York South Skilled Nursing And Rehabilitation Ctr

Based on facility policy reviews, clinical record review, observations, and staff interviews, it was determined that the facility failed to precisely and effectively monitor hydration for one of one resident reviewed for hydration status (Resident 78), and failed to ensure proper monitoring to maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range, for one of four residents reviewed for nutritional status (Resident 131). Findings include: Review of the facility's policy, titled Weights and Heights, recently revised June 15, 2022, read Patients are weighed upon admission and/or readmission, then weekly for four weeks and monthly thereafter. Review of facility policy, titled Hydration Plan with an effective date of May 1, 2023, read, in part, A hydration plan is developed for residents who are at risk of dehydration and for those requiring fluid restrictions. Nursing and Food and Nutrition Services work together to calculate the amount of fluid provided with meals and the amount of fluid provided by nursing in conjunction with…

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 and resident interviews, observation, and completion of one meal test tray, it was determined that the facility failed to provide foods that are palatable, attractive, and at appetizing temperatures at one of one meal observed (May 6, 2025, lunch meal). Findings include: During an interview with Resident 23 on May 5, 2025, at 12:11 PM, revealed meals are often served cold. Review of Resident Council Minutes for February 17th, 2025; March 17th, 2025; and April 21st, 2025, concerns were expressed regarding hot food being served cold. Review of facility form, Test Tray Evaluation, dated May 1, 2023, read, in part, test tray standard for hot entree and vegetable is greater than 140 degrees Fahrenheit (F). Test tray is also evaluated for taste, portion, and appearance of the food. A test tray completed on May 6, 2025, at 12:35 PM, revealed inadequate portions of coffee. The peas and coffee weren't palatable for temperature. The roast pork and mashed potatoes did not meet the standard. The test tray was placed on a meal cart to be delivered with room trays; 22 minutes 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.

Based on observations, facility policy review, clinical record review, and staff interviews, it was determined that the facility failed to ensure staff implemented infection control policies to prevent the spread of infection for two of 31 residents on transmission-based precautions reviewed (Residents 67 and 238) Findings Include: Review of facility policy, Transmission Based Precautions, revised May 1, 2025, revealed in a section: Initiating Transmission Based Precautions, Signage that includes instructions for use of specific PPE will be placed in a conspicuous location outside the patient's room. Additionally, either the CDC category of Transmission Based Precautions (e.g., Contact, Droplet, or Airborne) or instructions to see the nurse before entering the room will be included in the signage. Review of Resident 67's clinical record revealed diagnoses of sepsis (a serious condition in which the body responds improperly to an infection) and urinary tract infection (an infection of any part of the urinary system). Review of Resident 67's clinical record revealed a urine culture…

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

Based on facility policy review, clinical record review, and staff interview, it was determined that the facility failed to ensure a resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections consistent with physician orders and the resident's person-centered care plan for one of three residents reviewed (Resident 1). Findings include: Review of facility policy, titled Catheter: Indwelling Urinary last revised February 1, 2023, read, in part, Provide catheter care twice a day and as needed. Explain the procedure and provide privacy. Inspect the periurethral area for signs of inflammation and infection. Document: Catheter care provided; amount of urine output if ordered; and abnormal findings to the physician, if indicated. Review of Resident 1's clinical record revealed diagnoses that included obstructive uropathy (when urine can't flow normally through your urinary tract due to a blockage), congestive heart failure (a chronic condition in which the heart doesn't pump blood as well as it should), and dementia (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 policy review, clinical record review, document review, and staff interview, it was determined that the facility failed to ensure its residents receive treatment and care in accordance with professional standards of practice and the comprehensive person-centered plan of care for two of eight residents reviewed (Residents 1 and 3). Findings Include: A review of Resident 1's clinical record revealed diagnoses that included Alzheimer's disease (a brain disorder that gradually destroys memory and thinking skills, and eventually the ability to perform daily tasks) and acute pancreatitis (a sudden inflammation of the pancreas). A review of Resident 1's physician's orders revealed an order dated September 28, 2024, that read Daily Weight: Notify cardiology or PCP [primary care physician] if increased by 3 lbs.[pounds] in one day or greater than 5 lbs. in one week. A review of Resident 1's weight information revealed no documented weights on September 30, 2024, and October 1, 2024. A review of Resident 3's clinical record revealed diagnoses that included end-stage renal disease…

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 policy review, clinical record review, and staff interview, it was determined that the facility failed to provide routine drugs for its residents and provide pharmaceutical services, including procedures that assure the accurate acquiring and administration of drugs to meet the needs of each resident, for one of eight residents reviewed (Resident 2). Findings Include: A review of the facility's policy, titled Provider Pharmacy Requirements, dated 2007, read, Regular and reliable pharmaceutical service is available to provide residents with prescription and non-prescription medications . The policy continued, The provider pharmacy agrees to perform the following pharmaceutical services, including but not limited to accurately dispensing prescriptions based on authorized prescriber orders. Also, Providing routine and timely pharmacy service per contractual agreement and emergency pharmacy service 24 hours per day, seven days per week. A review of Resident 2's clinical record revealed diagnoses that included diabetes mellitus Type II (a common condition that occurs 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.

