Wyndmoor Hills Rehabilitation And Nursing Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical records review, facility investigations and staff interview, it was determined that the facility failed to maintain accurate records regarding wound care and nutritional intake for three of 24 residents reviewed. (Resident R1, R2 and R3) Findings include:Review of facility policy, titled Advance Directives dated March 17, 2025 states, Policy Statement- Advance directives will be respected in accordance with state law and facility policy. Further review of the facility policy reads, 10. The plan of care for each resident will be consistent with his or her documented treatment preferences and/or advance directiveReview of Resident R3's clinical record revealed the resident was re-admitted to the facility on [DATE] with the diagnsoses of Heart Failure (a condition where the heart muscle cannot pump blood effectively), Muscle Weakness, and Dysphagia (difficulty or discomfort swallowing).Review of Resident R3's electronic medical record revealed a physician order dated September 16, 2025 listed as…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on the facility documentation, clinical record review, observations and staff interviews, the facility failed to ensure that a mechanical lift was used in a safely manner to prevent accidents for one of six records reviewed. (Resident CL1)Findings include: Review of facility provided documentation titled, Invacare User Manual dated 2013, indicated that when lifting a resident or moving a resident while they are in the sling, the legs of the lift must be in the fully open position for maximum stability and safety. Review of clinical records for Resident CL1 revealed that the resident was admitted to the facility on [DATE], with diagnoses including muscle weakness, and difficulty walking. Continued review revealed that the resident required two people to assist with transfers via Hoyer lift (mechanical lift utilize to transfer a resident from one surface to another). Review of nursing notes for Resident CL1, dated October 31, 2025, revealed that a nurse aide reported that during the Hoyer lift transfer from…

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

Based on review of resident records, facility policy, and staff interviews, it was determined that the facility failed to maintain complete and accurate clinical records for one of six residents reviewed. (Resident CL1)Findings include: Review of facility policy titled, Repositioning revised May 2013, indicated that repositioning is critical for a resident who is immobile or dependent upon staff for repositioning. Continued review revealed that the following information should be recorded in the residents medical record: the position in which the resident was placed; the name and title of the individual who gave the care; any problems or complaints made by the resident related to the procedure; if the resident refused the care and the reasons why; and the signature and title of the person recording the data. Review of Resident CL1's clinical records titled, Encore Wound Care dated October 23, 2025, indicated that the resident must be repositioned per facility protocol. Further review of Resident Cl1's clinical records failed to reveal documented evidence of a turning 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 observations, and staff interviews, it was determined that the facility failed to maintain an effective pest control program in the main kitchen. Findings Include:Observation on August 25, 2025, at 9:20 a.m., in the facility's main kitchen revealed an unclean and unsanitary environment. A substantial amount of mouse droppings was observed in two separate areas on the kitchen floor.Interview conducted with Employee 7, the Dietary Director, confirmed the presence of mouse droppings in multiple areas of the kitchen. Employee E7 acknowledged that the floor had not been cleaned and explained that the cleaning schedule is based on focus areas, such as cleaning ceiling tiles, etc. Employee E7 further stated that staff just know what needs to be done, Interview with Nursing Home Administrator (NHA) Employee E1 on August 25, 2025, at 12:50 p.m. confirmed that the facility is aware of rodent problems. 28 Pa. Code 210.18(b)(1) Management

Based on review of facility documentation, observations, and resident and staff interviews, it was determined that the facility failed to provide food and drink that was palatable and served at the proper temperature. Findings include: Interview with Resident R8 on July 7, 2025, at 10:00 a.m. revealed that food room temperature. Interview with Resident R10 on July 7, 2025, at 10:05 a.m. revealed, we never get hot food, although I would prefer that. Observations during a test tray conducted with the Food Service Director, Employee E3, on July 7, 2025, at 9:38 a.m. revealed waffles registered at 90.1 degrees Fahrenheit (F); scrambles eggs registered 89.5 degrees F; pork sausage registered 86.2 degrees F; and orange registered 60 degrees F. Follow-up interview with the Food Service Director, at 9:41 a.m. confirmed that the tested food items were too cool to be palatable. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(3) Management 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(3) Management 28 Pa. Code 211.6(f) Dietary services

Based on review of facility policy, resident's clinical record , observation and interview with staff, it was determined that the facility failed to ensure the safety of the resident's environment related to medication left at the bedside for one of ten residents reviewed. (Resident R2) Findings include: Review of facility policy titled Administrating Medications revised December 2012. revealed that medications shall be administered in a safe and timely manner and as prescribed. Medications must be administered within one hour or prescribed time and the individual administering the medications must verify the resident's identity before giving his or her medications. If a drug is withheld, refused or given at a time other than scheduled time the individual administering the medication shall initial and circle the mar (medication administration record) space provided for that drug induce as required or indicated for the medication the individual administering the medication will record in the resident's medical record the date and time the medication was administered, the dosage, 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 review of facility documentation, clinical record and staff and family interview, it was determined that the facility failed to ensure that rehabilitation services were provided timely for one of ten residents reviewed. (Resident R1) Findings include: Review of Resident R1's clinical record revealed that the resident was admitted to the facility on [DATE]. Interview with Resident R1's family member on May 29, 2025 at 10:40 a.m. revealed that the resident entered the facility following knee surgery, and the resident arrived to the facility at approximately 6:00 pm. The resident's family member stated that her surgeon wanted her to be ambulating as soon as possible, it would benefit her recovery . Resident R1 was placed into bed and told she cannot get out of the bed until assessed by physical therapy. Resident R1 requested assistance to the lavatory but was told she needed to use a bed pan or brief until she was seen and assessed by physical therapy. Resident R1's family asked staff when she could 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview with staff and residents, and observations, it was determined that the facility did not ensure residents' received services in the facility with reasonable accommodation, needs, and preferences for two out of 17 residents reviewed (Resident R1, R2) Findings include: Review of facility policy 'Resident Rights Guidelines for All Nursing Procedures,' revised October 2010, indicates that purpose of policy is to provide general guidelines for resident rights while caring for the resident, including b. Resident dignity and respect, h. Resident freedom of choice. Interview with Resident R2 on Monday, February 24, 2025, at 11:30 am, indicated that residents stayed in their chairs during night shift after an emergency evacuation, during the overnight shift, from Saturday, February 22, 2025, through Sunday, February 23, 2025. Interview with licensed nurse, Employee E5, who worked night shift, confirmed that approximately 10 residents stayed in wheelchairs and regular chairs, during overnight shift, on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, review of clinical record, and staff interview, it was determined that the facility failed to ensure that pain management was provided in a timely manner to residents consistent with standards of professional practice for one of one resident reviewed for pain (Resident R18). Findings include: Review of facility policy on Pain Assessment and Management under section Purpose: The purposes of this procedure are to help the staff identify pain in the resident, and to develop interventions that are consistent with the resident's goals and needs and that address the underlying causes of pain. Under section General Guidelines: #1. The pain management program is based on a facility-wide commitment to appropriate assessment and treatment of pain, based on professional standards of practice, the comprehensive care plan, and the resident's choices related to pain management. #2. Pain management is defined as the process of alleviating the resident's pain based on his or her clinical…

