MIDTOWN OAKS HEALTH & REHAB CENTER
For profit - Corporation
120 Beds
SABER HEALTHCARE GROUP
Data: November 2025
1 Immediate Jeopardy citation
Trust Grade
0/100
Last Inspection: August 2024
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
Midtown Oaks Health & Rehab Center has received an F grade for trust, indicating significant concerns about the quality of care provided. They rank #None of None in Pennsylvania and #None of None in Blair County, suggesting there are no better local options available. While the facility has shown improvement over time, going from 63 issues in 2024 to 15 in 2025, the overall situation remains concerning with 131 total issues found during inspections. Staffing is a weakness, with a turnover rate of 57%, which is higher than the Pennsylvania average, indicating challenges in retaining staff. Additionally, there were critical findings, including a malfunctioning call bell system that put residents at risk and failures to follow physician recommendations for wound care, highlighting serious deficiencies in resident safety and treatment.
- Trust Score
- F
- In Pennsylvania
- #112/223
- Safety Record
- High Risk
- Inspections
- Getting Better
- Staff Stability ⚠ Watch
- 57% turnover. Above average. Higher turnover means staff may not know residents' routines.
- Penalties ⚠ Watch
- $106,485 in fines. Higher than 87% of Pennsylvania facilities, suggesting repeated compliance issues.
- Skilled Nurses ○ Average
- Each resident gets 39 minutes of Registered Nurse (RN) attention daily — about average for Pennsylvania. RNs are the most trained staff who monitor for health changes.
- Violations ⚠ Watch
- 131 deficiencies on record. Higher than average. Multiple issues found across inspections.
0/100
Top 50%
Review needed
63 → 15 violations
☆☆☆☆☆
0.0
Overall Rating
☆☆☆☆☆
0.0
Staff Levels
☆☆☆☆☆
0.0
Care Quality
☆☆☆☆☆
0.0
Inspection Score
↔
Stable
2024: 63 issues
2025: 15 issues
The Good
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
Facility shows strength in fire safety.
The Bad
Staff Turnover: 57%
11pts above Pennsylvania avg (46%)
Frequent staff changes - ask about care continuity
Federal Fines: $106,485
Well above median ($33,413)
Significant penalties indicating serious issues
Chain: SABER HEALTHCARE GROUP
Part of a multi-facility chain
Ask about local staffing decisions and management
Staff turnover is elevated (57%)
9 points above Pennsylvania average of 48%
The Ugly 131 deficiencies on record
1 life-threatening 3 actual harm
Sept 2025
1 deficiency
CONCERN
(F)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected most or all residents
Based on review of policies, observations and staff interviews, it was determined that the facility failed to ensure that food was stored, prepared, distributed and served in accordance with professio...
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Based on review of policies, observations and staff interviews, it was determined that the facility failed to ensure that food was stored, prepared, distributed and served in accordance with professional standards for food service safety in the kitchen, in one of two pantries (second floor) and one of two refrigerators (third floor pantry) observed.Findings include: The facility policy regarding food storage, dated April 29, 2025, revealed that any food that has been opened must be labeled, dated and secured in such a way that the food item is not open to air, and that the facility would ensure a clean and sanitary environment. The facility's policy regarding food production and safety, dated April 29, 2025, revealed that the purpose of the policy was to ensure food would be cooked and/or held at appropriate temperatures to maintain safety, and that temperatures would be taken prior to meal service. Observations in the main kitchen's walk in freezer on September 8, 2025, at 9:30 a.m. revealed that there were 25 egg omelets, 15 sausage patties, five chicken cutlets, six pork chops and approximately one third of a bag of cut frozen carrots that were not dated with an opened date and were all open to the air. Observations on the back wall of the main walk in freezer on September 8, 2025, at 9:35 a.m. revealed that there was an approximate three foot by one and one half foot build up of ice. This ice extended from the pipe below the ceiling into and through the lid of a cardboard box that contained bags of frozen perogies.Observations in the second floor panty on September 8, 2025, at 3:35 p.m. revealed that there were, 3 boxes of frozen waffles that were undated and open to the air, and a box containing one and one half pieces of pizza that was not dated or labeled with a resident name. Observations in the third floor pantry refrigerator on September 8, 2025, at 3:40 p.m. revealed a moderate amount of an orange colored dried on sticky substance on the lower bottom right storage drawer.Observations in the kitchen on September 9, 2025, at 9:32 a.m. and September 10, 2025, at 8:40 a.m. respectively, revealed that there were four washed and ready to use insulated serving bowls that had a moderate amount of a dried white food substance on them, six plastic measuring cups, and one large plastic pitcher, all of which were in circulation for kitchen use, that had a moderate to large amount of a removable substance inside them.Observations in the kitchen of the bottom shelf of the stainless steel prep table on September 10, 2025, at 11:31 a.m. revealed that there was one five pound bag of dried noodles that was labeled and dated, but was open to the air.Observations in the kitchen on September 10, 2025, at 12:10 p.m. revealed that [NAME] 2 was plating food for the lunch meal. The menu was a cold meal that included a turkey sandwich and macaroni salad. A hot substitute choice of hamburgers, mashed potatoes and gravy was available and was observed to be plated for a resident. Observations of the lunch food temperature log revealed that the temperatures of the hot food items were not obtained to ensure that food was served at the proper temperature. Interview with the Regional Dietician 3 on September 10, 2025, at 12:10 p.m. confirmed that the food temperature log did not indicate that the hot foods were temped (temperature was taken) prior to plating. She further indicated that all food items whether hot or cold are required to be monitored for the proper temperature and documented as such. Interview with the Nursing Home Administrator on September 11, 2025, at 10:01 a.m. confirmed that all food items in the kitchen and pantry should be labeled, dated and not open to the air, that dinnerware/serving ware and facility freezers and refrigerators should be sanitary and in good working order, and that all food should be temped prior to being served to residents, and they were not.28 Pa. Code 211.6(f) Dietary services.
Aug 2025
5 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Incontinence Care
(Tag F0690)
Could have caused harm · This affected 1 resident
Based on review of clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that residents who required urinary catheterization (a flexible ...
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Based on review of clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that residents who required urinary catheterization (a flexible tube inserted into the bladder to drain urine) was completed as ordered for one of 12 residents reviewed (Resident 2).Findings include:An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 2 revealed that the resident was cognitively intact, required assistance for care needs, had a diagnosis of end stage kidney failure and received dialysis three times per week. A care plan for Resident 2, dated March 3, 2025, indicated that the resident had urinary incontinence, and was to be provided straight catheterization (a medical procedure used to drain urine from the bladder using a thin, flexible tube called a straight catheter) as ordered.Physician's orders for Resident 2, dated May 28, 2025, included an order for the resident to be straight catheterized three times a day (once every shift) for a neurogenic bladder. Physician's orders for Resident 2, dated July 24, 2025, included an order that the resident was to receive dialysis on Tuesday, Thursday, and Saturday at 11:00 a.m. Review of Resident 2's July and August, 2025 medication and treatment administration records (MAR and TAR) revealed that the resident did not receive straight catheterization on July 1, 3, 8 10, 17, 24, 2025, on day shift because the resident was at dialysis. Resident 2 did not leave for dialysis until 10:30 a.m. Documentation for July 5 and 19, 2025 for day shift as well as July 23 and 31, 2025 for evening shift indicated the resident was not available. On August 4, 2025, Resident 2 was not straight catheterized because it was completed on the previous shift. On August 5, 2025, day shift Resident 2 was not catheterized due to being at dialysis, and it was not completed on night shift.Interview with the Director of Nursing on August 6 2025, at 4:25 p.m. confirmed that there was no documented evidence that Resident 2's straight catheterization was completed as ordered on the dates and shifts noted above.28 Pa. Code 211.12(d)(5) Nursing Services.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected multiple residents
Based on review of the Pennsylvania Nurse Practice Act and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that physician's orders were clarified wh...
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Based on review of the Pennsylvania Nurse Practice Act and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that physician's orders were clarified when needed for two of 12 residents reviewed (Residents 1, 2).Findings include:The Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.11 (a)(1)(2)(4) indicated that the registered nurse was to collect complete and ongoing data to determine nursing care needs, analyze the health status of individuals and compare the data with the norm when determining nursing care needs, and carry out nursing care actions that promote, maintain and restore the well-being of individuals.A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated May 23, 2025, revealed that the resident was understood, could understand others, had a diagnosis of included end-stage renal disease (ESRD - a permanent condition that occurs when the kidneys are no longer able to function properly), and received hemodialysis (a treatment that removes waste products and excess fluid from the blood when the kidneys are no longer functioning properly). A care plan for the resident, dated July 17, 2025, revealed that the resident received dialysis on Tuesday, Thursday, and Saturday. Physician's orders for Resident 1, dated May 19, 2025, included an order that the resident was to receive dialysis on Tuesday, Thursday, and Saturday at 6:15 a.m. Physician's orders for Resident 1, dated May 19, 2025, included an order that on dialysis days staff could administer the resident's medications prior to dialysis. Physician's orders for Resident 1, dated May 19, 2025, included an order that on dialysis days staff could administer the resident's medications upon return from dialysis. There was no documented evidence that Resident 1's physician was contacted to clarify which medications could be administered prior to dialysis and/or upon return from dialysis. A quarterly MDS assessment for Resident 2, dated June 2, 2025, revealed that the resident was cognitively intact, required assistance from staff for daily care needs, had a diagnosis which included end-stage renal disease (ESRD - a permanent condition that occurs when the kidneys are no longer able to function properly), and was receiving dialysis.Physician's orders for Resident 2, dated July 24, 2025, included an order that the resident was to receive dialysis on Tuesday, Thursday, and Saturday at 11:00 a.m. Physician's orders for Resident 2, dated July 24, 2025, included an order that on dialysis days staff could administer the resident's medications prior to dialysis. Physician's orders for Resident 2, dated July 24, 2025, included an order that on dialysis days staff could administer the resident's medications upon return from dialysis. There was no documented evidence that Resident 2's physician was contacted to clarify which medications could be administered prior to dialysis and/or upon return from dialysis. Interview with the Director of Nursing on August 6, 2025, at 4:30 p.m. confirmed that there was no documented evidence that Resident 1 and Resident 2's physicians were contacted to clarify which medications could be administered prior to dialysis and/or upon return from dialysis. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected multiple residents
Based on review of clinical records, as well as staff interviews, it was determined that the facility failed to ensure that residents received care and treatment in accordance with professional standa...
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Based on review of clinical records, as well as staff interviews, it was determined that the facility failed to ensure that residents received care and treatment in accordance with professional standards of practice, by failing to ensure that physician's orders were followed for two of 12 residents reviewed (Residents 1, 2), and failed to follow recommendations from the orthopedist (a medical doctor specializing in the diagnosis, treatment, and prevention of musculoskeletal system disorders) for a therapy evaluation for one of 12 residents reviewed (Resident 2).Findings include:
Findings include:
A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated May 23, 2025, revealed that the resident was understood, could understand others, had a diagnosis which included end-stage renal disease (ESRD - a permanent condition that occurs when the kidneys are no longer able to function properly), and received hemodialysis (a treatment that removes waste products and excess fluid from the blood when the kidneys are no longer functioning properly). A care plan for the resident, dated July 17, 2025, revealed that the resident received dialysis on Tuesday, Thursday, and Saturday.
Physician's orders for Resident 1, dated May 19, 2025, included an order that the resident was to receive dialysis on Tuesday, Thursday, and Saturday at 6:15 a.m.
Physician's orders for Resident 1, dated May 19, 2025, included an order that on dialysis days staff could administer the resident's medications prior to dialysis.
Physician's orders for Resident 1, dated May 19, 2025, included an order that on dialysis days staff could administer the resident's medications upon return from dialysis.
Physician's orders for Resident 1, dated May 19, 2025, and discontinued on June 24, 2025, included an order for the resident to receive one 10 milligram (mg) tablet of Amlodipine (used to treat high blood pressure) once a day.
Physician's orders for Resident 1, dated May 19, 2025, included an order for staff to administer one 0.8-15 mg tablet of Dialyvite 800 with Zinc 15 (replenish nutrients, ensuring that patients receive adequate levels of crucial vitamins) once a day.
Physician's orders for Resident 1, dated May 19, 2025, included an order for staff to administer one 10 mg tablet of Escitalopram (use to treat depression) once a day.
Physician's orders for Resident 1, dated May 19, 2025, included an order for staff to administer one 75 mg tablet of Plavix (a medication to prevent blood clots) once a day.
Physician's orders for Resident 1, dated May 29, 2025, included an order for staff to administer two tablets of Vitamin D3 (a dietary supplement) once a day.
Physician's orders for Resident 1, dated June 6, 2025, included an order for staff to administer two 210 mg tablets of Auryxia (to treat high phosphorus levels in adults with chronic kidney disease (CKD) on dialysis) with meals.
Physician's orders for Resident 1, dated June 24, 2025, included an order for staff to administer one 25 mg tablet of Metoprolol (used alone or in combination with other medications to treat high blood pressure) once a day.
Review of Resident 1's Medication Administration Records for June, July, and August 2025, revealed:
There was no documented evidence that staff administered the one 10 mg tablet of Amlodipine to Resident 1 prior to dialysis or upon return from dialysis on Tuesday June 3, 17, and 24, 2025, and on Thursday June 12, 2025.
There was no documented evidence that staff administered the one 0.8-15 mg tablet of Dialyvite 800 with Zinc 15 to Resident 1 prior to dialysis or upon return from dialysis on Tuesday June 3, 17, and 24, 2025, and July 15, 2025, on Thursday June 12, and 26, 2025, and July 3 and 31, 2025, and on Saturday July 5 and 19, 2025.
There was no documented evidence that staff administered the one 10 mg tablet of Escitalopram to Resident 1 prior to dialysis or upon return from dialysis on Tuesday June 3, 17, and 24, 2025, and July 15, 2025, on Thursday June 12, and 26, 2025, and July 31, 2025, and on Saturday July 5 and 19, 2025.
There was no documented evidence that staff administered the one 75 mg tablet of Plavix to Resident 1 prior to dialysis or upon return from dialysis on Tuesday June 3, 17, and 24, 2025, and July 15, 2025, on Thursday June 12, and 26, 2025, and July 31, 2025, and on Saturday July 5 and 19, 2025.
There was no documented evidence that staff administered the two tablets of Vitamin D3 to Resident 1 prior to dialysis or upon return from dialysis on Tuesday June 3, 17, and 24, 2025, and July 15, 2025, on Thursday June 12, and 26, 2025, and July 10 and 31, 2025, and on Saturday June 7, 2025, and July 5 and 19, 2025.
