Garden Spring Rehab And Care Center

Based on review of facility policy, clinical record review, observation, resident interview, and staff interview, it was determined that the facility failed to implement interventions that prevented new or worsened pressure ulcers for three of three sampled residents with skin impairments. (Residents 1, 2, 3) Findings include: Review of a facility policy entitled, Pressure Ulcer Prevention, last reviewed September 2024, revealed that staff were to conduct a skin assessment with the weekly risk assessment. Residents at risk for pressure ulcers were to be repositioned on an individualized schedule. Clinical record review revealed that Resident 1 had diagnoses that included protein calorie malnutrition (PCM), muscle weakness, and hemiplegia to the left side. The resident had a stage four pressure ulcer to the sacrum and a stage three pressure ulcer to the left shoulder. Staff were to turn and reposition the resident every two hours and check the resident for incontinence episodes and soiled bedding every hour. Review of the documentation for August and September 2024, revealed 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 ensure that physician's orders were implemented for one of five sampled residents. (Resident 1) Findings include: Clinical record review revealed that Resident 1 had diagnoses that included gastroesophageal reflux disease (acid reflux), pain, and neuropathy (nerve damage). Physician's orders dated July 26, 2024, directed staff to administer Acetaminophen (a medication for pain) and gabapentin (a medication for nerve pain) at 6:00 a.m. daily. A physician's order dated July 27, 2024, directed staff to administer omeprazole (a medication to treat acid reflux) at 6:00 a.m. daily. There was no evidence that the medications were offered or administered on August 7, 2024, per the physician's orders. In an interview on August 8, 2024, at 2:07 p.m., the Director of Nursing confirmed there was no evidence that the medications were administered per the physician's orders. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on facility policy review, observation, and staff interview, it was determined that the facility failed to maintain a medication error rate of less than five percent (%) on one of five nursing units. (Section 2) Findings include: A review of the facility policy entitled, Administering Medications, last reviewed September 2023, revealed that Medications were to be administered in accordance with the prescriber's orders, which included any required timeframe. Medications were to be administered within one hour of their prescribed time. Clinical record review revealed that Resident 2 had diagnoses that included major depressive disorder and multiple sclerosis. A review of physician's orders dated June 29, 2018, June 9, 2021, March 28, 2023, and August 5, 2024, revealed that staff were to administer the following medications at 8:00 a.m. daily: vitamin D3 1000 international units (IU), Zeposia 0.92 milligrams (mg), escitalopram 20 mg, and Bactrim 160 mg. Observation of the medication pass on August 8, 2024, revealed that licensed practical nurse (LPN) 1 did not administer 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, observation, and resident interview, it was determined that the facility failed to accommodate resident needs by providing access to the call bell system for two of six sampled residents. (Residents 4, 5) Findings include: Clinical record review revealed that Resident 4 had diagnoses that included Alzheimer's disease, abnormalities of gait and mobility, and muscle weakness. According to the Minimum Data Set (MDS) assessment, dated May 16, 2024, the resident could communicate her care needs and was dependent on staff for care. Review of the care plan revealed that the resident was at risk for falls and that staff was to keep her call bell within reach. Observations on July 12, 2024, at 10:00 a.m. and 12:15 p.m., revealed the resident was in bed and the call bell was wrapped around the armchair, out of reach. Clinical record review revealed that Resident 5 had diagnoses that included hemiplegia and hemiparesis (paralysis on left side) and heart failure. According to the MDS assessment, dated April 30, 2024, the resident was alert and was dependent on…