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, observation, and staff interview, it was determined that the facility failed to ensure that drugs ad biologicals are stored in a safe/secure environment in accordance with professional standards for two large tranparent plastic garbage bags containing blister packs of medications. Findings include: Review of undated facility Policy on Storage of Medication revealed that under section Policy Statement: The facility stores all drugs and biologicals in a safe, secure, and orderly manner. Under section Policy Interpretation and Implementation #1. Drugs and biologicals used in the facility are stored in locked compartments or room, #3. The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. #11. Only persons authorized to prepare and administer medications have access to locked medications. Observation conducted on February 24, 2025, at 9:40am together with DON ( Director of Nursing) Employee E2 of the first floor of the Assisted Living Facility where some of the residents from…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of clinical records, facility documentation and interviews with residents and staff, it was determined the Nursing Home Administrator failed to effectively manage the facility related to the failure to maintain air temperatures between 71 degrees Fahrenheit and 81 degrees Fahrenheit in 16 resident rooms, dining rooms and nursing units for two out of two nursing units. (Second and Third Floor) The failure to maintain comfortable and safe air temperatures for a total of 16 residents residing in rooms 202, 206, 211, 217, 224, 225, 228, 234, 238, 305, 306, 316, 325, 331, and 333 resulted in an Immediate Jeopardy situation. (Second and Third Floor) Findings include: Review of the job description for the Nursing Home Administrator revealed that the Administrator was responsible to operate the facility in accordance with the established policies and procedures of the governing body in compliance with federal, state and local regulations. Establish systems to enforce the facility policies and procedures.…

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

Based on observation, interviews with resident and staff, review of resident's clinical records, facility documentation and policy reviewed, it was determined that the facility failed to ensure essential mechanical equipment was in safe operating condition for one of two elevators and the heating system in the main kitchen. Findings include: Review of Resident R220 physician admission notes, dated December 31, 2024, indicated Resident R220 was diagnosed with Type II Diabetes (a chronic condition where the body does not use insulin effectively or does not produce enough insulin), high blood pressure, neuropathy, and a nonhealing diabetic foot ulcer diagnosed with osteomyelitis( bone infection) that required I.V. antibiotics of vancomycin (used to treat serious infections). On January 7, 2024, at 11:30 a.m. Resident R220 said he was stuck on the elevator Friday (January 3, 2025), on the way down from the third floor by himself. The resident described the elevator making very loud thumping sounds, describing as if the elevator wanted to stop while it made its way down. When 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 observations, review of facility documentation, and resident and staff interviews, it was determined that the facility failed to ensure that a safe, functional, and comfortable environment was maintained for two of ten residents rooms observed and laundry room . (Resident R49 and Resident R10) Findings: On January 7, 2025, at 10:43 a.m., an observation of Resident R49's bathroom revealed a dirty toilet with a brown substance and a soiled brief placed next to the toilet. Additionally, a sanitizer dispenser located near the resident's bedroom door was observed to be broken. On January 7, 2025, at 10:49 a.m., an observation of Resident R19's room revealed a broken baseboard near the table and a missing drawer on the left side of her desk. This observation was confirmed by Licensed Nurse, Employee E4 Observation conducted on January 7, 2025, at 10:58 a.m. revealed Resident R10's baseboard was off the wall next to her restroom wall in the corner. On January 7, 2025, at 11:58 a.m., an 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, resident and staff interviews and review of the pest control logs, pest control company management program and review of facility policies, it was determined that the facility failed to maintain an effective pest control program to ensure that the facility was pest free for two of two nursing units, the food and nutrition services department and laundry room. (2nd Floor nursing unit, 3rd Floor nursing unit, main kitchen and laundry room) Findings include: A review of the undated facility policy titled pest control revealed that pest control was extremely important to ensure safe foodservice. The policy indicated that pest control was important to prevent spread of disease. The pest control policy indicated that mice and roaches carry a wide range of diseases such as salmonella and staphylococcus. The policy and procedures to prevent household pest from entering the building were to fill all voids, store foods in tight containers, dispose of garbage and trash proptly and in sealed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility documents, facility policies and procedures, clinical records reviewed, and staff interview, it was determined that the facility failed to conduct complete and thorough investigations of allegations of physical abuse, neglect and misappropriation of property for 4 of 17 residents reviewed (Resident R1, R 120, R22, R58). Findings include: Review of facility policy Abuse Prevention Program dated November 30, 2024 , indicated protect our residents from abuse by anyone including, but not necessarily limited to facility staff, other residents, consultants, volunteers, staff from other agencies, family members, legal representative, friends, visitors, or any other individuals. Under bulletin # 7. it further states Investigate and report any allegations of possible abuse within timeframes as required by the federal and state requirement. A review of the policy titled abuse investigation and reporting dated November 30, 2024 also revealed that the purpose of the policy was to ensure that all…

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, observations, reviews of the facility policies and procedurs and interviews with staff, it was determined that for three of four residents reviewed, the facility failed to provide adequate supervision for residents who smoke. (Resident R24, R5 and R63) Findings include: The facility policy entitled Smoking policy revised December 2016 stated Smoking is not allowed inside the facility under any circumstances. According to the facility's established smoking policies and procedures, any residents found violating the smoking agreement would have their smoking priviledges revoked. The smoking agreement also indicated that the resident was also recommended to the physician for immediate discharge from the facility. On January 8, 2024, at 10:30 a.m. a resident council group meeting was held with six alert and oriented residents (Residents R14, R60, R47, R20, R17, R11) revealed that there was a resident who was a smoker and smokes in his room. The residents stated that the facility has…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on reviews of clinical records, observations of resident rooms, interviews with residents and staff, review of policies and procedures and review of the admission agreement, it was determined that the facility failed to exercise reasonable care for the protection of resident's property from loss or theft for two of four residents reviewed. (Residents R58 and R63) Findings include: A review of the facility's policy titled release of resident's personal belongings dated 2017 revealed that the facility was responsible for protecting the personal belongings of each resident. A review of the facility's admission agreement containing the established resident rights revealed that the facility was responsible for making reasonable accommodations and efforts to safeguard Resident's personal property. The agreement indicated that the facility was responsible to assist each resident in securing personal belongings, valuables or cash. The admission agreement indicated that this was a resident right to have his or her…

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 interviews with resident and staff and review of clinical records, review of facility documentation and review of facility policy, it was determined that the facility failed to report an allegation of suspected abuse and neglect to the Survey Agency for one of 17 residents reviewed. (Resident R1). Findings include: Review of Resident R1's admissions Minimum Data Set (MDS-an assessment of resident's needs) dated November 14, 2024 indicated that the resident was alert and oriented and able to make needs known. Continue review of the MDS revealed that the resident had diagnoses of chronic obstructive pulmonary disease, neuromuscular dysfunction of bladder, multiple sclerosis, malignant neoplasm of the large intestine, was frequently incontinent of bowel and bladder and required a staff member to assist with transfers. Review of Resident R1's clinical record revealed that Resident R1 was alert and oriented and diagnosed with colon cancer. The resident had loose stools and periods of incontinence of bowels and gastro intestinal upset. Review of Resident R1's care plan revealed…

