Passavant Retirement And Healt

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical record review, and staff interviews it was determined that the facility failed to obtain a physician order for care of an urostomy (surgical procedure that creates an opening in the abdomen wall to allow urine to exit the body when the bladder is not functioning properly) for one of three residents reviewed (Resident R7).Findings include: Review of facility policy Colostomy/Ileostomy/Urostomy Care last reviewed January 2026, indicated the purpose is to provide guidelines that will aid in preventing exposure of the resident's skin to fecal matter or urine. Review of the clinical record revealed that Resident R7 was admitted to the facility on [DATE]. Review of Resident R7s Minimum Data Set (MDS-periodic assessment of resident care needs) dated 2/11/26, indicated diagnoses of hypertension (high blood pressure), hemiplegia (one-sided paralysis) and depression. Section H0100 appliances indicated ostomy (including urostomy, ileostomy, and colostomy) present. 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to provide accurate and timely documentation related to offering the COVID-19 vaccination for one of five residents (Resident R88).Findings include: Review of facility policy Immunization Program dated January 2026, indicated when COVID-19 vaccine is available to the facility each resident will be offered the vaccine unless the immunization is medically contraindicated or the resident has already been vaccinated. Upon admission, if the above criteria is not met, reach Resident/Resident Representative will be provided educational material regarding the benefits and the risks of the COVID-19 vaccine. After reviewing educational information and the Immunization consent form, upon admission, the Resident/Resident Representative will sign the Immunization Consent form indicating their choice to accept or decline the COVID-19 vaccine. All documentation of acceptance or refusal must be transcribed…

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, facility in-service documentation, personnel files, and staff interviews, it was determined that the facility failed to provide training on Effective Communication for one of seven staff members (Licensed Practical Nurse (LPN) Employee E3).Findings include: Review of facility policy Inservice - Mandatory Hours for Registered Nurses (RN) and Licensed Practical Nurses dated January 2026, indicated RNs and LPNs will be provided with opportunities to acquire annual continued education from in-services, self-studies, or seminars. Each nurse is responsible to attend in-services each anniversary year. The nurse will notify the Nursing Educator ahead of time if in-services are needed to meet their annual anniversary deadline. Review of LPN Employee E3's personnel file indicated a date of hire on 3/31/21. Review of LPN Employee E3's personnel file did not include annual in-service training on Effective Communication from 3/31/24 through 3/31/25. During an interview on 2/25/26, at 1:24 p.m. Clinical Nurse Educator Employee E8 confirmed that the facility…

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, facility in-service documentation, personnel files, and staff interviews, it was determined that the facility failed to provide training on Resident Rights for two of seven staff members (Licensed Practical Nurse (LPN) Employee E3 and Nurse Aide (NA) Employee E5).Findings include: Review of facility policy Inservice - Mandatory Hours for Registered Nurses (RN) and Licensed Practical Nurses dated January 2026, indicated RNs and LPNs will be provided with opportunities to acquire annual continued education from in-services, self-studies, or seminars. Each nurse is responsible to attend in-services each anniversary year. The nurse will notify the Nursing Educator ahead of time if in-services are needed to meet their annual anniversary deadline. Review of facility policy Inservice - Mandatory Hours for Nurse Aides dated January 2026, indicated Nurse Aides will be provided with opportunities to acquire at least 12 hours annually of continued education from in-services or seminars, as required by OBRA (Omnibus Budget Reconciliation Act) regulations. The…

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

Based on review of facility policy, facility in-service documentation, personnel files, and staff interviews, it was determined that the facility failed to provide training on Abuse, Neglect, and Exploitation for one of seven staff members (Nurse Aide (NA) Employee E5).Findings include: Review of facility policy Inservice - Mandatory Hours for Nurse Aides dated January 2026, indicated Nurse Aides will be provided with opportunities to acquire at least 12 hours annually of continued education from in-services or seminars, as required by OBRA (Omnibus Budget Reconciliation Act) regulations. The facility has high standards for the team members and has an obligation to provide continued training and education to help team members perform their jobs effectively. The nurse aide is required to complete the 12 hours of annual continued education prior to their annual review. Review of NA Employee E5's personnel file indicated a date of hire on 11/4/20. Review of NA Employee E5's personnel file did not include annual in-service training on Abuse, Neglect, and Exploitation from 11/4/24…