Based on clinical record review and staff interview, it was determined that the facility failed to ensure care and services were provided in accordance with professional standards of practice to meet each resident's physical, mental, and psychosocial needs for four of five residents reviewed with wound care orders (Residents 15, 17, 18, and 19). Findings Include: Review of Resident 15's clinical record revealed diagnoses that included severe protein-calorie malnutrition (insufficient protein intake or protein deficiency) and congestive heart failure (CHF-weakness of the heart that leads to buildup of fluid in the lungs and surrounding body tissues). Review of Resident 15's July 2024 TAR (Treatment Administration Record - form used to document physician orders as well as when and how treatments are administered to a resident) revealed the following orders: Cleanse open area on buttocks with wound cleanser. Apply therahoney (promotes wound closure) and cover with 4x4 foam border (type of dressing) for protection every day shift, starting July 6, 2024, and ending July 19, 2024; Cleanse…

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 investigation documentation and job descriptions, review of online nurse aide registry information, as well as staff interview, it was determined that the facility failed to ensure that services provided to residents were provided by staff with the appropriate skills, experience, and qualifications to provide such services for two of two residents reviewed (Residents 20 and 21). Findings include: Review of facility Certified Nursing Assistant job description, revised November 23, 2020, revealed, He/she will function within the standards of practice as accorded by his/her Certification. Review of online Nurse Aide Registry information revealed that Employee 3 (Nurse Aide [NA]) was currently actively registered as a certified NA in Pennsylvania, with an effective date of January 31, 2023, and an expiration date of February 7, 2025. Review of facility electronic event report submission and related investigation documentation revealed that on July 10, 2024, nursing administration was made…

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 a safe, clean, comfortable, and home-like interior in three of four resident shower rooms (first and second floor nursing units). Findings include: Observations in the second floor men's shower room on June 26, 2024, at 12:48 PM and at 1:50 PM, with Employee 3 (Director of Housekeeping), revealed in two of the three showers there was a black substance on the floor at the base of the wall. Observations in the second floor women's shower room on June 26, 2024, at 12:49 PM and at 1:55 PM, with Employee 3, revealed there was a pink and black substance on the floor at the base of the wall on all 3 sides of the shower, the blue mat on the shower gurney was cracked in seven areas with the foam exposed, and the ceiling vent in front of shower on the right wasn't functioning. Observations in the first floor shower room on June 26, 2024, at 12:54 PM and at 2:00 PM, with Employee 3, revealed there was a black substance on the floor at the base of the wall on two sides, the sink was separated 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 policy review, document review, clinical record review, and resident and staff interviews, it was determined that the facility failed to ensure that all allegations of abuse, neglect, or mistreatment are reported no later than 24 hours to other officials, including Adult Protective Services, for two of three resident abuse investigations reviewed (Residents 40 and 61). Findings Include: A review of the facility's policy, titled Abuse Prohibition, revised October 24, 2022, defined abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, injury or mental anguish. Verbal abuse is defined as any use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to patients . A continued review of the policy revealed, regarding reporting allegations of abuse, read The Administrator and/or DON [Director of Nursing] will verify that the state reporting occurs within required time frames and via appropriate method of reporting. The policy continued under the section titled When to…

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

Based on observation, clinical record review, and staff interviews, it was determined that the facility failed to ensure that a comprehensive, person-centered care plan was developed for four of 31 residents reviewed (Residents 38, 67, 68, and 82). Findings include: Review of a facility policy, titled Person-Centered Care Plan, with a review date of May 28, 2024, revealed that: Care plans will be reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments, and as needed to reflect the response to care and changing needs and goals. Review of Resident 38's clinical record revealed diagnoses that included dementia (A group of thinking and social symptoms that interferes with daily functioning) and hypertension (elevated blood pressure). Review of Resident 38's clinical record revealed an admission to hospice care and services on June 17, 2024. Review of Resident 38's interdisciplinary plan of care revealed none developed to address Resident 38's need for hospice care and services. Continued review of…