There was no documented evidence that staff administered the two 210 mg tablets of Auryxia to Resident 1 prior to dialysis or upon return from dialysis at 8:00 a.m. on Tuesday June 17 and 24, 2025, and July 1, 8, 15, and 22, 2025, on Thursday June 12, and 26, 2025, and July 3, 10, and 31, 2025, and on Saturday June 7 and 28, 2025, and July 5, 12,and 19, 2025, and at 12:00 p.m. on Tuesday June 24, 2025, and July 15, 2025, and on Saturday July 5, 2025.
There was no documented evidence that staff administered the one 25 mg tablet of Metoprolol to Resident 1 prior to dialysis or upon return from dialysis on Tuesday July 15, 2025, on Thursday June 26, 2025, and July 31, 2025, and on Saturday July 5, and 19, 2025, and August 2, 2025.
An quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 2, dated June 2, 2025, revealed that the resident was cognitively intact, required assistance from staff for daily care needs, had diagnosis which included end-stage renal disease (ESRD - a permanent condition that occurs when the kidneys are no longer able to function properly) and Parkinson's disease (a progressive brain disorder that affects movement), and was receiving dialysis. The care plan for resident 2 dated March 20, 2025, indicated that the resident was receiving dialysis at a dialysis center every Tuesday, Thursday, and Saturday and staff were to assure medications were administered before and after dialysis as ordered by the physician to ensure maximum effectiveness and to avoid adverse effects of the medications.
Physician's orders for Resident 2, dated July 24, 2025, included an order that the resident was to receive dialysis on Tuesday, Thursday, and Saturday at 11:00 a.m.
Physician's orders for Resident 2, dated July 24, 2025, included an order that on dialysis days staff could administer the resident's medications prior to dialysis.
Physician's orders for Resident 2, dated July 24, 2025, included an order that on dialysis days staff could administer the resident's medications upon return from dialysis.
Physician's orders for Resident 2, dated June 3, 2025, included for staff to administer two five milligrams (mg) midodrine (medication primarily used to treat low blood pressure) tablets three times a day.
Physician's orders for Resident 2, dated May 28, 2025, included for staff to administer one-half of a 500 mg tablet of methocarbamol (muscle relaxant primarily used for short-term relief of muscle pain and spasms) three times a day.
Physician's orders for Resident 2, dated May 28, 2025, included for staff to administer one 25-100 mg carbidopa-levodopa (used to treat the symptoms of Parkinson's disease) tablet three times a day.
Review of Resident 2's Medication Administration Records for July, and August 2025, revealed:
There was no documented evidence that staff administered 3:00 p.m. dose of two five mg midodrine tablets to Resident 2 prior to dialysis or upon return from dialysis on Tuesday July 8 and 22, 2025, on Thursday July 10, 17, and 31, 2025, and on Saturday July 12, 2025.
There was no documented evidence that staff administered 2:00 p.m. dose of one-half of a 500 mg methocarbamol tablet to Resident 2 prior to dialysis or upon return from dialysis on Tuesday July 8, 15, and 22, 2025, on Thursday July 10, 17, 24, and 31, 2025, and on Saturday July 12, 2025.
There was no documented evidence that staff administered 2:00 p.m. dose of one 25-100 mg carbidopa-levodopa tablet to Resident 2 prior to dialysis or upon return from dialysis on Tuesday July 8, 15, 22, and 26, 2025, on Thursday July 10, 17, 24, and 31, 2025, and on Saturday July 12, 2025.
Interview with the Director of Nursing on August 6, 2025, at 4:30 p.m. confirmed that there was no documented evidence that on the above dates and times, the above medications were administered by staff to Residents 1 or 2 prior to dialysis and/or upon return from dialysis. The Director of Nursing revealed medications that are given three times a day may be too close to the next dose if given before or after dialysis, however, it was not clarified with the physician.
Therapy documentation for Resident 2, dated June 13, 2025, indicated that a therapy referral was requested by the orthopedic physician at the consult appointment.
Physician’s orders for Resident 2, dated June 13, 2025, included an order for a therapy screening per the orthopedic consult.
Interview with the Director of Rehabilitation on August 6, 2025, at 2:15 p.m. revealed that Resident 2 received therapy services from May 29, 2025, through June 12, 2025 and that a therapy screen had not been conducted as ordered on June 13, 2025.
Interview with the Director of Nursing on August 6, 2025, at 4:25 p.m. confirmed that Resident 2 was ordered to have a therapy screen on June 13, 2025; however, the screening was not completed and should have been.
28 Pa. Code 211.12(d)(1)(5) Nursing Services.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0698
(Tag F0698)
Could have caused harm · This affected multiple residents
Based on review of policies and clinical records, as well as observations and resident and staff interviews, it was determined that the facility failed to follow facility policy for the care and monit...
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Based on review of policies and clinical records, as well as observations and resident and staff interviews, it was determined that the facility failed to follow facility policy for the care and monitoring of residents receiving dialysis for one of 12 residents reviewed (Resident 2). Findings include: A facility policy for Hemodialysis Care, dated April 29, 2025, indicated that communication between the dialysis provider and the facility will occur before and after each hemodialysis treatment and as needed. Pre-dialysis, the staff are to document an assessment in the dialysis communication tool, print the tool and send it with the resident to dialysis. Post dialysis, staff are to receive report from the dialysis provider and/or review the dialysis communication tool documentation by the dialysis provider and contact dialysis promptly with any questions or concerns. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 2, dated June 2, 2025, revealed that the resident was cognitively intact, required assistance from staff for daily care needs, had a diagnosis which included end-stage renal disease (ESRD - a permanent condition that occurs when the kidneys are no longer able to function properly), and was receiving dialysis. Physician's orders for Resident 2, dated July 24, 2025, included an order that the resident was to receive dialysis on Tuesday, Thursday, and Saturday at 11:00 a.m. The care plan for Resident 2, dated March 20, 2025, indicated that the resident was receiving dialysis at a dialysis center every Tuesday, Thursday, and Saturday. Review of Resident 2's clinical record, an observations of the nursing station, revealed no evidence that any form of resident assessments or communication related to the resident's health status before and after dialysis was being shared between the facility and the dialysis center. Interview with the Director of Nursing on August 6, 2025, at 5:23 p.m. confirmed that there was no documented evidence that pre-dialysis assessments were sent with the resident to the dialysis center and there was no evidence that post dialysis information was received from the dialysis center and reviewed by staff per the facility policy. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0804
(Tag F0804)
Could have caused harm · This affected multiple residents
Based on a review of facility policies, observations, and staff interviews, it was determined that the facility failed to serve food items that were palatable.Findings include: The facility's policy r...
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Based on a review of facility policies, observations, and staff interviews, it was determined that the facility failed to serve food items that were palatable.Findings include: The facility's policy regarding food temperatures, dated April 29, 2025, revealed that hot food should be palatable at point of delivery. Observations of the lunch meal tray line on August 6, 2025, at 11:41 a.m. revealed that dietary staff began to prepare the second floor low hall cart. At 12:04 p.m. the second floor low hall cart arrived on the unit and at 12:14 p.m. all but one of the trays from that cart were delivered to the residents. A test tray completed on August 6, 2025, at 12:16 p.m. revealed that the milk was 45.4 degrees Fahrenheit and tasted cold, the orange juice was 51.4 degrees Fahrenheit, the coffee was 142 degrees Fahrenheit, the beef stew was 117 degrees Fahrenheit and tasted cold and was not palatable, and the cauliflower was 129 degrees Fahrenheit, unseasoned, tasted cold and overcooked, and was not palatable. Interview with the Dietary Manager on August 6, 2025, at 12:18 p.m. confirmed that beef stew was cold and not palatable, and that the cauliflower was mushy, and had no seasoning. 28 Pa. Code 201.18(b)(1)(2)(e) Management. 28 Pa. Code 211.6(c) Dietary Services.
Jun 2025
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policies, clinical records, and shower schedules, as well as staff and resident interviews, it was d...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policies, clinical records, and shower schedules, as well as staff and resident interviews, it was determined that the facility failed to ensure that residents were provided with showers as scheduled for four of nine residents reviewed (Residents 4, 5, 6, 7).
Findings include:
The facility policy for bathing and showering, dated April 29, 2025, indicated that residents will be bathed or showered according to their preferences in order to maintain healthy hygiene and skin condition. Each resident will be asked about his/her bathing preferences upon admission (type of bath, preferred days and times). Each resident will be scheduled to receive bathing a minimum of two times per week. If the bath/shower cannot be given or the resident refuses, the nursing assistant will promptly report this to the charge nurse. The charge nurse will speak to the resident who refuses to ascertain why they are refusing and to determine if alternative arrangements that suit the resident can be made. If the resident continues to refuse, the charge nurse will document the resident's refusal in the medical record.
An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) assessment for Resident 4, dated June 12, 2025, revealed that the resident was cognitively intact, required assistance with care needs including bathing and toileting hygiene, was frequently incontinent of bowel and bladder, and had a diagnosis of diabetes.
An interview with Resident 4 on June 25, 2025, at 10:05 a.m. revealed that he has had one shower since he was admitted to the facility, and he had been at the facility for about two weeks. A review of Resident 4's clinical record revealed that the resident was admitted on [DATE]. A review of Resident 4's bathing detail report for June 2025 revealed that he had received one shower since he was admitted to the facility. There was no documented evidence that the resident's bathing/shower preferences were obtained on admission and no documented evidence that the resident received a bath/shower a minimum of two times per week per facility policy.
Interview with the Director of Nursing on June 25, 2025, at 3:50 p.m. indicated that shower preferences were obtained for Resident 4 on admission; however, the preferences were not documented in the resident's clinical record including the resident's care plan and shower schedule. She confirmed that there was no documented evidence that Resident 4 received showers per facility policy.
An admission MDS assessment for Resident 5, dated May 18, 2025, revealed that the resident was cognitively intact, required assistance with care needs including bathing and toileting hygiene, was frequently incontinent of bowel and occasionally incontinent of bladder, and had a diagnosis including morbid obesity.
A physician's order for Resident 5, dated May 12, 2025, included an order for the resident to receive a shower on Wednesday and Friday mornings. A care plan for Resident 5, dated May 14, 2025, included an intervention that the resident was to receive a shower in the mornings on Wednesdays and Fridays and to offer bed baths if he refused and document.
A review of the bathing detail report for Resident 5 for May and June 2025 revealed that there was no documented evidence that the resident received his showers per physician's orders and preference, and there was no documented evidence that the resident refused his showers, requiring a bed bath be given.
Interview with the Director of Nursing on June 25, 2025, at 3:50 p.m. confirmed that there was no documented evidence that Resident 5 received or refused showers from May to June 2025 as per the resident's orders/preferences and plan of care.
A quarterly MDS assessment for Resident 6, dated May 6, 2025, revealed that the resident was cognitively impaired, required assistance with care needs including bathing and toileting hygiene, was occasionally incontinent of bowel and bladder, and had a diagnosis of diabetes.
A physician's order for Resident 6, dated March 11, 2025, included an order for the resident to receive a shower every other day in the evening and to document in the progress notes any refusal, offer bed bath, notify medical director and power of attorney. A care plan for Resident 6, dated December 19, 2024, included an intervention that the resident prefers to shower every other day in the evenings.
A review of the bathing detail report for Resident 6 from March 2025 through June 2025 revealed that there was no documented evidence that the resident received her shower's per physician's orders and preference, and there was no documented evidence that the resident refused her showers, requiring a bed bath be given.
Interview with the Director of Nursing on June 25, 2025, at 3:50 p.m. confirmed that there was no documented evidence that Resident 6 received and/or refused showers from March 2025 through June 2025 as per the resident's orders/preferences and plan of care.
An annual MDS assessment for Resident 7, dated June 9, 2025, revealed that the resident was cognitively intact, required assistance with care needs including bathing and toileting hygiene, was occasionally incontinent of bowel and bladder, and had diagnoses including diabetes and peripheral vascular disease (a disease causing poor blood circulation to lower limbs).
A physician's order for Resident 7, dated March 11, 2025, included an order for the resident to receive a shower on Mondays, Wednesdays, and Fridays in the a.m. and to document in the progress notes any refusal, offer bed bath, notify medical director and power of attorney. A care plan for Resident 7, dated August 6, 2024, included an intervention that the resident prefers to shower on Monday, Wednesday, and Friday on the first shift and may have a complete bed bath if she refuses a shower.
A review of the bathing detail report for Resident 7 from March 2025 through June 2025 revealed that there was no documented evidence that the resident received her shower's per physician's orders and preference, and there was no documented evidence that the resident refused her showers, requiring a bed bath be given.
Interview with the Director of Nursing on June 25, 2025, at 3:50 p.m. confirmed that there was no documented evidence that Resident 7 received and/or refused showers from March 2025 through June 2025 as per the resident's orders/preferences and plan of care.
28 Pa. Code 211.12(d)(5) Nursing Services.
Jun 2025
1 deficiency
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0804
(Tag F0804)
Could have caused harm · This affected multiple residents
Based on a review of facility policies, observations, and staff interviews, it was determined that the facility failed to serve food items that were palatable.
Findings include:
The facility's policy ...
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Based on a review of facility policies, observations, and staff interviews, it was determined that the facility failed to serve food items that were palatable.
Findings include:
The facility's policy regarding food temperatures, dated April 29, 2025, revealed that hot food should be palatable at point of delivery.
Observations of the supper meal on June 16, 2025, at 4:55 p.m. revealed that dietary staff began to prepare the second floor low-hall cart. At 5:35 p.m. the second floor low-hall cart was complete and left the kitchen at 5:36 p.m. The cart arrived on second floor and staff began to pass the trays at 5:40 p.m. At 5:52 p.m. all supper trays were passed.
A test tray was completed on June 16, 2025, at 5:52 p.m. revealing the milk was 41.4 degrees Fahrenheit and tasted cold, the salsa salad was 41.4 degrees Fahrenheit and tasted cold, the coffee was 133.3 degrees Fahrenheit and tasted hot, the taco beef was 109.3 degrees Fahrenheit and tasted cold and was not palatable, and the rice was 113.2 degrees Fahrenheit, tasted cold and was not palatable.
Interview with the Dietary Manager on June 16, 2025, at 5:55 p.m. confirmed that the taco beef and the rice were cold and not palatable.
