Yorkview Nursing And Rehabilitation

Based on facility policy review, clinical records review, observations, and staff interview, it was determined that the facility failed to ensure that the resident environment was free of accident hazards by providing bilateral fall mats for one of two Residents reviewed for falls (Resident 49).Findings include: Review of facility policy, titled Falls Management System, last revised September 2022, revealed, The care plan interventions will address those elements determined by investigation as probable causal factors that contributed to the fall. The updated plan will be reviewed and revised as indicated by the Falls Management Team at the meeting. Documentation of implementation will be in accordance with accepted standards of clinical record keeping as outlined in Federal and State regulations and industry standards of practice. Review of Resident 's clinical record revealed diagnoses that included repeated falls (two or more falls within 12 months) and hemiplegia (paralysis on one side of the body). Observation of Resident 49 on June 23, 2026, 11:24 AM, revealed the Resident 49…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy reviews, observations, and staff interviews, it was determined that the facility failed to properly label medications in one of six medications carts reviewed ([NAME] 2) and one medication storage room (Subacute Care); and failed to discard expired medications in one of four medication storage rooms observed (Subacute Care).Findings include: Review of facility policy, titled Medication Labeling and Storage, reviewed January 2026, revealed, in part, Multi-dose vials that have been opened or accessed (e.g. needle punctured) are dated. Review of facility policy, titled Medication Labeling and Storage, reviewed January 2026, revealed, in part, If the facility has discontinued outdated or deteriorated medications or biologicals, the dispensing pharmacy is contacted for instructions regarding returning or destroying these items. Observation of [NAME] 2 medication cart with Employee 10 (Licensed Practical Nurse) on June 25, 2026, at 11:00 AM, revealed a Humalog Kwik insulin pen belonging 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 review of facility policies, observations, clinical record reviews, and resident and staff interviews, it was determined that the facility failed to provide residents with food that accommodates resident allergies, intolerances, and preferences for one of 39 residents reviewed (Resident 157).Findings include: Review of facility policy, titled Food and Nutrition Services, not date marked, read, in part, reasonable efforts will be made to accommodate resident choices and preferences. Each resident will be provided with a well-balanced diet taking into consideration the preferences of each resident. Food and nutrition services staff will inspect food trays to ensure that the correct mis is provided for each resident. Review of facility policy, titled Fluid Restriction, not dated, read, in part, a fluid restriction is put in place to limit the amount of fluid that is consumed each day. In addition to beverages, foods may be considered liquids. Anything that is liquid or melts at room temperature must be counted in the allotted fluids (i.e. ice cream). Review of Resident 157'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 facility documents, clinical record review, observations, and staff interviews, it was determined that the facility failed to provide a nutritionally adequate meal for one of one meal observed (May 18, 2026, lunch meal). Findings include: Review of the facility Long Term Care Diet Manual- Regular Diet, not dated, read, in part, regular diet is to receive 3 ounces of protein at lunch. Review of the production sheets (guidance for dietary staff regarding portion size and number of servings required for each menu item) documented to serve three chicken tenders. Observation on May 18, 2026, at 12:30 PM, during lunch meal service revealed residents were served two chicken tenders as the main entree. Interview with Employee 10 (Food Service Director), at 1:40 PM, revealed the serving for the main entree should be two chicken tenders. The surveyor asked for the portion of chicken to be weighed, and Employee 10 revealed a scale wasn't available to obtain the weight of the chicken. Review of the Diet Manual and production sheets with Employee 10, at 1:50 PM, he stated that three…

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, staff interviews, and policy review, it was determined that the facility failed to treat each resident with respect and dignity and care in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality, for one of the five residents observed (Resident 5).Findings Include: Review of the facility's Dignity policy, dated August 2009, read, in part, Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality. The policy continued, Staff shall maintain an environment in which confidential clinical information is protected. Review of Resident 5's clinical record revealed an admission date of May 16, 2026. Review of Resident 5's interdisciplinary plan of care revealed diagnoses that included trauma related to PTSD (Post-Traumatic Stress Disorder - a serious mental health condition that can develop after an individual experiences or witnesses a traumatic event) and depression (Depression is a mood…

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 for two rooms on two of nine units (Units B and C). Observation in Resident 7's room on May 18, 2026, at 10:17 AM, revealed the multiple slats on the blinds were broken off or bent, dried food was observed around and under the bed. Observation in Resident 8's room on May 18, 2026, at 10:45 AM, revealed the papers, used cups, dried liquid, red and brown and dried food particles ground into the floor, and the floor note to contain a hazy film. Interview with Nursing Home Administrator on May 18, 2026, at 2:40 PM, revealed that when blinds need to be replaced, a work order should be submitted, and that Resident 8 likes to keep food in his room. 28 Pa. Code 201.18 (e)(1)(2.1) Management

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of select grievances, observation, staff interview, 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.Findings include: Review of grievance submitted on April 30, 2026, on behalf of Resident 6, documented milk on top of the food cart for two hours not in ice, and family was concerned that milk would be reused. Resolution documented that milk should've been on ice and staff were educated. Review of facility provided Test tray evaluation form, not dated, read, in part, hot entree, starch and vegetable should be greater than 135 degrees Fahrenheit (F), cold entree less than 41 degrees F, and dessert less than 41 degrees or greater than 135 degrees F. Observation on May 18, 2026, at 9:26 AM, revealed the breakfast cart was delivered to C unit and the milk on top of the food cart was not on ice. A test tray was completed on May 18, 2026. Employee 10 (Food Service…