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

Based on review of facility policy, observations, and staff interviews, it was determined that the facility failed to appropriately monitor the pH of the sanitizer sink for manual ware-washing, and failed to store and serve food/beverages in accordance with professional standards for food safety in the kitchen area and two of three nourishment pantries (second floor and Arcadia units). Findings include: Review of Facility policy, titled Manual Ware-washing and Sanitizing, effective May 1, 2023, read, in part, sanitizing is accomplished in the third sink by use of chemical sanitizer. Measure the concentration of the sanitizer utilizing a quaternary test strip; the strip should darken to the range of 200-400 parts per million. If the test strip doesn't turn the appropriate darkness, corrections are made before the sanitizing process can take place. The result of the test is recorded on the Manual Ware-washing Sanitation Long at each wash period. Review of facility policy, titled Pantry/Nourishment Room Sanitation, effective date May 1, 2023, read, in part, food and beverages are to 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 clinical record review, policy review, observations, and staff interviews, it was determined that the facility failed to maintain infection control practices to prevent the spread of infection for two of 31 residents reviewed (Resident 78 and 82). Findings include: Review of facility policy, titled Procedure: Enhanced Barrier Precautions, last revised May 1, 2024, revealed enhanced barrier precautions should be used when a resident has, Chronic wounds .regardless of [multi-drug resistant organism] colonization status. Further review of the document revealed that implementation of enhanced barrier precautions included posting a sign on the resident's door, indicating the resident is on enhanced barrier precautions and the use of a gown and gloves during wound care. Review of Resident 78's clinical record revealed diagnoses that included congestive heart failure (CHF - decreased ability of the heart to pump blood throughout the body) and peripheral vascular disease (decreased blood circulation to extremities due to a narrowing of the arteries). Further review of Resident 78'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 document review and staff interview, it was determined that the facility failed to ensure each resident is periodically informed of charges for services not covered under Medicare or Medicaid for one of three residents reviewed at the termination of Medicare A services (Resident 239). Findings Include: A review of Resident 239's clinical record revealed an admission date of November 29, 2023, with diagnoses that included hypertension (elevated blood pressure) and heart failure (A lifelong condition in which the heart muscle can't pump enough blood to meet the body's needs for blood and oxygen). According to the clinical record, Resident 239 was admitted for short-term rehabilitation with a planned discharge to return to the community. A review of Resident 239's Notice of Medicare Non-Coverage (NOMNC) form revealed the last covered day of Medicare A services ending on January 30, 2024. As of January 31, 2024, Resident 239 would be responsible for privately paying, or out of pocket, for the facility's daily rate for the non-covered services provided at the facility. Continued…

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, clinical record review, and resident and staff interviews, it was determined that the facility failed to ensure the care plan was reviewed and revised for three of 31 residents reviewed (residents 32, 62, and 70). Findings include: Review of Resident 32's clinical record revealed diagnoses that included hemi-paresis (partial paralysis) right dominate side, stroke (damage to the brain from interruption of blood supply), and aphagia (language disorder that affects a person's ability to communicate). Review of Resident 32's care plan documented a focus area for neurological deficiencies and dysfunction of activities of daily living related to stroke, initiated August 13, 2014, revised September 18, 2023. Interventions included for Resident to wear a palm protector as ordered, initiated September 28, 2022, revised on May 16, 2024. Further review of the care plan included a focus area for activities of daily living self-care deficit secondary to stroke, initiated August 13, 2014, revised September 18, 2023. Interventions included cam boot to right lower extremity,…

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, facility policy review, observations, and resident and staff interviews, it was determined that the facility failed to provide care and services regarding shaving facial hair for one of 31 residents reviewed (Resident 72). Findings include: Review of facility policy, titled Activities of Daily Living (ADLs), revised May 1, 2023, revealed, A patient who is unable to carry out ADLs will receive the necessary level of ADL assistance to maintain good nutrition, grooming, and personal and oral hygiene. Review of Resident 72's clinical record revealed diagnoses that included Alzheimer's disease (loss of cognitive functioning) and pleural effusion (a condition that occurs when fluid builds up in the pleural space, the thin cavity between the layers of tissue that line the lungs and chest cavity). Observation of Resident 72 on June 25, 2024, at 8:45 AM, revealed the Resident lying in bed. At that time, Resident 47 was observed to have significant facial hair above her upper lip and on her chin. An interview with Resident 72 revealed that she would like to…