28 Pa. Code 201.18(b)(1)(2)(e) Management.
28 Pa. Code 211.6(c) Dietary Services.
Apr 2025
3 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
Based on review of clinical records, as well as staff interviews, it was determined that the facility failed to follow physician's orders for one of five residents reviewed (Resident 2).
Findings incl...
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Based on review of clinical records, as well as staff interviews, it was determined that the facility failed to follow physician's orders for one of five residents reviewed (Resident 2).
Findings include:
A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) assessment for Resident 2, dated April 7, 2025, indicated that the resident was sometimes understood and able to sometimes understand others, was dependent on staff for personal hygiene care, and was always incontinent of urine and bowel. An incontinence care plan for Resident 2, dated July 4, 2023, revealed that the resident was to have barrier cream applied every shift and after every incontinent episode. Physician's orders for Resident 2, dated June 29, 2023, revealed that triad (barrier) cream was to be applied every shift and after each incontinent episode as needed.
A wound care note for Resident 2, dated March 26, 2025, revealed that the resident was seen by wound care due to redness in the perineal region and denudement (missing the outer layer of skin). New orders were received to ensure that physician's orders were being followed to apply barrier cream every shift and as needed.
Interview with Resident 2 on April 22, 2025, at 9:50 a.m. revealed that the staff apply cream every shift; however, they do not apply barrier cream after episodes of incontinence.
Interview with Licensed Practical nurse 5 on April 22, 2025, at 2:01 p.m. confirmed that the Triad barrier cream was only applied every shift, and it was not applied after incontinent episodes per care plan and physician's order.
A review of Resident 2's clinical record revealed no documented evidence that the Triad Cream was applied on first shift on March 1, 2, 4, 5, 6, 8, 14, 20, 21, 25, 29, and 30, 2025; on second shift on March 25 and 30, 2025; and third shift on March 5, 11, 19, and 20, 2025; and no documented evidence that it was applied after each incontinent episode as needed.
Interview with the Director of Nursing on April 22, 2025, at 1:56 p.m. confirmed that Resident 2 did not have barrier cream applied as ordered by the physician.
28 Pa. Code 211.12(d)(1)(5) Nursing Services.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected 1 resident
Based on review of clinical records, as well as staff interviews, it was determined that the facility failed to ensure that clinical records were complete and accurately documented for one of five res...
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Based on review of clinical records, as well as staff interviews, it was determined that the facility failed to ensure that clinical records were complete and accurately documented for one of five residents reviewed (Resident 2).
Findings included:
A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) assessment for Resident 2, dated April 7, 2025, indicated that the resident was sometimes understood and able to sometimes understand others, and was dependent on staff for personal hygiene care.
A nursing note for Resident 2, dated April 24, 2025, at 10:00 a.m., revealed that the Registered Nurse Supervisor was made aware that the resident's daughter was requesting testing be completed to check for urinary tract infection (UTI).
A nursing note for Resident 2, dated April 2, 2025, at 11:54 p.m., revealed that a straight catheterization (a tube used to drain urine from the bladder) was attempted three times without success.
Interview with the Director of Nursing on April 22, 2025, at 1:56 p.m. revealed that a straight catheterization was not attempted on Resident 2, and that the nursing note was placed in the wrong chart.
28 Pa. Code 211.5(f) Clinical Records.
CONCERN
(F)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected most or all residents
Based on review of facility policies, as well as observations and staff interviews, it was determined that the facility failed to store and prepare food in accordance with professional standards for f...
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Based on review of facility policies, as well as observations and staff interviews, it was determined that the facility failed to store and prepare food in accordance with professional standards for food service safety by failing to have staff wear appropriate hair restraints during food preparation and tray line service.
Findings include:
The facility's policy regarding dress and personal hygiene, dated February 14, 2025, revealed that staff working in Food and Nutrition Services will wear a clean and appropriate hairnet and hair restraint. The hairnet/hair restraint will cover all hair. Beards and facial hair will be contained.
Observations in the main kitchen on April 22, 2025, at 8:34 a.m. revealed three dietary staff on the tray line. Dietary Staff 2 was plating the breakfast meal cheesy eggs, cinnamon rolls, toast, and hot cereal without wearing a facial hair restraint. Interview with Dietary Staff 2, on April 22, 2025, at 8:43 a.m. confirmed that he should be wearing a facial hair restraint, but he took it off because it was hot and he had to answer the phone multiple times.
Observations in the main kitchen on April 22, 2025, at 12:20 p.m. revealed dietary staff on the tray line for lunch. Dietary Aide 3 was pushing carts in the main kitchen. Dietary Aide 3 was not wearing a hair restraint. Interview with Dietary Aide 3 at the time of the observation confirmed that she should have had a hair restraint on and it must have fallen off when she went outside.
Interview with the Interim Certified Dietary Director on April 22, 2025, at 10:04 a.m. confirmed that the dietary department was fully staffed on April 21, 2025, and that staff should have had hair covered appropriately with hair restraints.
28 Pa. Code 211.6(f) Dietary Services.
Mar 2025
1 deficiency
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected multiple residents
Based on clinical record reviews, as well as staff interviews, it was determined that the facility failed to ensure that dependent residents were provided with the necessary services to maintain perso...
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Based on clinical record reviews, as well as staff interviews, it was determined that the facility failed to ensure that dependent residents were provided with the necessary services to maintain personal hygiene by failing to provide showers as scheduled for one of six residents reviewed (Resident 2).
Findings include:
A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 2, dated January 16, 2025, revealed that the resident was cognitively impaired, required assistance from staff for daily care needs, required extensive assistance from staff for personal hygiene, was dependent on staff for bathing, and had diagnoses that included stroke. The resident's care plan, dated October 31, 2024, indicated that the resident preferred showers on Sunday and Wednesday during the second shift. However, the resident's bathing records for January, February, and March 2025 revealed that the resident did not receive a shower at all in those months. There was no documented evidence that the resident was offered a shower and refused in January, February, or March 2025.
Interview with the Director of Nursing on March 4, 2025, at 1:18 p.m. confirmed that Resident 2 was not showered in January, February, or March, and that there was no indication that she refused a shower.
28 Pa. Code 211.12(d)(5) Nursing Services.
Jan 2025
3 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Pressure Ulcer Prevention
(Tag F0686)
Could have caused harm · This affected 1 resident
Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to provide timely treatment to a newly identified pressure ulcer for one of 10...
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Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to provide timely treatment to a newly identified pressure ulcer for one of 10 residents reviewed (Resident 9).
Findings include:
The facility's policy regarding skin and wound care best practices, dated November 18, 2024, indicated that pressure injuries and wounds will be treated with evidence-based interventions as ordered by the provider.
An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 9, dated November 19, 2024, revealed that the resident was cognitively intact, required substantial assistance with bed mobility, was incontinent of urine and frequently incontinent of bowel, was at risk for developing pressure ulcers (an injury to the skin and underlying tissue resulting from prolonged pressure), and had no unhealed pressure ulcers.
A nursing note for Resident 9, dated December 28, 2024, at 3:25 p.m., revealed that the registered nurse was notified that the resident had a new pressure ulcer to her coccyx (tailbone). The area measured 0.5 x 1.0 x 2.0 centimeters (cm) and was tunneling (a passage deeper under the skin that extends from the main wound bed into surrounding tissue) under upwards with no redness or drainage. The licensed practical nurse applied a foam dressing. The physician and the resident representative were notified, and an email was sent to the Assistant Director of Nursing to have the wound consultant see the resident the next time they were in the facility.
There was no documented evidence in Resident 9's clinical record until December 31, 2024, that a physician's order was received to cleanse the resident's coccyx wound with Vashe (a wound cleanser that promotes healing), apply a 0.25 inch plain packing strip (for deep or tunneling wounds), pack loosely into the wound bed, and cover with an abdominal dressing (used for large or heavily draining wounds) daily and as needed. The order indicated that an Iodoform strip (a medicated packing with antiseptic/antimicrobial properties) may be substituted. The treatment was scheduled to start on January 1, 2025, on the day shift.
A wound note for Resident 9, dated January 3, 2025, revealed that she was seen by the consulting wound Certified Registered Nurse Practitioner (CRNP) related to the new ulceration to the resident's coccyx region that was identified on December 28, 2024. The wound was identified as a Stage 3 pressure ulcer (a full-thickness pressure wound involving the fat layers beneath the skin) that had worsened, measuring 1.5 x 1.3 x 1.0 cm and had a moderate amount of serosanguineous drainage (a wound drainage present with wound healing, infection, or trauma).
Interview with the Director of Nursing on January 28, 2025, at 6:30 p.m. confirmed that the physician was notified of Resident 9's new pressure ulcer to her coccyx; however, a treatment was not ordered at that time and should have been.
28 Pa. Code 211.12(d)(1)(5) Nursing Services.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected 1 resident
Based on review of clinical records, as well staff interviews, it was determined that the facility failed to ensure that residents received oxygen as ordered by the physician for one of 10 residents r...
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Based on review of clinical records, as well staff interviews, it was determined that the facility failed to ensure that residents received oxygen as ordered by the physician for one of 10 residents reviewed (Resident 10).
Findings include:
A nursing note for Resident 10, dated January 17, 2025, at 6:03 p.m. revealed that an admission assessment indicated that his lung sounds were clear and diminished. A diagnoses list for Resident 10 revealed that he was admitted with acute respiratory failure (blood does not have enough oxygen and causes difficulty breathing) with hypoxia (low levels of oxygen in body tissues).
A nursing note for Resident 10, dated January 19, 2025, at 10:46 a.m. revealed that the registered nurse was called to resident's bedside by his daughter who came in to visit. She was reporting that the resident's oxygen was at a flow rate of 3 liters per minute (LPM) and his oxygen was to be at a flow rate of 4 LPM. Upon assessment, the resident's oxygen saturation (blood oxygen level) was 68 percent (normal oxygen saturation ranges are 95-100 percent) on an oxygen flow rate of 3 LPM via nasal cannula (a small tube that delivers oxygen through the nasal passages). His oxygen was increased to a flow rate of 5 LPM and his oxygen saturation increased to 77 percent. The nurse placed the resident on a non-rebreather mask (an oxygen mask that delivers high levels of oxygen) and his oxygen saturation increased to 93 percent, but the resident's mental status remained unchanged at that time. The physician was notified, and an order was obtained to send the resident to the hospital. The resident was admitted with pneumonia, hypoxia, and non-ST-elevation myocardial infarction (NSTEMI - type of heart attack that occurs when the heart's need for oxygen cannot be met).
Physician's orders for Resident 10, dated January 18, 2025, included an order for the resident to receive continuous oxygen at a flow rate of 4 LPM via nasal cannula.
Interview with the Director of Nursing on January 28, 2025, at 6:30 p.m. confirmed that Resident 10's oxygen flow rate should have been set at 4 LPM continuously as per physician order, and it was not as per the documentation.
28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0760
(Tag F0760)
Could have caused harm · This affected 1 resident
Based on review of clinical records, as well as staff interviews, it was determined that the facility failed to ensure that residents were free from significant medication errors for one of 10 residen...
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Based on review of clinical records, as well as staff interviews, it was determined that the facility failed to ensure that residents were free from significant medication errors for one of 10 residents reviewed (Resident 1).
Findings include:
An annual Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated January 9, 2025, revealed that the resident was cognitively intact, was independent to set up with care needs, used oxygen, and had diagnoses that included chronic obstructive pulmonary disease (COPD) (chronic lung disease making breathing difficult) and asthma (a lung disease making it difficult to breathe).
Physician's orders for Resident 1, dated March 3, 2024, included orders for the resident to receive one puff/inhalation of fluticasone propionate inhaler 100 micrograms (mcg) twice daily for the morning medication pass between 7:00 a.m. and 11:00 a.m. and for the evening medication pass between 8:00 p.m. and 11:00 p.m.
Review of Resident 1's Medication Administration Record (MAR) for January 2025 revealed that the fluticasone propionate inhaler was documented as not administered or on hold due to the medication being unavailable in the Omnicell (an automated dispensing machine for medications) or waiting for delivery from the pharmacy on the following dates/times: January 11 and 12 morning and evening; January 14, 15, and 16 evening; and January 17 and 18 morning.
A nursing note for Resident 1, dated January 14, 2025, at 10:28 p.m., indicated that the registered nurse was notified that the resident did not have her fluticasone propionate inhaler and that it was not stocked in the Omnicell.
A nursing note for Resident 1, dated January 15, 2025, at 10:10 a.m., indicated that the registered nurse spoke with the pharmacy regarding the fluticasone propionate inhaler and was told that it will be delivered that evening.
Interview with Resident 1 on January 28, 2025, at 1:17 p.m. revealed that they run out of medication, and she cannot understand why they cannot order it before they run out.
Interview with the Director of Nursing on January 28, 2025, at 3:33 p.m. confirmed that there was no documented evidence that Resident 1's fluticasone propionate inhaler was administered on the above-mentioned dates/times. She was unaware that the medication was not available, and she could not explain why there was documentation that the medication was administered between that dates that it was documented as not being available. She indicated that
they usually had no issues with deliveries from the pharmacy and had no documentation to indicate why the medication would not have been delivered or ordered when they were running low.
28 Pa. Code 211.12(d)(1)(5) Nursing Services.
Dec 2024
2 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected 1 resident
Based on review of facility polices and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that a resident's care plan was updated/revised to reflect t...
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Based on review of facility polices and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that a resident's care plan was updated/revised to reflect the resident's specific care needs for two of eight residents reviewed (Residents 2, 5).
Findings include:
A facility policy for Comprehensive Care Plans, dated November 18, 2024, indicated that a comprehensive, person-centered care plan is developed and implemented for each resident that includes measurable objectives and timetables to meet the resident's medical, nursing and mental and psychosocial needs. The care planning coordinator will add minor changes in the resident's status to the existing care plans on a daily basis.
A significant change Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 2, dated December 5, 2024, indicated that the resident was cognitively impaired, required substantial assistance with bed mobility and transfers, had a history of two or more falls since the prior assessment, and had a diagnosis of dementia.
A nursing note for Resident 2, dated December 4, 2024, at 9:20 a.m. revealed that Resident 2 had an unwitnessed fall and was found sitting on the floor beside her bed holding onto the enabler bar with her left hand. She was assisted into bed by two staff members without difficulty and had no injuries.