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 pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for one of the four residents reviewed (Resident 2). Findings Include: Review of the facility's policy, titled Medication Ordering and Receiving from Pharmacy read Medications and related products are received from the dispensing pharmacy on a timely basis. The policy continued, Timely delivery of new orders is required so that medication administration is not delayed. Review of Resident 2's clinical record revealed diagnoses that included asthma (a chronic, long-term lung disease that causes inflammation and narrowing of the airways, making breathing difficult) and chronic pain due to trauma (a complex condition where the nervous system becomes sensitized, often causing pain to persist long after injuries heal). Review of Resident 2's census information revealed an admission…

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 and staff interviews, facility policy review, 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. Findings include: Review of facility form Culinary and Nutrition Test Tray, read, in part, hot items should be served at greater than 135 degrees Fahrenheit (F), and cold items served at less than 41 degrees F. Interviews with Residents 2, 3, 4, and 8 revealed concerns with the temperature, texture, and appearance of the food. A test tray completed on October 20, 2025, revealed the temperature of the breaded chicken patty, mixed vegetables, and potato salad weren't palatable for temperature, and the chicken patty wasn't visually appealing (it looked dry). The test tray was placed on a meal cart and delivered to F-east unit with other trays being delivered at that time; 20 minutes had elapsed between the time the test tray was delivered to the unit and presented for evaluation. Employee 1 (Food Service Supervisor) took…

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 interviews, it was determined that the facility failed to ensure each resident the right to receive notice in advance of the resident's room or roommate change for one of six resident records reviewed (Resident 4).Findings Include:Review of the facility's policy, titled Resident Rights, revised June 2023, reads, Employees shall treat all residents with kindness, respect, and dignity.Review of Resident 4's clinical record revealed diagnoses that included dementia (Dementia is the loss of cognitive functioning - thinking, remembering, and reasoning - to such an extent that it interferes with a person's daily life and activities) and muscle weakness (a lack of muscle strength).Review of Resident 4's clinical record revealed she received a new roommate on October 23, 2025.Continued review of Resident 4's clinical record revealed documentation of a progress note dated November 17, 2025, of a care plan meeting held regarding a recent resident-to-resident incident involving Resident 4's new roommate. According to the progress note, Resident 4'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 facility policy, investigation reports, clinical records, and staff interviews, it was determined the facility failed to ensure residents are treated with respect and dignity for one of three residents reviewed (Resident 1).Findings include: Review of facility policy, titled Quality of life -Dignity, with revision date of August 2009, indicated; Residents shall be treated with dignity and respect at all times. Treated with dignity means the resident will be assisted in maintaining and enhancing his or her self-esteem and self-worth. Review of the clinical record for Resident 1 reveled diagnoses that included dementia (a group of conditions characterized by impairment of at least two brain functions, such as memory loss and judgement) with behavioral disturbance and adult failure to thrive (a syndrome characterized by unexplained weight loss, muscle wasting, and functional decline). Review of Resident 1 Quarterly MDS (periodic assessment of resident health, functional status, and needs) dated July 16, 2025, revealed the Resident had a brief interview of mental status (BIMS)…

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 and resident interviews, it was determined that the facility failed to provide a comfortable and homelike environment on two of nine nursing units (100 and 200 hall). Findings include: On May 19, 2025, between 10:30 AM and 11:00 AM, during an interview with Resident 63, the Resident stated that she was very cold. Cold air was felt blowing across the room. Resident 63 stated only maintenance can change the temperature by using pliers. During an interview with Resident 108, the Resident complained of being cold and was covered with 3 blankets. On May 19, 2025, at approximately 11:00 AM, Employee 1 (Director of Maintenance) was requested to come to the 200's hall to obtain temperatures. Employee 1 utilized an infrared thermometer. Resident 63's room temperature was 64 degrees Fahrenheit (F). Resident 108's room temperature was 69.8 degrees F. Four additional rooms on the unit were 67 degrees, 69.5 degrees, 70.0 degrees, and 70.8 degrees F. The remaining rooms on the unit and other units and halls had recorded temperatures between 71 and 81 degrees F.…

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, clinical record reviews, and staff interviews, it was determined that the facility failed to ensure that the comprehensive care plan is reviewed and revised for three of 35 residents reviewed (Residents 43,108, and 166). Findings include: Review of facility policy, titled Care Plans, Comprehensive Person-Centered with a last revision date of March 2022, and a last review date of January 2025, revealed, in part, 11. Assessments of residents are ongoing and care plans are revised as information about the residents and the resident's condition change; and 12. The interdisciplinary team reviews and updates the care plan a. when there is a significant change in the resident's condition; and d. at least quarterly, in conjunction with the required quarterly MDS [Minimum Data Set - an assessment tool to review all care areas specific to the resident such as a resident's physical, mental or psychosocial needs] assessment. Review of Resident 43's clinical record documented diagnoses…

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 procedure for fortified foods, observations, clinical record reviews, and resident and staff interviews, it was determined that the facility failed to provide physician ordered fortified food program for three of 35 residents reviewed (Resident 28, 85, and 99); and failed to ensure proper monitoring for acceptable parameters of nutritional status for one of seven residents reviewed for nutrition (Resident 166). Findings include: Review of facility provided document, Diet Type Report, generated May 22, 2025, revealed 51 residents were to receive a fortified food diet. Review of facility provided fortified foods procedure, not dated, read in part, physician orders must be obtained for residents who are deemed appropriate for the fortified food program, order should read Fortified Diet. The fortified diet differs from the regular diet, some examples are: cereals at breakfast are replaced with super cereal, starch at lunch is replaced with super mashed potatoes, super pudding is added to dinner, and 8 ounces of whole milk provided with each meal. Staff should…