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, facility in-service documentation, personnel files, and staff interviews, it was determined that the facility failed to provide training on Infection Control for one of seven staff members (Nurse Aide (NA) Employee E5).Findings include: Review of facility policy Inservice - Mandatory Hours for Nurse Aides dated January 2026, indicated Nurse Aides will be provided with opportunities to acquire at least 12 hours annually of continued education from in-services or seminars, as required by OBRA (Omnibus Budget Reconciliation Act) regulations. The facility has high standards for the team members and has an obligation to provide continued training and education to help team members perform their jobs effectively. The nurse aide is required to complete the 12 hours of annual continued education prior to their annual review. Review of NA Employee E5's personnel file indicated a date of hire on 11/4/20. Review of NA Employee E5's personnel file did not include annual in-service training on Infection Control from 11/4/24 through 11/4/25. 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 clinical record review, reports submitted to the State, and staff interview, it was determined that the facility failed to report and investigate an allegation of physical abuse for two of three residents. Findings include: Abuse, is defined at §483.5 as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. Review of Closed Record Resident R1 (CRR1) indicated admission to the facility on 4/4/22. Review of Resident CRR1's Minimum Data Set assessment (MDS periodic assessment of resident care needs) dated 2/12/25, indicated the 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, resident, and staff interviews, it was determined that the facility failed to determine the ability to self-administer medications for one of three residents (Residents R51). Findings include: Review of the facility policy Medication-Self-Administration January 2025, indicates residents have the right to self-administer medications as long as it is determined that it is safe for them to do so. Self-administration will refer to residents who do not need any assistance or reminders in order to take their medications. If the resident indicates that they are requesting the right to self-administer their own medications, a licensed nurse must complete an assessment for self-administration of medications and the attending physician will be notified within 24 hours. Review of the clinical record indicated Resident R51 was admitted to the facility on [DATE]. Review of Resident R51's Minimum Data Set (MDS - a periodic assessment of care needs) dated 12/10/24, indicates the diagnosis of anemia (low…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of facility policies, documents, observations and staff interviews it was determined that the facility failed to provide a non-institutional dining experience by administering medications during the breakfast meal service for two of six residents. (Resident R3 and Resident R66). Findings include: A review of facility policy Supporting the Resident's Right to Privacy and Confidentially last reviewed January 2025, indicates it is the responsibility of each employee of this community to ensure the privacy and confidentiality of each resident is protected. A review of the facility policy Medication Administration - General Guidelines last reviewed January 2025, indicates for residents not in their rooms or otherwise unavailable to receive medication on the pass, the medication administration record (MAR) is flagged. After completing the medication pass, the nurse returns to the missed resident to administer the medication. Review of the clinical record indicated Resident R3 was admitted to the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical records, and staff interview it was determined that the facility failed to ensure residents medication regime was free from unnecessary psychotropic medications for two of four residents (Resident R46 and R86). Findings include: Review of facility policy medication management dated January 2025, indicated The interdisciplinary team reviews the resident's medication regimen for efficacy and actual or potential medication -related problems on an on-going basis. Resident R46 was admitted on [DATE]. Review of Resident R46 MDS (minimum data set a periodic assessment of resident needs) dated 1/15/25, indicated a diagnosis of dementia (dementia is a term for several diseases that affect memory, thinking and the ability to perform daily activities) and depression (is a common and serious medical illness that negatively affects how you feel, the way you think and how you act). Review of Resident R46 physician orders indicated to administer: Quetiapine (antipsychotic used 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, observations and staff interview it was determined that the facility failed to date opened medications, and properly store/label medication in three of three medication rooms (Mountain Laurel, Tionesta, and Trillium Medication Rooms), failed to discard expired nursing supplies in one of three medication rooms (Tionesta Medication Room), and failed to properly store medications in one of three residents' medication cabinet in the resident room (Resident R77). Findings include: Review of facility policy Preparation and General Guidelines - Vials and Ampules of Injectable Medications dated [DATE], indicated opening a vial triggers a shortened expiration date that is unique for that product. It is important to record the date opened and the triggered expiration date on a multi-dose vial. Review of the facility policy Storage of Medications dated [DATE], indicated all medications dispensed by the pharmacy are stored in the container with the pharmacy label. Medications labeled 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility documents, resident clinical records and staff interviews it was determined that the facility failed to ensure residents had the capacity to understand the terms of a binding arbitration agreement (A binding agreement by the parties to submit to arbitration all or certain disputes which have arisen or may arise between them in respect of a defined legal relationship, whether contractual or not.) for one of five residents (Resident R67). Findings include: Review of the admission record indicated Resident R67 was admitted to the facility on [DATE]. Review of Resident R67's Binding Arbitration Agreement indicated that the resident signed the document on 1/13/25. Review of Resident R67's Minimum Data Set (MDS - a periodic assessment of care needs) dated 1/20/25, indicated the diagnoses of Non-Alzheimer's Dementia (dementia caused by other diseases with symptoms forgetfulness, limited social skills, and impaired thinking abilities that interfere with daily functioning), diabetes (a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy, clinical record review, observation, and staff interview, it was determined that the facility failed to ensure droplet precautions were ordered and a care plan implemented for one of three residents (Resident R40), and failed to provide a safe and sanitary environment to help prevent the potential for cross contamination for one of six household kitchen areas (Mountain Laurel Neighborhood). Findings include: Review of the facility policy COVID-19 Plan dated January 2025, indicated the facility will make every attempt to reduce the risk of transmission of COVID-19 in order to protect those it serves, its personnel, volunteers and visitors. In the event transmission does occur, prompt detection and effective triage and isolation of infectious residents are essential to prevent unnecessary exposure. Transmission-based precautions are the second tier of basic infection control and are used in addition to standard precautions for residents with known or suspected infections. There are 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of clinical records and staff interview, it was determined that the facility failed to provide adequate supervision transfers for one of six residents (Resident R1), which resulted in a fall. Findings include: Review of Resident R1's admission record indicated she was admitted to the facility on [DATE]. Review of Resident R1's Minimum Data Set (MDS-periodic assessment of a resident's abilities and care needs) dated 11/21/24, indicated diagnoses of right fibula fracture, anxiety and depression. Review of Resident R1's physician orders dated 12/5/24 indicated toilet transfer to be completed assist x 2. Review of Resident R1's profile/preference (tool nursing staff uses for transfer status, ADL assistance) indicated assist x 2 for toileting. Review of a progress note written by Licensed Practical Nurse (LPN) Employee E1 dated 12/29/24, at 9:45 p.m. indicated While Nurse Aid (NA) was transferring resident on to the commode resident slipped and lost her balance and fell in her bathroom, she hit back…