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

Based on clinical record review and observation, it was determined that the facility failed to ensure that safety interventions for falls were in place for one of six sampled residents. (Resident 4) Findings include: Clinical record review revealed that Resident 4 had diagnoses that included Alzheimer's disease, abnormalities of gait and mobility, and muscle weakness. According to the Minimum Data Set assessment, dated May 16, 2024, the resident could communicate her care needs and was dependent on staff for care. Review of the care plan revealed that the resident was at risk for falls and staff was instructed to place the bed in the low position with floor mats on both sides of the bed while the resident was in bed. Observations on July 12, 2024, at 10:00 a.m. and 12:15 p.m., revealed the resident was in bed without the floor mats in place, and the bed was not in a low position. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on facility policy review, clinical record review, and resident and staff interview, it was determined that the facility failed to provide written notice, including the reason for the change, prior to moving a resident to another room, for four of 12 sampled residents. (Residents 9, 10, 11, 12) Findings include: Review of the facility policy entitled Room Change/Roommate Assignment, last reviewed Ocotber 30, 2023, revealed that prior to changing a room or roommate assignment residents and their representatives are given advanced written notice of the change. The advance notice would include why the change is being made and documention of the change would be recorded in the resident's medical record. Clinical record review revealed that Resident 9 had a room change completed on May 24, 2024. There was no documented evidence that Resident 9 and their representative were given notice, including written notice, of the room change. In an interview on June 17, 2024, at 10:45 a.m., Resident 9 stated he did not know why or when he changes rooms, they just moved him. 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 observation, it was determined that the facility failed to ensure that a safe, clean, and comfortable environment was maintained on three of four nursing units. (Units 1, 2, 3) Findings include: On November 13, 2023, at 11:24 a.m., standing water was observed on the floor in the hallway outside of room [ROOM NUMBER] and the shower room opposite room [ROOM NUMBER]. In an interview at this time with Housekeeper 1, it was revealed that this had been an ongoing problem for longer than two weeks. On November 15, 2023, at 11:40 a.m., the shower room opposite room [ROOM NUMBER] was cluttered with numerous shower beds and equipment, the toilet seat on the toilet was crooked, protruding into a walking path. There were black spots on the floor and the sink. The sharps container on the wall was filled beyond capacity. Multiple bottles of soap/shampoo were sitting on top of the sharps container and blocking the grab rails of the shower stall sides. There was a rust stain on the shower stall floor. On November 13,…

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, observations, and staff interview, it was determined that the facility failed to ensure physician's orders were implemented for one of 27 sampled residents. (Resident 118) Findings include: Clinical record review revealed that Resident 118 had diagnoses that included osteoarthritis of both knees and hips, high blood pressure, and stroke. A physician's order dated June 14, 2023, directed staff to apply heel boots (devices to protect the skin of the feet) while in bed. Review of the comprehensive care plan revealed that the resident was at risk for skin breakdown. Multiple observations on November 13 through 15, 2023, between 9:46 a.m. and 1:30 p.m., revealed Resident 118 in bed and the heel boots were not applied. In an interview on November 16, 2023, at 9:48 a.m., the Director of Nursing confirmed that staff did not apply the heel boots as ordered by the physician. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, facility policy review, and staff interview, it was determined that the facility failed to provide restorative nursing services to increase or prevent a reduction in range of motion for three of 27 sampled residents. (Residents 36, 47, 116) Findings include: Review of the facility policy entitled, Restorative Nursing Services, reviewed October 30, 2023, revealed that restorative nursing programs were to be individualized to specific resident needs and the care plan was to be updated or developed to include interventions to support the resident's restorative nursing program. Clinical record review revealed that Resident 36 had diagnoses that included quadriplegia and neuropathy. Review of the Minimum Data Set (MDS) assessment dated [DATE], revealed that Resident 36 had functional limitation in range of motion to his upper and lower limbs. On November 10, 2023, the occupational therapist recommended a restorative nursing program for passive range of motion to upper and lower limbs…

