Windber Woods Senior Living & Rehabilitation Ctr

Based on review of policies and clinical records, as well as observations and resident and staff interviews, it was determined that the facility failed to follow facility policy for the care and monitoring of residents receiving dialysis for one of 33 residents reviewed (Resident 61). Findings include:Review of the facility's dialysis policy, dated December 18, 2025, revealed that when a resident is requiring dialysis an order will be written for the dialysis, place of treatment, port check every shift and as needed, medications to be held prior to dialysis, and any specific orders from dialysis including dietary restrictions, fluid restrictions and intake and output and laboratory studies. The Licensed Practical Nurse/Registered Nurse will monitor the dialysis port or catheter every shift and as needed. The nurse will report any bleeding, redness, inflammation, drainage or catheter dysfunction. An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 61, dated February 17, 2026, revealed that the resident was…

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

Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to maintain accountability for controlled medications (drugs with the potential to be abused) for one of 33 residents reviewed (Resident 12). Findings include: The facility's policy regarding medication administration, dated December 18, 2025, indicated that documentation of narcotic administration will be done in accordance with applicable law including documenting necessary medication administration treatment information on appropriate forms, and removal of fentanyl patches (a narcotic medication) will require two signatures to ensure proper disposal of the patch. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a residents abilities and care needs) for Resident 12, dated January 8, 2026, revealed that the resident was cognitively intact, required extensive assistance with daily care needs, and had diagnoses that included Parkinson's (a progressive neurological disease that affects movement). Physician's orders for Resident 12 dated…

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

Based on review of manufacturer's instructions and clinical records, as well as observations and staff interviews, it was determined that the facility failed to maintain a medication error rate of less than five percent.Findings include: Observations during medication administration on February 26, 2026, and February 27, 2026, revealed that three medication administration errors were made during 38 opportunities for error, resulting in a medication administration error rate of 7.89 percent. Manufacturer's directions for Trelegy Ellipta (medication that reduces inflammation in the airways)100-62.5-25 micrograms/activation (mcg/act), dated January 2019, indicated to advise patients to rinse his/her mouth with water without swallowing after inhalation to reduce the risk of candida albicans, an infection of the mouth and pharynx (throat). Physician's orders for Resident 68, dated February 11, 2026, included an order for the resident to receive one puff (inhalation) of 100-62.5-25 mcg/act of Trelegy Ellipta daily in the morning for chronic obstructive pulmonary disease (COPD) (chronic…

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

Based on clinical record reviews and staff interviews, it was determined that the facility failed to obtain a physician's order for an invasive procedure to collect a specimen for a laboratory test for one of 33 residents reviewed (Resident 4).Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 4, dated February 12, 2026, revealed that the resident was cognitively intact and had diagnoses that included a urinary tract infection. Physician's orders for Resident 4, dated June 24, 2025 included an order for staff to obtain a urine specimen to rule out a urinary tract infection. A progress note for Resident 4, dated June 24, 2025, revealed that the writer performed a straight catheterization (the manual insertion of a plastic tube into the bladder to drain urine) on the resident at this time to obtain a urinalysis and culture and sensitivity (UA C&S - urine tests to check for the presence of bacteria and determine which antibiotics the bacteria is sensitive to).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 review of the facility's plans of correction and the results of the current survey, it was determined that the facility's Quality Assurance Performance Improvement (QAPI) committee failed to correct quality deficiencies and ensure that plans to improve the delivery of care and services effectively addressed recurring deficiencies.Findings include: The facility's deficiencies and plans of corrections for State Survey and Certification (Department of Health) survey ending March 27, 2025, revealed that the facility developed plans of correction that included quality assurance systems to ensure that the facility maintained compliance with cited nursing home regulations. The results of the current survey, ending February 27, 2026, identified repeated deficiencies related to failure to correct deficient practices related to care plan revision, quality of care, services to prevent/heal pressure ulcers, safe environment that is free of accident hazards, laboratory services, complete and accurate accounting of controlled medications and infection control. The facility's plan of…