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

Based on review of clinical records, review of facility policy, and interviews with staff, it was determined that the facility failed to develop and implement a comprehensive care plan related to Resident R220's diagnosis of post-traumatic stress disorder for one of 17 resident records reviewed (Resident R220). Findings include: Review of the facility's policy titled, Trauma-Informed Care not date, stated the purpose of the policy is to establish guidelines for implementing trauma-informed care (TIC) in the long-term care facility to support residents who may have experienced trauma. The goal is to provide care that is safe, respectful, and responsive to the effects of trauma while fostering a supportive environment. Care will be provided in a manner that prevents re-traumatization and promotes healing and empowerment. The policy defines TIC as an approach that recognizes the prevalence of trauma and understands its impact and integrate knowledge of trauma into care policies to ensure the physical and emotional safety of the resident. Review of Resident R220's psychiatric evaluation…

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 reviews of policies and procedures, interviews with residents and staff and review of the outside services agreement, it was determined that facility failed to offer each resident who was not able to carry out activities of daily living for grooming, the opportunity for hair dresser or barber services to meet their needs. (Residents R24, R63, R22,R58, R64, R5, R19, R35, R23, R1, R65, R51 and R62). Findings include: A review of the undated facility policy titled beauty and barber services revealed that the purpose of the policy was to provide each resident with access to professional grooming services in a safe, hygienic and respectful manner while enhancing their quality of life. The policy indicated that professional beauty and barber services were to be available and offered to the residents on a regular basis. The services offered would be haircuts, styling, coloring, shaving and other grooming based on the residents'needs. A review of the service agreement dated September, 2024, revealed that an agreement was established for the facility with a cosmotology and barber…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, resident and staff interviews, it was determined the facility failed to ensure each resident receives proper treatment and assistive devices to maintain vision abilities for one of 17 resident records reviewed (Resident 55). Findings include: Review of Resident R55's clinical record revealed the resident was admitted on [DATE], with diagnoses of muscle weakness, lack of coordination, abnormal gait and mobility, high blood pressure, and glaucoma (a chronic eye disease that causes damage to the optic nerve). Interview with Resident R55 on January 7, 2025, at 10:30 a.m. indicated the resident had not seen the eye doctor since admission. This was confirmed by the Director of Nursing on January 10, 2025, at 3:00 p.m. there was no evidence Resident R55 had an eye exam since the resident's admission to the facility. 28 Pa. Code 211.12 (d) (5) Nursing services

Based on observations, interviews with resident and staff, review of clinical records and facility policy, it was determined that the facility failed to provide assistant device for one of 17 residents reviewed to maintain independence with bed mobility (Resident R23). Findings include: Review of the facility's policy for bed safety (undated) states the resident should be assessed for safety, medical conditions comfort and freedom of movement as well as input from the resident. If side rails are used there should be a resident assessment and consultation with physician and input from the resident. Side rails may be used if assessment and consultation with the physician has determined that they are needed to help manage a condition or to help the resident reposition or move in bed and transfer. Review of Resident R23's the quarterly MDS (an assessment of resident needs) date November 6, 2024, indicated the resident was alert and oriented, able to make decisions for self, independent with all activities of daily living, and continent of bowel and bladder. Interview with Resident R23…

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 resident clinical records reviewed, interview with staff and review of facility policy, it was determined that the facility did not ensure one resident that entered the facility with an indwelling catheter was assessed for removal of the catheter or the resident's clinical condition demonstrates that catheterization was necessary for one of 17 resident records reviewed (Resident R64). Findings include: Review of the facility's policy Urinary Continence and Incontinence Assessment and Management not dated indicates an indwelling urinary catheter will be used Sparingly for appropriate indications only. As part of the initial and ongoing assessments, the nursing staff and physician will screen for information related to urinary continence. Examples of sources of such information may include the resident, family, or a hospital discharge describing placement of an indwelling urinary catheter during a recent hospitalization. When a resident is admitted from the hospital with a newly placed indwelling catheter, they physician will evaluate the potential for removing it, depending…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, reviews of clinical records, and interviews with resident and staff, it was determined that the facility failed to provide adequate treatment and care for intravenous catheter (IV) line in accordance with professional standards of practice for one of 17 resident records reviewed (Resident R220). Findings included According to the standard of nursing practice guidelines the Pharmacy and Therapeutic peer-reviewed journal for managed care and hospital formulary management February 2011, titled Capping Intravenous Tubing and Disinfecting Intravenous Ports Reduce [NAME] of Infection. The article states, Failure to place a sterile cap on the end of a reusable intravenous(IV) administration set that has been removed from a primary administration set saline lock, or IV catheter hub, with the tubing left hanging between uses is exposed to potential contaminants that can lead to infection if the non-sterile IV set is reconnected to the patient's IV access. Health care practitioners who administer…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of clinical records and facility policies and procedures, observations of care and services, and interviews with staff, it was determined that the facility failed to consistently provide respiratory care and supplemental oxygen as ordered by the physician for two of 28 residents reviewed. (Resident R2 and R5). Findings included: A review of the facility policy titled Oxygen Administration dated October, 2010, stated The purpose of this procedure is to provide guidelines for safe oxygen administration. Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration. Review the resident's care plan to assess for any special needs of the resident. A review of Resident 2's clinical record revealed the resident was admitted on [DATE], with diagnoses to include: chronic respiratory failure with hypoxia (not enough oxygen passes from the lungs to the blood, making it difficult to breath), and congestive heart failure (a 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 review of clinical record, and interviews with resident and staff, it was determined that the facility failed developed a plan of care for a resident with a diagnosis of PTSD and provided psychological services after the resident was stuck inside the facility's elevator for one of 17 residents reviewed. (Resident R220) Findings include: Review of Resident R220's nursing note dated December 31, 2024 revealed that the resident was admitted to the facility with a past medical history of hypertension (elevated blood pressure), depression (major loss of interest in pleasurable activities), anxiety and Post Traumatic Stress Disorder (is a mental health condition that's caused by an extremely stressful or terrifying event - either being part of it or witnessing it. Symptoms may include flashbacks, nightmares, severe anxiety and uncontrollable thoughts about the event). The resident was alert and oriented x 3 (person, place and time) with adequate vision. Review of Resident R220's physician admission notes, dated December 31, 2024, indicated Resident R220 was also diagnosed with a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of clinical records and interview with resident and staff, it was determined that the facility did not ensure that routine dental services were provided to residents in a timely manner for one of 17 records reviewed (Resident R55) Findings include: Review of Resident R55 clinical record revealed the resident was admitted on [DATE], diagnosed with muscle weakness, lack of coordination abnormal gait and mobility, high blood pressure, and glaucoma (a chronic eye disease that causes damage to the optic nerve). Interview with Resident R55 on January 7, 2025, at 10:30 a.m. indicated the resident had not seen the dentist since admission. It was confirmed by the Director of Nursing on January 10, 2025, at 3:00 p.m. there was no evidence Resident R55 had a dental exam since admission. 28 Pa. Code 211.12 (d) (5) Nursing services

Based on observations of the food and nutrition services department, reviews of County Office of Public Health report, interviews with staff and policies and procedure reviews, it was determined that the dietary services was not being operated under sanitary conditions. Findings include: A review of the undated policy titled cleaning and sanitizing of dietary areas and equipment revealed that all kitchen areas and equipment was to be maintained in a sanitary manner free of build up of food debris, grease and soil. A review of the undated policy titled floors revealed the floors must be cleaned daily. Floors must be cleaned of obvious litter, food spillagestacky substances and excessive water. The ceiling tiles in the hot food preparation area contained a coating of grease and dried splattered food. The ceiling tiles were brown stained and water damaged evidening leaking of water above the ceiling tiles. The ceiling light fixtures in the hot food preparation area contained dirt and dead bugs. The low temperature dish machine, when tested was not registering the proper concentration…