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, policy review, observation, and resident and staff interview, it was determined that the facility failed to ensure that staff properly secured smoking materials for one of one sampled resident that smoked (Resident 48) and failed to ensure that safety interventions were in place to prevent accidents for one of 37 sampled residents. (Resident 88) Findings include: Review of the facility's policy entitled, Smoking Policy, last reviewed October 30, 2023, revealed that facility staff was to keep cigarettes, electronic cigarettes, and lighters in a secure place. In an interview conducted on Novemeber 16, 2023, at 9:55 a.m., the Director of Nursing stated that staff was to store smoking materials in a locked cart. On November 15, 2023, at 10:36 a.m., an electronic cigarette device was observed in Resident 48's room, not properly secured and accessible to unauthorized residents. In an interview at that time, Resident 48 stated, I keep my electronic cigarette on me. 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 clinical record review, resident interview, and staff interview, it was determined that 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 (PTSD) for one of 27 sampled residents. (Resident 36) Findings include: Clinical record review revealed that Resident 36 had diagnoses that included PTSD, insomnia, anxiety, and bipolar disorder. On October 3, 2023, a psychologist noted that the resident had a diagnosis of PTSD and reported childhood abuse. In an interview on November 13, 2023, at 10:46 a.m., the resident stated he still thinks about his traumatic childhood and it continues to affect him daily. There was no documented assessment or care plan that identified symptoms or triggers related to the PTSD diagnosis and there were no resident specific interventions to meet the resident's needs for minimizing triggers and/or re-traumatization. In an interview on November 16, 2023, at 9:48 a.m., the Director of Nursing confirmed that there was 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 review of facility policy and observation, it was determined that the facility failed to ensure that medications/biologicals were securely stored on one of four nursing units. (Unit 1) Findings include: Review of the facility policy entitled, Storage of Medications, last reviewed October 20, 2023, revealed that drugs and biologicals used in the facility were to be stored in locked compartments and only persons authorized to prepare and administer medications have access to locked medications. Medication storage rooms were to be locked when not in use and unlocked medications are not to be left unattended. On November 15, 2023, at 11:39 a.m., the medication room on Unit 1 was unlocked and unattended. The refrigerator inside was also unlocked and contained medication including insulin. On November 16, 2023, from 11:45 a.m. through 11:55 a.m., the medication room on Unit 1 was again unlocked. There were two open cardboard boxes containing medications, including ibuprofen, in the room. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on policy review, observation, and staff interview, it was determined that the facility failed to properly store food and maintain sanitary conditions in the dietary department. Findings include: Review of the facility's policy entitled, Food Storage, dated September 29, 2022, revealed that all food must be labelled with the name of the item and that if opened, the date it was opened and use by date should be on the food item. Observation during the tour of the dietary department on November 29, 2022, at 10:22 a.m., revealed the following: There was an opened bag of beef patties in the freezer with no date on it and two aluminum pans of a food item that the Food Service Director (FSD) identified as churros that were not dated and labelled. In the dry food storage area, numerous items were opened and not labelled with a date, including a bin of a white powdery substance that the FSD identified as sugar. There was a dented can of pineapple tidbits that had leaked onto the floor below the shelves. There were two packages of cheese in the cooler that were not labelled or dated.…

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

Based on a review of facility policy, observation, review of facility documentation, and staff interview, it was determined that the facility staff failed to wash hands during the medication pass in accordance with facility infection control policy on two of four nursing units(Units 2 and 3) and failed to perform infection surveillance in accordance with facility policy. Findings include: Review of the facility policy entitled, Administering Oral Medication, last reviewed September 29, 2022, revealed that staff was to wash or sanitize hands before and after giving medications to residents. On November 30, 2022, between 9:30 and 10:30 a.m., LPN 1 was observed giving medication to Residents 62 and 105 without washing or sanitizing her hands between residents. At the same time, LPN 2 was observed giving medication to Residents 18, 59, and 107 without washing or sanitizing her hands between residents. Review of the facility policy entitled, Surveillance for Infections, last reviewed September 29, 2022, revealed that the infection preventionist will conduct ongoing surveillance 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 observation, it was determined that the facility failed to ensure that a safe, clean, and comfortable environment was maintained on three of four nursing units. (Units 1, 2, 3) Findings include: On November 29, 2022, from 10:30 a.m. through 2:00 p.m., observations on the Unit 1 nursing unit revealed missing molding around the air conditioning unit, a hole in the wall next to the window, the dresser in the middle of the room was missing the handle for the fourth drawer, and the wall behind the television was heavily marred in room [ROOM NUMBER]. The wall by the doorway in room [ROOM NUMBER] was marred. The front of the air conditioning unit was missing in room [ROOM NUMBER] and the window was propped open with a bottle of deodorant. In the shared bathroom for rooms [ROOM NUMBERS], the doorway molding was broken with a jagged edge for room [ROOM NUMBER], the flooring was bowing and curling up, there were three soiled towels on the floor, there were broken tiles around the sink, the towel rack to the right…