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 policy review, review of the facility provided diet manual, observations, and resident and staff interviews, it was determined that the facility failed to note or update menu changes and notify Residents of a change to the posted menu; and failed to provide a nutritionally adequate menu substitution for two of two meals observed (lunch meal on May 19th, and 21st, 2025). Findings include: Review of facility policy, Menu, revised July 2023, read, in part, standardized seasonal cycle menus are prepared by the Corporate Menu Team. The menu will meet all resident's nutritional and therapeutic diet needs. Standardized menus are based on guidelines set forth by the approved facility diet manual dictated by state and federal regulations. Facility posting of menus will be done on a daily and/or weekly basis. Temporary changes in the menu are noted on the Menu Substitution Log. Review of facility policy, Menu Substitutions, revised July 2023, read, in part, the Substitution Log is utilized when changes 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 facility Test Tray form, resident and staff interviews, observations, 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. Findings include: Resident interviews with Residents 78, 85, and 122 obtained May 19, 2025, between 10:30 AM and 12:57 AM, concerns were revealed with the temperature of hot food. Interview with Resident 144 on May 19, 2025, 11:06 AM, it was stated that the food is bland/ it has no flavor; and she is served items such as milk and coffee that she shouldn't receive. Review of facility provided form Culinary and Nutrition Test Tray, not dated, read, in part, point of service temperatures for hot entree, vegetable, and hot beverage greater than 135 degrees Fahrenheit (F), and cold beverage less than 41 degrees F. Test tray also evaluated for taste and appearance. A test tray completed on May 21, 2025, at 1:25 PM, revealed adequate portions size, pork, potato, and green beans weren't palatable for temperature, the texture of the green beans were over…

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 policy, and staff interviews, it was determined that the facility failed to store and serve food/beverages in accordance with professional standards for food safety for two of four pantry refrigerators and in the kitchen. Findings include: Review of facility policy Food from Outside Sources, revised July 2023, read, in part, visitors/family members will label food and beverages with the resident's name, room number and date. Observation in dry storage on May 19, 2025, at 9:50 AM, the following cases were on the floor: oatmeal cream pies, egg noodles, animal crackers, elbow pasta, rotini pasta, basic muffin mix, gallons of mayonnaise, apple sauce, rice, mandarin oranges, and potato chips. Additional observation one bag of rotini and elbow pasta was open and not date marked. Interview with Employee 3 (Food Service Director) it was revealed that food deliveries are Tuesday and Friday, the cases of food should be stored off the floor, and the rotini and elbow pasta should be date marked when opened. Observation in the walk-in freezer on May 19,…

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

Based on observations and staff interviews, it was determined that the facility failed to ensure that a resident right to a dignified existence during two of three meals observed (breakfast and lunch May 19, 2025). Findings include: Observations during breakfast on May 19, 2025, on unit A, revealed Residents 117 and 158 received their breakfast in a Styrofoam container. Further observation revealed the swirl hot beverage carafes and the cold beverage 2-quart pitchers were covered with plastic wrap and not the coordinating lid. During an interview with Employee 3 (Food Service Director) on May 19, 2025, at 1:41 PM, it was revealed that Styrofoam containers were utilized for several residents at breakfast because there weren't enough plates. When Employee 3 was questioned further, it was revealed that the facility was also short scoop plates, lids for the hot beverage swirl carafes, and the 2- quart cold beverage pitchers. During an interview with the Nursing Home Administrator (NHA) on May 22, 2025, at 10:30 AM, it was revealed that Employee 3 is in the process of ordering necessary…

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, observation, and staff interview, it was determined that the facility failed to determine a resident's right to self-administer medications was clinically appropriate for one of 35 residents reviewed (Resident 97). Findings include: Review of facility policy, titled Self-Administration of Medications with a last review date of January 2025, revealed the following, in part, Residents have the right to self-administer medications if the interdisciplinary team has determined that it is clinically appropriate and safe for the resident to do so; 1. As part of the evaluation comprehensive assessment, the interdisciplinary team (IDT) assesses each resident's cognitive and physical abilities to determine whether self-administering medications is clinically appropriate for the resident. Review of Resident 97's clinical record revealed diagnoses that included lung cancer, hypertension (high blood pressure), and chronic obstructive pulmonary disorder (COPD-a type of progressive lung disease characterized by long term respiratory symptoms…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy review, clinical record reviews, and staff interviews, it was determined that the facility failed to ensure residents received adequate monitoring to ensure the right to be free from chemical restraints for two of five residents reviewed for unnecessary medications (Residents 19 and 166). Findings include: Review of facility policy, titled Psychotropic Medication Use, last revised February 2025, revealed subsection titled Policy Interpretation and Implementation, stated, 2. Medications in the following categories are considered psychotropic medications and are subject to prescribing, monitoring, and review requirements specific to psychotropic medications: a. Anti-psychotics .3. Psychotropic medication management is an interdisciplinary process that involves the resident, family, and/or the representative and includes [sic] c. adequate monitoring for efficacy and adverse consequences . Review of subsection, titled Monitoring and Adverse Consequences, of the aforementioned policy 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 facility policy review, personnel file review, and staff interviews, it was determined that the facility failed to ensure that residents were protected from the potential for abuse by failing to determine and complete appropriate criminal history background checks for three of five personnel files reviewed (Employees 13, 15, and 16); failing to complete a license or registry verification at time of hire for two of three nursing staff reviewed (Employees 15 and 16); and by failing to perform a FBI (Federal) criminal history background check prior to hire for one of five personnel files reviewed (Employee 17). Findings include: Review of facility policy, titled Abuse Policy, undated, with a last review date of January 2025, revealed Our abuse prevention program as a minimum provides: screening for conducting employment background checks; background checks include State Criminal, Federal Criminal (if applicable), reference checks, OIG check, Sex Offender check, and any other review required under State or Federal regulation. Review of personnel files for Employees 13, 15, and…