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

Based on review of guidance from the Centers for Disease Control (CDC - the national health protection agency) and clinical records, as well as observations and staff interviews, it was determined that the facility failed to follow CDC guidelines to reduce the spread of infections and prevent cross-contamination related to Clostridioides difficile (C-diff-a bacteria that can cause severe diarrhea and inflammation of the colon) infection for one of 33 residents reviewed (Resident 11). Findings include: The Facility's policy regarding isolation and transmission-based precautions dated December 18, 2025, indicated that contact precautions are implemented for residents known or suspected to be infected with microorganisms that can be transmitted by direct contact with the resident or indirect contact with environmental surfaces or resident-care items in the resident's environment. Residents with diarrhea and suspected clostridium difficile will be placed on contact precautions while awaiting laboratory results.A quarterly Minimum Data Set (MDS) assessment (required assessment of 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 review of facility policy and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that residents received care and treatment in accordance with professional standards of practice, by failing to ensure that physician's orders were followed for four of 44 residents reviewed (Residents 19, 41, 60, 102), and failed to ensure that bowel protocols were followed as ordered by the physician for two of 44 residents reviewed (Residents 52, 82). Findings include: The facility's policy regarding medication administration, dated December 20, 2024, indicated that medications are to be administered in a safe and legal manner. Medications given need to follow the 5 Rights, right resident, right time, right drug, right frequency, and right route. Recently a sixth right was implemented. The right documentation. Pour the medication reading each order on the computer screen and comparing the directions on each medication box. After the resident takes the medication, electronically record your signature. Any narcotic medication given must be…

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

Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that physician's orders were followed for the care and maintenance of intravenous catheters and failed to ensure that intravenous catheters were flushed according to facility policy for three of 44 residents reviewed (Residents 1, 45, 255). Findings include: The facility's policy regarding intravenous fluid/medication administration, dated December 20, 2024, indicated that if administering only, flush before and after each infusion or per protocol for the access device. An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's care needs and abilities) for Resident 1, dated February 26, 2025, revealed that the resident was cognitively intact, was understood, could understand others, and was receiving intravenous (IV-into the vein) medications. Physician's orders for Resident 1, dated February 20, 2025, included an order for the resident to receive a 10 milliliter (ml) flush with normal saline every shift for 12 days for IV…

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

Based on review of facility policies, clinical records, and staff interviews, it was determined that the facility failed to develop a comprehensive care plan that included specific and individualized interventions to address care needs for one of 44 residents reviewed (Resident 60). Findings include: A facility policy for care plans, dated December 20, 2024, indicated that resident care plans will have multiple focuses, goals, and interventions according to their needs, level of care, and capabilities. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 60, dated February 7, 2025, indicated that the resident was cognitively impaired, required assistance from staff for daily care needs, and diagnoses that included high blood pressure and diabetes. Observations of Resident 60 on March 26, 2025, at 8:35 a.m. revealed that he had two containers of smokeless tobacco and an empty milk carton that he was using as a spittoon. There was no documented evidence that a care plan was developed to address the resident's use…

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

Based on review of facility policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that care plans were updated/revised to reflect specific care needs for three of 44 residents reviewed (Residents 48, 90, 94). Findings include: A facility policy for care plans, dated December 20, 2024, indicated that resident care plans will have multiple focuses, goals, and interventions according to their needs level of care and capabilities. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's care needs and abilities) for Resident 48, dated March 5, 2025, revealed that the resident had moderate cognitive impairment and was occasionally incontinent of urine. Physician's orders for Resident 48, dated January 16, 2025, included orders for the resident to receive 70 milligrams (mg) of Gentamicin Sulfate intramuscularly one time a day for three days for a urinary tract infection and contact isolation precautions (used to prevent the spread of infections that can be transmitted through direct or…

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

Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that pressure ulcer dressing changes were completed as ordered to prevent skin breakdown for one of 44 residents reviewed (Resident 106). Findings include: A facility policy regarding treatment of wounds, dated December 20, 2024, revealed that the facility had a no touch care policy and that staff were to clean and dry a wound and surrounding skin with gauze without letting any unsterile item touch the wound. An admission Minimum Data assessment Set (MDS) (a mandated assessment of a resident's abilities and care needs) for Resident 106, dated March 13, 2025, revealed that the resident was understood; could sometimes understand; was dependent on staff for turning, transfers, and lower body care; had diagnoses that included a stroke; and had one unstageable pressure ulcer (unable to determine the depth of the wound due to slough or eschar) that was present on admission. A care plan for Resident 106, dated March 6, 2025, revealed that she had an…