An interdisciplinary post-fall review note, dated December 5, 2024, at 8:45 a.m. revealed that Resident 2 sustained an unwitnessed fall on December 4, 2024, where the resident was found on the floor alongside the bed in her room. There were no injuries reported. Interventions post fall included to discontinue the air mattress and issue a pressure-redistribution mattress. Therapy was to screen and evaluate/treat as indicated. Clinical record review for Resident 2 revealed that a bed and air mattress safety assessment was completed on December 4, 2024. A rehabilitation screen completed on December 6, 2024, indicated that the appropriate height of the mattress was marked with a decal for an identifier for staff to keep the bed at that level.
Observations on December 23, 2024, at 2:45 p.m. revealed that Resident 2 had an air mattress on her bed, and there was a flower decal on the wall at the height of the mattress. There was no documented evidence that Resident 2's care plan was revised to reflect that the appropriate height of the mattress was marked with a decal for an identifier for staff to keep the bed at the appropriate level.
Interview with the Director of Nursing on December 23, 2024, at 4:00 p.m. indicated that the initial intervention was to discontinue Resident 2's air mattress; however, after therapy evaluated the resident's air mattress, the plan was to place a decal on the wall to keep the mattress at that height. The Director of Nursing confirmed that Resident 2's care plan was not revised to reflect the intervention for the decal for identification to staff to keep the mattress at the appropriate level.
A quarterly MDS assessment for Resident 5, dated October 18, 2024, indicated that the resident was cognitively impaired, required assistance with care needs, had a history of falls in last 30 days and two to six months prior to entry/reentry, and had a diagnosis of dementia.
Observations on December 23, 2024, at 10:45 a.m. revealed that Resident 5 was in his room sleeping in a low bed. The low bed was in the lowest position, and there were bilateral fall mats on the floor on each side of his bed. There was no documented evidence that Resident 5's care plan was revised to reflect his need for a low bed and bilateral fall mats.
Interview with the Assistant Director of Nursing on December 23, 2024, at 5:16 p.m. confirmed that Resident 5's care plan was not revised to reflect his need for the low bed and bilateral fall mats.
28 Pa. Code 201.24(e)(4) admission Policy.
28 Pa. Code 211.12(d)(5) Nursing Services.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
Based on review of facility investigation documents and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that safe transfer techniques were used in a...
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Based on review of facility investigation documents and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that safe transfer techniques were used in accordance with their care plans for one of eight residents reviewed (Resident 1) resulting in a fall.
Findings include:
An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated November 12, 2024, revealed that the resident was cognitively impaired, was understood and able to understand others, was dependent for transfers, had no history of falls, and had a diagnosis that included hemiparesis (weakness to one side of the body due to brain injury). A care plan for Resident 1, dated November 1, 2024, included an intervention with a start date of December 4, 2024, that indicated the resident's transfer status was moderate assistance (staff and the resident each put in half the effort) of two staff with use of the orbiturn (a transfer aid to facilitate standing and seat-to-seat transfers).
A physical therapy discharge note, dated December 4, 2024, revealed that Resident 1 had improved with sit-to-stand transfer and pivot transfers to a moderate assist of two staff and use of the orbiturn with right upper extremity support and lateral support to the left lower extremity to improve tolerance to weight-bearing during transfers.
A nursing note for Resident 1, dated December 11, 2024, at 4:05 p.m. revealed that the registered nurse was called to the third floor for a reported witnessed fall during a transfer. The resident was lying on the floor face down between the two beds. She had sneakers on bilateral feet and when asked what happened, the resident reported that she slid out of her chair when she sat down after the transfer . She reported some discomfort to her left arm. Bruising was noted to the left flank (lower back) and left posterior axilla (back side of armpit area) and she denied hitting her head.
A witness statement completed by Nurse Aide 1, dated December 11, 2024, revealed that she was transferring Resident 1 into her chair with the orbiturn. She indicated that the resident was not on the chair fully and she slid off the chair and fell onto the floor. Nurse Aide 1 indicated that the wheelchair was locked and behind the resident prior to the fall.
An interdisciplinary post fall review note, dated December 16, 2024, at 9:10 a.m., revealed that Resident 1 sustained a witnessed fall on December 11, 2024. When staff was attempting to transfer the resident, the resident began to slide off the chair and fell to the floor. The resident's transfer status was moderate assistance of two staff with use of the orbiturn. Interventions included staff education on proper transferring of Resident 1 and disciplinary action.
A rehabilitation screening form, dated December 16, 2024, revealed that Resident 1's transfer status was downgraded to use the full body mechanical lift for transfers per the resident's request related to her fall on December 11, 2024, with staff and family.
A disciplinary action form for Nurse Aide 1, dated December 18, 2024, indicated that Nurse Aide 1 transferred Resident 1 without the assistance of facility staff. She transferred the resident with the orbiturn and the resident's private caregiver. Description of the counseling included that Nurse Aide 1 was educated on proper transfers and that residents who require a two-person assist for transfers are transferred with the facility staff, not a private caregiver. The education on transfers included: Transferring residents should only occur with Midtown Nursing/Therapy Employees and not with family, relatives, friends or personal or private caregivers from outside sources. Resident care plans and profiles must be checked each shift and throughout shift to be sure care plan interventions are followed for all care.
Interview with the Director of Nursing on December 23, 2024, at 2:00 p.m. confirmed that Nurse Aide 1 did not follow Resident 1's care plan to transfer the resident using moderate assistance of two staff members and use of the orbiturn. She indicated that it was not known until further investigation that the nurse aide used the caregiver to assist with the transfer. The Director of Nursing indicated that she thought Nurse Aide 1 was technically following the care plan since she was still using two-person assistance with the transfer, despite that it was a caregiver and not staff. The education the facility provided indicated not to use outside sources to assist with transfers and to only use facility staff. The Director of Nursing indicated that the facility staff will be educated on transfers in the near future.
28 Pa. Code 211.12(d)(1)(5) Nursing Services.
Aug 2024
32 deficiencies
2 Harm
SERIOUS
(G)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Actual Harm - a resident was hurt due to facility failures
Quality of Care
(Tag F0684)
A resident was harmed · This affected 1 resident
Based on a review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to follow a physician's recommendations for one of 45 residents rev...
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Based on a review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to follow a physician's recommendations for one of 45 residents reviewed (Residents 13) resulting in a deterioration of the wound with increased size, and there was no documented evidence that physician's orders were followed for two of 45 residents reviewed (Residents 12, 86).
Findings include:
A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 13, dated June 29, 2024, revealed that the resident was understood, could understand others, was cognitively intact, required assistance from staff for care needs, and had a Stage IV pressure ulcer (a wound with full-thickness skin loss that extends through into the muscle, exposing the bone, tendon, or joint) upon admission.
A wound healing consult for Resident 13 (outside the facility), dated July 5, 2024, revealed that the resident had a Stage 4 pressure injury with bone exposed on the sacral area. Recommendations included a high protein diet, a low air loss mattress, frequent scheduled repositioning, a wound vacuum on the wound (uses negative pressure to help wounds heal faster), and a follow-up appointment to be scheduled in four to six weeks. Until the wound vacuum could be obtained, it was recommended that the resident receive 15 milliters (ml) of Dakins (a solution used to clean pressure ulcers) irrigation to the wound and patted dry, fluffed Dakins moistened gauze into the wound space to address all undermining areas, then cover with a dry gauze and secure with tape to be changed daily or as needed. The order for the wound vacuum was to clean the area with soap and water, pat dry, then irrigate the wound with 15 ml of Dakins, pat dry, apply skin prep to the periwound (the skin that surrounds the wound), cut and apply black granufoam (specialized foam dressing) to fit inside of the wound and depth, seal the dressing and bridge the dressing (technique can be used to prevent pressure to the area) to the left or right hip to keep pressure off the area, and to run at 125 millimeters of mercury (mmHg) continuous suction. The wound vacuum dressing was to be changed once a week or as needed.
Physician's orders for Resident 13, dated July 6, 2024, only included orders for the resident to have a Dakins wet-dry dressing. Irrigate the wound with 15 ml of Dakins and pat dry, fluff Dakins moistened gauze into the wound space to address all areas, then cover with a dry gauze and secure with tape changed daily or as needed; however, there was no documented evidence in the clinical record to indicate that the wound vacuum machine and treatment was ordered, and no documented evidence to indicate that the follow-up appointment for four to six weeks was made.
A wound consult for Resident 13 (outside of the facility) dated July 23, 2024, revealed that the wound was a Stage 4 with stalled wound healing and measured 3 centimeters (cm) by 2 cm with a depth of 1 cm. There was a 0.4 cm undermining from 11 o'clock to 1 o'clock. The exposed bone was palpable (able to be touched).
A wound consult report (conducted within the facility) for Resident 13, dated July 31, 2024, revealed that the resident was not seen or evaluated by the wound team because she was out at dialysis.
A wound consult (conducted within the facility) for Resident 13, dated August 7, 2024, revealed that the resident was not seen or evaluated by the wound team because she was out at dialysis. The wound consult recommended that she be referred to the local wound center due to conflicting schedules; however, there was no documented evidence in the clinical record to indicate that the referral was made.
A registered nurse progress note and wound assessment for Resident 13, dated August 21, 2024, revealed that the Stage 4 sacral wound measured 4 centimeters (cm) by 2.5 cm with a depth of 1.5 cm with undermining.
A review of the clinical record for Resident 13 revealed no documented evidence that a wound vacuum was ordered, applied, or that wound consultant recommendations were followed for negative pressure wound therapy. There was no documented evidence that the resident returned to the outside wound clinic in four to six weeks for follow-up as recommended, and there was no documented evidence that an outside wound clinic appointment was scheduled until August 22, 2024, after it was brought to the facility's attention by the surveyor.
Interview with the Assistant Director of Nursing on August 22, 2024, at 1:30 p.m. revealed that she spoke with the wound clinic and Resident 13 was to follow up with them on August 7, 2024; however, Resident 13 was a no-call no-show for that appointment and was not seen.
Interview with the Director of Nursing on August 22, 2024, at 10:49 a.m. and 1:22 p.m. confirmed that the facility failed to follow through with orders for a wound vacuum, failed to ensure that the resident went to a follow-up wound appointment, and failed to make an additional referral to the wound clinic for ongoing treatment and evaluation due to scheduling conflicts. She also confirmed that Resident 13's wound was last assessed on July 23, 2024, and was not provided the wound vacuum as recommended or weekly wound assessments, and the wound declined.
The facility's policy for personal care, dated July 1, 2024, indicated that the nursing assistant will observe all areas of the resident's skin and indicate any abnormalities or changes, and the nurse will address any findings in the clinical record and appropriate interventions will be initiated.
A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 12, dated June 19, 2024, revealed that the resident was cognitively intact, understood, could usually understand others, and required maximum assistance from staff for care.
A physician's order for Resident 12, dated March 19, 2024, included an order for weekly skin checks to be completed and documented in the resident's clinical record.
A review of the clinical record for June and July for Resident 12 revealed no documented evidence that skin checks were being completed for June and July.
An interview with the Assistant Director of Nursing on August 22, 2024, at 3:43 p.m. confirmed that there was no documented evidence that skin checks were being completed for Resident 12.
An annual MDS assessment for Resident 86, dated July 22, 2024, revealed that the resident was cognitively intact, understood, could understand others, required maximum assistance from staff for care, and had a foley catheter (a tube placed in the bladder and drains urine into a collection bag).
A physician's order for documentation on urinary output, dated March 1, 2024, revealed that the total amount of urine output in the bag was to be documented in the clinical record each shift.
A review of the clinical record for March 1, 2024, to August 20, 2024, for Resident 86 revealed no documented evidence that the urine output was documented in the clinical record each shift.
An interview with the Director of Nursing on August 20, 2024, at 2:37 p.m. confirmed that there was no documented evidence that urinary output was being documented and should have been.
28 Pa. Code 211.12(d)(1)(5) Nursing Services.
SERIOUS
(G)
Actual Harm - a resident was hurt due to facility failures
Pressure Ulcer Prevention
(Tag F0686)
A resident was harmed · This affected 1 resident
Based on review of clinical records, as well as resident and staff interviews, it was determined that the facility failed to provide necessary treatment and services for a Stage 4 pressure ulcer for o...
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Based on review of clinical records, as well as resident and staff interviews, it was determined that the facility failed to provide necessary treatment and services for a Stage 4 pressure ulcer for one of 45 residents reviewed (Resident 13) resulting in a deterioration of the wound.
Findings include:
A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 13, dated June 29, 2024, revealed that the resident was understood, could understand others, was cognitively intact, required assistance from staff for care needs, and had a Stage IV pressure ulcer (a wound with full-thickness skin loss that extends through into the muscle, exposing the bone, tendon, or joint) upon admission.
A wound healing consult for Resident 13 (outside the facility), dated July 5, 2024, revealed that the resident had a Stage 4 pressure injury with bone exposed on the sacral area. Recommendations included a high protein diet, a low air loss mattress, frequent scheduled repositioning, a wound vacuum on the wound (uses negative pressure to help wounds heal faster), and a follow-up appointment to be scheduled in four to six weeks. Until the wound vacuum could be obtained, it was recommended that the resident receive 15 milliters (ml) of Dakins (a solution used to clean pressure ulcers) irrigation to the wound and patted dry, fluffed Dakins moistened gauze into the wound space to address all undermining areas, then cover with a dry gauze and secure with tape to be changed daily or as needed. The order for the wound vacuum was to clean the area with soap and water, pat dry, then irrigate the wound with 15 ml of Dakins, pat dry, apply skin prep to the periwound (the skin that surrounds the wound), cut and apply black granufoam (specialized foam dressing) to fit inside of the wound and depth, seal the dressing and bridge the dressing (technique can be used to prevent pressure to the area) to the left or right hip to keep pressure off the area, and to run at 125 millimeters of mercury (mmHg) continuous suction. The wound vacuum dressing was to be changed once a week or as needed.
Physician's orders for Resident 13, dated July 6, 2024, only included orders for the resident to have a Dakins wet-dry dressing. Irrigate the wound with 15 ml of Dakins and pat dry, fluff Dakins moistened gauze into the wound space to address all areas, then cover with a dry gauze and secure with tape changed daily or as needed.
A wound consult for Resident 13 (outside of the facility), dated July 23, 2024, revealed that the wound was a Stage 4 with stalled wound healing and measured 3 centimeters (cm) by 2 cm with a depth of 1 cm. There was a 0.4 cm undermining from 11 o'clock to 1 o'clock. The exposed bone was palpable (able to be touched).
A wound consult report (conducted within the facility) for Resident 13, dated July 31, 2024, revealed that the resident was not seen or evaluated by the wound team because she was out at dialysis.