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

Based on review of facility policy, clinical record reviews, and staff interviews, it was determined that the facility failed to ensure that the resident assessment accurately reflected the resident status for three of 35 residents reviewed (Residents 11, 24, and 26). Findings include: Review of facility policy, titled Resident Assessments, with the last revised date of October 2023, and a last review date of January 2025, revealed 12. Information in the MDS assessments will consistently reflect information in the progress notes, plans of care, and resident observations/interviews. Review of Resident 11's clinical record revealed diagnoses that included hypertension (high blood pressure), chronic diastolic heart failure (heart failure that occurs when the heart does not relax properly between beats causing the heart to be unable to pump an adequate amount of blood to the body), and diabetes mellitus type II (disease that occurs when your blood glucose, also called blood sugar, is too high, but does not require the use of insulin). Review of Resident 11's clinical record 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, resident and staff interviews, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for one of 35 records reviewed (Resident 122). Findings include: Review of Resident 122's clinical record revealed diagnoses that included cerebral infarction (stroke - sudden loss of blood flow to the brain, leading to brain damage), hemiplegia (paralysis or severe weakness on one side of the body), contracture right lower leg, muscle weakness, vascular dementia (a condition characterized by progressive loss of intellectual functioning, impairment of memory, and abstract thinking), and pain in joints of right hand. Observation on May 19, 2025, at 11:52 AM, revealed Resident 122's right hand was slightly contracted. In an interview with Resident 122 she stated that she wears a splint on her right hand at night, and that it is helping her hand to not become contracted. Resident 12's physician orders included a right resting hand splint, apply on night shift and remove in AM due to hemiplegia, start date March 19, 2024. Review…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, resident and staff interviews, and facility documentation review, it was determined that the facility failed to maintain adequate personal hygiene and grooming per resident preference for residents dependent on staff for assistance with these activities of daily living for two of 35 residents reviewed (Residents 11 and 122 ). Findings include: Review of Resident 11's clinical record revealed diagnoses that included muscle weakness, chronic diastolic heart failure (heart failure that occurs when the heart does not relax properly between beats causing the heart to be unable to pump an adequate amount of blood to the body), and diabetes mellitus type II (disease that occurs when your blood glucose, also called blood sugar, is too high, but does not require the use of insulin). During an interview with Resident 11 on May 19, 2025, at 10:57 AM, she indicated that on occasion she has not received her showers on her scheduled days. Review of Resident 11's care plan revealed that 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 review of the clinical record and resident and staff interviews, it was determined that the facility failed to ensure care and services were provided in accordance with professional standards of practice that met each resident's physical, mental, and psychosocial needs for two of 35 residents reviewed (Residents 43 and 78). Findings include: Review of Resident 43's clinical record documented diagnoses that included diabetes mellitus (the body's ability to produce or respond to the hormone insulin is impaired, resulting in abnormal metabolism of carbohydrates and elevated levels of glucose in the blood and urine). Resident 43's Medication Administration Record (MAR - documentation of physician prescribed medication and administration schedule) failed to document administration on May 12th and 18th, 2025, of Lantus SoloStar Solution Pen-injector (Insulin Glargine - long-acting insulin use to manage diabetes mellitus) inject 42 units subcutaneously (under the skin) at bedtime/ 8:00 PM. Resident 43's May Medication Administration Record (MAR - documentation of physician…

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

Based on clinical record review and resident and staff interviews, it was determined that the facility failed to ensure each resident receives proper treatment to maintain vision for one of two residents reviewed (Resident 11). Findings include: Review of Resident 11's clinical record revealed diagnoses that included hypertension (high blood pressure), chronic diastolic heart failure (heart failure that occurs when the heart does not relax properly between beats, causing the heart to be unable to pump an adequate amount of blood to the body), and diabetes mellitus type II (disease that occurs when your blood glucose, also called blood sugar, is too high, but does not require the use of insulin). During an interview with Resident 11 on May 19, 2025, at 10:58 AM, she indicated that she saw the eye doctor who had recommended eye drops for her eyes and that she has been waiting a couple of weeks to get them. Review of Resident 11's vision consult dated May 1, 2025, revealed that she was diagnosed with dry eye syndrome of both eyes and recommendation was given for artificial tears twice…