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

Based on review of clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that the residents' environment remained free of accident hazards for one of 44 residents reviewed (Resident 90) who resides on the alarmed unit. Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 90, dated February 3, 2025, indicated that the resident was cognitively impaired, was understood and could sometimes understand others, and was ambulatory with a walker or wheelchair. The current care plan for resident 90 revealed that she self-propels in the facility and will take herself to and from activities A nursing note for Resident 90, dated November 2, 2025, at 2:23 p.m. revealed that the resident was found in the basement of the facility. A progress note for Resident 90, dated November 4, 2025, at 10:59 a.m. revealed that the resident was alert to person only, does not follow commands, and was found in the basement over the weekend. Interview with 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 policies and clinical records, as well as staff interviews, it was determined that the facility failed to maintain a complete and accurate accounting of controlled medications (medications with the potential to be abused) for one of 33 residents reviewed (Resident 46). Findings include: The facility's policy regarding medication administration, dated December 20, 2024, indicated that medications are to be administered in a safe and legal manner. Medications given need to follow the 5 Rights, right resident, right time, right drug, right frequency, and right route. Recently a sixth right was implemented, the right documentation. Staff must sign out the narcotic on the controlled drug record prior to administration of the medication and electronically record their signature in the resident's Medication Administration Record (MAR) after the resident takes the medication. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's care needs and abilities) for Resident 102, dated March 5, 2025, revealed that the resident was cognitively…

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

Based on review of facility policies, manufacturer's instructions, and clinical records, as well as observations and staff interviews, it was determined that the facility failed to store unopened (unused) multi-dose containers of insulin according to manufacturer's instructions for two of 44 residents reviewed (Residents 74, 85), and failed to label multi-dose containers of medications with the date they were opened in one of two medication carts observed (First-Floor medication cart). Findings include: The facility's policy regarding medication labeling and storage, dated December 20, 2024, revealed that multi-dose vials that have been opened or accessed were to be dated and discarded within 28 days unless the manufacturer specifies a shorter or longer date for the open vial. Manufacturer's directions for the use of Lantus insulin (a long-acting insulin used to lower blood sugar levels), dated September 2023, revealed that unused Lantus should be stored in a refrigerator between 36 degrees F to 46 degrees F. After initial use it may be kept at temperatures below 86 degrees F for up…

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

Based on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to obtain laboratory studies as ordered by the physician for one of 44 residents reviewed (Resident 1), and failed to obtain a physician's order for an invasive procedure to collect a specimen for a laboratory test for two of 44 residents reviewed (Residents 6, 41). Findings include: An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's care needs and abilities) for Resident 1, dated March 5, 2025, revealed that the resident was cognitively intact, was understood and understood others, and had a diagnosis of atrial fibrillation (an abnormal heart rhythm). The resident's care plan, dated March 5, 2025, indicated that she was at risk for bleeding due to anticoagulant therapy (providing medication to thin the blood), and she was to have blood tests and medications as ordered by the physician and was to be observed for any bruising or bleeding. Physician's orders for Resident 1, dated March 17, 2025, included an order for 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 the facility's plans of correction for previous surveys, and the results of the current survey, it was determined that the facility's Quality Assurance Performance Improvement (QAPI) committee failed to correct quality deficiencies and ensure that plans to improve the delivery of care and services effectively addressed recurring deficiencies. Findings include: The facility's deficiencies and plans of corrections for a State Survey and Certification (Department of Health) survey ending April 18, 2024, and a complaint investigation survey ending October 23, 2024, revealed that the facility developed plans of correction that included quality assurance systems to ensure that the facility maintained compliance with cited nursing home regulations. The results of the current survey, ending March 27, 2025, identified repeated deficiencies related to revision of care plans, accident hazards, and pharmacy procedures, services, and records. The facility's plan of correction for a deficiency regarding a failure to update residents' care plans, cited during the survey ending…