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 records, observations, and staff interviews it was determined that the facility failed to make certain each resident received adequate supervision that resulted in one elopement (resident exits to an unsupervised or unauthorized area without the facility's knowledge) for one of three residents (Resident R1). Findings include: Review of the facility's policy Elopement Protocol dated 1/24, indicated to promote the safety of all residents and maintains a process to assess residents for risk of elopement, implement prevention strategies for those identified as an elopement risk and conduct a missing resident protocol. Review of the facility's policy Accidents and Incidents-Investigation and Reporting dated 1/24, indicated will provide a safe and secure environment in order to prevent incidents and accidents from occurring. Review of Residents R1's clinical record indicated admission to facility to on 6/29/24. Review of Resident R1's Minimum Data Set (MDS- a periodic…

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 review, and staff interviews, it was determined that the facility failed to ensure that a resident was free from neglect by not providing a two-person transfer per physician's order for one of four residents (Resident R1) resulting in a fall. Findings include: Review of facility policy Abuse, Recognizing Signs and Symptoms of Abuse, Neglect, Mental Abuse, Exploitation and Misappropriation of Resident Property last reviewed January 2024, indicated neglect is defined as failure or omission by employees of this community, the resident's legal representative, or family of goods and services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Each resident living in this community has the right to be free from abuse, neglect, exploitation and misappropriation of their property. Review of facility policy Abuse, Prevention of Resident Abuse, Neglect, Mental Abuse, Reports of Theft, Exploitation and Misappropriation of Property last…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy, clinical record review, and interview, the facility failed to have a physician's order, and a care plan, for the use of an indwelling catheter (a tube placed in the bladder to drain urine), for one of four residents (Resident R193), and failed to ensure that appropriate treatment and services were provided for two of four residents (Resident R67 and R73) with an indwelling urinary catheter. Findings include: Review of facility policy Catheter Care; Urinary dated 1/23/24, indicated to review the resident's care plan to assess for any special needs of the resident. It is suggested to change catheters and drainage bags based on clinical indications, and a physician's order. Review of the Centers for Disease Control guidance Guidelines for Prevention of Catheter-Associated Urinary Tract Infections updated 6/6/19, indicated to keep the collecting bag below the level of the bladder at all times. Review of the clinical record indicated Resident R67 was admitted to the facility on [DATE].…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to conduct ongoing accurate assessments to ensure that bedrails were used to meet residents' needs and the risks associated with bedrail usage for five of five residents (Residents R6, R14, R31, R32, and R34). Findings include: Review of Title 42 Code of Federal Regulations (CFR) §483.25(n) - Bed Rails states that the facility must assess the resident for risk of entrapment from bed rails prior to installation. Additionally, there should be evidence in the resident's records that the facility performed ongoing assessments to assure that the bed rail is used to meet the resident's needs and that there is an ongoing evaluation of risks associated with bed rail usage. Review of facility policy Mobility Bars/Bedrails dated 1/23/24, indicated before a resident is fitted with mobility bars or bed rails, an interdisciplinary team must determine the presence of a specific medical…