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

Based on clinical record review and resident and staff interviews, it was determined that the facility failed to provide pain management consistent with professional standards of practice for one of two residents reviewed for pain (Resident 143). Findings include: Review of Resident 143's clinical record revealed diagnoses that included history of fracture of thoracic 11-12 vertebra (fracture in bones that make up the spine) and polyneuropathy (pain in various places of the body as a result of neurological dysfunction). Review of Resident 143's clinical record revealed that Resident 143 had an order dated January 17, 2025, for Oxycodone (opioid medication used to treat pain) 5 mg (milligrams - metric unit of measure) one tablet by mouth one time a day for chronic pain. During a Resident interview with Resident 143, she expressed there had been times that she did not receive her scheduled pain medication as ordered. Review of Resident 143's medication administration record, progress notes, and the controlled substance declining count sheet for Resident 143's Oxycodone revealed 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy review, clinical record review, observation, and staff interviews, it was determined that the facility failed to maintain complete and accurate records related to dialysis communication, and failed to provide professional standards of practice for the care of a dialysis resident for one of two residents reviewed (Resident 181). Findings Include: Review of facility policy, titled End-Stage Renal Disease, Care of a Resident with with a revision date of September 2010, and a last review date of January 2025, revealed, in part, 4. Agreements between this facility and the contracted ESRD facility include all aspects of how the resident's care will be managed, including: b. how information will be exchanged between the facilities. Review of Resident's 181's clinical record revealed that she was admitted to the facility on [DATE], with diagnoses that included end stage renal disease (ESRD-condition in which a person's kidneys cease functioning on a permanent basis), chronic systolic congestive…

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, facility policy review, and clinical record review, it was determined that the facility failed to ensure that a comprehensive, person-centered care plan was developed for three of 34 residents reviewed (Residents 12, 142, and 163) . Findings include: Review of facility policy, titled Care Plans, Comprehensive Person-Centered, with a last revised date of September 2022, revealed the following: 1) The interdisciplinary team, in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person centered care plan for each resident; 8) h. incorporate identified problem areas; and 10) identifying problem areas and their causes, and developing interventions that are targeted and meaningful to the resident, are the endpoint of an interdisciplinary process. Review of Resident 12's clinical record revealed diagnoses that included vascular dementia (a decline in thinking skills caused by conditions that block or reduce blood flow to various regions of the brain) and paroxysmal atrial fibrillation (a fast…

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, observations, and staff and resident 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 two of 34 residents reviewed (Residents 140 and 163). Findings include: Review of Resident 140's clinical record revealed diagnoses that included malignant neoplasm of the colon (colorectal cancer, is a cancerous tumor that develops in the colon or rectum) and diabetes (a chronic disease that occurs when the pancreas does not produce enough insulin). Observation of Resident 140 on June 2, 2024, at 10:45 AM, revealed the Resident lying in bed. During an immediate interview with Resident 140, the Resident revealed he was on hospice. Review of Resident 140's current physician orders on June 3, 2024, failed to reveal a current physician order for Hospice care and services. Review of Resident 140's Care Plan on June 4, 2024, revealed a care plan of, Resident is receiving hospice care…

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

Based on facility policy, clinical record review, observations, and resident and staff interviews, it was determined that the facility failed to provide a therapeutic diet, per physician's order, for two of 34 residents reviewed (Resident 74 and 137). Findings include: Review of facility Snack policy, revised July 2023, read, in part, afternoon snacks will be provided to those residents as labelled snacks per Registered Dietitian or resident request. Nourishing snack is defined as an offering of items, single or in combination, from the basic food groups. Review of facility policy Encouraging and Restricting Fluids, revised October 2010, read, in part, when a resident had been placed on restricted fluids, remove the water pitcher and cup from residents' room. Clinical record review for Resident 74 revealed diagnosis that included diabetes mellitus (the body's ability to produce or respond to the hormone insulin is impaired, resulting in abnormal metabolism of carbohydrates and elevated levels of glucose in the blood and urine). During an interview with Resident 74 on June 3, 2024,…

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

Based on document review, clinical record review, and staff interviews, it was determined that the facility failed to ensure that residents who require dialysis receive such services consistent with professional standards of practice for one of one resident reviewed for dialysis (Resident 46). Findings include: Review of the facility's Nursing Home Dialysis Transfer Agreement, read, in part, #3. Designated resident information. Facility shall ensure that all appropriate medical, social, administrative, and other information accompany all Designated Residents at the time of transfer to Center. This information shall include but is not limited to where appropriate the following: (d) Appropriate medical records, including history of the Designated Resident's illness, including laboratory and x-ray findings. (e) Treatment presently being provided to the Designated Resident, including medications and any changes in a patient's condition (physical or mental), change of medication, diet, or fluid intake. (h) Any other information that will facilitate the adequate coordination of care, 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.

Based on observations, facility policy review, manufacturer label review, and staff interviews, it was determined that the facility failed to store medications in a manner consistent with professional standards for two of five medication carts observed (300 medication cart and F Wing 2 medication cart). Findings include: Review of facility policy, titled Storage of Medications, last revised April 2007, revealed the policy statement read, The facility shall store all drugs and biologicals in a safe, secure, and orderly manner. Subsection 1 stated, Drugs and biologicals shall be stored in the packaging, containers or other dispensing systems in which they are received. Only the issuing pharmacy is authorized to transfer medication between containers. Further, subsection 2 stated, The nursing staff shall be responsible for maintaining medication storage AND preparation areas in a clean, safe, and sanitary manner. Observation of the 300 medication cart on June 6, 2024, at approximately 11:15 AM, revealed two Lantus insulin pen (insulin delivery system), that were partially used, with no…

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

Based on clinical record review, document review, observations, and resident and staff interviews, it was determined that the facility failed to provide a nutritionally adequate menu substitution for one of two meals observed (June 3rd and 4th, 2024, lunch meal) and failed to follow the menu for lunch meals observed on June 3, 2024, for one of seven resident areas observed (Rosemont Hall). Findings include: A review of the facility's planned lunch menu for June 3, 2024, included chicken tenders, dipping sauce, French fries, coleslaw, cinnamon applesauce, and assorted beverages. A review of the menu extension sheet (documentation of menu substitutions for therapeutic and altered textured diets) documented that all diets except for the finger food diet were to receive applesauce. During an interview with Employee 9 (Dietary Aide) June 3, 2024, at 2:22 PM, it was revealed that they ran out of applesauce during the F- west unit food cart and that the remaining residents were served ice cream. A review of the tray delivery schedule documented that there were two food carts delivered to A…