A wound consult (conducted with in the facility) for Resident 13, dated August 7, 2024, revealed that the resident was not seen or evaluated by the wound team because she was out at dialysis. The wound consult recommended that she be referred to the local wound center due to conflicting schedules.
A review of the clinical record revealed that as of August 21, 2024, there was no documented evidence in the clinical record to indicate that Resident 13's Stage 4 sacral wound had been assessed by a registered nurse or the wound team since July 23, 2024; no documented evidence that a wound vacuum was ordered, applied, or that wound dressing recommendations were followed for the negative pressure wound therapy; no documented evidence that the resident returned to the outside wound clinic in four to six weeks for a follow-up as recommended; and no documented evidence that the recommendation for an outside wound clinic appointment was made due to conflicting schedules until it was brought to the facility's attention by the surveyor.
A registered nurse progress note and wound assessment for Resident 13, dated August 21, 2024, revealed that the Stage 4 sacral wound measured 4 centimeters (cm) by 2.5 cm with a depth of 1.5 cm with undermining.
Observations and interviews with Resident 13 on August 22, 2024, at 6:17 p.m. revealed that she was awake, eating, and lying in bed. She was positioned on her left side with a wedge toward the window. She stated that she received wound changes daily and was told that the wound was deep. She was comfortable at that time without the additional positional pressure on the wound area. She stated that she finds the wound to be very painful and very uncomfortable when she has to sit in a chair at dialysis and she is unable to offload the pressure or reposition.
Interview with the Assistant Director of Nursing on August 22, 2024, at 1:30 p.m. revealed that she spoke with the wound clinic and Resident 13 was to follow up with them on August 7, 2024; however, Resident 13 was a no-call no-show for that appointment and was not seen.
Interview with the Director of Nursing on August 22, 2024, at 10:49 a.m. and 1:22 p.m. confirmed that the facility failed to obtain a wound vacuum, failed to ensure that the resident went to a follow-up wound appointment, and failed to make an additional referral to the wound clinic for ongoing treatment and evaluation due to scheduling conflicts. She also confirmed that Resident 13's wound had not been assessed since July 23, 2024, was not provided the wound vacuum or weekly wound assessments and the wound declined.
28 Pa. Code 211.12(d)(1)(5) Nursing Services.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0554
(Tag F0554)
Could have caused harm · This affected 1 resident
Based on review of facility policies and clinical records, as well as observations and staff interviews, it was determined that facility failed to determine if residents were safe to self-administer m...
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Based on review of facility policies and clinical records, as well as observations and staff interviews, it was determined that facility failed to determine if residents were safe to self-administer medications for one of 45 residents reviewed (Resident 100).
Findings include:
The facility's medication brought in from home/self administration education policy, dated July 2024, indicated that residents were not permitted to bring in medications from outside the facility. If self administration was deemed safe then medications must be stored properly and should not be sitting out in open view on the night stand or over-bed table.
An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 100, dated July 31, 2024, indicated that the resident was cognitively intact, required supervision for care needs, had a diagnosis of cellulitis (infection of skin and tissue), and was taking an antibiotic. Physician's orders, dated July 24, 2024 included orders for the resident to receive two tablets of 800-160 milligrams of Bactrim DS (antibiotic) twice a day until July 27, 2024. The resident's record contained no documented evidence that an evaluation was completed to determine if the resident was capable of self-administering medications.
Observations and interview with Resident 100 on August 19, 2024, at 12:06 p.m. revealed that the resident was sitting on his bed and there was a medication bottle on his over-bed table. The medication was labeled Bactrim DS from a hospital pharmacy. Resident 100 stated that the medication was from the hospital. The resident said he was no longer taking the antibiotic, but he had to take two of them when the machine was not working and staff could not pull the medication.
Interview with Licensed Practical Nurse 8 on August 19, 2024, at 12:10 p.m. confirmed that there should not be any medications at bedside, confirmed the medication was Bactrim DS, and there were two tablets missing from the bottle.
A nursing note, dated July 24, 2024, revealed that Resident 100 was admitted with cellulitis of his left lower leg and was taking Bactrim DS through August 27, 2024.
A review of the medication administration record for July 2024 revealed that the 8:00 p.m. dose of Bactrim DS was not administered on July 25, 2024, because the medication was not available.
Interview with the Director of Nursing on August 20, 2024, at 1:31 p.m. confirmed Resident 100 should not have had medication at bed side, had not been assessed for self-administration, and that the two unaccounted pills could have been taken when the medication was documented as unavailable.
28 Pa. Code 211.12(d)(1)(5) Nursing Services.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0558
(Tag F0558)
Could have caused harm · This affected 1 resident
Based on review of facility policies and clinical records, as well as observations and resident and staff interviews, it was determined that the facility failed to ensure that a resident's call bell w...
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Based on review of facility policies and clinical records, as well as observations and resident and staff interviews, it was determined that the facility failed to ensure that a resident's call bell was within reach for one of 45 residents reviewed (Resident 19).
Findings include:
The facility's policy regarding answering call bells, dated July 1, 2024, indicated that the facility provides residents with a means of communicating with staff. A call system was installed in each residents' room and toilet/bath area.
A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 19, dated July 29, 2024, revealed that the resident was understood, could understand, was cognitively impaired, and was totally dependent on two staff for assistance with bed mobility and transfers. A care plan for Resident 19, revised on July 30, 2023, revealed that she was at risk for falls related to being non-ambulatory. Interventions included having the call bell in reach at all times.
Observations on August 19, 2024, at 1:00 a.m. revealed that Resident 19 was sitting a geri-chair and her call bell was not within in reach. The call bell was on the head of the bed behind her. Resident 19 stated that she needed changed. Interview with Nurse Aide 5 at 1:10 p.m. confirmed that the call bell was not in reach, and the nurse aide then unwound it from the enabler bar and handed it to the resident.
Interview with the Nursing Home Administrator on August 22, 2024, at 3:10 p.m. confirmed that the call bell should have been in reach of the resident.
28 Pa. Code 211.12(d)(1)(5) Nursing Services.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0583
(Tag F0583)
Could have caused harm · This affected 1 resident
Based on review of policies, as well as observations and staff interviews, it was determined that the facility failed to provide confidentiality of residents' personal health information during medica...
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Based on review of policies, as well as observations and staff interviews, it was determined that the facility failed to provide confidentiality of residents' personal health information during medication administration for one of 45 residents reviewed (Resident 5).
Findings include:
The facility's policy regarding privacy of health information, dated July 1, 2024, indicated that the facility was to protect the confidentiality of a resident's health information.
Observations during medication administration on August 21, 2024, at 7:50 a.m. revealed that Licensed Practical Nurse 1 walked away from the medication cart to take the blood sugar of another resident without securing the computer screen. Resident 5's personal health information was visible on the computer screen, which was facing the hallway and elevator door.
Interview with Licensed Practical Nurse 1 on August 21, 2024, at 7:57 a.m. confirmed that she should have covered Resident 5's personal information on the computer screen when leaving the medication cart.
Interview with the Assistant Director of Nursing on August 21, 2024, at 11:43 a.m. confirmed that the computer screen with residents' personal health information should have been covered when the nurse was not attending the medication cart.
28 Pa. Code 211.5(b) Clinical Records.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
Based on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to develop and implement comprehensive care plans that included speci...
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Based on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to develop and implement comprehensive care plans that included specific and individualized interventions to address specific care needs for two of 45 residents reviewed (Residents 12, 30).
Findings include:
The facility's policy regarding care plans, dated July 1, 2024, indicated that a comprehensive person-centered care plan for each resident will be developed that includes measurable objective and timetables to meet the resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessments.
A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 12, dated June 19, 2024, revealed that the resident was cognitively intact, understood, could usually understand others, and was receiving physical therapy and occupational therapy.
Observations of Resident 12 on August 22, 2024, at 1:00 p.m. revealed that the resident was unable to move her left arm to feed herself, and the resident had a blue splint on left hand and wrist for contractures.
Interview with Resident 12 on August 22, 2024, at 1:05 p.m. revealed that the resident had been unable to move her left side since she was four years old due to a brain tumor she had removed.
Interview with Certified Occupational Therapist Assistant (COTA) 2 on August 22, 2024, at 1:15 p.m. revealed that Resident 12 had been working with therapy due to left-sided hemiparesis (paralysis on left side of the body). She was working with therapy regarding activities of daily living and contractures in the left hand.
There was no documented evidence in Resident 12's clinical record to indicate that a comprehensive care plan was developed that included care for left-sided hemiparesis.
Interview with the Assistant Director of Nursing on August 22, 2024, at 1:39 p.m. revealed that Resident 12 was not care planned for left-sided hemiparesis and should have been.
An admission MDS assessment for Resident 30, dated July 3, 2024, revealed that the resident was cognitively impaired, usually understood, usually understood others, required assistance with daily care needs, and had a diagnosis of schizophrenia.
A nurse's note for Resident 30, dated July 10, 2024, at 4:51 p.m., revealed that the resident was yelling out and hitting himself.
An Interdisciplinary Team note for Resident 30, dated July 16, 2024, at 1:46 p.m., revealed that the Interdisciplinary Team including the Registered Nurse Assessment Coordinator, Social Worker, and therapy worker discussed the increased behaviors of Resident 30.
A nurse's note for Resident 30, dated July 24, 2024, revealed that the resident was hitting himself and stating, I'm crazy, for a duration of five minutes and making disruptive sounds.
There was no documented evidence in Resident 30's clinical record to indicate that a comprehensive care plan was developed that included care for behaviors.
Interview with Nursing Home Administrator on August 22, 2024, at 7:59 p.m. confirmed that there was no documented evidence that a care plan was created for Resident 30 for behaviors, and there should have been.
28 Pa. Code 211.12(d)(5) Nursing Services.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected 1 resident
Based on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that care plans were updated/revised to reflect changes in ...
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Based on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that care plans were updated/revised to reflect changes in care needs for three of 45 residents reviewed (Residents 5, 12, 77).
Findings include:
The facility's policy regarding care plans, dated July 1, 2024 revealed that the care planning coordinator will add minor changes in the resident's status to the existing care plans on a daily basis, and care plans are to be maintained with the current medical record.
A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 5, dated July 8, 2024, revealed that the resident was cognitively impaired, understood, usually able to understand others, required maximum assistance with care needs, and had a mechanically altered diet.
A nurse's note for Resident 5, dated July 25, 2024, at 6:40 a.m., revealed that hospital radiology recommended a level 7, easy-to-chew diet, with thin liquids.
Interview with the Director of Rehabilitation on August 21, 2024, at 9:17 a.m. revealed that the recommendations from radiology were followed and Resident 5 was upgraded to thin liquids on the above date.
A dietary care plan for Resident 5, dated July 21, 2024, revealed that the resident was to be on low concentrated sweets, no added salt, mechanically soft diet, with nectar thick liquids. There was no documented evidence that the resident's care plan was revised to reflect thin liquids.
Interview with the Registered Dietician on August 21, 2024, at 10:59 a.m. confirmed that Resident 5's diet was upgraded from nectar thick liquids to thin liquids on July 25, 2024, and confirmed that the care plan should have been revised to reflect the change from nectar think liquids to thin liquids.
A quarterly MDS assessment for Resident 12, dated June 19, 2024, revealed that the resident was cognitively intact, understood, usually able to understand others, required maximum assistance with care needs, and had a history of rejecting care.
A nurse's note for Resident 12, dated July 3, 2024, at 8:14 p.m. revealed that the social worker informed the registered nurse that Resident 12's sister was concerned about resident not eating, not participating in activities, and refusing showers. The Social worker offered to have staff reach out when the resident refused care.
Interview with the Director of Nursing on August 22, 2024, at 4:48 p.m. confirmed that Resident 12's care plan should have been updated to include contacting her sister for refusals.
A quarterly MDS assessment for Resident 77, dated July 19, 2024, revealed that the resident was cognitively intact, clearly understood, able to clearly understand others, required assistance with care needs, and had an unstageable pressure ulcer (full-thickness pressure injuries in which the base is obscured by slough and/or eschar) and four arterial ulcers (ulcers caused by poor with blood flow to the lower extremities).
Physician's orders for Resident 77, dated August 14, 2024, included an order to cleanse the wounds to his left achilles, left heel and left malleolus with normal saline (a sterile solution used for the moistening of wound dressings and wound debridement), apply santyl (a wound debridement treatment), and cover with an abdominal dressing (used for wounds with larger amounts of drainage) and Kerlix (bandage used to secure dressings in place) daily and as needed.
A skin integrity care plan for Resident 77, dated May 27, 2024, indicated that the resident had a Stage 2 pressure ulcer to his right buttock. A nursing note, dated August 15, 2024, at 3:07 p.m. revealed that the resident's skin was assessed and the wound on the buttocks was healed. There was no documented evidence that the resident's skin integrity care plan was revised to reflect that the Stage 2 pressure ulcer to his buttocks was healed, and no documented evidence to reflect that the skin integrity care plan was revised to include the wound to his left malleolus.
Interview with the Director of Nursing on August 22, 2024, at 4:50 p.m. confirmed that Resident 77's Stage 2 pressure ulcer to his right buttocks was healed, the care plan should have been revised to reflect the area was resolved, and the care plan should have been revised to include the resident's wound to his left malleolus.
28 Pa. Code 211.12(d)(5) Nursing Services.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0661
(Tag F0661)
Could have caused harm · This affected 1 resident
Based on clinical record reviews and staff interviews, it was determined that the facility failed to ensure that upon discharge from the facility, a discharge summary, including a recapitulation of th...
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Based on clinical record reviews and staff interviews, it was determined that the facility failed to ensure that upon discharge from the facility, a discharge summary, including a recapitulation of the resident's stay, was completed for one of three discharged residents reviewed (Resident 104).
Findings include:
admission diagnoses for Resident 104, dated June 25, 2024, revealed that the resident was admitted to the facility with diagnoses that included diabetes mellitus, hypertension (high blood pressure), atrial fibrillation (irregular heartbeat), and cellulitis (bacterial infection of the skin).
A nurse's note for Resident 104, dated June 29, 2024, revealed that the resident left the facility against medical advice (AMA).
As of August 22, 2024, there was no documented evidence that a discharge summary that included a recapitulation of the resident's stay was completed for Resident 104.
Interview with Registered Nurse Assessment Coordinator (RNAC) on August 22, 2024, at 6:35 p.m. confirmed that a discharge summary with a recapitulation of the resident's stay was not completed for Resident 104.