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

Based on observation, clinical record review, and staff interview, it was determined that the facility failed to ensure treatment and services were provided to promote healing and prevent infection for one of four resident's reviewed for pressure injury (Resident 78). Findings include: Review of Resident 78's clinical record revealed diagnoses that included congestive heart failure (CHF - decreased ability of the heart to pump blood throughout the body) and peripheral vascular disease (decreased blood circulation to extremities due to a narrowing of the arteries). Review of Resident 78's clinical record revealed Resident 78 had a stage 4 pressure ulcer (wound of the skin over a bony prominence that extends to the bone or other connective tissue) to the sacrum, stage 4 pressure ulcer to the right heel, and non-pressure full thickness ulcer (wound of the skin that extends below the layers of the skin to the muscle, bone, or other connective tissue) of the lower right leg. During wound treatment change observation conducted on June 26, 2024, at approximately 10:00 AM, Employee 1 was…

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

Based on record review and staff interview, it was determined the facility failed to ensure that a resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for one of 31 residents reviewed (Resident 56). Findings include: Review of Resident 56's clinical record revealed diagnoses that included peripheral vascular disease (a slow and progressive disorder of the blood vessels) and hypertension (high blood pressure). Review of Resident 56's clinical record revealed a diagnosis of a urinary tract infection (UTI), with an active date of April 30, 2024. Review of Resident 56's May 2024 Medication Administration Record revealed the Resident was prescribed Keflex Oral Capsule 500 milligrams, one capsule by mouth three times a day for UTI for seven days. The last day Resident 56 received a dose of Keflex was on May 8, 2024, at 2:00 PM. Review of Resident 56's clinical record revealed a progress note on May 8, 2024, at 2:58 PM, with the following text: Continues Keflex/UTI, no…

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

Based on observations, facility policy review, clinical record review, and resident and staff interviews, it was determined that the facility failed to provide respiratory care/oxygen services consistent with professional standards of practice for one of three residents reviewed for respiratory care (Resident 62). Findings Include: Review of facility policy, titled Bi-level Positive Airway Pressure (Bi-PAP- non-invasive ventilation is the use of breathing support administered through a face mask) /Continuous Positive Airway Pressure (CPAP- a machine that uses mild air pressure to keep breathing airways open while you sleep) including Trilogy (an all-in-one ventilation device capable of delivering both invasive and non-invasive ventilation modes) , revised April 1, 2022, failed to include information pertaining to cleaning and storage of equipment. Review of Resident 62's clinical record revealed diagnoses that included amyotrophic lateral sclerosis (ALS - a nervous system disease that affect nerve cells in the brain and spinal cord, causes loss of muscle control), abnormal posture,…

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

Based on facility policy review, facility document review, and staff interview, it was determined that the facility failed to complete a performance review for one of five nurse aides reviewed at least once every 12 months (Employee 2). Findings include: Review of facility policy, titled HR616 Performance Appraisal, last reviewed June 20, 2024, revealed the facility policy stated, Managers will meet with their regular full-time, regular part-time and regular casual employees at least annually to conduct a performance appraisal or have a performance based conversation. In-service education will be provided based on the outcome of these reviews. Review of facility documentation revealed Employee 2's hire date was December 10, 2022. On June 26, 2024, a request was made for Employee 2's yearly performance evaluation. During a staff interview on June 27, 2024, at approximately 11:15 AM, Nursing Home Administrator (NHA) revealed that Employee 2 did not have a performance evaluation conducted. During the interview, the NHA revealed employees should have performance reviews conducted yearly…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff interview, it was determined that the facility failed to ensure residents were educated on influenza vaccination for one of five residents reviewed (Resident 82). Findings include: Review of Resident 82's clinical record revealed diagnoses that included type 2 diabetes mellitus (decreased ability of the body to utilize insulin for the transport of glucose from the blood stream into the cells for nourishment) and hypertension (elevated/high blood pressure). Review of Resident 82's clinical record revealed that Resident 82 was admitted to the facility on [DATE]. Further review the clinical record revealed that staff documented that Resident 82 refused the influenza vaccination for the 2023-2024 influenza season (period of time between October to May). During a staff interview on June 27, 2024, Director of Nursing revealed the facility did not have documentation of Resident 82's declination of the 2023-2024 influenza vaccination nor evidence that Resident 82 was provided…

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 care and services were provided in accordance with professional standards of practice to meet each resident's physical, mental, and psychosocial needs for five of seven newly admitted residents reviewed (Residents 1, 4, 5, 7, 8). Findings Include: Review of Resident 1's clinical record revealed diagnoses that included cellulitis of left lower limb (bacterial infection involving the inner layers of the skin) and diabetes mellitus (impairment in the way the body regulates and uses sugar [glucose] as a fuel resulting in too much sugar circulating in the bloodstream). Review of Resident 1's January and February 2024 MARs (Medication Administration Records - forms used to document physician orders as well as when and how medications are administered to a resident) revealed orders for insulin glargine twice daily for diabetes mellitus, and hydralazine three times a day for hypertension (high blood pressure) and metoprolol every 12 hours for hypertension. Further review of the MAR…