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

Based on review of facility policy, observations, and interviews, it was determined that the facility failed to store and serve food/beverages in accordance with professional standards for food safety in the kitchen and two of two nourishment pantries observed (B/C unit and Wedge [NAME] 1). Findings include: Review of facility policy Food Storage Areas, revised July 2023, read, in part, storage of dry items must be accurately labeled and dated. Leftover food is clearly labeled, dated, a used within three days or discarded. All refrigerators are kept clean. All food should be covered labeled and date. Frozen food should be defrosted in a refrigerator and date marked with a pull and use by date. Review of facility policy Food from Outside Sources, revised July 2023, read, in part, perishable foods will be marked with a use by date which is three days from the date that it was brought into the facility. Visitors/family members will label food and beverages with the resident's name, room number, and date. Observation in the walk-in refrigerator on June 3, 2024, at 9:42 AM, revealed 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 clinical record review and staff interviews, it was determined that the facility failed to ensure that the resident assessment accurately reflected the resident's status for one of 34 residents reviewed (Resident 5). Findings include: Review of Resident 5's clinical record documented diagnoses that included sleep apnea (a sleep disorder in which breathing repeatedly stops and starts), heart failure (the heart doesn't pump blood as it should), and respiratory failure (a condition in which your blood doesn't have enough oxygen or has too much carbon dioxide). Review of Resident 5's physician orders included BiPAP (a bilevel positive airway pressure machine - a type of ventilator that helps people breathe by delivering pressurized air int their lungs through a mask) minimum 5, maximum 20, PS 4-8 (unit of measure) with 2 Liters oxygen bleed, in at bedtime, with a start date of June 2, 2022. Review of Resident 5's annual MDS (Minimum Data Set - an assessment tool to review all care areas specific to the resident such as a resident's physical, mental, or psychosocial needs)…

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 clinical records, and resident and staff interviews, it was revealed that the facility failed to provide necessary individualized services to maintain Activities of Daily Living (ADL- wash face, brush teeth, eating, brush hair) regarding fingernail care for one of 34 residents reviewed (Resident 110). Findings include: Review of Resident 110's clinical record revealed diagnoses that included diabetes mellitus (the body's ability to produce or respond to the hormone insulin is impaired, resulting in abnormal metabolism of carbohydrates and elevated levels of glucose in the blood and urine), macular degeneration in both eyes (an eye disease that causes vision loss), anxiety (a feeling of worry, nervousness, or unease), and dementia (a condition characterized by progressive loss of intellectual functioning, impairment of memory and abstract thinking). Observation on June 3, 2024, at 10:43 AM, revealed Resident 110's fingernails on both hands were long and jagged. During an interview with Resident 110 on June 3, 2024, at 10:43 AM, it was revealed that he…

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 the resident received care, consistent with professional standards, to prevent pressure ulcers for one of 37 residents reviewed (Resident 140). Findings Include: Review of facility policy, titled Wound Care, revised October 2010, revealed Steps in the Procedure, 1. Use disposable cloth (paper towel is adequate) to establish clean field on resident's overbed table. Place all items to be used during the procedure on the clean field. Also, 4. Put on exam glove. Loosen tape and remove dressing. 5. Pull glove over dressing and discard into appropriate receptacle. Wash and dry your hands thoroughly. 6. Put on gloves. Review of Resident 140's clinical record revealed diagnoses that included pressure ulcer of left heel (skin ulcer caused by excess pressure) and diabetes (a chronic disease that occurs when the pancreas does not produce enough insulin). Observation of a dressing change to Resident 140's left heel on June 5, 2024, at 10:47 AM, revealed Employee 17 gathered…

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 complete a performance review of every nurse aide at least once every 12 months for two of five nurse aide documents reviewed (Employees 12 and 13). Findings Include: A review of Employee 12's personnel information revealed a hire date of May 13, 1991. A review of Employee 12's most recent Competency Evaluation revealed a review and completion date of May 6, 2023. A review of Employee 13's personnel information revealed a hire date of April 9, 2013. A review of Employee 13's most recent Competency Evaluation revealed a review and completion date of April 5, 2023. An interview with the Director of Nursing on June 6, 2024, at 12:15 PM, revealed the evaluations provided are the most recent and additional information will be sought. After the survey, no additional information was provided to verify the completion of annual performance reviews for Employees 12 and 13 thus far in the year 2024. 28 Pa. Code 201.19 (2) Personnel policies and procedures

Based on staff interview and document review, it was determined the facility failed to develop a water management program based on a risk analysis of the facility for the prevention, detection, and control of water-borne contaminants, such as Legionella, a bacteria that may cause Legionnaires' Disease (a serious type of pneumonia). Findings include: On June 4, 2024, the facility provided a policy, titled Legionella Surveillance and Detection, last revised September 2022. The policy focused on the signs and symptoms of Legionnaires' Disease when a resident develops pneumonia. On June 4, 2024, the facility was requested to provide their water management program that includes a water flow schematic, a documented risk analysis for areas at risk of contamination with Legionella (gram negative bacteria), and any routine preventative measures being performed that includes water temperature logs, flushing of stagnant water flow systems. The facility in response provided the Center for Disease Control (CDC) toolkit, titled Developing a Legionella Water Management Program. During an interview…

