Paoli Health and Living Community

In the surveyor’s words

From the most serious findings on record at Paoli Health and Living Community, in the surveyor’s own words.

• Immediate jeopardy, isolatedF600Jan 24, 2025

  Based on observation, interview, and record review, the facility failed to protect a resident's right to be free from sexual abuse by staff for 1 of 3 residents reviewed for abuse allegations. (Resident C) This deficient practice resulted in an alert and oriented female resident alleging staff to resident sexual abuse on 12/28/24 when Resident C indicated that Certified Nurse Aide (CNA) 13 lifted her gown during care and licked or sucked on her breast a week prior. CNA 13 indicated to a police detective on 12/21/24 that, she asked me to do it, so I done it, to shut her up. This Immediate Jeopardy began on 12/18/24 at approximately 4:00 P.M. when Resident C alleged that CNA 13 had lifted her gown and placed his mouth on her breasts. […]

• Immediate jeopardy, isolatedF689Jan 24, 2025

  Based on interview and record review, the facility failed to ensure a resident was free from accidents for 1 of 3 residents reviewed for the use of a mechanical lift. A resident was in the process of transferring in a mechanical lift while the lift pad was wrapped under the resident's legs rather than through the resident's legs. The resident did not possess the required stability to transfer safely with the lift pad wrapped under her legs. The resident slid feet first out of the lift pad which resulted in multiple lower extremity fractures and a laceration to the back of her head. The resident was transferred to a local Emergency Department (ED) where she expired. […]

• No harm, potential for more than minimal, patternF921Jan 15, 2026

  Based on observation, interview, and record review, the facility failed to ensure a safe, sanitary, and homelike environment in 3 of 4 resident halls observed. Resident rooms contained used towels/washcloths on the floors, resident bed pans were stored uncovered in shared restrooms, resident toothbrushes were stored uncovered and unlabeled in shared restrooms, and odors were present 2 of 2 days during the survey. (100 hall, 200 hall, 300 hall, room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER])Findings include:1. During a review of the facility grievance log on 1/14/26 at 11:00 A.M., a grievance was filed on 12/18/25 that dirty laundry was left in a resident's room. 2. On 1/14/26 at 11:15, Hall 300 contained a urine odor. […]

• No harm, potential for more than minimal, patternF623Apr 11, 2025

  3. On 4/8/25 at 10:03 A.M., Resident 41's clinical record was reviewed. Diagnoses included, but were not limited to, malignant neoplasm of external lower lip and dysphasia. A progress note, dated 11/6/25 at 3:48 P.M., indicated Resident 41 was scheduled to leave the facility the following day for a surgery. Resident was discharged on 11/7/24 at 6:23 A.M. and returned 11/14/24. A Discharge Minimum Data Set (MDS) assessment was completed and signed on 11/7/24. Resident 41's clinical record lacked documentation that a Notice of Transfer or Discharge form was completed and/or sent with the resident and representative at the time of discharge on [DATE]. 4. On 4/8/25 at 9:47 A.M., Resident 48's clinical record was reviewed. […]

• No harm, potential for more than minimal, patternF641Apr 11, 2025

  Based on interview and record review, the facility failed to ensure the Minimum Data Set (MDS) assessments were accurate for 2 of 5 residents reviewed for unnecessary medications, 1 of 2 residents reviewed for skin conditions, and 1 of 4 residents reviewed for accidents. Residents were taking an anticoagulant, antiplatelet, and anticonvulsant medications and a resident had falls that were not listed on the MDS assessments. (Resident 231, Resident 57, Resident 15, Resident 56) Findings include: 1. On 4/8/25 at 1:29 P.M., Resident 231's clinical record was reviewed. […]