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, observation, and staff interview it was determined that the facility failed to maintain the confidentiality of resident's medical information on one of six nursing households (second floor Tionesta household). Findings include: Review of the facility policy Use of Laptops or other portable computers, last reviewed on 1/23/24, indicated that resident information should be kept confidential. The computer screen should be turned so that only the resident or resident's family can see the screen. Keep the lid partially closed if resident data is displayed and information is not actively being documented. No resident data should be displayed if information is not actively being documented. Review of facility policy Medication Administration-General Guidelines, last reviewed on 1/23/24, indicate privacy is always maintained for all resident information by closing computer screen when not in use. During an observation on 3/26/24, at 11:58 a.m., the medication cart/portable computer…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policies, clinical records, facility documents and staff interview, it was determined that the facility failed to ensure that residents received neurological assessment after an incident involving a fall for two of five residents (Resident R9 and Resident R69). Findings include: Review of facility policy Falls - Resident Treatment Of dated 1/23/24, indicated a fall will refer to an incident when a resident drops to the floor suddenly or if a resident moves from one plane to another. Incidents that are considered a fall are when a resident is slowly and gently lowered to the floor, or when a resident slowly and purposefully lies or sits on the floor. If the resident is on the floor and the incident was unobserved, staff is to presume that it was a fall and proceed accordingly. When there is doubt, an incident should be considered a fall. Review of facility policy Neurological Assessment - Using the Flowsheet dated 1/23/24, indicated that a Neurological Review Flowsheet will be…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy review, resident observations and interviews, clinical record review and staff interviews, it was determined that the facility failed to make certain a physician order for use of and cleaning of a Bi-PAP/CPAP machine (machines used to make breathing easier) and failed to develop a plan of care for one of three residents (Resident R58). Findings include: Review of the policy Respiratory Care Documentation dated 1/23/24, indicated nurses will be responsible for completing the eTAR (electronic treatment administration record), for any resident who has physician orders CPAP, Bi-PAP therapy. Review of the policy Respiratory Care Equipment Changes dated 12/12/23, indicated CPAP/BIPAP maintenance included the following: mask cleaning, headgear (helps secure the mask around the nose, mouth, or both to prevent pressure leaks during sleep) cleaning, tubing cleaning, humidifier chamber cleaning, filter cleaning, and replacement of worn-out components. Review of the admission record indicated…

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, resident record review, and staff interviews, it was determined to facility failed to provide a trauma survivor with trauma informed care to eliminate or mitigate triggers that may cause re-traumatization of the resident for one of one residents (Resident R69). Findings include: Review of facility policy Trauma-Informed Care dated 1/23/24, indicated the facility will provide culturally competent, trauma-informed care across all disciplines to mitigate potential triggers for nursing residents who have experienced past or present trauma. Review of the clinical record indicated Resident R69 was admitted to the facility on [DATE]. Review of Resident R69's Minimum Data Set (MDS - a periodic assessment of care needs) dated 1/18/24, indicated diagnoses of high blood pressure, Alzheimer's Disease (a progressive disease that destroys memory and other important mental functions), and Post Traumatic Stress Disorder (PTSD - a disorder in which a person has difficulty recovering after…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policies, observations, and staff interviews, it was determined that the facility failed to properly secure a medication drawer on four occasions in one of six households (Tionesta household). Findings include: Review of facility policy Medication Administration-General Guidelines, last reviewed 1/23/24, indicate during administration of medications, the medication cart /portable computer unit is kept closed and locked when out of sight of the medication nurse. During an observation on 3/26/24, 11:58 a.m., outside room [ROOM NUMBER] the portable computer unit medication drawer was left open, unattended, and out of site of the medication nurse. During an observation on 3/26/24, 12:10 p.m., outside room [ROOM NUMBER] the portable computer unit medication drawer was left open, unattended, and out of site of the medication nurse. During an interview on 3/26/24, at 12:17 p.m., Licensed Practical Nurse (LPN) Employee E7 confirmed the above findings. During an observation on 3/27/24, 8:40…

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 interviews, it was determined that the facility failed to implement measures to prevent the potential for cross contamination during finger stick blood sugar monitoring for one of two residents (Resident R301) and failed to complete hand hygiene after a finger stick blood sampling on one of two residents (Resident R299) Findings include: Review of facility policy Hand Hygiene/Handwashing last reviewed on 1/23/24, indicate it is the policy of Passavant Community that all staff will follow the principles of good hand hygiene. Appropriate times to use hand hygiene include but are not limited to the following: - Before and after performing a task that includes hand washing in the procedure. For example, before and after performing a task that includes any invasive procedure, finger stick blood sampling, inserting urinary catheters, caring for vascular catheters, and changing dressing. Review of facility policy Diabetes-Glucometer last reviewed 1/23/24, indicate after completion of finger stick dispose of lancet, gloves and used…

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.