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

Based on observation and resident and staff interviews, it was determined that the facility failed to ensure each resident's bedside is equipped to allow for residents to call for staff assistance through a communication system for one of seven resident areas reviewed (Rosemont Hall). Findings Include: Observations on the Rosemont Hall in one room occupied by Residents 16 and 135 on June 4, 2024, at 9:24 AM, revealed no call bell cords leaving the Resident wall above the beds. Interviews with Residents 16 and 135 revealed they have no call bells available to call for staff assistance. An interview with the Nurse Aide (Employee 19) on June 4, 2024, at 9:28 AM, confirmed the lack of call bells available to Residents 16 and 135 in their room. An interview with the Nursing Home Administrator on June 5, 2024, at 11:58 AM, confirmed the room lacked call bells for Residents 16 and 135, and that the call bells were added and are now available for the Residents to contact staff for assistance as needed. 28 Pa. Code 205.67 (j) Electric requirements for existing construction

Based on observations and resident and staff interviews, it was determined that the facility failed to maintain a safe, clean, comfortable, and home-like interior on five of six nursing units (Rosemont, A wing, B wing, C wing, Wedge [NAME] 1, and F wing west). Findings include: Observation in Resident 1's room on April 17, 2024, at 11:10 AM, revealed: there were crumbs on floor around the bed; a dried red liquid in a puddle in front of the closet and on the base board that encompassed an area of 18 inches by 6 inches; the over-bed table contained a dried liquid, and the wood was exposed due to the laminate missing; a section of the radiator cover was missing, and the inside of the unit was exposed; and there was a dried yellow liquid on the windowsill. Observation with Employee 1 (Licensed Practical Nurse) on April 17, 2024, at 11:15 AM, revealed Resident 1's room remained in the same condition as noted above. During an interview with Employee 1 on April 17, 2024, at 11:55 AM, it was revealed that the floor and windowsill needed cleaned, and a work order needed entered for the cover…

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 test tray and staff interviews, it was determined that the facility failed to provide food and beverage that are at a safe and appetizing temperature for one of one meal observed on the C Wing. Findings include: A test tray was completed on April 17, 2024, at 12:50 PM, on C Wing. Test tray temperatures were taken by Employee 6 (Food Service Director 1) and revealed the following: Chicken Parmesan 103 degrees Fahrenheit (F), and the product was cold, hard, and dry Penne with marinara sauce 98 degrees F. Italian Blend Vegetables 103 degrees F. Mandarin Oranges 62, degrees F, product was served at room temperature Milk 47 degrees F, palatable During an interview with the Employee 6 on April 17, 2024, at 12:55 PM, it was revealed that the hot foods should've been warmer. During an interview with the Nursing Home Administrator on April 17, 2024, at 1:21 PM, the surveyor discussed concerns regarding the test tray pertaining to food temperature and food quality. No further information was provided. 28 Pa code 211.6 - Dietary Services

Based on observations, staff interviews, and pests service report review, it was determined that the facility failed to maintain an effective pest control program so that the facility is free from pests in the kitchen and the boiler room. Findings include: Observation in the dish room on April 17, 2024, at 9:26 AM, revealed there was a smell of rotting trash near the disposal. On the floor under the disposal was one plastic cup, a ball of used plastic wrap, one bowl lid, and one fork. Three cockroaches were observed on the pipe from the disposal into the wall, on the wall behind the disposal, and on the floor. Several gnats were observed flying around the dish room. Under the dish machine on the floor were two medicine cups, one plastic bowl, and several pieces of paper trash. It was noted that the dish room wasn't being utilized at that time. Observation on April 17, 2024, at 9:34 AM, in the utility hallway outside of the kitchen, along the wall on the floor between the dish room and boiler room, were dead bugs along the baseboard, in the corners, and at the base of the door…

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

Based on observations and staff interviews, it was determined that the facility failed to ensure a safe, functional, and sanitary environment for residents, staff, and the public in the dish room and boiler room. Findings include: Observation in the dish room on April 17, 2024, at 9:26 AM, revealed there was a smell of rotting trash near the disposal. Observation on April 17, 2024, at 9:34 AM, revealed in the utility hallway outside of the kitchen, along the wall on the floor between the dish room and boiler room were dead bugs along the baseboard, in the corners, and at the base of the door frames. Observation on April 17, 2024, at 9:35 AM, with Employee 7 (Maintenance worker) in the boiler room, which is on the opposite side of the wall from the dish room, revealed the floor was noted to be damp and multiple live bugs were observed on the floor, on the wall, and coming from one of the two holes in the wall. One hole was noted to be 15 by 30 inches and was covered with a painted wood board, and the other hole was 24 by 30 inches and was covered with a painted board. There was 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 observations and staff interviews, it was determined that the facility failed to maintain a safe, clean, comfortable, and home-like interior for three Resident's rooms (Residents 2, 4, and 8). Findings include: Observation in Resident 2's room on January 8, 2024, at 3:26 PM, revealed there was no fitted sheet on the Resident's air mattress, and the mattress contained a dried film as well as crumbs on the mattress and in the crease of the raised sides. Observation and interview with Employee 2 (Licensed Practical Nurse) on January 8, 2024, at 3:27 PM, Resident 2's mattress was observed as above. It was also revealed that the air mattress should not be covered with a fitted sheet, however, it should be cleaned. Observation and interview with the Nursing Home Administrator (NHA) on January 8, 2024, at 4:05 PM, the mattress was observed as above, and it was revealed that the air mattress should be cleaned when the Resident is bathed and as needed. Observation in Resident 4's room on January 8, 2024, at 3:40 PM, revealed the Resident's air mattress was not covered with a fitted…