28 Pa. Code 211.5(d) Clinical Records.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0676
(Tag F0676)
Could have caused harm · This affected 1 resident
Based on a review of clinical records, as well as resident and staff interviews, it was determined that the facility failed to ensure that restorative nursing programs to maintain or improve physical ...
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Based on a review of clinical records, as well as resident and staff interviews, it was determined that the facility failed to ensure that restorative nursing programs to maintain or improve physical abilities were provided as ordered and/or care planned for one of 45 residents reviewed (Resident 56).
Findings include:
A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 56, dated July 10, 2024, revealed that the resident was cognitively intact, clearly understood, able to clearly understand others, required supervision with care needs, had a fall without injury since prior assessment, and had a diagnosis of Cerebral Palsy. A care plan for Resident 56, initiated July 5, 2023, indicated that he had an activities of daily living deficit related to impaired balance. A care plan intervention for Resident 56, initiated on July 12, 2023, indicated that the resident was on a restorative ambulation program with a goal to walk 100 feet with a front-wheeled walker and non-skid footwear with supervision twice a day (between 7:00 a.m. and 3:00 p.m.) and (between 3:00 p.m. and 11:00 p.m). The restorative ambulation was to be documented on the activity of daily living flowsheet.
A physical therapy discharge evaluation for Resident 56, dated April 12, 2024, indicated that the resident was on a restorative nursing program for ambulation 100 feet times two with supervision and front-wheeled walker.
An interview with Resident 56 on August 19, 2024, at 12:18 p.m. revealed that he was care planned to receive restorative ambulation from the staff when discharged from therapy and indicated that he does not get walked as much as he should. He indicated that he has been care planned since July 2023 to walk with the staff after being discharged from therapy and they are not doing it.
Review of Resident 56's restorative ambulation documentation from June 15, 2024, through August 20, 2024, as well as the clinical record, revealed no documented evidence that the restorative ambulation program was completed as per therapy recommendations and as per care plan between 7:00 a.m. and 3:00 p.m. for the following dates: June 15, 16, 17, 20, 21, 23, 28, 29, 30, 2024; July 2, 5, 6, 7, 9, 11, 12, 17, 19, 20, 21, 22, 23, 24, 25, 28, 29, 30, 31, 2024; and August 12, 18, 19, 20, 2024.
Review of Resident 56's restorative ambulation documentation from June 15, 2024, through August 20, 2024, as well as the clinical record, revealed no documented evidence that the restorative ambulation program was completed as per therapy recommendations and as per care plan between 3:00 p.m. and 11:00 p.m. for the following dates: June 15, 21, 23, 27, 2024; July 3, 5, 7, 13, 19, 24, 29, 2024; and August 3, 9, 10, 15, 16, 20, 2024.
An interview with the Nursing Home Administrator on August 21, 2024, at 2:27 p.m. confirmed that there was no documented evidence that Resident 56's restorative ambulation program was completed as per therapy recommendations and as per care plan on the dates and times listed above.
28 Pa. Code 211.12(d)(3)(5) Nursing Services.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected 1 resident
Based on a review of clinical records, facility policy review, and resident and staff interviews, it was determined that the facility failed to ensure that residents were provided with showers as sche...
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Based on a review of clinical records, facility policy review, and resident and staff interviews, it was determined that the facility failed to ensure that residents were provided with showers as scheduled for one of 45 residents reviewed (Resident 12).
Findings include:
A facility policy for resident personal care, dated July 1, 2024, indicated that residents will be provided showers and oral care as per request or as per facility schedule protocols.
A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 12, dated June 19, 2024, indicated that the resident was understood, could usually understand others, cognitively intact, and dependent on staff for personal care needs.
A care plan for Resident 12, dated March 27, 2024, indicated that the resident preferred to have showers every Tuesday and Saturday during the second shift and to have oral care completed twice a day.
Review of bathing documentation for Resident 12 from August 13, 2024, through August 22, 2024, indicated that the resident did not receive a shower during that time. There was no documented evidence that the resident was offered and refused showers twice weekly as per her care plan.
A review of oral care documentation for Resident 12 from August 13, 2024, through August 22, 2024, revealed that the resident only received oral care three times. There was no documented evidence that the resident was offered and refused the oral care twice a day per her care plan.
Interview with Resident 12's sister on August 21, 2024, at 3:56 p.m. revealed that there were times when the resident was not clean, had greasy hair, dirty clothes, and her teeth were not brushed, so she cleaned the resident herself. She was concerned that there was not enough staff to provide her with the proper care, so she comes in and does it herself.
Interview with the Assistant Director of Nursing on August 22, 2024, at 3:44 p.m. confirmed that there was no documented evidence that Resident 12 was offered or refused showers twice a week, and no documented evidence that oral care was offered or refused from August 13, 2024, to August 22, 2024.
28 Pa. Code 211.12(d)(5) Nursing Services.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
Based on review of clinical records and facility investigation reports, as well as staff interviews, it was determined that the facility failed to complete safety assessments for two of 45 residents r...
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Based on review of clinical records and facility investigation reports, as well as staff interviews, it was determined that the facility failed to complete safety assessments for two of 45 residents reviewed (Residents 13, 51) who used an air mattress.
Findings include:
A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 13, dated June 29, 2024, revealed that the resident was understood, could understand others, was cognitively intact, required assistance from staff for care needs, and had a Stage IV pressure ulcer (a wound with full-thickness skin loss that extends through into the muscle, exposing the bone, tendon, or joint) upon admission. A care plan for Resident 13, dated December 22, 2024, revealed that the resident had a Stage IV pressure ulcer.
A wound healing consult completed outside of the facility for Resident 13, dated July 5, 2024, revealed that the resident had a Stage 4 pressure injury with bone exposed on the sacral area. The wound consult recommended a low air loss mattress and frequent scheduled repositioning.
Physician's orders for Resident 13, dated July 6, 2024, indicated that the facility was to obtain a low air loss mattress.
Observations on August 19, 2024, at 12:45 p.m. and August 22, 2024, at 6:17 p.m. revealed that Resident 13 was lying in bed and the bed was equipped with an air mattress; however, there was no documented evidence that the use of an air mattress was assessed for potential safety hazards prior to being placed on Resident 13's bed.
A significant change MDS Resident 51, dated July 10, 2024, revealed that the resident was understood, understood others, was severely cognitively impaired, was dependent on staff for his daily care needs, had impairment on one side of his body, and had unhealed Stage 3 (full thickness skin loss into the lower layers of skin) and Stage 4 pressure ulcers.
Observations on August 19, 2024, at 11:55 a.m. revealed that Resident 51 was lying in bed and the bed was equipped with an air mattress; however, there was no documented evidence that the use of an air mattress was assessed for potential safety hazards prior to being placed on Resident 51's bed.
A nurses' note for Resident 51, dated July 21, 2024, at 4:53 p.m., revealed that the resident had a fall from the bed due to leaning on his left side, and the air mattress was forcing him to the edge of the bed. The bed enablers were recently removed, and the resident was unable to reposition himself, resulting in a fall from the bed. There was no injury noted.
Interview with the Director of Nursing on August 22, 2024, at 6:27 p.m. confirmed that there were no assessments for potential safety hazards prior to the air mattresses being placed on the resident's beds and there should have been.
28 Pa. Code 211.12(d)(3)(5) Nursing Services.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Incontinence Care
(Tag F0690)
Could have caused harm · This affected 1 resident
Based on review of facility policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to address a change in urine status for one of 45 re...
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Based on review of facility policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to address a change in urine status for one of 45 residents (Resident 12), and failed to provide proper care for indwelling urinary catheters for one of 45 residents reviewed (Resident 67).
Findings include:
A diagnosis list for Resident 12, dated March 19, 2024, revealed that the resident had a history of chronic urinary tract infections (UTI's). A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs), dated June 19, 2024, revealed that the resident was cognitively intact, required extensive assistance from staff for daily care tasks, and had an indwelling urinary catheter (a flexible tube inserted and held in the bladder to drain urine).
A review of the clinical record for Resident 12 revealed that on August 15, 2024, the resident had 300 milliliters (ml) of blood-tinged urine in her foley catheter collection bag.
A nursing note for Resident 12, dated August 18, 2024, at 7:40 p.m., revealed that the resident's sister spoke with a licensed practical nurse regarding the resident having tea-colored urine in her foley collection bag, and new orders were received from the doctor for a urinalysis to determine if the resident had a UTI.
A nurse's note dated, August 21, 2024, at 1:01 p.m. revealed that Resident 12 began a new order for 400 mg of Cefpodoxime (an antibiotic) every 12 hours for seven days for a UTI.
Interview with the Director of Nursing on August 22, 2024, at 4:49 p.m. confirmed that Resident 12 should have been assessed on August 15, 2024, when there was 300 ml of blood tinged urine in her foley bag.
The facility's policy regarding urinary catheter care, dated July 1, 2024, revealed that the catheter tubing and drainage bag were to be kept off the floor and in a dignity bag.
A significant change MDS assessment for Resident 67, dated June 10, 2024, revealed that the resident was severely cognitively impaired; had diagnoses that included dementia, down syndrome, and urinary retention; and had an indwelling catheter.
Observations of Resident 67 on August 21, 2024, at 9:46 a.m. revealed that the resident was lying in bed with the indwelling catheter tubing and drainage bag lying on the floor underneath his bed with no dignity bag in place.
Interview with Nurse Aide 4 on August 21, 2024, at 9: 50 a.m. confirmed that Resident 67's indwelling catheter tubing and drainage bag should not be on the floor, and that it should be in a dignity bag.
Interview with the Assistant Director of Nursing/Infection Control on August 21, 2024, at 9:55 p.m. confirmed that the catheter tubing and drainage bag should not be on the floor, and that it should be in a dignity bag.
28 Pa. Code 211.12(d)(3)(5) Nursing Services.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0692
(Tag F0692)
Could have caused harm · This affected 1 resident
Based on review of clinical records, as well as staff interviews, it was determined that the facility failed to provide aggressive hydration of 4 liters a day recommended by urology for one of 45 resi...
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Based on review of clinical records, as well as staff interviews, it was determined that the facility failed to provide aggressive hydration of 4 liters a day recommended by urology for one of 45 residents reviewed (Resident 12).
Findings include:
A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 12, dated June 19, 2024, indicated that the resident was cognitively intact, required assistance from staff for her daily care needs, and had a medical diagnosis of chronic urinary tract infections (UTI).
A urology consult for Resident 12, dated July 17, 2024, included a recommendation for the resident to have aggressive hydration of 4 liters (4000 milliliters) a day.
Physician's orders for Resident 12, dated July 17, 2024, included an order for the resident to have 4 liters of water a day and to have the total water intake documented every 6 hours (at 9:00 a.m., 3:00 p.m., 9:00 p.m., and 3:00 a.m.).
A review of the clinical records for Resident 12 revealed a total fluid intake of 1162 milliliters (mL) on August 20, 2024; 670 mL on August 19, 2024; 1640 mL on August 18, 2024; 1255 mL on August 17, 2024; 1640 mL on August 16, 2024; 1020 mL on August 15, 2024; 490 mL on August 14, 2024; and 620 mL on August 13, 2024.
There was no documented evidence that Resident 12 refused or was receiving the ordered 4 liters of fluid a day.
An interview with the Nursing Home Administrator on August 22, 2024, at 4:55 p.m. confirmed that there was no documented evidence that Resident 12 refused or was receiving the ordered 4 liters of fluid a day and there should have been.
28 Pa. Code 211.12(d)(3)(5) Nursing Services.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0725
(Tag F0725)
Could have caused harm · This affected 1 resident
Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to have sufficient nursing staff to provide and document care as scheduled for...
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Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to have sufficient nursing staff to provide and document care as scheduled for two of 45 residents reviewed (Residents 12, 19).
Findings include:
A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 12, dated June 19, 2024, indicated that the resident was understood and could usually understand others, was cognitively intact, and was dependent on staff for personal care needs.
A care plan for Resident 12, dated March 27, 2024, indicated that the resident preferred to have showers every Tuesday and Saturday during the second shift, and to have oral care completed twice a day.
Review of bathing documentation for Resident 12 from August 13, 2024, through August 22, 2024, indicated that the resident did not receive a shower during that time. There was no documented evidence that the resident was offered and refused showers twice weekly as per her care plan.
A review of oral care documentation for Resident 12 from August 13, 2024, through August 22, 2024, revealed that the resident only received oral care three times. There was no documented evidence that the resident was offered and refused the oral care twice a day per her care plan.
Interview with Resident 12's sister on August 21, 2024, at 3:56 p.m. revealed that there were times the resident was not clean, her hair was greasy, her clothes were dirty, and her teeth were not brushed, so she cleaned the resident herself. She is concerned that there is not enough staff to provide her with the proper care, so she comes in and does it herself.
Interview with the Assistant Director of Nursing on August 22, 2024, at 2:22 p.m. confirmed that there was no documented evidence that Resident 12 was offered or refused showers twice a week, and no documented evidence that oral care was offered or refused from August 13, 2024, to August 22, 2024. Interviews with direct care staff throughout the survey revealed that there is not enough staff to complete all tasks for residents.
A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 19, dated July 29, 2024, revealed that the resident was understood, could understand, was cognitively impaired, and was totally dependent on two staff for assistance with bed mobility and transfers. The current care plan for Resident 19 revealed that she was at risk for falls related to being non-ambulatory.
Observations on August 19, 2024, at 1:13 p.m. revealed that Resident 19 was sitting and activated her call bell. Resident 19 stated that she needed changed. Nurse Aide 5 entered the room at 1:13 p.m. and told the resident, Okay, in one minute, and turned the call bell off. Continued observations revealed that Resident 19 activated her call bell again at 1:55 p.m. Resident 19 said she was wet and needed to be changed, and said she takes a fluid pill that makes her urinate frequently. Nurse Aide 5 changed her shirt but did not provide incontinence care or change the resident's soiled brief.
Interview with Nurse Aide 5 at 1:59 p.m. revealed that Resident 19 was a two-person assist with a full body lift. She reported that she had already changed Resident 19 before getting her up for lunch and that there were other residents that still needed care. There were five nurse aides on the floor for over 55 residents and not enough staff to provide the care.
Interview with the Nursing Home Administrator on August 22, 2024, at 3:10 p.m. confirmed that the call bell wait was not appropriate, and that the facility has been trying to make staff accountable for breaks and lunches.
28 Pa. Code 201.18(e)(1) Management.
28 Pa. Code 211.12(d)(5) Nursing Services.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected 1 resident
Based on review of clinical records and staff interviews, it was determined that the facility failed to ensure the accountability of controlled medications for one of 45 residents reviewed (Resident 8...