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 resident and staff interviews, it was determined that the facility failed to maintain clinical records that were complete and accurately documented for 1 of 17 residents reviewed (Resident R24) . Findings include: On January 9, 2025, at 2:50 p.m., an interview with the Social Worker, Employee E13, revealed that there were other instances before New Year where a smoking odor was allegedly detected in Resident R24's room. However, Employee E13 stated that the Administrator advised not to document these instances, explaining that a record of non-compliance would make it more difficult to find a placement for Resident R24 in other facilities. On January 10, 2024, at 9:59 a.m., an interview was conducted with Housekeeping Aide, Employee E7. She reported that on January 2, 2025, she noticed a strong smell of cigarettes in Resident R24's room. She also observed three cigarette burn holes on Resident R24's lunch tray, along with a burnt-out cigarette on the tray table. Employee E7 stated that she immediately reported the incident to her…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policies, clinical record reviews and interviews with staff, it was determined that the facility failed to develop a baseline care plan within 48 hours of a resident's admission that includes the minimum healthcare information necessary to properly care for a resident, for one of five residents reviewed (Resident R1). Findings include: Review of facility policy, Care Plans - Baseline undated, revealed, A baseline plan of care to meet the resident's immediate needs shall be developed for each resident within forty-eight (48) hours of admission. Continued review revealed that the baseline care plan will include initial goals based on admission orders, physician orders, dietary orders, therapy services, social services and PASARR (screening tool for mental illnesses) recommendations. Review of facility policy, New admission Chart Review Checklist undated, revealed that upon admission staff will ensure that a baseline care plan is completed. Review of Resident R1's Medicare 5-Day 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policies, clinical record reviews and interviews with staff, it was determined that the facility failed to follow physician orders related to medications for one of five residents reviewed (Resident R1). Findings include: Review of facility policy, Administering Medications dated revised April 2020, revealed, Medications are administered in a safe and timely manner, and as prescribed. Continued review revealed, Medications are administered in accordance with prescriber orders, including any required timeframe. Review of Resident R1's Medicare 5-Day MDS (Minimum Data Set - a mandatory periodic resident assessment tool), dated August 18, 2024, revealed that the resident was admitted to the facility on [DATE], and had diagnoses including heart failure (a chronic condition in which the heart doesn't pump blood as well as it should), depression (mood disorder characterized by low mood, a feeling of sadness, and a general loss of interest in things), diabetes (ability to produce or respond…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policies, clinical record reviews and interviews with staff, it was determined that the facility failed to maintain complete and accurate documentation for one of five residents reviewed (Resident R1). Findings include: Review of facility policy, New admission Chart Review Checklist undated, revealed that, upon the resident's admission to the facility, the Nursing admission Evaluation packet should be completed and that tasks, such as shower day schedules and level of assistance needed with activities of daily living should be entered. Continued review revealed that the resident's advance directives and code status should be entered in the electronic medical record. Further review revealed that staff will ensure that diet orders are entered in the electronic medical record. Review of Resident R1's Medicare 5-Day MDS (Minimum Data Set - a mandatory periodic resident assessment tool), dated August 18, 2024, revealed that the resident was admitted to the facility on [DATE], and had…

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, a review of facility documentation and interviews with resident, staff and contractors, it was determined that the Nursing Home Administrator failed to effectively manage the facility related to ensuring that comfortable air temperatures were maintained between 71 degrees Fahrenheit and 81 degrees and that the central air conditioning system was maintained in a safe operating condition which resulted in an Immediate Jeopardy situation. Findings inlcude: Review of the Nursing Home Administrator's job description revealed that the purpose of this position is to establish and maintain systems that are effective and efficient to operate the facility in a manner to safely meet residents' needs in compliance with federal, state and local requirements. To establish and maintain systems that are effective and efficient to operate the facility in a financially sound manner. Under delegation the authority is delegated to the individual in this position to develop, maintain and implement operational…

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, observations, interview with residents and staff, it was determined that the facility failed to prevent transmission of infection precautions and implement policies and procedure to prevent infections related to the transporting and handling of linens on one of one laundry rooms observed and failed to conduct assesment to identify Legionella and other opportunistic waterborne pathogens. Finding include: Review of facility policy titled Infection Prevention and Control Program revised October 2018 revealed important facets of infection prevention include : educating staff and ensuring that they adhere to proper techniques and procedures, immunizing residents and staff to try to prevent illness, and following established general and disease specific guidelines such as those of the Center for Disease Control (CDC), the facility provides personal protective equipment, checks for proper use, and provides appropriate means for needle disposal. Review of the facility's Infection preventionist job description reveals the infection preventionist's duties include…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews with residents, and interviews with staff, it was determined tha tthe facility did not ensure a safe, clean, comfortable, homelike environment for three of three floors observed. (First floor, Second floor, and Third floor). Findings include: Observation of the First-floor therapy room revealed four buckets and one large trash can with standing water. Water was observed leaking consistently onto the wall and floor where a puddle was located. Interview with Assistant Director of Maintenance, Employee E6 and Nursing Home Administrator, Employee E1 confirmed that the space had not been in use since around November 2023 when the water leaks started. When asked who was supposed to be checking on these leaks assistant Director of Maintenance, Employee E6 stated he should be. He last checked on Friday and that the trash can was empty when he left. Currently, the large trash can was full three quarters of the way with standing water. There was black substance with the apperance of mold…

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 resident clinical records, staff and resident interviews, it was determined that the facility failed to implement infection control by not ensuring availability of immunization and offering vaccination to eight of 16 residents reviewed. ( Findings include: Review of facility policy, Infection Prevention and Control Program revised 2018, revealed the elements of this program consists of policies, surveillance, data analysis, antibiotic stewardship, prevention of infection, including immunization of residents and staff to prevent illness. Review of the facility policy titled Influenza Vaccine revealed that all resident and employees who have no medical contradictions to the vaccine will be offered the influenza vaccine annually to encourage and promote the benefits associated with vaccinations against influenza. Further review of the policy titled Influenza Vaccine revealed that employees hired, or residents admitted between October 1, and March 31, shall be offered the vaccine within five working days of the employees' job assignment or the resident's…

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

Based on review of facility policy, interviews with staff and residents, it was determined that the facility did not ensure privacy and dignity was upheld for two of 16 residents reviewed. (Residents R20 and R26). Findings Include: Review of facility policy titled, Resident Rights with a revision date of December 2016 states, Employees shall treat all residents with kindness, respected, and dignity. 1. Federal and state laws guarantee basic rights to all residents of this facility. These rights include the resident's right to: a. a dignified existence, b. be treated with respect, kindness, and dignity. An interview was held with Resident R20 on February 20, 2024 at 10:11 a.m. During the resident interview Resident R20 mentioned on the Third-floor shower room there was no shower curtain. Resident R20 stated he has mentioned this to staff a few times and there is still no curtain. Resident R20 stated that he will be in the shower room taking a shower and staff or other residents will walk right into the space outside of the shower and be able to see him naked. Observation made 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 review of the facility policy, facility grievance log, review of facility grievances, interviews with residents and staff, it was determined that the facility did not ensure resident grivance was documented for one of 16 residents reviewed. (Resident R4) Findings Include: Review of facility policy titled Grievance/Complaints, Filing with a revised dated on April 2017 states, Residents and their representatives have the right to file grievances, either orally or in writing, to the facility staff or to the agency designated to hear grievances (e.g., the State Ombudsman). The Administrator and staff will make prompt efforts to resolve grievances to the satisfaction of the resident and/or representative. Interview during resident council held on February 21, 2024 at 10:00 a.m. with nine awake, alert, and oriented residents revealed Resident R4 had a concern with missing clothing. Resident R4 revealed a concern regarding never receiving an explanation about clothing items of his that went missing back in November 2023. After resident council was held the facility was asked if a…