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 established infection control guidelines, facility policy, and residents' clinical records, as well as observations and staff interviews, it was determined that the facility failed to follow infection control guidelines from the Centers for Medicare/Medicaid Services (CMS) and the Centers for Disease Control (CDC) to reduce the spread of infections and prevent cross-contamination for three of 36 residents reviewed (Residents 47, 106). Findings include: CDC guidance on isolation precautions and Implementation of Personal Protective Equipment (PPE) use in Nursing Homes to Prevent Spread of Multidrug-Resistant Organisms (MDRO's - bacteria that have become resistant to certain antibiotics, and these antibiotics can no longer be used to control or kill the bacteria), dated July 12, 2022, indicates that MDRO transmission is common in skilled nursing facilities, contributing to substantial resident morbidity and mortality and increased healthcare costs. Enhanced Barrier Precautions (EBP) are an infection control intervention designed to reduce transmission of resistant…

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 policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that the physician was notified timely about a change in condition for one of five residents reviewed (Resident 1). The facility's policy regarding changes in condition, dated December 14, 2023, indicated that the nurse would notify the resident's physician when there was a change in the resident's condition. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated August 19, 2024, revealed that the resident was severely cognitively impaired and had diagnoses that included dementia, depression, and Alzheimer's disease. A health status note for Resident 1, dated September 13, 2024, at 9:30 p.m., revealed that the nurse aide updated the licensed practical nurse, who in turn updated the registered nurse supervisor, that the resident was more confused than usual and that the resident's daughter was in to visit earlier in the evening and left early due to the resident swearing and…

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

Based on review of Pennsylvania's Nursing Practice Act, facility policies, and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that an assessment was completed by a professional (registered) nurse after a change in condition occurred for one of five residents reviewed (Resident 1). Findings include: The Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.11 (a)(1)(2)(4) indicated that the registered nurse was to collect complete and ongoing data to determine nursing care needs, analyze the health status of individuals and compare the data with the norm when determining nursing care needs, and carry out nursing care actions that promote, maintain, and restore the well-being of individuals. The facility's policy for change in condition, dated December 14, 2024, indicated that if a resident has a change in condition, it is the registered nurse's responsibility to assess, chart on, and update the physician regarding that resident's altered condition. A quarterly Minimum Data Set (MDS)…

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

Based on observations and staff interviews, it was determined that the facility failed to ensure the environment remained as free of accident hazards as possible for one resident (Resident 7) who had a fall. Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 7, dated May 20, 2024, revealed that the resident was cognitively impaired, required extensive assistance with personal hygiene, and had diagnoses that included Alzheimer's disease and anxiety. Review of Resident 7's clinical record indicated that on June 19, 2024, the resident was found lying on her right side on the floor with the mattress completely off the bed behind her back. Interview with the Nursing Home Administrator on July 3, 2024, at 12:30 p.m. revealed that Resident 7's room was cleaned and that the housekeeper did not secure the mattress to the bed with the straps as it should have been. 28 Pa. Code 201.14(a) Responsibility of Licensee. 28 Pa. Code 201.18(b)(1)(e)(1) Management. 28 Pa. Code 211.12(d)(1)(5) Nursing Services.

Based on review of policies, observations, and staff interviews, it was determined that the facility failed to ensure that food stored in the kitchen was labeled, dated and secured. Findings include: The facility policy regarding food storage, dated December 14, 2023, revealed that any food that has been opened must be labeled, dated and secured in such a way that the food item is air tight. Observations in the walk-in freezer on April 15, 2024, at 8:35 a.m. revealed that there was one bag containing six chicken tenders that was not labeled, dated or secured and one bag containing five chicken patties that was dated but unsecured. Observations in the cook's cooler on April 15, 2024, at 8:40 a.m. revealed that there was approximately eighteen sausage patties in a box that was dated but the bag holding the sausage patties was open and unsecured. Interview with the Dietary Manager on April 15, 2024, at 8:45 a.m. confirmed that all food items in the kitchen should be labeled, dated and secured. Interview with the Nursing Home Administrator on April 15, 2024, at 10:26 a.m. confirmed that…

