that the facility failed to implement interventions to address a decline in range of motion for one of one resident reviewed (Resident 95). Findings include: Review of Resident 95's clinical record revealed a Minimum Data Set Assessment (MDS, an assessment completed at specific intervals to determine care needs) dated December 13, 2023, indicating that the facility assessed Resident 95 as having range of motion limitations to one side of her lower extremities. Previous MDS assessments dated June 28, 2023, and September 23, 2023, indicated that the facility assessed Resident 95 as having no range of motion limitations to her lower extremities. There was no documented evidence in Resident 95's clinical record to indicate that the facility identified her change in range of motion after the facility completed the December 13, 2023, MDS nor implemented or assessed Resident 95 for a restorative range of motion program. Interview with the Director of Nursing on February 16, 2024, at 9:26 AM confirmed the above findings…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff interview, it was determined that the facility failed to ensure a resident's medication regime was free from potentially unnecessary medications for two of six residents reviewed (Residents 23 and 107). Findings include: Review of Resident 23's clinical record revealed a physician order dated December 15, 2023, for nursing staff to administer Ativan (used to treat anxiety) 0.5 mg (milligrams) every four hours as needed for restlessness and agitation. This order was to continue for three months. There was no documented evidence in Resident 23's clinical record to indicate a rationale for the Ativan to extend past the 14 day timeframe for as needed psychoactive medications. Review of Resident 23's Medication Administration Record (MAR, a form used to document the administration of medications) dated December 2023 indicated that Resident 23 did not require nursing staff to administer the Ativan. Review of Resident 23's MAR dated January 2024 revealed that nursing 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.

Based on observation and staff interview, it was determined that the facility failed to secure medications on one of two nursing units (South Hall; Residents 36 and 82). Findings include: Observation on February 14, 2024, at 8:41 AM revealed an open bottle of acetic acid solution (strong vinegar solution to cleanse wounds, that can be harmful if not used properly) on Resident 36's dresser. Concurrent observation of Resident 82's windowsill revealed an open bottle without a lid of acetic acid solution. During an interview with Employee 5, licensed practical nurse, on February 14, 2024, at 10:12 AM revealed that Resident 36 takes items that belong to Resident 82 and the acetic acid was used for Resident 82's dressing changes. Employee 5 removed the items from the room and indicated they should be stored in a locked area. The facility failed to safely store medications. The above findings for Residents 36 and were reviewed with the Nursing Home Administrator and Director of Nursing on February 14, 2024, at 2:30 PM. 28 Pa. Code 211.9 (a)(1)(k) Pharmacy services 28 Pa. Code 211.12…

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 to serve food in a sanitary manner on one of two nursing units (nursing station 2). Findings include: An observation of the lunch meal service on November 8, 2023, at 12:05 PM with Employee 1, dietetic technician, revealed a metal meal tray delivery cart parked outside the west hall dining room located on the station 2 nursing unit. One resident lunch tray remained in the cart and several residents were observed being served and eating in the west hall dining room. The meal delivery cart was observed to have multiple dried brown and various colored runs/splatter on the sides of the cart. The base of the cart had dried food and thick buildup of dried debris on the top of the cart bottom bumper and dried food stuck to the surface of the bumper. A concurrent observation on the south hall of the station 2 nursing unit revealed a meal delivery cart parked outside the south dining room. Several residents were observed eating lunch in the south dining room. The meal delivery cart was observed with several 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.

Based on clinical record review and staff interview, it was determined that the facility failed to provide the highest practicable care regarding physician ordered vital signs for three of 11 residents reviewed (Residents 4, 5, and 6). Findings include: Clinical record review for Resident 4 revealed a physician's order dated October 2, 2023, for staff to complete vital signs every shift and to report to the physician if the heart rate was below 40 bpm (beats per minute) and the blood pressure was below 90/60 mmHg (millimeters of Mercury) Review of Resident 4's clinical documentation revealed that staff signed that they completed Resident 4's vital signs; however, there were no vital signs documented in her clinical record on the following dates: Day shift: October 4, 5, 6, and 10, 2023 Evening shift: October 2, 3, 4, 8, and 9, 2023 Night shift: October 2, 3, 4, 6, and 9, 2023 Further review revealed that staff did not complete Resident 4's vital signs on October 9, 2023, day shift. From October 8, 2023, at 10:00 AM through October 12, 2023, at 6:16 AM, Resident 4's physician ordered…

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, as well as staff and resident interviews, it was determined that the facility failed to ensure self-determination for resident's choices related to wake time schedules for 10 of 11 residents sampled (Residents 2, 3, 4, 5, 6, 7, 8, 9, 10, and 11). Findings include: Observation of the facility on September 20, 2023, at 5:50 AM revealed there were residents on each hall up in wheelchairs and dressed for the day. Observation of Resident 10 on September 20, 2023, at 5:50 AM revealed she was dressed for the day and in her wheelchair in the hallway. A review of Resident 10's admission MDS (Minimum Data Set, an assessment completed at specific intervals to determine care needs) dated August 31, 2023, revealed staff assessed her as requiring extensive assistance of one staff for dressing. An interview with Resident 10 revealed she has to get up at this time because the girls are waking my husband (Resident 11) up before 6:00 AM. Observation of Residents 8 and 9 on September 20, 2023, at 5:52 AM revealed they were in the South Hall up and dressed. Attempts to interview…

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

Based on clinical record review, review of select facility policies and procedures, and staff and family interview, it was determined that the facility failed to report, document, and investigate an injury of unknown origin for one of one resident sampled for injuries of unknown origin (Resident 13) and failed to implement interventions to prevent potential accidents for one of one resident reviewed (Resident 15). Findings include: The facility policy entitled Resident Accidents and Incidents, last reviewed without changes on April 1, 2022, revealed that all incidents involving a resident are reported, and documented, and an investigation is initiated after the incident is identified. The Clinical Manager or Nursing Supervisor is immediately notified of incidents (skin conditions, falls, etc.) An interview with Resident 13's daughter on September 20, 2023, at 12:25 PM revealed that she visited Resident 13 on September 16, 2023. During the visit, she noticed blood on Resident 13's floor by his wheelchair and bathroom floor. Resident 13's daughter stated that he indicated that he cut…

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.