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 it was determinied that the facility failed to ensure that the Minimum Data Set (MDS) assessments were complete for 15 of 32 sampled residents. (Residents 6, 10, 30, 43, 53, 58, 59, 65, 71, 94, 104, 112, 121, 123, 124) Findings include: Clinical record review revealed that Sections C (Brief Interview for Mental Status) and D (Mood Assessment/Interview) of Resident 6's MDS assessment dated [DATE], were incomplete. Clinical record review revealed that Sections C and D of Resident 10's MDS assessment dated [DATE], were incomplete. Clinical record review revealed that Sections C, D, and J (Pain Assessment Interview) of Resident 30's MDS assessment dated [DATE], were incomplete. Clinical record review revealed that Sections C and D of Resident 43's MDS assessment dated [DATE], were incomplete. Clinical record review revealed that Sections C and D of Resident 53's MDS assessment dated [DATE], were incomplete. Clinical record review revealed that Sections C and D of Resident 58's MDS…

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

Based on clinical record review and staff interview, it was determined that the facility failed to develop a comprehensive care plan that addressed individual resident needs as identified in the comprehensive assessment for six of 32 sampled residents. (Residents 14, 59, 104, 115, 121, 124) Findings include: Clinical record review revealed that Resident 14 had a Minimum Data Set (MDS) assessment completed on September 6, 2022. According to the assessment the resident had difficulty communicating. The clinical record reflected that the resident's primary language was not English. According to the Care Area Assessment (CAA) summary from that assessment, the facility identified that communication was a problem area for the resident and should have been included on the resident's comprehensive care plan. Review of the care plan revealed that the facility did not develop interventions to address this care area. Clinical record review revealed that Resident 59 had a MDS assessment completed on June 15, 2022. According to the assessment the resident had difficulty with vision. According 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 staff interview, it was determined that the facility failed to ensure that a licensed pharmacist conducted medication regimen reviews at least monthly or that the physician acknowledged the pharmacist's recommendations for five of 32 sampled residents. (Residents 13, 30, 63, 81, 112) Findings include: Clinical record review revealed that between September and December 2022, the pharmacist reviewed Resident 13's medication regimen only once, and not monthly. Clinical record review for Resident 30 revealed multiple recommendations from the consultant pharmacist on July 19, August 13 and November 15, 2022. These included recommendations regarding diabetes medications, psychotropic medications, and anticoagulants. There was no documentation that the attending physician had acknowledged or acted upon these recommendations. Clinical record review revealed that Resident 63's medication regimen was not reviewed in September and October 2022. In an interview on December 2, 2022, the Director of Nursing confirmed that the pharmacist did not review 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 facility policy review, clinical record review, and staff interview, it was determined that the facility failed to notify a resident's responsible party or the physician of a significant change in condition for four of 32 sampled residents. (Residents 53, 61, 123, 141) Findings include: Review of the facility policy entitled, Nutrition/Unplanned Weight Loss-Clinical Protocol, last reviewed September 29, 2022, revealed that the staff was to report significant weight gains or losses to the physician and the physician would review the resident's weight change for medical causes. Clinical record review revealed that Resident 53 had diagnoses that included dysphagia and diabetes mellitus. Review of the current care plan revealed that Resident 53 was at risk for nutrition problems and an intervention was to notify the physician of significant changes. On August 2, 2022, September 13, 2022, October 12, 2022, and November 3, 2022, Resident 53 had significant weight changes. There was no documented evidence 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 facility policy review, clinical record review, and staff interview, it was determined that the facility failed to report an allegation of abuse to the local Area Agency of Aging and the State Survey Agency for of one of 32 sampled residents. (Resident 83) Findings include: Review of the facility policy entitled, Abuse Prevention Program, last reviewed September 29, 2022, revealed that staff was to identify and assess all possible instances of abuse and report any allegations of abuse as required by federal requirements. Clinical record review revealed that Resident 83 was admitted to the facility with diagnoses that included alcohol abuse and cirrhosis of the liver. Review of the current care plan revealed that the resident was cognitively impaired, had a history of alcohol abuse, and was confused and disoriented at times. On November 9, 2022, a nurse noted that Resident 83 was sitting in the hallway in her wheelchair. Resident 10 was observed pouring a bottle of alcohol into Resident 83's mouth without consent. In an interview on December 2, 2022, at 12:40 p.m., 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 that a significant change assessment was completed to reflect a change in overall status for one of 32 sampled residents. (Resident 63) Findings include: Clinical record review revealed that Resident 63 had diagnoses that included congestive heart failure and hypertension. A physician's order dated October 22, 2022, revealed that the resident started to receive hospice services. There was no documented evidence that a significant change Minimum Data Set (MDS) assessment was completed after hospice services began. In an interview conducted on December 2, 2022, at 12:00 p.m., RN 1 confirmed that a significant change MDS was not completed and should have been. 28 Pa. Code 211.5(f) Clinical records. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