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

Based on review of policies, as well as observations and staff interviews, it was determined that the facility failed to maintain a clean and homelike environment for one of 32 residents reviewed (Resident 7). Findings include: The facility's policy regarding cleaning and disinfecting, dated December 14, 2023, indicated that housekeeping was to remove visible debris from surfaces and that proper cleaning was necessary to provide a healthy environment. A quarterly Minimum data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 7, dated March 12, 2024, revealed that the resident was cognitively impaired, required extensive assistance from staff for daily care needs, had diagnoses that included pulmonary embolism (a blood clot that stops blood flow to the lung) and anemia (not enough red blood cells to carry oxygen to the tissues). A care plan, dated March 14, 2024, indicated that Resident 7 had a potential for altered respiratory status related to her pulmonary embolism and was to receive oxygen as needed at 2 to 4 liters per minute via…

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

Based on review of clinical records and observations, as well as resident and staff interviews, it was determined that the facility failed to ensure that care plans were updated to reflect changes in care needs for one of 32 residents reviewed (Resident 51). Findings include: An annual Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 51, dated February 2, 2024, revealed that the resident was cognitively intact, required assistance with daily care needs, and had diagnoses that included obstructive and reflux uropathy (a disorder of the urinary tract that occurs due to obstructed urinary flow). A care plan for Resident 51, revised on February 16, 2024, indicated that the resident had an indwelling foley catheter (tube that is inserted into the bladder allowing urine to drain in to a collection bag) size 16 French, 10 cc balloon. Physician's orders, dated February 2, 2024, included an order to change the size of the indwelling foley catheter to an 18 French, 10 cc balloon. There was no documented evidence in Resident 51's…

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

Based on clinical record reviews, observations, and staff interviews, it was determined that the facility failed to ensure that the residents' environment remained as free of accident hazards as possible by transporting a resident without leg rests for one of 32 residents reviewed (Resident 70), and failed to conduct thorough investigations for one of 32 residents reviewed (Resident 84) by using photocopied witness statements for fall investigations. Findings include: An annual Minimum Data Set (MDS) assessment (a federally-mandated assessment of a resident's abilities and care needs) for Resident 70, dated February 21, 2024, revealed that the resident was cognitively intact, required extensive assistance for all of her care, and used a wheelchair. Observations on April 16, 2024, at 12:47 p.m. revealed that Licensed Practical Nurse 3 pushed Resident 70 in a wheelchair without leg rests around other residents who were waiting at the elevator, through the hallway, and into the common area while the resident elevated her feet. The leg rests were in a bag hanging off the back of the…

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

Based on review of policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that a no smoking/oxygen-in-use sign was in place for one of 32 residents reviewed (Resident 7). Findings include: The facility's policy regarding oxygen therapy, dated December 14, 2023, indicated that a sign would be in place indicating that oxygen was in use. A quarterly Minimum data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 7, dated March 12, 2024, revealed that the resident was cognitively impaired, required extensive assistance from staff for daily care needs, had diagnoses that included pulmonary embolism (a blood clot that stops blood flow to the lung ) and anemia (not enough red blood cells to carry oxygen to the tissues). Physician's orders, dated September 27, 2023, included orders for the resident to receive oxygen as needed at a flow rate of 2 to 4 liters per minute by nasal cannula (tubes that deliver oxygen into the nostrils). The resident's care plan, revised March…

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 policies and clinical records, as well as staff interviews, it was determined that the facility failed to maintain accountability for controlled medications (drugs with the potential to be abused) for one of 33 residents reviewed (Resident 64). Findings include: The facility's policy regarding narcotic patches, dated December 14, 2023, indicated that all narcotic patches should be placed immediately in a sharps container when discarding and require a double signature. An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 64, dated January 2, 2024, revealed that the resident was cognitively intact, received routine pain medication, received an opioid (a controlled pain medication), and had diagnoses that included a fracture. Physician's orders for Resident 64, dated January 4, 2024, included an order for the resident to receive a 12 micrograms (mcg) Fentanyl (a narcotic pain patch) patch to be applied every three days for pain. The Medication Administration Record (MAR) and a controlled drug…

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

Based on review of the facility's plans of correction for previous surveys, and the results of the current survey, it was determined that the facility's Quality Assurance Performance Improvement (QAPI) committee failed to correct quality deficiencies and ensure that plans to improve the delivery of care and services effectively addressed recurring deficiencies. Findings include: The facility's deficiencies and plans of corrections for State Survey and Certification (Department of Health) survey ending March 16, 2023, and March 12, 2024, revealed that the facility developed plans of correction that included quality assurance systems to ensure that the facility maintained compliance with cited nursing home regulations. The results of the current survey, ending April 18, 2024, identified repeated deficiencies related to free of accident hazards/supervision/devices, respiratory care, pharmacy services/procedures/records, and food procurement storage/prepare/serve-sanitary. The facility's plan of correction for a deficiency regarding free of accident hazards/supervision/devices, cited…