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 residents with limited mobility received appropriate services, equipment, and assistance to maintain or improve mobility for two of 27 residents reviewed (Residents 37 and 48). Findings include: Review of Resident 37's clinical record revealed diagnoses that included difficulty in walking, major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest in things), and type 2 diabetes mellitus (decreased ability of the body to utilize insulin for the transport of glucose from the blood stream into the cells). Review of Resident 37's care plan revealed a focus area: At risk for loss of range of motion related to impaired mobility, last revised June 22, 2022, with an intervention for: Restorative Active ROM (Range of Motion): Bilateral hips, ankles, knees and toes of upper extremities twice daily with ADL (Activities of Daily Living) care X 10 reps each for 15 minutes, initiated June 22, 2022. Review of Resident 37's clinical record on…

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

Based on clinical record review, policy review, and staff interview, it was determined that the facility failed to ensure residents who require dialysis receive such services consistent with professional standards of practice for one of 27 residents reviewed (Resident 81). Findings Include: Review of the facility's policy, titled Dialysis Guidelines with an original date of November 2017, reads, in part, Before, during, and after receiving .dialysis, based on medical practitioner's orders and professional standards of practice, obtain vital signs and weights; assess the patient's level of consciousness, and comfort or distress; monitor for post-dialysis complications and symptoms such as but not limited to dizziness, nausea, fatigue . Dialysis is defined as, the process of removing excess water, solutes, and toxins from the blood in people whose kidneys can no longer perform these functions naturally. Continued review of the policy revealed a Hemodialysis Communication Form with instruction to be completed by facility staff, send with patient to the dialysis center, and return with…

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 document review, policy review, and staff interview, it was determined that the facility failed to complete a performance evaluation review on its nurse aide staff once every 12 months for four and five nurse aide performance evaluations reviewed (Nurse Aides 6, 7, 8, and 9). Findings Include: Review of the facility's policy, titled Managing and Improving Performance read, in part, Most employees receive a 30-day and 90-day evaluation in their introductory period with the Company, and all employees should be receiving an annual appraisal. Review of the facility provided performance review for Nurse Aide 6 revealed the most recent evaluation completed was August 2021. Review of the facility provided performance review for Nurse Aide 7 revealed the most recent evaluation completed was April 2022. Review of the facility provided performance review for Nurse Aide 8 revealed the most recent evaluation completed was May 2022. Review of the facility provided performance review for Nurse Aide 9 revealed the most recent evaluation completed was May 2022. 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.

Based on clinical record review, facility policy review, and staff interviews, it was determined that the facility failed to ensure Medication Regimen Reviews were completed by a consultant pharmacist and responded to in a timely manner by the attending physician or prescriber for three of 27 residents reviewed (Residents 61, 98, and 115). Findings include: Review of the facility's Medication Regimen Review Policy, last reviewed in January 2022, indicated in section 7.2.1, if the attending physician has decided to make no change in the medication, the attending physician should document the rationale in the resident's health record. Review of facility policy, titled 9.1 Medication Regimen Review revised March 2020, revealed, The attending physician should document in the residents' health record that the identified irregularity has been reviewed and what, if any, action has been taken to address it. If the attending physician has decided to make no change in the medication, the attending physician should document the rationale in the residents' health record. Review of Resident 61'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 observation, test trays, review of select facility forms, and resident and staff interview, it was determined that the facility failed to provide foods and beverage that were at an appetizing temperature for two of two test trays. Findings Include: Review of facility document, titled Food and Nutrition Services Test Tray Evaluation last revised May 01, 2023, revealed that hot foods and hot beverages should be served above 140 degrees Fahrenheit (a unit of measure). Based on multiple Resident interviews on July 31, 2023; August 1, 2023; and August 2, 2023, revealed Residents voiced concerns with the temperature of the food during meal service. During an interview with Resident 29 on August 1, 2023, at approximately 9:30 AM, it was revealed that Resident 29 considered the food cold most of the time and not palatable. During an interview with Resident 49 on July 31, 2023, at 10:02 AM, Resident 49 indicated that their hot food was often cold, their cold food was often warm, and their food was either without taste or tasted awful. During an interview with Resident 99 on July 31,…

