United Zion Retirement Communi

In the surveyor’s words

From the most serious findings on record at United Zion Retirement Communi, in the surveyor’s own words.

• Actual harm, isolatedF689Feb 4, 2026

  Based on observation, review of clinical records and facility documentation, and staff interviews, it was determined the facility failed to ensure staff monitored temperature of hot liquids to mitigate the risk of injury. This failure resulted in actual harm to one resident (Resident R1), who sustained burn injuries to the chest and upper thigh.Findings include:Findings include:Review of the facility policy titled Safety of Hot Liquids, dated October 2014, revealed facility interventions to prevent burns included maintaining hot liquid serving temperatures at no more than 180 degrees Fahrenheit.Review of a facility procedure, undated and untitled, stated: All liquids heated in the microwave should be heated at 6 ounces per one beverage setting cycle.Review of information dated January 21,… […]

• Actual harm, isolatedF689Sep 29, 2023

  Based on clinical record and facility documentation review, and staff interview, it was determined that the facility failed to ensure that one of four residents reviewed was provided with adequate supervision to prevent accidents which resulted in actual harm to Resident 9 sustaining a fall, requiring transfer to the hospital via emergency medical services and the diagnosis of a fracture to the humerus (long bone of the upper arm). Findings include: Review of Resident 9's clinical record included diagnoses of, but not limited to, Cerebrovascular accident (stroke) with left side hemiparesis (weakness or paralysis on one side of the body), Dementia (decline in cognitive abilities that affects the brain's ability to think, remember, and function normally), and Ambulatory Dysfunction… […]

• No harm, potential for more than minimal, isolatedF661Jul 18, 2024

  Based on a review of clinical records and interview with staff, it was determined that the facility failed to ensure a physician's discharge summary was completed prior to or at the time of discharge for one of two closed records (Resident 57). Findings include: Review of Resident 57's clinical record revealed that the resident was discharged from the facility on May 6, 2024. Further review of Resident 57's clinical record failed to reveal evidence that the discharge summary was completed by the physician prior to or at the time of discharge. Interview with the Nursing Home Administrator on July 18, 2024 at 11:00 a.m. confirmed that the discharge summary was not completed. 28 Pa Code 211.5(d) Clinical record

• No harm, potential for more than minimal, isolatedF758Jul 18, 2024

  Based on clinical records review and staff interview, it was determined that the facility failed to ensure non-pharmacological interventions were attempted, and documented indication was provided before administering as-needed anti-anxiety medication for one of 5 residents reviewed (Resident 14). Findings include: Review of Resident 14's physician's order dated June 14, 2024, revealed an order for Lorazepam (anti-anxiety medication) 0.5 mg (milligram) one tablet twice daily as needed for anxiety. […]

• No harm, potential for more than minimal, isolatedF686Oct 18, 2021

  Based on clinical record review, facility policy and procedure review, and staff interview it was determined the facility failed to document and follow wound care protocol as ordered after the development of a pressure ulcer for one of 3 residents reviewed. (Resident 51) Findings Include: Review of facility policy and procedure titled Wound Care Guidelines, undated, revealed a wound care protocol for a stage II pressure ulcer (partial thickness loss of dermis presenting as a shallow open ulcer with a red/pink wound bed) to have hydrogel (gel applied to wounds to moisten wound and promote healing) and a border gauze (bandage surround by adhesive layer for attachment to healthy skin) placed to the wound every three days or as needed. […]