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

Based on observations, a review of clinical records, as well as staff interviews, it was determined that the facility failed to maintain an effective pest control program. Findings include: The facility's policy on pest control, dated December 14, 2023, indicated that the facility will maintain a pest control program and that treatment will be rendered as required to control insects. Observations of the handwashing sink in the kitchen on April 15, 2024, at 8:36 a.m. revealed a large number of ants on the sink around the faucet area, as well as on the wall directly behind the sink. There were also several gnats in the area as well as a gnat trap on the sink by the faucet. Interview with Dietary Manager on April 15, 2024, at 8:38 a.m. revealed that he did not realize that the ants were there. However, he was aware of some gnats in the sink area, as there was a small red container on the sink to catch gnats. He stated that the ants and gnats should not be around the handwashing sink in the kitchen. Interview with Maintenance Director on April 17, 2024, at 9:39 a.m. revealed 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 review of facility policies, information provided to staff upon hire, investigation documents, and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that each resident's personal privacy was maintained for one of three residents reviewed (Resident 2). Findings include: The facility's abuse policy, dated December 14, 2023, included policies and procedures related to training, preventative measures, identifying, investigating, reporting, and protecting residents from exposure to abuse, neglect, mistreatment, and misappropriation. The facility's cell phone usage policy, dated December 14, 2023, indicated that cell phones were not to be used in resident care units or carried on one's body while the employee was working. No staff member was allowed to photograph a resident or their surroundings and post it on social media of any kind. Even if a resident consented, and regardless of the resident's cognitive status, abuse will be presumed and investigated whenever there was a photograph or recording of a resident, or the manner…

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

Based on review of facility policies, clinical records and investigation documents, as well as staff interviews, it was determined that the facility failed to ensure that residents were free from mental abuse for one of three residents reviewed (Resident 2). Findings include: The facility's abuse policy, dated December 14, 2023, included policies and procedures related to training, preventative measures, identifying, investigating, reporting, and protecting residents from exposure to abuse, neglect, mistreatment, and misappropriation. The facility's cell phone usage policy, dated December 14, 2023, indicated that cell phones were not to be used in resident care units or carried on one's body while the employee was working. No staff member was allowed to photograph a resident or their surroundings and post it on social media of any kind. Even if a resident consented, and regardless of the resident's cognitive status, abuse will be presumed and investigated whenever there was a photograph or recording of a resident, or the manner that it was used (if it demeaned or humiliated 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 review of Pennsylvania's Nursing Practice Act, residents' clinical records, personnel files, and the licensed practical nurse job description, as well as staff interviews, it was determined that the facility failed to ensure that the nurse documented treatments accurately for one of 10 residents reviewed (Resident 6). This deficiency was cited as past non-compliance. Findings include: The Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.148. Standards of nursing conduct (a)(5)(8) indicated that the licensed practical nurse was to document and maintain accurate records. Not to falsify or knowingly make incorrect entries into the patient's record or other related documents. The facility's licensed practical nurse job description, dated May 8, 2018, revealed that the licensed practical nurse was to chart nurses' notes in an informative and descriptive manner that reflects the care provided to the resident, as well as the resident's response to the care, and perform routine charting duties as required and in accordance with 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 clinical records and personnel files, as well as staff interviews, it was determined that the facility failed to ensure that residents received care and treatment in accordance with professional standards of practice by failing to ensure that physician's orders were followed for two of 10 residents reviewed (Residents 4, 6). Findings include: A physician's progress note, dated January 25, 2024, revealed that Resident 4 was seen for a rash on his back that began suddenly and was itchy and red. The plan was to apply 0.025 percent Triamcinolone cream to the rash twice a day; however, there was no physician's order that included the recommended treatment. A review of Resident 4's Treatment Administration Record (TAR) for January and February 2024 revealed that there was no documented evidence that Triamcinolone cream was applied to the resident's rash as recommended by the physician. Interview with Registered Nurse 2 on March 11, 2024, at 2:58 p.m. confirmed that she missed the physician's order and did not enter it into the electric medical record. Interview with 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 clinical records and investigation reports, as well as staff interviews, it was determined that the facility failed to provide an environment that was free of accident hazards to residents who were at risk for falls for one of 10 residents reviewed (Resident 6), resulting in a fall. This deficiency was cited as past non-compliance. Findings include: A significant change in condition Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 6, dated December 28, 2023, revealed that the resident was understood and could understand. The resident's care plan, dated November 2, 2023, revealed that he was at risk for falls related to weakness/balance problems and poor safety awareness, and required assistance but does not always ask for assistance with transfers/ambulation (walking). Physician's orders for Resident 6, dated November 20, 2023, included an order for the resident to always have bed and chair alarms. Staff was to check the function and placement every shift. A nursing note for Resident 6, dated November…