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Based on review of clinical records and staff interviews, it was determined that the facility failed to ensure the accountability of controlled medications for one of 45 residents reviewed (Resident 86).
Findings include:
An annual Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 86, dated July 22, 2024, indicated that the resident was cognitively intact, required assistance from staff for all daily care needs, and had pain rated as a 6 on a scale of 1 to 10 (with 1 being mild and 10 being the worst) during the assessment period.
Physician's orders for Resident 86, dated December 26, 2023, included an order for the resident to receive one 10-325 milligram (mg) tablet of oxycodone/Tylenol (a combination controlled narcotic pain medication) between the hours of 12:00 a.m. and 4:00 a.m. as needed.
Review of Resident 86's controlled drug record (used to keep count of narcotic medication) for April and May 2024 revealed that staff signed out one table of hydrocodone/Tylenol on the controlled drug log on April 7, 2024, at 3:34 a.m.; April 14, 2024, at 3:34 a.m.; April 24, 2024 at 2:10 a.m.; May 6, 2024, at 1:00 a.m.; and May 8, 2024 at 2:15 a.m. However, there was no indication on the resident's Medication Administration Record for April and May 2024 that the narcotic medication was administered to the resident on those dates and times.
Interview with the Director of Nursing on August 22, 2024, at 10:06 a.m. confirmed that there was no documented evidence that the narcotic pain medication was administered to Resident 86 on those dates and times and that the nurses are expected to sign the MAR when they administer a pain medication.
28 Pa. Code 211.12(d)(3)(5) Nursing Services.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Unnecessary Medications
(Tag F0759)
Could have caused harm · This affected 1 resident
Based on review of manufacturer's instructions, facility policies, and clinical records, as well as observations and staff interviews, it was determined that the facility failed to maintain a medicati...
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Based on review of manufacturer's instructions, facility policies, and clinical records, as well as observations and staff interviews, it was determined that the facility failed to maintain a medication error rate of less than five percent.
Findings include:
The facility's policy regarding medication administration procedures, dated July 1, 2024, indicated that medications were to be administered in a safe and timely manner, and medications listed as should not crush should not be crushed unless the physician writes otherwise, and manufacturer's instructions were to be followed unless otherwise directed.
Observations during medication administration on August 21, 2024, revealed that two medication administration errors were made during 30 opportunities for error, resulting in a medication administration error rate of 6.67 percent.
The manufacturer's instructions for Trelegy Ellipta (a combination medicine that is inhaled to treat chronic obstructive pulmonary disease (COPD) and asthma), dated May 2024, indicated that after inhalation, the resident was to rinse their mouth with water without swallowing to help reduce the risk of fungal infections.
A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 68, dated June 13, 2024, revealed that the resident was severely cognitively impaired and had diagnoses that included seizures. Physician's orders for Resident 68, dated March 13, 2024, included orders for the resident to be given a 250 mg tablet of Depakote-delayed release (medication used to treat seizures, migraines and bipolar disorder) daily in the a.m., and one inhalation of Trelegy Ellipta 100-62.5-25 mcg (micrograms) daily in the a.m.
Observations during medication administration on August 21, 2024, at 9:09 a.m. revealed that Licensed Practical Nurse (LPN) 6 crushed all of Resident 68's morning medications, including the Depakote, and administered them in applesauce. She then administered one inhalation of Trelegy Ellipta; however, the resident did not rinse and spit and the nurse did not instruct the resident to swish and spit after the administration. Interview with LPN 6 at that time revealed that the resident would not take pills whole, and she confirmed that she did not direct the resident to rinse his mouth. She stated that he always refused in the past. LPN 6 further confirmed that there was a do not crush order for the Depakote and that there was no documentation to indicate the resident routinely refused to rinse his mouth after using the inhaler.
Interview with Registered Nurse Supervisor 7 on August 22, 2024, at 9:50 a.m. confirmed that Depakote delayed release tablet should not have been crushed, and that the resident should have been directed to rinse his mouth after using the inhaler. A thorough review of Resident 68's clinical record by RN Supervisor 7 confirmed that there was no documentation to indicate that the physician was aware the resident would not take pills whole and no documented evidence that he was refusing to rinse out his mouth after using the inhaler.
Interview with the Director Of Nursing on August 22, 2024, at 10:45 confirmed that Resident 68's Depakote delayed release tablet should not have been crushed, and that the physician should have been notified that the resident refused to rinse his mouth after using the inhaler.
28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected 1 resident
Based on observations and staff interviews, it was determined that the facility failed to ensure that controlled medications were stored in a separately locked, permanently affixed compartment in one ...
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Based on observations and staff interviews, it was determined that the facility failed to ensure that controlled medications were stored in a separately locked, permanently affixed compartment in one of two medication rooms reviewed (second floor), and failed to date an insulin pen with the date it was opened (third floor long hall medication cart).
Findings include:
A facility policy titled Storage and Expiration Dating of Medications and Biologicals, dated July 1, 2024, revealed that the facility will maintain narcotics stored in the medication room locked refrigerator in a separately locked permanently affixed compartment, and that upon using an insulin pen for the first time, it must be dated with the opened date.
Observations in the second floor medication room on August 21, 2024, at 9:50 am. revealed that there was a narcotic storage box containing two bottles of 2 mg/ml liquid Ativan (a controlled medication used to treat anxiety). The storage box was attached to the glass shelf; however, the shelf was not permanently affixed to the inside of the refrigerator.
An interview with the Assistant Director of Nursing at that time confirmed that the narcotic storage box containing the liquid Ativan should have been permanently affixed to the inside of the medication room refrigerator, and it was not.
A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 19, dated July 29, 2024, revealed that the resident was understood and understood others, was cognitively intact, was dependent on staff for her daily care needs, had a diagnosis of diabetes mellitus, and received insulin injections daily.
Observations in the third short hall medication cart on August 22, 2024, at 10:05 a.m. revealed that there was an glargine insulin pen (a medication used to treat diabetes mellitus) for Resident 19 that was opened and undated and was in use.
Interview with Licensed Practical Nurse 8 on August 22, 2024, at 10:19 a.m. confirmed that the insulin pen for Resident 19 was in use and should have been dated when opened, but was not.
Interview with the Nursing Home Administrator on August 22, 2024, at 12:40 p.m. confirmed that the narcotic storage box containing Ativan was not permanently affixed inside the refrigerator and insulin pens, once opened, must have an opened date placed on them.
28 Pa. Code 211.9(a)(1) Pharmacy Services.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0810
(Tag F0810)
Could have caused harm · This affected 1 resident
Based on review of policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that staff provided assistive devices to eat in acc...
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Based on review of policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that staff provided assistive devices to eat in accordance with the resident's care plan for two of 45 residents reviewed (Residents 12, 28).
Findings include:
The facility's policy regarding adaptive equipment, dated July 1, 2024, indicated that adaptive equipment to meet residents' needs would be provided per order.
An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 12, dated June 19, 2024, indicated that the resident was cognitively intact and required set-up assistance with eating.
A speech therapy note, dated June 20, 2024, at 9:54 a.m. indicated that Resident 12 was to use a two-handled cup with all liquids. A nursing note for Resident 12, dated June 20, 2024, at 2:12 p.m., indicated that the resident was on a straw restriction.
Observations of Resident 12 during the lunch meal on August 22, 2024, at 1:09 p.m. revealed that the resident was in the dining area on the third floor and had a can of soda with a straw and a carton of milk with a straw.
Interview with Licensed Practical Nurse 10 on August 22, 2024, at 1:15 p.m. confirmed that Resident 12 did not have a two-handled cup for all liquids with her meal, which was not in accordance with the meal ticket.
Interview with the Assistant Director of Nursing on August 22, 2024, at 1:39 p.m. confirmed that if Resident 12's meal ticket indicated that the resident was to have had two-handled cup with all liquids, then it should have been on her tray.
A quarterly MDS assessment for Resident 28, dated August 9, 2024, revealed that the resident was understood, could understand, was cognitively intact, and required set up and clean up for eating. A care plan for Resident 28, revised on August 17, 2023, revealed that the resident was at risk for a nutritional problem. Interventions included having adaptive equipment for feeding, which included weighted built-up utensils. Current physician's orders for Resident 28 included an order for the resident to be provided black, weighted built-up utensils on all trays for all meals.
Observations of Resident 28 during the lunch meal on August 22, 2024, at 12:50 p.m. revealed that the resident was in his room eating lunch with regular flatware. Resident 28 stated that he finds it very difficult to eat without his weighted black silverware.
Interview with Nurse Aide 5 on August 22, 2024, at 12:56 p.m. confirmed that Resident 28 did not have built-up silverware with his meal, which was not in accordance with the meal ticket.
Interview with the Director of Nursing on August 21, 2024, at 12:04 p.m. confirmed that Resident 28 should have been provided weighted silverware for his lunch meal as ordered.
28 Pa. Code 211.12(d)(3)(5) Nursing Services.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
QAPI Program
(Tag F0867)
Could have caused harm · This affected 1 resident
Based on review of the facility's plans of correction and the results of the current survey, it was determined that the facility's Quality Assurance Performance Improvement (QAPI) committee failed to ...
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Based on review of the facility's plans of correction and the results of the current survey, it was determined that the facility's Quality Assurance Performance Improvement (QAPI) committee failed to correct quality deficiencies and ensure that plans to improve the delivery of care and services effectively addressed recurring deficiencies.
Findings include:
The facility's deficiencies and plans of corrections for State Survey and Certification (Department of Health) survey ending September 8, 2023, revealed that the facility developed plans of correction that included quality assurance systems to ensure that the facility maintained compliance with cited nursing home regulations. The results of the current survey, ending August 22, 2024, identified repeated deficiencies related to failure to correct deficient practices related to accommodation of resident needs, accuracy of Minimum Data Set (MDS) assessments, professional standards of practice, quality care, safe environment free from accident hazards, nutrition and hydration maintenance, accounting of controlled medications, storage and labeling of medications, assistive devices to maintain eating and hydration needs, food preparation and storage, and infection control.
The facility's plan of correction for a deficiency regarding a failure to accommodate the residents' needs, cited during the survey ending September 8, 2023, revealed that audits would be conducted, and the results of the audits would be brought before the QAPI committee for further monitoring. The results of the current survey, cited under F558, revealed that the QAPI committee was ineffective in correcting deficient practices related to accommodation of resident needs.
The facility's plan of correction for a deficiency regarding the accuracy of MDS assessments, cited during the survey ending September 8, 2023, revealed that the facility would complete audits and report the results of the audits to the QAPI committee for review. The results of the current survey, cited under F641, revealed that the facility's QAPI committee failed to successfully implement their plan to ensure ongoing compliance with regulations regarding accuracy of MDS assessments.
The facility's plan of correction for a deficiency regarding professional standards, cited during the survey ending September 8, 2023, revealed that the facility would complete audits and report the results of the audits to the QAPI committee for review. The results of the current survey, cited under F658, revealed that the facility's QAPI committee failed to successfully implement their plan to ensure ongoing compliance with regulations regarding professional standards.
The facility's plan of correction for a deficiency regarding quality of care, cited during the survey ending September 8, 2023, revealed that the facility would complete audits and report the results of the audits to the QAPI committee for review. The results of the current survey, cited under F684, revealed that the facility's QAPI committee was ineffective in maintaining compliance with the regulation regarding quality of care.
The facility's plans of correction for deficiencies regarding a safe environment that is free of accident hazards, cited during the survey ending September 8, 2023, revealed that the facility developed plans of correction that included completing audits and reporting the results of the audits to the QAPI committee for review. The results of the current survey, cited under F689, revealed that the facility's QAPI committee failed to maintain compliance with the regulation regarding a safe environment that is free of accident hazards.
The facility's plan of correction for a deficiency regarding nutrition and hydration maintenance, cited during the survey ending on September 8, 2023, revealed that audits would be conducted, and the results of the audits would be brought before the QAPI committee for further monitoring. The results of the current survey, cited under F692, revealed that the QAPI committee was ineffective in maintaining compliance with the regulation regarding nutrition and hydration maintenance.
The facility's plan of correction for a deficiency regarding complete and accurate accounting of controlled medications, cited during the survey ending September 8, 2023, revealed that the facility developed a plan of correction that included completing audits and reporting the results of the audits to the QAPI committee for review. The results of the current survey, cited under F755, revealed that the facility's QAPI committee failed to maintain compliance with the regulation regarding complete and accurate accounting of controlled medications.
The facility's plans of correction for deficiencies regarding storage and labeling of medications, cited during the survey ending September 8, 2023, revealed that the facility developed plans of correction that included completing audits and reporting the results of the audits to the QAPI committee for review. The results of the current survey, cited under F761, revealed that the facility's QAPI committee failed to maintain compliance with the regulation regarding storage and labeling of medications.
The facility's plan of correction for a deficiency regarding assistive devices to maintain eating and hydration needs, cited during the survey ending on September 8, 2023, revealed that audits would be conducted, and the results of the audits would be brought before the QAPI committee for further monitoring. The results of the current survey, cited under F810, revealed that the QAPI committee was ineffective in maintaining compliance with the regulation regarding assistive devices to maintain eating and hydration needs.
The facility's plan of correction for a deficiency regarding proper food preparation and storage, cited during the survey ending September 8, 2023, revealed that proper food preparation and storage would be monitored by QAPI. The results of the current survey, cited under F812, revealed that the QAPI committee was ineffective in maintaining compliance with proper food preparation and storage.
The facility's plans of correction for deficiencies regarding infection control, cited during the surveys ending September 8, 2023, revealed that the facility developed plans of correction that included completing audits and reporting the results of the audits to the QAPI committee for review. The results of the current survey, cited under F880, revealed that the facility's QAPI committee failed to maintain compliance with the regulation regarding infection control.
Refer to F558, F641, F658, F684, F689, F692, F755, F761, F810, F812, F880.
28 Pa. Code 201.14(a) Responsibility of Licensee.
28 Pa. Code 201.18(e)(1) Management.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0868
(Tag F0868)
Could have caused harm · This affected 1 resident
Based on review of attendance records for the facility's Quality Assurance Committee, as well as staff interviews, it was determined that the facility failed to ensure that Quality Assurance meetings ...
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Based on review of attendance records for the facility's Quality Assurance Committee, as well as staff interviews, it was determined that the facility failed to ensure that Quality Assurance meetings were held at least quarterly.