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

Based on facility policy review, observations, clinical record review, and staff interview, it was determined that the facility failed to provide food that accommodates resident preferences or appealing options of similar nutritive value to residents who request a different meal choice for five of five residents reviewed (Resident 12, 54, 63, 79, and 105). Findings Include: Review of facility policy, titled EBC Implementation Guidelines last reviewed May 2023, revealed, The EBC planned menu items will be prepared daily by the Food and Nutrition department. The menu will consist of one fortified food item at each meal and 8 oz (oz-ounce- unit of measure) of whole milk. Review of Resident 12's clinical record revealed diagnoses that included dysphagia (difficulty swallowing), chronic kidney disease (a condition characterized by a gradual loss of kidney function), and sepsis (an infection of the blood stream). Review of Resident 12's meal tickets revealed Resident 12 prefers to have four pepper packets served with his meals and dislikes salad. Observation of the tray line service 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 facility policy review, observations, and staff interviews, it was determined that the facility failed to store food, beverages, and equipment in accordance with professional standards for food service safety in the main kitchen and two of two nourishment areas. Findings include: Review of facility policy, titled FNS407 Food Handling with an effective date of May 1, 2023, revealed, Foods in storage are in closed, labeled, and dated containers; no open boxes or bags .Room temperature food can be covered, labeled, dated with 'use by' dates, and served by 'use by' date Employees must wash hands before putting on disposable gloves. Review of facility policy, titled FNS413 Food Brought in for Patients/Residents with an effective date of May 1, 2023, revealed, Food items that require refrigeration must be labeled with the resident's name and date the food was brought in. Observation in the main kitchen on July, 31, 2023, at 9:24 AM, revealed: one container of snacks with three oatmeal cookies, two bags of pretzels, three fig cookies, and two packs of crackers without a date; one…

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

Based on facility policy review, observations, record review, facility records review, and staff interview, it was determined that the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections; and that the facility failed to ensure staff implemented infection control policies to prevent the spread of infection by posting signs and making personal protective equipment (PPE) available on one of eight areas observed (500 hallway). Findings include: Review of facility policy, titled IC405 COVID-19 with a last revised/review date of June 30, 2023, revealed the following: Entrance Screening: 1. Screening of all persons entering the Center (such as HCP [Healthcare Provider], visitors, medically necessary personnel, contracted staff/vendors, and volunteers) will be done upon entry into the Center; and 1.2 Any HCP who reports symptoms that meet criteria will be tested prior to entry. Review of facility policy, titled…

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 document review and staff interview, it was determined that the facility failed to ensure its nurse aide staff receiving in-service training to be proficient and competent and the training be no less that 12 hours annually for three of five nurse aide staff training information reviewed (Nurse Aides 6, 7, and 9). Findings Include: Review of the nurse aide annual training information revealed the hours for Nurse Aides 6, 7, and 9 did not meet the minimum required 12 hours. An interview with Employee 1 (Human Resources Director) on August 3, 2023, at 9:00 AM, revealed no additional information is available regarding the annual training hours for Nurse Aides 6, 7, or 9. An interview with the Nursing Home Administrator on August 2, 2023, at 11:40 AM, confirmed the aforementioned nurse aides did not meet the minimum required hours of training. 28 Pa. Code 201.29 Personnel polices and procedures

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and resident and staff interviews, it was determined the facility failed to post the results of the most recent surveys in a place readily accessible to residents for three of five resident areas reviewed (400 Unit Dining Room, 500 Unit Lounge, and 700 Unit Lounge). Findings Include: During the Resident Council group meeting on August 2, 2023, several residents participating in the meeting explained they are unaware of the location of the survey results books stationed throughout the facility. An observation on August 1, 2023, at 1:08 PM, revealed that the survey results book on the 400 Unit Dining Room was not in the 400 Unit Dining Room. An observation on August 3, 2023, at 9:38 AM, revealed the 500 Unit Lounge survey results book and the 700 Unit Lounge survey results book did not include the most recent survey results. The most recent survey results in the 500 Unit Lounge and the 700 Unit Lounge books were from June 23, 2022. An observation on August 3, 2023, at 9:24 AM, outside 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 policy review, clinical record review, and staff interview, it was determined that the facility failed to ensure the resident the right to formulate an advance directive for one of 27 residents reviewed (Resident 81). Findings Include: Review of the facility's policy, titled Health Care Decision Making revised March 2022, describes an Advance Directive as Written instruction, such as a living will or durable power of attorney, for health care, recognized under state law relating to the provision of health care when the patient is incapacitated. The purpose of the policy is described, To provide [the] patient the opportunity and knowledge necessary to make his/her health care decisions known. The policy continues, Throughout the stay, advance care planning conversations will be conducted as part of the care plan process .and determine whether the patient wishes to change or continue these instructions. Review of Resident 81's physician orders revealed diagnoses that included hypertension (elevated blood pressure) and a history of falling. Review of Resident 81's 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 record review and staff interview, it was determined that the facility failed to inform the resident periodically during the resident's stay of services available in the facility and of charges from those services not covered under Medicare for one of three residents reviewed (Resident 232). Findings Include: Review of facility provided documentation revealed Resident 232's last covered day of Medicare covered services was on April 3, 2023. Review of the Beneficiary Protection Notification Review Form revealed the facility had not provided the Resident and/or Resident Representative the required Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNF-ABN) form that details the cost of care and services no longer covered under Medicare beginning April 4, 2023. An interview with the Nursing Home Administrator, on August 2, 2023, at 11:51 AM, confirmed Resident 232 had not been provided the required SNF-ABN form at the end of the Medicare covered services, and acknowledged the form should have been provided to the Resident and/or Resident Representative. 28…