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 residents' clinical records, personnel files, the licensed practical nurse job description, as well as staff interviews, it was determined that the facility failed to ensure that residents' clinical records were complete and accurately documented for one of 10 residents reviewed (Resident 6). This deficiency was cited as past non-compliance. Findings include: The facility's licensed practical nurse job description, dated May 8, 2018, revealed that the licensed practical nurse was to chart nurses' notes in an informative and descriptive manner that reflects the care provided to the resident, as well as the resident's response to the care. Perform routine charting duties as required and in accordance with the facility's established charting and documentation policies and procedures. Physician's order for Resident 6, dated January 10, 2024, revealed that staff was to cleanse the resident's left shin with wound cleanser, then apply Xeroform gauze (a sterile, non-adhering protective dressing consisting of absorbent, fine-mesh gauze impregnated with a petrolatum) and…

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

Based on review of clinical records, as well as staff interviews, it was determined that the facility failed issue a bed-hold notice at the time of an anticipated leave of absence from the facility for one of four residents reviewed (Resident 2). Findings include: A discharge with return anticipated Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 2, dated August 5, 2023, required supervision with personal hygiene needs, required extensive assistance with toileting and dressing, and had diagnoses that included osteoarthritis of the left hip. Nurse's notes for Resident 2, dated September 5, 2023, at 6:02 a.m. revealed that the resident was transferred to the hospital for a scheduled surgery. There was no documented evidence that the resident and/or the responsible party was notified about the facility's bed-hold policy at the time of this transfer to the hospital. Interview with the Nursing Home Administrator on October 23, 2023, at 11:11 a.m. confirmed that there was no documented evidence that a bed-hold notice was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record reviews and staff interviews, it was determined that the facility failed to permit the readmission of a hospitalized resident without providing evidence that the facility was not able to meet the resident's needs for one of four residents reviewed (Resident 2). Findings include: admission information for Resident 2 revealed that the resident was admitted to the facility on [DATE], with diagnoses that included osteoarthritis of the left hip and dementia. A nursing note, dated July 18, 2023, indicated that the resident was scheduled for hip surgery on September 5, 2023. A nurse's note, dated September 5, 2023, at 6:02 a.m. revealed that the resident was transferred to the hospital for a scheduled surgery. Interview with the Nursing Home Administrator on October 23, 2023, at 11:11 a.m. revealed that the facility decided not to allow Resident 2 to return to the facility because her responsible party refused to pay for a bed hold and the resident had a bill for room and board that was not…

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

Based on review of facility policies, as well as observations and staff interviews, it was determined that the facility failed to ensure the consistent implementation of infection control procedures designed to prevent the spread of infection. Findings include: Facility policy for handwashing, dated December 14, 2022, included that all personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infection to other personnel, residents, and visitors. Hand hygiene should be performed before applying gloves and after removing and discarding gloves. Observations on the Maple nursing unit on September 20, 2023, at 11:20 a.m. revealed that Nurse Aide 1 was wearing gloves as she pushed a resident in a wheelchair. After placing the resident in front of a table in the center common area of the unit, Nurse Aide 1 removed her gloves, discarded them in a garbage receptacle and picked up a plastic cup from the medication cart in the hallway. The nurse aide then put water in the cup, opened the wrapper of a straw, and placed the straw in the water and gave it 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.