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 complete a Preadmission Screening to identify a mental disorder for one of 32 sampled residents. (Resident 6) Findings include: Clinical record review revealed that Resident 6 was admitted to the facility on [DATE], and had diagnoses that included schizophrenia (a mental disorder that involves a range of problems with thinking, behavior, and emotions). There was no evidence that the facility completed a Preadmission Screening for Resident 6. In an interview on December 2, 2022, at 1:43 p.m., the Administrator confirmed that the screening was not done.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, observation, and resident interview, it was determined that the facility failed to revise the comprehensive care plan to reflect the resident's status after each assessment for three of 32 sampled residents. (Residents 10, 58, 61) Findings include: Clinical record review revealed that Resident 61 was readmitted to the facility on [DATE], following a hospitalization. The Minimum Data Set (MDS) assessment dated [DATE], identified that the resident had experienced a decline in activities of daily living, including no longer being able to walk. Review of the current care plan revealed that it had not been revised to reflect the resident's decline in activities of daily living and included the intervention for a restorative ambulation program. During an interview on November 30, 2022, at 1:40 p.m., Resident 61 confirmed the inability to walk following hospitalization in July and reported he stayed in bed most of the time. The resident was observed in bed three of four days during 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, observation, and resident interview, it was determined that the facility failed to provide assistance with personal grooming and hygiene to one of 32 sampled residents. (Resident 104) Findings include: Clinical record review revealed that Resident 104 was admitted to the facility on [DATE], and had diagnoses that included chronic respiratory failure and chronic obstructive pulmonary disease. According to the Minimum Data Set assessment dated [DATE], the resident required extensive assistance from staff for personal hygiene. On November 30, 2022, at 10:45 a.m. and again on December 2, 2022, at 9:30 a.m., the resident was observed with a heavy beard. At that time, the resident stated that he preferred to not have such a long beard, and that staff had not been assisting him with his personal grooming. 28 Pa. Code 211.12(d)(5) Nursing services.

Based on clinical record review and staff interview it was determined that the facility failed to ensure that physician's orders were implemented for two of 32 sampled residents. (Residents 83, 123) Findings include: Clinical record review revealed that Resident 83 had diagnoses that included cirrhosis and seizures. On February 9, 2022, a physician ordered that staff to administer a medication (midodrine hydrochloride) three times a day to treat the resident's low blood pressure. Staff was not to give the medication if the resident had a systolic blood pressure of 120 mm/Hg (millimeters of mercury) or more. A review of the October and November 2022, Medication Administration Records revealed that staff administered the medication when the resident's systolic blood pressure was over the established parameter three times in October and eight times in November. In an interview on December 2, 2022, at 12:15 p.m., the Corporate Nurse Consultant, RN 1, confirmed that the documentation indicated that Resident 83 received the midodrine hydrochloride when her systolic blood pressure 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.