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

Based on observation and an interview with staff, it was determined that the facility failed to ensure that the most recent Department of Health survey results were readily accessible to residents and visitors. Findings Include: Observation on Ferbruary 22, 2024 at 8:50 a.m. and February 23, 2024 at 11:05 a.m. revealead a survey binder located in the lobby area with past Department of Health survey reports only available through April 30, 2023. Interview and observation of the Department of Health's survey results binder on February 23, 2024 at 11:07 a.m. with Nursing Home Administrator confirmed that the State survey results were not kept up to date for resident, families and visitors to review. 28 Pa. Code 201.14 (a) Responsibility of licensee

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, facility documentation, review of clinical records, interviews with staff and the resident, it was determined that the facility failed to implement an abuse prohibition policy that included a complete a thorough investigation of an incident involving verbal abuse for one of 16 residents reviewed. (Resident R14) Findings Include: Review of facility policy titled Abuse Prevention Program dated January 1, 2022 reads, Our residents have the right to be free from abuse, neglect, misappropriation or resident property and exploitation. Role of the Investigator: 16. The individual conducting the investigation will, as a minimum: a. Review the completed documentation forms: b. Review the resident's medical record to determine events leading up to the incident; c. Interview the person (s) report the incident; d. Interview any witnesses to the incident; e. Interview the resident (as medically appropriate) f. Interview the resident's Attending Physician as needed to determine 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 the review of clinical records and interview with staff, it was determined that the facility failed to notify the resident and the resident's representative(s) of the transfer to the hospital and the reasons for the transfer in a timely manner, in writing and in a language and manner they understood for three of 16 residents reviewed (Residents R23 and R61). Findings include: Review of Resident R23's clinical record revealed that the resident was transferred to the hospital on September 6, 2023, due to a change in mental status. Review of clinical record revealed no evidence that Resident R23 was not notified of the transfer to the hospital and the reasons for the transfer in writing, and in a language and manner they understood. Review of Resident R61'sclinical record revealed that the resident was sent to ER (emergency room) on December 18, 2023, due to foot infection. Review of clinical record revealed no evidence that Resident R61 was notified of the transfer to the hospital and the reasons for the transfer in writing, and in a language and manner they understood.…

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

Based on clinical record review and staff interview, it was determined that the facility failed to ensure that the resident and resident representative receive written notice of the facility bed-hold policy at the time of a facility-initiated transfer to a hospital for two of 32 residents reviewed. (Resident R91 and R71) Findings include: Review of Resident R23's clinical record revealed that the resident was transferred to the hospital on September 6, 2023, due to a change in mental status. Review of Resident R61's clinical record revealed that the resident was sent to ER (emergency room) on December 18, 2023, due to foot infection. Further review of Resident R23 and R61's clinical record revealed that there was no documented evidence that the residents' were provided with a written notice of the facility bed-hold policy at the time of Resident R23 and R61's facility-initiated transfer to the hospital. Interview with the Nursing Home Administrator, Employee E1, and Director of Nursing, Employee E2, on February 22, 2024, at 3:05 p.m. confirmed that the Residents R23 and R61 were 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 documentation, review of clinical records, and staff interviews, it was determined that the facility failed to provide safe wheelchair transport resulting in a fall and laceration of scalp for one of 16 residents reviewed (Resident R41). Findings include: Review of facility documentation dated, February 6, 2024, revealed that Resident R41 fell out of wheelchair while being wheeled on a wheelchair by the nurse aide, Employee E25. Review of clinical records revealed that Resident R41's fall resulted in a laceration to left forehead with 1 inch raised hematoma and a transport to the hospital for evaluation. Review of written statement by nurse aide, Employee E25, dated February 6, 2024, revealed that when pushing the resident on the wheelchair, Resident R41 portrayed resistive behavior by placing her feet on the floor, to stop the wheelchair, and she went flying out of her chair, and her head hit the floor and she was bleeding. Review of nursing progress notes for Resident R41, dated February 6, 2024, revealed that the nurse aide, Employee E25, stated…

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

Based on review of personnel files and staff interviews, it was determined that the facility failed to ensure that nurse aides were able to demonstrate competency in skills and techniques necessary to care for residents for four of four nursing staff reviewed. (Employeees E2, E10, E11, E29) On February 23, 2024 at 1:24 p.m. nurse aides competencies were reviewed for the following staff Licensed Nurses Employee E2, E10, E11, and E29. Review of Director of Nursing, Employee E2's personnel file revealed the licensed nurse, E2 was hired February 4, 2020. Further review of Director of Nursing, Employe E2's personnel file revealed no competencies were available to ensure that the licensed nurse was competent in skills and techniques necessary to care for residents needs including infection control, hand hygiene, wound care, and medication administration. Review of licensed nurse, Employee E10's, personnel file revealed the licensed nurse was hired by the facility on October 4, 2022 and there had been no nursing competencies completed between October 4, 2022 and February 20, 2024. Further…

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, observation and staff interviews it was determined that the facility failed to assure that medications were labeled, current, securely stored, properly disposed of and inaccessible related to one of four medication carts (Second floor low side), one of two medication rooms (Third floor), and one medication refrigerator (Second floor). Findings include: Review of the American Diabetes Association recommendation of safe storage of insulin, insulin products contained in vials or cartridges supplied by manufacture (opened or unopened) may be left unrefrigerated at a temperature between 59degrees and 86degrees for up to 28 days. Review of Sanofi pharmaceutical insert of Lantus insulin dated 2022, (glargine is an unbranded biologic for Lantus insulin). Revealed the storage of this product, the 10 ml multi-dose vial and the 3 ml single dose pen, in use and or unopened room temperature are only to be used up until 28 days of opening. Review of Seqirus pharmaceutical insert revised 2022, for the vaccine Afluria quadrivalent influenza vaccine, revealed the storage…

