Ephrata Manor

In the surveyor’s words

From the most serious findings on record at Ephrata Manor, in the surveyor’s own words.

• Actual harm, isolatedF686Nov 3, 2023

  Based upon review of facility policy and procedure, clinical record review and interview it was determined the facility failed to provide interventions to prevent pressure ulcers, failed to timely identify pressure ulcers and failed to provide treatment for pressure ulcers causing harm to one of two residents reviewed (Resident 40). Findings include: Review of facility policy and procedure titled Skin Integrity Program - Pressure Ulcer Prevention/Treatment Program, revised April 27, 2023, revealed Pressure Ulcer Prevention: Every resident shall have a skin risk assessment (Braden Scale) upon admission, return from hospitalization , any significant change in condition and a routine quarterly screening to be completed by a licensed nurse. […]

• No harm, potential for more than minimal, isolatedF745Feb 2, 2026

  Based on review of clinical records, hospital records, and staff interviews, it was determined that the facility failed to ensure appropriate social services were provided to ensure a safe discharge to home for one of the two residents reviewed (Resident CL1).Findings include: Review of Resident CL1 diagnosis list includes the following diagnoses: Altered mental status (Unusual changes in a person's emotional response, thinking, and behavior) and Metabolic Encephalopathy (A non-traumatic brain dysfunction caused by illnesses or chemical imbalance, resulting in altered mental status). Review of Resident CL1's admission Visit Physician Orders, dated December 4, 2025, revealed Resident is not capable of understanding rights and exercising own rights. […]

• No harm, potential for more than minimal, isolatedF758Sep 20, 2024

  Based on a review of the facility's policy, clinical records, and staff interview, it was determined the facility failed to monitor potential side effects of anti-psychotropic medication for one of five residents reviewed (Resident 99). Findings include: Review of the facility's policy titled Psychotropic Medications, dated March 2021, revealed the facility would make every effort to comply with state and federal regulations related to the use of psychotropic medications to include regular review for continued need, appropriate dosage, side effects, risk, and benefits. […]

• No harm, potential for more than minimal, isolatedF580Nov 3, 2023

  Based upon clinical record review and interview it was determined the facility failed to notify resident's physician regarding the development of a pressure ulcer for one of two residents reviewed (Resident 40). Findings include: Review of Resident 40's diagnosis list revealed diagnoses including Alzheimer's disease (irreversible progressive degenerative disease of the brain, resulting in loss of reality contact and functioning ability) and Peripheral Vascular Disease (poor circulation of the extremities). Review of facility's Skin/Wound Tracking Report revealed on August 15, 2023, the facility identified an open left heel wound, unstageable with slough measuring 1.3 centimeters (cm) x 2.6 cm. […]

• No harm, potential for more than minimal, isolatedF638Nov 3, 2023

  Based on clinical record review and interviews with staff, it was determined that the facility failed to complete a Quarterly MDS assessment at least every three months as required for one of eight residents reviewed (Resident 100). Findings include: Review of Resident 100's MDS (Minimum Data Set - a mandatory periodic assessment) assessments revealed that the resident had an Admission MDS assessment completed on May 29, 2023. Continued review revealed that no further MDS assessments had been completed for Resident 100 since May 29, 2023. Interview on November 3. 2023, at 10:20 a.m. with Employee E3, Registered Nurse Assessment Coordinator, confirmed that Resident 100 had not had an MDS assessment since her admission in May 2023. […]