Based on clinical record review and staff and resident interview, it was determined the facility failed to provide restorative nursing services to prevent further decrease in range of motion for two of seven sampled residents with limited range of motion. (Residents 14, 104) Findings include: Clinical record review revealed that Resident 14 had diagnoses that included right sided hemiplegia and hemiparesis (paralysis and weakness), contracture of muscle of right hand, and vascular dementia. On September 19, 2022, the physical therapist recommended restorative nursing for passive range of motion of the right upper and lower extremities. On the same day, the physician ordered that staff provide a restorative nursing program five times a week for passive range of motion of the right upper and lower extremities. Review of the clinical record revealed there was no documented evidence to support that the resident received any restorative nursing services in November 2022. Clinical record record review revealed that Resident 104 had diagnoses that included chronic respiratory failure 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 clinical record review, policy review, observation, and staff interview, it was determined that the facility failed to ensure that staff properly secured smoking materials for three of three sampled residents that smoke. (Residents 35, 59, 71) Findings include: Review of the facility's policy entitiled, Smoking Policy, last reviewed September 29, 2022, revealed that facility staff was to keep cigarettes, electric cigarettes, and lighters in a secure place. In an interview conducted on November 30, 2022, at 1:00 p.m., Employee 1 stated that the smoking materials were to be kept in a secure cart and taken out every smoking break when staff then distribute and light the cigarettes for the residents. On November 30, 2022, at 10:30 a.m., a pack of cigarettes was observed in Resident 35's room on the tray table, not properly secured and accessible to unauthorized residents. On November 30, 2022, at 1:30 p.m., an electric cigarette device was observed in Resident 59's room, not properly secured and accessible to unauthorized residents. In an interview on December 1, 2022, at 10:15…

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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy review, clinical record review, observation, and staff interview, it was determined that the facility failed to assess residents identified with urinary incontinence or an indwelling catheter, failed to provide services to restore bladder function as much as possible, and/or failed to provide proper catheter care for four of 32 sampled residents. (Residents 30 39, 61, 65) Findings include: Review of the facility policy entitled, Urinary Catheter Care, last reviewed September 29, 2022, revealed that staff was to provide services to residents in an effort to prevent urinary tract infections and directed that urinary catheter tubing and drainage bags were to be kept off of the floor. Clinical record review revealed that Resident 30 had diagnoses that included chronic respiratory failure. The Minimum Data Set (MDS) assessment dated [DATE], indicated that he was incontinent of urine and required extensive assistance from staff to use the toilet. According to a bowel and bladder 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 clinical record review and staff interview, it was determined that the facility failed to timely assess the nutritional status of three of nine sampled residents at nutritional risk. (Residents 53, 61, 123) Findings include: Clinical record review revealed that Resident 53 was admitted to the facility with diagnoses including dysphagia and diabetes mellitus. Review of the current care plan revealed that the resident was at risk for a nutrition problems and an intervention was for the registered dietitian to evaluate and make diet change recommendations as needed. On July 11, 2022, Resident 53 weighed 158.4 pounds (lbs.). On August 2, 2022, the resident weighed 148 lbs., a significant 6.3 percent weight loss. On October 12, 2022, Resident 53 weighed 149.5 lbs. On November 3, 2022, the resident weighted 169 lbs., a significant 13 percent weight gain. There was no documented evidence that the register dietitian evaluated Resident 53's significant weight changes. Clinical record review revealed that Resident 61 had diagnoses that included obesity and high blood pressure. Review…

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

Based on clinical record review, staff interview, and resident interview, it was determined that the facility failed to provide necessary interventions to address pain for one of 32 sampled residents. Findings include: Clinical record review revealed that Resident 94 had diagnoses that included spinal stenosis (a condition where the spinal column narrows and compresses the spinal cord) and muscle weakness. Nursing documentation dated November 9, 2022, indicated that there was a physician's verbal order for the resident to have a pain management consultation for spinal stenosis. On November 14, 2022, the physician ordered that staff administer a narcotic pain medication (oxycodone) every eight hours as needed for moderate to severe pain. Review of the Medication Administration Record revealed that the resident had received the as needed narcotic medication 30 times in November since ordered. There was no documentation to support that a pain management consultation had been scheduled or provided. In addition, there was a lack of documentation to support that non-pharmacological…

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 ongoing assessment and monitoring for two of four sampled residents receiving dialysis (process of removing excess toxins and water from the blood). (Residents 115, 123) Findings include: Clinical record review revealed that Resident 115 had diagnoses that included end-stage renal disease and had a physician's order for in-house dialysis three times a week. The resident's care plan included that staff use dialysis communication forms to assess the resident. These forms were to be exchanged between the dialysis center and the nursing unit on days when dialysis was provided. The forms included pre and post dialysis weights, vital signs and recommendations from the center. There was a lack of documented evidence to support that the facility obtained the pre and post dialysis weights and consistently assessed the resident before and after dialysis on 13 of 13 days in November 2022. Clinical record review revealed that Resident 123 had diagnoses that included end-stage renal…

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.