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 of the food and nutrition department, and interviews with residents and staff, it was determined that the facility failed to provide residents with nourishing, palatable, well-balanced diets that met their daily nutritional and special dietary needs for one of two nursing units observed (third floor nursing unit). Findings include: Dining observations conducted on the third floor, on February 21, 2024, at 12:40 p.m. revealed that Resident R18 received chicken and potatoes on his lunch meal tray, but no vegetable. Review of resident's meal slip, under food dislikes, failed to reveal any food items listed. Interview with Resident R18 at 12:41 p.m. revealed that he preferred a vegetable with his lunch meal. At 12:41 p.m. observations revealed that Resident R26 received chicken and potatoes on her lunch meal tray, but no vegetable. Review of Resident R26's meal slip, under food dislikes failed to reveal the vegetable of the day listed, which was corn. Further observations failed to reveal dining staff offer Resident R26 a vegetable 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 facility documentation, observations, and resident and staff interviews, it was determined that the facility failed to provide food that was palatable and served at the proper temperature for 3 of 16 residents reviewed (Residents R15, R22, R11). Findings include: Review of undated facility policy titled, Food Temperatures, revealed that the point of service temperature to residents will be within the range of 120-140 degrees . and the temperature of potentially hazardous cold foods will be not greater than 40 degrees when served to the resident. Interview with Resident R15 on February 21, 2024, at 10:28 a.m. revealed that morning eggs come frozen. Interview with Resident R22 on February 21, 2024, at 10:34 a.m. revealed that food is always cold, especially breakfast. Interview with Resident R11 on February 22, 2024, at 10:44 a.m. revealed that hot food comes cold. Observations during a test tray conducted with the Food Service Director (FSD), Employee E24, on February 22, 2024, at 12:44 p.m. revealed that the milk registered at 45.1 degrees Fahrenheit (F); juice…

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, facility documentation, job descriptions, and interviews with staff, and interviews with residents, it was determined that the Nursing Home Administrator failed to effectively manage the facility related to grievances being filed properly for one of 16 residents reviewed (Resident R4). Findings Include: Review of the job description for the Nursing Home Administrator revealed, the primary purpose of the job position is to manage the Facility in accordance with current applicable federal, state, and local standards, guidelines, and regulations that govern long-term care facilities. To follow all facility policies and apply them uniformly to all employees. To ensure the highest degree of quality care is provided to our residents at all times. Review of the job description for the Social Worker reads, The Social Worker provides medically related social services to assigned caseload that assist residents to attain or maintain the highest practicable physical, mental, and psycho-social well-being. Services provided meet professional standards 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 facility documentation and interviews with staff, it was determined that the facility failed to maintain an effective, comprehensive, data-driven quality assurance and performance improvement program (QAPI) that focuses on indicators of the outcomes of care and quality of life as required. Findings include: Review of facility policy, Quality Assurance and Performance Improvement (QAPI) Plan revised April 2014, revealed that the facility will: develop, implement, and maintain an ongoing, facility wide QAPI Plan designed to monitor and evaluate the quality and safety of resident care, pursue methods to improve care quality, and resolve identified problems . This committee shall meet monthly to review reports, evaluate the significance of data, and monitor quality-related activities of all departments, services, or committees. Further review of facility policy revealed, Feedback, data systems and monitoring: Systems are in place to monitor care and services; care process and outcomes are monitored using performance indicators. These performance indicators are…

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

Based on a review of facility documents of Quality Assurance meeting attendance and staff interviews, it was determined that the facility failed to ensure that the Infection Preventionist or designee attended quarterly Quality Assurance Process Improvement (QAPI) Committee meetings for one of four quarterly meeting (November 2023 through January 2023). Findings Include: A review of QAPI committee meeting sign-in sheets for the period of January An interview with the Nursing Home Administrator (NHA) on February 23, 2024, at approximately 10:38 a.m. revealed that committee meetings are conducted monthly. Further interview revealed that the last Infection Preventionist, Employee E30, was last employed on November 3, 2023. Further interview revealed that the current Director of Nursing, Employee E2, had no completion records of the Nursing Home Infection Preventionist training and was not certified by The Centers for Disease Control and Prevention (CDC) at the time of survey. A review of QAPI committee meeting sign-in sheet for the third quarter, dated Q3 October 24, confirmed the last…

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's, job description documentation, review of employee's employment file and employee interview, it was determined that the facility failed to ensure the Infection Preventionist was qualified by training and certification to implementing programs and activities to prevent and control infections. Finding include: Review of the facility policy infection prevention and control program revised 2018 revealed that the program is developed to address the facility specific infection control needs and consist of oversight, policies procedures, surveillance, data analysis, antibiotic stewardship, outbreak management, prevention of infection, and employee health and safety. This program is overseen coordination and oversight of this program is to be overseen by an infection prevention specialist . Review of the facility InfectionPpreventionist job description reveals the infection preventionist's duties include collects, analyses, and interprets health data to plan implement, evaluate, and disseminate appropriate public health practices. The qualification 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 observations of the food and nutrition department, review of facility policy and interviews with staff, it was determined that the facility failed to maintain essential food service equipment in safe operating condition. Findings Include: An initial tour of the main kitchen was conducted on February 20, 2024, at approximately 9:30 a.m. with the Food Service Director (FSD), Employee E24. Observations of the stove, in the main cooking area, revealed that the stove control knobs were missing. Further observations revealed that one of the stove piolet lights was lit more than 2-3 inches with yellow and orange flames and protruding through the two burners on the right side. Interview conducted with the FSD at the time of observation revealed that the stove has has not funtion properly for approximately six months. Further interview revealed that the piolet light is defective and does not fully shut off; and that the 2-3-inch flame remained on. Review of the stove manufacturer's instructions, titled Installation and operation Owner's Manual, revealed that for complete shutdown,…

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 staff education records and interviews with staff, it was determined that the facility failed to conduct at least twelve hours of in-service education, within 12 months of their hire date anniversary, for nurse aides as required for two of two nurse aides personnel files reviewed. (Employees E19 and E20) Finding Include: Review of Nurse Aide, Employee 19's personnel file revealed that the employee was hired on May 6, 2022. There was no documented evidence of in-service education hours between May 6, 2022 and February 20, 2024. Review of Nurse Aide, Employee E20's personnel file revealed that the employee was hired on June 16, 2022. There was no documented evidence of in-service education hours between June 16, 2022 and February 20, 2024. Interview held on February 23, 2023 at 2:47 p.m. with Human Resources Director, Employee E7 stated that there was a binder that has yearly competencies that had been lost. Human Resources Director, Emplyoee E7 confirmed that Employees E19 and E20 did not have their yearly competencies in their personnel's file. 28 Pa. Code…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility documentation, and interviews with staff and residents, it was determined that the facility did not follow menus that meet the nutritional needs of residents in accordance with established national guideline and that menus were prepared in advance and followed. Findings include: Review of Wyndmoor Hills Rehab and Nursing Emergency Operations Program and Plan Manual revealed, Operations Chief: Provide reassurance to residents and visitors Provide increased hydration and implement cooling and warming measures, as indicated Consider temporarily gathering residents in an area where lighting and temperatures can be maintained within an acceptable range (Main Dining Room) Ensure generator is running properly Initiate Disaster menus or alternative meals/snacks Emergency and Disaster Supplies-3 day, non-perishable supply (100 beds) ( 9 meals) Fruit: to be served twice per day, 1/2 cup per serving=28 #10 cans or 5 cases. 25 portions per #12 can Vegetables: to be served twice a day, 1/2 cup per…

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 staff interviews and review of employee's credentials, it was determined that the facility failed to employee a qualified Director of Food and Nutrition Services, as required. (Employee E5) Finding include: During the tour of the food and nutrition services department on December 26,2023 at 9:30 a.m., the Food Service Director (FSD), Employee E5 stated that her responsibility included the oversight of ordering, receiving, storing, preparation and services of food and has been working for the facility for three years. Interview on December 26, 2023, at 11:10 a.m. with FSD, Employee E5, confirmed that she was not a certified dietary manager; or a certified food manager; or had a national certification for food service management and safety from a National certifying body. Interview on December 26, 2023 at 9:10 p.m. with the Nursing Home Administrator (NHA) Employee E1, acknowledged that the FSD did not possess the regulatory required qualifications to provide operational oversight of the dietary department. 28 Pa Code 201.18 (e)(1)(6) Management