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 grievance policy, review of facility documentation, and resident and staff interviews, it was determined that the facility failed to resolve a grievance in a timely manner for one of 27 residents reviewed (Resident 11). Findings include: Review of facility policy, titled OPS204 Grievance/Concern last revised July 19, 2023, revealed The administrator will serve as the Grievance Officer who is responsible for overseeing the grievance process .receiving and tracking grievances through to their conclusion, leading any necessary investigations by the facility .immediate action will be taken to prevent further potential violations of any patient right while the alleged violation is being investigated .The department manager will contact the person filing the grievance to acknowledge receipt; investigate the grievance; take corrective actions, if needed; and notify the person filing the grievance of resolution in a timely manner. Review of Resident 11's clinical record revealed diagnoses that included paraplegia (paralysis of all or part of a persons trunk,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff interviews, it was determined that the facility failed to ensure the resident assessment accurately reflected the resident status for three of 27 residents reviewed (Residents 37, 71, and 126). Findings include: Review of Resident 37's clinical record revealed diagnoses that included difficulty in walking, major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest in things), and type 2 diabetes mellitus (decreased ability of the body to utilize insulin for the transport of glucose from the blood stream into the cells). Review of Resident 37's care plan revealed a focus area: ADL self-care deficit related to physical limitations, with interventions for: one person assist with rolling walker with wheelchair follow 80 -120, with an initiated date of June, 22, 2022; and Resident is independent after set-up for eating. Review of Resident 37's Annual Minimum Data Set (MDS - Assessment tool utilized to identify a resident's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, policy review, and staff interviews, it was determined that the facility failed to ensure the resident comprehensive plan of care was developed and implemented for two of 27 residents reviewed (Residents 61 and 71). Findings include: Review of the facility's Person-Centered Care Plan Policy, last reviewed on October 24, 2022, indicated that care plans will be reviewed and revised by the interdisciplinary team after each assessment, including both comprehensive and quarterly review assessments, and as needed to reflect the response to care and changing needs and goals. Review of Resident 61's clinical record revealed diagnoses that included Hypertension (elevated blood pressure) and Dementia (a chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning). Review of Resident 61's Quarterly Minimum Data Set (MDS) completed on May 30, 2023, under Section I - Active Diagnosis,…

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

Based on facility policy review, observations, clinical record review, and staff interviews, it was determined that the facility failed to review and revise the resident plan of care for three of 30 residents reviewed (Residents 24, 49, and 50). Findings include: Review of facility policy, titled OPS416 Person-Centered Care Plan dated November 28, 2016, with a revision date of October 24, 2022, and a last review date of May 24, 2023, revealed, 7. Care plans will be: 7.2 Reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments, and as needed to reflect the response to care and changing needs and goals. Review of Resident 24's clinical record revealed diagnoses that included a Stage 3 Pressure Ulcer. Review of Resident 24's current physician orders revealed the following order: Sacrum: Cleanse with normal saline solution, pat dry, apply slightly moist silver collagen (advanced, topically applied wound dressings that transform into cool, soothing gel upon contact with drainage), and cover with bordered…

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, clinical record review, facility policy review, and staff interview, it was determined that the facility failed to provide care and services regarding hygiene and bathing for one of 29 residents reviewed (Resident 56). Findings Include: Review of facility policy, titled NSG200 Activities of Daily Living (ADLs) with a revision date of May 1, 2023, revealed, Documentation of ADL care is recorded in the medical record and is reflective of the care provided by nursing staff. ADL care will be documented in real time, as close to the time that care was provided, and information obtained as possible. ADL care is documented every shift by the nursing assistant. Review of Resident 56's clinical record revealed diagnoses that included clostridium difficile colitis (Inflammation of the colon caused by the bacteria Clostridium difficile) and irritable bowel syndrome (a group of symptoms that occur together, including repeated pain in your abdomen and changes in your bowel movements, which may be diarrhea, constipation, or both). Observation of Resident 56 on July 31,…