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

Based on clinical record reviews, facility documentation, and staff interviews, it was determined the facility failed to ensure necessary treatment and services, consistent with professional standards of practice to promote healing and prevent infection for two of four residents reviewed (Residents 1 and 3). Findings include: Review of Resident 1's clinical record documented diagnoses that included history of stroke, diabetes mellitus (the body's ability to produce or respond to the hormone insulin is impaired, resulting in abnormal metabolism of carbohydrates and elevated levels of glucose in the blood and urine), dementia (a condition characterized by progressive loss of intellectual functioning and impairment of memory and abstract thinking), dysphagia (difficulty swallowing), contracture (a condition of shortening and hardening of muscles and tendons, often leading to rigidity of joints) of left and right knees, and pressure ulcer (injury to the skin and underlying tissue resulting from prolonged pressure on the skin) to the right heel. Review of Resident 1's November 2023…

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 scheduled meal times, staff and resident interviews, and observations, it was revealed that the facility failed to serve meals routinely at regular mealtimes comparable to normal mealtimes in the community or in accordance with resident needs, preferences, and requests for one of one meal observed (November 3, 2023, lunch meal, F-West unit). Findings include: Review of facility scheduled meal times read, in part, F-West 1st cart breakfast between 8:15 and 8:25 AM, lunch between 12:15 and 12:25 PM, and dinner between 5:15 and 5:25 PM. Interviews with Residents 1, 2, 3, 4, and 5 on November 3, 2023 between 11:00AM and 2:00 PM, it was revealed that breakfast that morning wasn't served until just before 10:00 AM. It was also revealed that meals are consistently late and, for a short period, it was better; however, the past few weeks meals have been late again. Lunch had been served between 2:00 and 3:00 PM, and supper, at times, was delivered around 7:00 PM. Interview with Employee 1 (Licensed Practical Nurse) on November 3, 2023, at 12:13 PM, it was revealed 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 observations, review of facility policy, and resident and staff interviews, it was determined that the facility failed to provide food and beverage that are at a safe and appetizing temperature for one of one meal observed (F-West unit; November 3, 2023, lunch). Findings include: Review of facility policy, titled Service of Food (Point of Service), revised July 2023, read, in part, hot food should be at or above 135 degrees Fahrenheit (F), and cold food should be held at or below 41 degrees F. Review of facility policy, titled Cold Food temps, revised July 2023, read, in part, canned pudding should be chilled 3-4 hours prior to service and should be chilled to 41 degrees Fahrenheit. Review of resident council meeting minutes from August 28, 2023, documented concerns with meals being served late, the quality and temperature of the food, and items missing from meal trays. Interviews with Residents 1, 2, 3, 4, and 5 on November 3, 2023, between 11:00 and 1:00 PM, revealed concerns with food and beverage temperatures at meals. It was noted that, at times, the facility utilized…

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, staff interviews, and facility policy review, it was determined that the facility failed to develop and implement a comprehensive plan of care for one of three residents reviewed for bowel and bladder incontinence (Resident 16), and for two of 38 residents reviewed (Residents 136 and 149). Findings include: Review of facility policy, titled Care Plans, Comprehensive Person-Centered with last revision date November 2019, revealed the policy statement was, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Review of aforementioned facility policy revealed that subsection 8 stated, The comprehensive, person-centered care plan will .Incorporate identified problem areas .Incorporate risk factors associated with identified problems .Build on resident's strengths .Reflect treatment goals, timetables and objectives in measure…

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 policy, and resident and staff interviews, it was determined that the facility failed to provide food and beverage that are at a safe and appetizing temperature for one of one meal observed on the F [NAME] Unit. Findings include: Review of the facility's Culinary and Nutrition Test Tray form, no date, read, in part, point of service temperature for hot entrée, starch, vegetable, and hot coffee should be greater than 135 degrees Fahrenheit, and cold beverages should be less than 41 degrees Fahrenheit. Multiple resident interviews on August 21, 2023, revealed residents voiced concerns with the temperature of the food during meal service. Interview with Resident 140 on August 21, 2023, at 10:00 AM, revealed the food tastes bland and does not come hot. Interview with Resident 17 on August 21, 2023, at 10:44 AM, revealed the menu is repetitive and she is served cold food most of the time. A test tray was completed on August 22, 2023, on the F [NAME] Unit second food cart. Test tray temperatures were taken by Employee 14 (Assistant Food Service…

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, clinical record review, and staff interviews, it was determined that the facility failed to ensure that the resident care plan was reviewed and revised to reflect the resident's current care needs for three of 37 residents reviewed (Residents 21, 32, and 105). Findings include: Review of Resident 21's medical record revealed diagnoses that included Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow imprecise movement), dementia (a chronic disorder of the mental processes caused by brain disease, marked by memory disorders, personality changes, and impaired reasoning), and dysphagia (difficulty swallowing). Review of Resident 21's physician orders revealed an order for Seroquel oral tablet, with a start date of July 6, 2023. Review of Resident 21's care plan did not reveal a care plan for antipsychotic use. Interview with the Director of Nursing (DON) on August 23, 2023, at 2:41 PM, revealed she would expect a care plan 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.