Based on observation, interviews with staff, and review of facility policy, it was determined that the facility did not ensure that food was stored, prepared, distributed, and served in accordance with professional standards for food services safety. Findings: Review of the facility's policy titles Personal Hygiene undated; states hands must be washed prior to beginning work and a hair net must be worn. Review of the facility's policy titled Infection Control undated; states the dietary manager is ultimately responsible for the supervision of all sanitation and housekeeping procedures to maintain an environment that is safe for storage, preparation, and service of food. Garbage and waste are disposed of promptly and properly. Further review of this policy reveals that adequate hand washing facilities are available and include hot and cold running water, soap, and individual towels. Review of facility's policy titles Sanitation/Infection Control states Effective sanitary practices include effect pest control is provided by an outside company. Outside doors and windows will 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 observation, review of facility documentation, and staff and resident interviews, it was determined that the facility failed to ensure that each resident received at least three meals daily, at regular times comparable to normal meal times in the community for two of three meal observed. (breakfast and lunch meal) Finding include: Review of facility policy titled Meal Hours revealed meals are served at scheduled hours and there must not be over fourteen hours between dinner and breakfast the following morning. The resident meal hours at breakfast 8:30 a.m., Lunch 11:00-11:30 am and dinner at 5:00 p.m. Observation of the breakfast meal on December 26, 2023, on the second-floor nursing station revealed that the staff were still passing breakfast trays after 9:30 a.m. (an hour after scheduled time). Observation of the lunch meal on the second-floor nursing station on December 26, 2023 at 1:30 p.m. revealed the staff passing lunch trays after 1:30 p.m. (two hours after scheduled time). Interview with Food Service Director, Employee E5 on December 26, 2023, at 1:30 p.m., at 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 observations, review of facility policies and interview with staff, it was determined that the facility failed to ensure that garbage and refuse was disposed of properly. Findings include: Review of facility policy titled Sanitation/ Infection Control, undated stated that the garbage and refuse are to be disposed of properly. Containers are in good condition and waste is properly contained in covered dumpsters or compactors. Review of Facility Policy titled Infection Control undated, states that garbage and waste are to be disposed of promptly and properly. Observation of the main kitchen on December 26, 2023 at 9:30 a.m. revealed that the trash had not been emptied. The area on the side of kitchen leading to the back door appeared with piled up trash and boxes exceeding the trash bin, the trash placed all over the floor. Interview with Employee E5 Food Service Director, and Employee E6, Regional Human Resources Director, at time of observation confirmed that the trash had been left there for over a day and should have been emptied. 28 Pa. Code 201.18(b)(3) Management

Based on clinical record review, review of facility policy and interviews with staff, it was determined the facility failed to send all completed clinical documentation for the discharge of one of one resident. (Resident R1) Findings include: Review of facility policy titled Discharge Summary and Plan revised December 2016 stated When the facility anticipates a resident's discharge to a private residence, another nursing care facility, a discharge summary, and post discharge plan will be developed which will assists the resident to adjust to his or her new living environment. The discharge summary will include a recapitulation of the residents stay at this facility and a final summary of the resident's status at time of discharge. The discharge summary shall include current diagnosis, medical history, course of illness, current laboratory and diagnostic test results, physical and mental functional status, ability to perform activities of daily living, nutritional status and requirements, mental and psychosocial status, discharge potential, and dental conditions. Review of Resident…

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

Based on observations of the food and nutrition services, review of facility policy, and interviews with staff and residents, it was determined that the facility failed to ensure that each resident received food at safe and appetizing temperatures. Findings Include: Review of facility policy titled, Food temperatures the policy states foods will be maintained at a proper temperature to insure food safety. Further review of the policy states 3. The cook is responsible to see that all food is at proper temperature. 6. The following range of temperature is recommended for food at point of tray assembly. d. Potatoes and vegetables- 160 degrees Fahrenheit. Interview on October 23, 2023 at 10:42 a.m. with Resident R6 revealed most meals that are supposed to be warm are served cold, especially the breakfast meal. Interview on October 23, 2023 at 11:27 p.m. with Resident R10 revealed that most of her meals were supposed to be warm are served to her cold. Observation in the kitchen of the food service line on October 26, 2023 at 12:02 p.m. revealed Director of Dining Employee E3, taking 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 observations and interviews with staff, it was determined the facility failed to maintain all mechanical, electrical, and patient care equipment in safe operating condition.on three of three floors (First, Second, and Third Floors). Findings Include: Review of policy titled, Quality of Life- Homelike Environment revealed, The facility staff and management shall maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include: a. Clean, sanitary, and orderly environment. Comfortable and safe temperatures (71- 81 degrees Fahrenheit). Observation on October 26 at 9:50 a.m. of Resident R11 room revealed trash on floor and the bathroom sink in the room leaking. Resident R11 stated the facility was aware of his leaking sink but they were unable to fix it the first time. A tour was taken of the third floor at 10:05 a.m. with Nursing Home Administrator, Employee E1 and Director of Maintenance Employee E4. A digital thermometer was used to take temperatures throughout the facility. The temperatures…

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 interviews with staff, it was determined that the facility failed to ensure call systems were in proper working order for residents to call for staff assistance through a communication system for two of two floors reviewed. (Second and Third floors) Findings Include: Observation was made with Nursing Home Administrator, Employee E1, and Director of Maintenance, Employee E4, on October 26, 2023 at 10:55 a.m. of all three floors for call bells. Observation at 10:57 a.m. revealed Resident R5's call bell was shown not to reset and it did not light up on the outside of the room. Observation at 11:00 a.m. of Resident R5's call light was shown not lighting up correctly. Call light was lighting up green in the room. A call bell audit was completed by the Director of Maintenance Employee E4. Review of call bell audit records taken October 26. 2023 showed a total number of rooms on the second floor and third floor that were improperly functioning. The call bell audit revealed a total of eight call bells not working on the second floor. The call bell audit revealed a…

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

Based on observation, and interviews with staff, it was determined that the facility did not maintain a safe, clean, homelike environment on the faciltiy's lobby area and on three of three floors observed. (lobby, Second floor and Third floor) Findings include: Observations conducted on August 30, 2023, at 10:15 a.m. revealed that the ceiling in the lobby was stained with a brown-yellow color, and that some of the paint on it had a bubble like, peeling appearance. Interview with the Nursing Home Aministrator at 2:15 p.m. confirmed that the appearance was due to water damage. Observations of the Second floor conducted on August 30, 2023 at 1:19 p.m. revealed that the area behind the nurse's station had the following noted: cracked, broken floor tiles, missing ceiling tiles, broken cupboards, and rotting wood and peeling paint behind the sink. This area, which is not closed to residents, also contained the ice machine for the building, which was open. The machine appeared to be leaking, as there were wet linens underneath it. Interview with Nurse aide, Employee E4 at the time 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 observations and interviews with staff, it was determined that the facility did not ensure that food was stored, prepared, distributed, and served in accordance with professional standards for food service safety. Findings include: An initial tour of the Food Service Department was conducted on May 8, 2023, at 10:30 a.m. with Employee E3, Food Service Director (FSD), which revealed the following: Observation in the receiving area revealed a green dumpster with the lids open and cardboard boxes sticking out the top, and eight wooden pallets stacked up behind the dumpster. Observation in the mop closet area near the receiving door revealed a thick build-up of black substance in the floor drain area and the walls were splashed with dark substance. Observation in the walk-in refrigerator Box 1 revealed a metal piece along the floor and wall which was corroded and lose causing sharp edge and creating space that is not able to be cleaned and sanitized. Further observation revealed a cardboard box containing fried eggs which was open to the air, and a gallon size plastic jug that…