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 clinical record, observation, and staff interviews, it was determined that the facility failed to ensure care and services are provided in accordance with professional standards of practice that will meet each resident's physical, mental, and psychosocial needs for three of 27 residents reviewed (Residents 11, 18, and 50). Findings include: Review of Resident 11's clinical record revealed diagnoses that included paraplegia (paralysis of all or part of a persons trunk, legs, and pelvic organs), urinary tract infection (UTI - common and painful infections of the urinary system), and hypertension (high blood pressure). Review of Resident 11's physician orders revealed an order for temperature checks every day shift for chronic UTI's, with a start date of July 4, 2023, at 7:00 AM. Review of Resident 11's TAR (Treatment Administration Record- documentation for treatments/medication administered or monitored) revealed no documentation to indicate temperature checks were obtained on July 4, 6, 11, 16, and 29, 2023. Interview with the Director of Nursing (DON) 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 observations, clinical record review, and staff interview, it was determined that the facility failed to ensure the resident environment is free from accident hazards for one of 27 residents reviewed (Resident 50). Findings Include: Review of Resident 50's clinical record revealed diagnoses that included dementia, muscle weakness and wasting, and history of falling. Review of Resident 50's care plan revealed a problem for self-care deficit related to physical limitations due to a history of left hip fracture, dated September 6, 2016, with a revision date of June 12, 2017. Interventions included a standard wheelchair with pressure reducing cushion and elevating leg rests, with an initiated date of June 24, 2023. Observation of Resident 50 on August 2, 2023, at 10:25 AM, revealed that they were being transported in the hallway from the shower room to their room by Employee 17 (Nurse Aide) with no leg rests present on the chair. Observation of Resident 50's room as Employee 18 returned the Resident to the room, revealed that their wheelchair leg rests were laying on the top 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 policy review, clinical record review, observations, and staff interview, it was determined that the facility failed to provide respiratory care/oxygen services consistent with professional standards of practice for one of four residents reviewed (Resident 99). Findings include: Review of facility policy, titled Oxygen: Nasal Cannula dated January 1, 2004, with a revision date of June 15, 2022, and a last review date of May 24, 2023, revealed, 22. replace disposable set-up every seven days. Date and store cannula in treatment bag when not in use. Review of Resident 99's clinical record revealed diagnoses that included obstructive sleep apnea and muscle wasting and atrophy (partial or complete wasting away of a part of the body), multiple sites. Review of Resident 99's physician orders revealed orders for CPAP (Continuous Positive Airway Pressure - a machine that uses mild air pressure to keep breathing airways open while one sleeps): Full face mask with oxygen at 2 Liters per minute, Pressure Settings: Auto CPAP 8 to 20 centimeters of water at bedtime for…

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

Based on review of clinical records and staff interview, it was determined that the facility failed to implement procedures to ensure availability of prescribed medications for one of 27 Resident reviewed (Resident 61). Findings include: Review of Resident 61's clinical record revealed diagnoses that included Hypertension (elevated blood pressure) and Dementia (a chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning). Review of physician orders for Resident 61 from May 1, 2023, to May 31, 2023, revealed an order for Cefdinir Oral Capsule 300 milligrams (mg), give 300 mg by mouth every 12 hours for urinary tract infection (UTI) for three days, with an order start date of May 27, 2023. Review of Resident 61's Medication Administration Record (MAR) from May 2023, revealed Resident 61 was not administered Cefdinir as prescribed on May 27, 2023; May 28, 2023; and May 29, 2023. The MAR was documented as '9', which is code for 'Other/See Nurse Notes'. Review of progress notes for…

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 document review and staff interview, it was determined that the facility failed to maintain a quality assessment and assurance committee consisting of the required Medical Director or his/her designee for two attendance records reviewed (October 2022 and May 2022.) Findings Include: Review of the facility's Quality Assurance and Performance Improvement Committee Meeting Attendance Record forms, dated October 31, 2022, and May 30, 2023, revealed no signature to confirm the facility's Medical Director or Designee to be in attendance. An interview with the Nursing Home Administrator on August 2, 2023, at 9:14 AM, confirmed the attendance forms were not signed by the Medical Director. The interview also revealed the facility had not met the regulation regarding the Medical Director's attendance at the meetings. 28 Pa. Code 201.14 (a) Responsibility of licensee