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

Based on observation, policy review, and staff interviews, it was determined that the facility failed to maintain an effective infection control plan related to hand hygiene for one of one residents observed (Resident R16) and the development and implementation of an effective Water Management Program for the prevention, detection, and control of water-borne contaminants. Findings include: Review of facility policy, Handwashing/Hand Hygiene, revised August 2015, revealed, Policy: The facility considers hand hygiene the primary means to prevent the spread of infection. Use an alcohol-based hand rub containing at least 62% alcohol; or alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: Before handling clean or soiled dressings. After handling used dressings. After removing gloves. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents and visitors. Applying and Removing Gloves: 1. Perform hand hygiene before applying non-sterile gloves. 2. When applying,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and review of facility policy, it was determined that the facility failed to provide a clean, orderly, and comfortable home-like interior on one of two floors. (3rd Floor) Findings include: Review of Policy Interpretation and Implementation, date in December 2009, it states that the maintenance department is responsible for maintain the buildings, grounds, and equipment in a safe and operable manner at all times. Maintaining the building in compliance with current federal, state and local laws, regulations, and guidelines. Observation was made on the 3rd floor May 8, 2023, at 10:43 a.m. revealed soiled floors through out the hallway. The floor had dark spots and some areas on the 3rd floor didn't have base boards or broken base boards. Observation of room [ROOM NUMBER] conducted during the tour of the 3rd floor on May 8, 2023, at 10:45 a.m. revealed a broken dresser drawers' door, the floor was soiled with spots and the baseboard broken. Observation of room [ROOM NUMBER] conducted during…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff interviews and a review of facility policies and documentation, it was determined that the facility was not maintaining an effective pest control program. Findings include: A review of the undated facility Pest Control policy revealed that it states that the facility will maintain an on-going pest control program to ensure that the building is kept free of insects and rodents. Observations during a tour of the facility on May 8, 2023, at 10:45 a.m. in room [ROOM NUMBER] revealed small flies buzzing around the room and further observation revealed that the window was being held open with a urinal stuck in the bottom of the window and that there was no screen in the window. Observation in room [ROOM NUMBER] on May 10, 2023, at 1:15 p.m revealed a fly in the room and the window was open with no screen. Further observation down two of three hallways on the second floor that the windows were open in all rooms from room [ROOM NUMBER] to room [ROOM NUMBER] and that none of these open…

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, interviews with residents, interviews with staff, and review of facility documentation, it was determined that the facility failed to ensure residents had access to grievance/concern forms for one of two nursing floors. (3rd Floor) Findings Include: Review of policy Resident and Family Concerns and Grievances Policy and Procedure date in 2020, Filling of Grievances: a). Residents or their family member, guardian or representative may voice a grievance to the Facility staff in person, by telephone, or a via written communication. The facility shall provide the attached Grievance Report Form to facilitate the voicing of a grievance if requested by a resident or family member. Observation made on the 3rd floor on May 8, 2023, at 10:38 a.m. revealed that there were no grievances forms by the grievances box. A tour of the facility on May 10, 2023, at 9:57 a.m. with the Director of Nursing, revealed did not have access to grievance/concern forms readily available for residents, family, or visitors. A tour of the facility with Director of…

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

Based on clinical record review and staff interview, it was determined that the facility failed to notify the resident or the resident's representative, and the Office of the State Long Term Care Ombudsman of a transfer to the hospital and the reasons for transfer in writing for two of 38 residents reviewed. (Residents R12 and R48) Findings include: Review both clinical records for Residents R12 and R48 revealed that the Resident R12 was sent to hospital from the facility on February 15, 2023, and Resident R48 resident was sent to hospital from the facility on April 6, 2023. There was no documented evidence that the office of the State Long Term Care Ombudsman was notified of the resident's discharge and that the resident was provided with the contact and address of the Office of the State Long Term Care Ombudsman. An interview on May 11, 2023, at 12:06 p.m., with the Nursing Home Administrator, couldn't provide the residents discharge list for February 2023 and April 2023 to the Office of the State Long Term Care Ombudsman. 28 Pa. Code 201.29(i) Resident rights

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, a review of the clinical record and interviews with staff, it was determined that the facility did not ensure that a comprehensive person-centered care plan with measurable objectives and goals was developed and implemented for one of 17 residents reviewed related to oxygen and CPCP machine usage (Resident R1). Findings include: Observations of room [ROOM NUMBER] on May 8, 2023, at 11:45 a.m. revealed Resident R20 sitting in her wheelchair wearing a nasal cannula (plastic tubing designed to deliver oxygen directly into the nose) with long tubing connected to an oxygen concentrator next to her bed. Also on her bedside table was her BIPAP (a type of ventilator used to treat chronic conditions that affect your breathing, similar to a CPAP machine, but unlike a CPAP, which delivers a continuous level of air pressure, a BPAP delivers two levels of air pressure) machine with tubing and a mask. Interview with Resident R20 on May 8, 2023, at 11:45 a.m. revealed that she required the oxygen…

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

Based on review of facility documentation and staff interview, it was determined that the facility did not review and revise a care plan related to weight loss for one of 17 records reviewed (Resident R34). Findings include: Review of Resident R34's plan of care revealed that a focus area dated November 23, 2022 addressed resident as having an Activities of Daily Living self-care deficit related to activity intolerance and obesity. Resident R34 has had a significant weight loss and now receives Remeron and supplemental shakes. Interview on May 10, 2023 at 2:00 p.m. with the Director of Nursing, confirmed that Resident R34 care plan was not updated to accurately reflect the resident weight loss. Resident R34's care plan continued to identify resident as obese. 28 Pa. Code 211.11(a)(b)(c) Resident care plan 28 Pa. Code 211.11(d) Resident care plan

Based on clinical record review, review of facility policy and staff interviews, it was determined that the facility failed to ensure that the proper connector piece was available for a suprapubic urinary catheter for one of one resident observed with an urinary catheter. (Resident R48)\ Finding include: Review of facility policy, Urinary Catheter Care, revised September 2014, revealed: The purpose of this procedure is to prevent catheter-associated urinary tract infections. General Guidelines: 2. If breaks in aseptic technique, disconnection, or leakage occur, replace the catheter and collecting system using aseptic technique and sterile equipment, as ordered. Observation during medication administration on May 10, 2023 at 9:15 a.m. with Employee E4, licensed nurse, revealed a strong odor of urine in Resident R48's room. Resident R48 was observed in his bed completing his breakfast when Employee E4 approached with medication. Urine was observed on the floor and a urine collection bag was observed in a pink basin on the floor. Upon exiting Resident R48's room after medication…

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