Findings include:
Review of the attendance records for the facility's Quality Assurance Committee meetings revealed that there were no records of a meeting held during the facility's second quarter of 2024 (April, May and June of 2024).
Interview with the Nursing Home Administrator on August 22, 2024, at 3:09 p.m. confirmed that there were no records of any Quality Assurance meetings held during the second quarter in 2024. She stated that they were to have a meeting in July 2024 but it was pushed back. She indicated that it had still not been scheduled as of this date.
28 Pa. Code 201.18(e)(1)(2)(3) Management.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Antibiotic Stewardship
(Tag F0881)
Could have caused harm · This affected 1 resident
Based on review of facility policies, infection control documentation, and staff interviews, it was determined that the facility failed to implement an antibiotic stewardship program that contained a ...
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Based on review of facility policies, infection control documentation, and staff interviews, it was determined that the facility failed to implement an antibiotic stewardship program that contained a system of reports and forms, and collaboration with an interdisciplinary team approach to monitor, track and trend antibiotic use and resistance for seven consecutive months (January 2024 through July 2024).
Findings include:
A facility policy regarding Antimicrobial Stewardship Program, dated July 1, 2024, indicated that the antimicrobial stewardship will focus on improving antibiotic/antimicrobial use by avoiding unnecessary or inappropriate antibiotics. The process will be overseen and managed by the Infection Preventionist (IP) who works collaboratively with the medical director, consulting pharmacist, nursing and administrative leadership to also implement the Antimicrobial Stewardship Program (ASP).
As a component of the monthly Infection and Prevention and Control Committee (IPCC) meeting, the facility's use of antibiotics will be reviewed to include monitoring and tracking of antibiotic prescribing, use, and resistance.
Review of the facility infection control binder containing the documentation to support that the facility followed their policies and procedures related to their Antibiotic/Antimicrobial Stewardship Program revealed that there was no documented evidence to support that the facility implemented their Antibiotic/Antimicrobial Stewardship Program (ASP) over the last seven consecutive months (January 2024 through July 2024). The last available information the facility had related to antibiotic monitoring, tracking and trending was from 2023.
Interview with the Infection Preventionist (IP) on August 20, 2024, at 4:12 p.m. revealed that as of April 2024, when she assumed the position as the IP, the facility has not monitored antibiotic use as per the facility's antibiotic/antimicrobial stewardship program. She indicated that she was not trained after receiving her required IP education from the Center of Disease Control (CDC) in March 2024 and assuming the role as IP. She indicated that she had no documented evidence that antibiotic monitoring, tracking and trending occurred since January 2024.
Interview with the Nursing Home Administrator on August 20, 2024, at 4:15 p.m. confirmed that the facility was not following their antibiotic/antimicrobial stewardship program and had not been monitoring, tracking and trending antibiotic use since the IP assumed the role in March 2024. The Nursing Home Administrator also confirmed they had no documentation to support that antibiotic use was monitored, tracked and trended since January 2024. She revealed that the current IP's last day in that position would be August 22, 2024, and that they had hired a new IP that would be starting soon.
28 Pa. Code 201.14(a) Responsibility of Licensee.
28 Pa. Code 201.18(b)(1) Management.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0919
(Tag F0919)
Could have caused harm · This affected 1 resident
Based on review of facility policy and clinical records, as well as observations and resident and staff interviews, it was determined that the facility failed to ensure that the call bell system was a...
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Based on review of facility policy and clinical records, as well as observations and resident and staff interviews, it was determined that the facility failed to ensure that the call bell system was adequately equipped to allow residents to call for staff assistance, by failing to ensure that the call bell system was working for one of 45 resident reviewed (Resident 34).
Findings include:
The facility's policy regarding resident communication system and call lights, dated April 30, 2024, revealed that it was the policy of the facility to provide residents with a means of communicating with staff. A call system is installed in each resident room and toilet/bath area. The facility will respond to resident needs and requests.
A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 34, dated August 6, 2024, revealed that the resident was understood, could understand others, was cognitively impaired, and required staff assistance for all care needs.
Observations on August 19, 2024, at 1:00 a.m. revealed that Resident 34 was sitting in bed with her call bell in her hand. Resident 34 pressed her call bell but it did not function and no light came on to indicate the call bell was activated. Interview with Nurse Aide 5 at 1:10 p.m. revealed that she did not receive a notification on her beeper, she was unsure why the call bell was not functioning, and would notify maintenance.
Interview with the Maintenance Director on August 21, 2024, at 1:10 p.m. revealed that the call bell system was battery operated and the batteries need to be replaced frequently.
Interview with the Nursing Home Administrator on August 22, 2024, at 3:10 p.m. revealed that the call bell should be functioning, and if not the resident should have a cow bell.
28 Pa. Code 207.2(a) Administrator's Responsibility.
28 Pa. Code 211.12(d)(5) Nursing Services.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0553
(Tag F0553)
Could have caused harm · This affected multiple residents
Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that the resident and/or the resident's responsible party was given ...
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Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that the resident and/or the resident's responsible party was given the opportunity to participate timely in the development and implementation of a person-centered care plan for two of 45 residents reviewed (Residents 12, 77).
Findings include:
The facility's policy regarding care planning, dated July 1, 2024, revealed that the resident and their representative will be given the opportunity to discuss their goals for care including their preference for advanced care planning. The results of the advanced care planning will be communicated to the resident's care providers and documented in the clinical record.
A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 12, dated June 19, 2024, revealed that the resident was cognitively impaired, was clearly understood and could usually understand others, and required assistance with care needs.
There was no documented evidence that a care plan conference was scheduled or completed following the completion of the MDS or that notifications or invitations were provided to the resident and/or the representative.
Interview with the Registered Social Worker on August 22, 2024, at 12:05 p.m. confirmed that there was a meeting scheduled on March 27, 2024, but the meeting was rescheduled for April 3, 2024; however, the meeting did not happen. The next meeting was to be scheduled in June, but the care conferences letters were not sent or scheduled.
Interview with the Director of Nursing on August 22, 2024, at 12:22 p.m. confirmed that care conferences should be scheduled quarterly.
A quarterly MDS assessment for Resident 77, dated July 19, 2024, revealed that the resident was cognitively intact, was clearly understood, able to clearly understand others, and required assistance with care needs. There was no documented evidence that a care plan conference was scheduled or completed following the completion of the MDS or that notifications or invitations were provided to the resident and/or the representative.
Interview with the Registered Nurse Assessment Coordinator (RNAC- a registered nurse who is responsible for completing MDS assessments and who is often involved in the development of care plans) on August 22, 2024, at 7:12 p.m. confirmed that there was no documented evidence that a care plan conference was scheduled or completed following the completion of the MDS or that notifications or invitations were provided to the resident and/or the representative for Resident 77. The RNAC confirmed that the care plan meeting was missed.
28 Pa. Code 201.18(e)(1) Management.
28 Pa. Code 201.24(e)(4) admission Policy.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of Pennsylvania's Nursing Practice Act, facility policies, and clinical records, as well as staff interviews, it...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of Pennsylvania's Nursing Practice Act, facility policies, and clinical records, as well as staff interviews, it was determined that the facility failed to obtain physician's orders for pacemaker checks for one of 45 resident reviewed (Resident 78).
Findings include:
The Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.11 (a)(1)(2)(4) indicated that the registered nurse was to collect complete and ongoing data to determine nursing care needs, analyze the health status of individuals and compare the data with the norm when determining nursing care needs, and carry out nursing care actions that promote, maintain, and restore the well-being of individuals.
The facility's policy regarding pacemaker rate checks, dated July 1, 2024, indicated that upon the resident admission with, or insertion of, a cardiac pacemaker, the licensed nurse will gather pertinent information and complete the cardiac pacemaker data sheet, and it will be kept in the resident's medical record. The licensed staff will obtain an order for routine pacemaker checks, and the checks will be completed per manufacture's recommendations. Documentation of any checks and services provided will be maintained in the nurse's notes.
A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 78, dated June 19, 2024, revealed that the resident was cognitively impaired, clearly understood, able to clearly understand others, required supervision with care needs, and had diagnoses that included congestive heart failure (the heart cannot pump blood well enough to meet the body's needs) and cardiac pacemaker (a surgically-implanted, small battery-powered device to manage irregular heartbeats or heart failure).
A care plan for Resident 78, dated July 18, 2023, indicated that the resident had a cardiac pacemaker and was to have pacemaker checks (to check if pacemaker is functioning properly) done as per physician's order. There was no documented evidence in Resident 78's clinical record of a physician's order for pacemaker checks per facility policy and per care plan, and no documented evidence that any pacemaker checks had been completed since his admission to the facility.
Interview with the Nursing Home Administrator on August 21, 2024, at 11:22 a.m. confirmed that there was no documented evidence in Resident 78's clinical record that pacemaker checks were being done as per facility policy and resident care plan.
Interview with the Registered Nurse Assessment Coordinator (RNAC- a registered nurse who is responsible for completing MDS assessments and who is often involved in the development of care plans) on August 21, 2024, at 1:42 p.m. confirmed that Resident 78 was admitted to the facility on [DATE], and was scheduled to have a pacer clinic appointment on March 22, 2023 but it was missed.
28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0685
(Tag F0685)
Could have caused harm · This affected multiple residents
Based on clinical record reviews and staff interviews, it was determined that the facility failed to follow physician's orders and residents' requests for ophthalmology appointments for two of 45 resi...
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Based on clinical record reviews and staff interviews, it was determined that the facility failed to follow physician's orders and residents' requests for ophthalmology appointments for two of 45 residents reviewed (Residents 69, 87).
Findings include:
A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 69, dated July 10, 2024, revealed that the resident was cognitively intact, clearly understood, able to clearly understand others, and required supervision with care needs.
An interview with Resident 69 on August 19, 2024, at 11:44 a.m. revealed that she wanted to go to the eye doctor and that Senior Life was not scheduling it. She indicated that it had been scheduled, but she did not go due to a screw up with Senior Life and transportation. She voiced that she was nearly blind, could not see, and wanted to be seen by the eye doctor.
The Social Service Director received an email from the local Senior Services office on July 18, 2024, regarding Resident 69's vision exam. They had left messages with Senior Life about rescheduling the vision exam, but there had been no return call from them. The Social Service Director then sent an email to Senior Life on July 18, 2024, regarding Resident 69's vision exam needing to be rescheduled.
There was no documented evidence in Resident 69's clinical record to indicate that any further attempts to reschedule the vision exam had been made since the July 18, 2024, email to Senior Life.
Interview with the Social Service Director on August 22, 2024, at 8:30 p.m. confirmed that there had been no further follow-ups or attempts to communicate with Senior Life to reschedule Resident 69's vision exam.
An annual MDS assessment for Resident 87, dated July 2, 2024, revealed that the resident was cognitively impaired, usually understood, able to sometimes understand others, required assistance with care needs, and had a diagnosis of diabetes.
Physician's orders for Resident 87, dated April 4, 2024, indicated that the resident was to be scheduled for a vision exam with 360 services.
Documentation provided by the Nursing Home Administrator, dated April 4, 2024, at 5:52 p.m. revealed that an email was sent by Registered Nurse 3 to the Social Service Director informing her that Resident 87 was ordered to have a vision exam with 360 services; however, there was no documented evidence in the resident's clinical record that the vision exam was scheduled.
Interview with the Nursing Home Administrator on August 21, 2024, at 8:46 a.m. confirmed that there was no documented evidence in Resident 87's clinical record that a vision exam was scheduled with 360 services.
28 Pa. Code 211.12(d)(3)(5) Nursing Services.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Drug Regimen Review
(Tag F0756)
Could have caused harm · This affected multiple residents
Based on review of policy and clinical records, as well as staff interviews, it was determined that the facility failed to respond timely to a pharmacy recommendation for two of 45 residents reviewed ...
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Based on review of policy and clinical records, as well as staff interviews, it was determined that the facility failed to respond timely to a pharmacy recommendation for two of 45 residents reviewed (Residents 30, 89).
Findings include:
A facility policy for medication regimen review, dated July 1, 2024, revealed that the attending physician should document in the resident's health record that the identified irregularity has been reviewed and what, if any, action has been taken to address it.
An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 30, dated July 3, 2024, revealed that the resident was cognitively impaired, required total care from staff, and was medicated with a hypotensive (a medication to treat low blood pressure).
A pharmacy consultant note for Resident 30, dated June 27, 2024, revealed that the pharmacist recommended that the physician reassess the prescription for midodrine scheduled medication times. It was not to be given after 6:00 p.m., and it was scheduled to be given at 8:00 p.m. As of August 22, 2024, there was no documented evidence the pharmacist medication regimen review was addressed by the physician.
An interview with the Director of Nursing on August 22, 2024, at 7:24 p.m. confirmed that there was no documented evidence the pharmacist medication regimen review was addressed by the physician.
A quarterly MDS assessment for Resident 89, dated June 25, 2024, revealed that the resident was cognitively intact, was dependent on staff for daily care needs, and was medicated with anti-anxiety medication.
A pharmacy consultant note for Resident 89, dated June 23, 2024, revealed that the pharmacist recommended that the physician review the orders for using the medications Citalopram (a medication used to treat depression) and Cilostazol (a mediation used to treat blood clots) together, and to stop the order for nystatin (a medication used to treat fungal infections). There was no documented evident that pharmacist medication regimen review was addressed by the physician.
A pharmacy consultant note for Resident 89, dated July 24, 2024, revealed that that pharmacist recommended that a lipid panel (a test to measure the amount of fats in the blood) be completed for the resident the next lab day. There was no documented evidence that the pharmacist medication regimen review was addressed by the physician.
An interview with the Assistant Director of Nursing on August 22, 2024, at 3:04 p.m. confirmed that there was no documented evidence that the pharmacist medication regimen review was addressed by the physician.
28 Pa. Code 211.9(f)(3) Pharmacy Services.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Medication Errors
(Tag F0758)
Could have caused harm · This affected multiple residents
Based on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that residents were free from unnecessary psychotropic medi...
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Based on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that residents were free from unnecessary psychotropic medications for one of 45 residents reviewed (Resident 87).
Findings include:
The facility's policy regarding psychotropic medications (any medication that affects brain activities associated with mental processes and behavior), dated July 1, 2024, indicated that all residents receiving psychoactive medications will have their behaviors and effectiveness of interventions (pharmacological and non-pharmacological) monitored and documented. Nurses will document on the following each shift: number of behavioral episodes, specific non-medication interventions used, and outcomes of interventions including individualized non-pharmacological approaches.
An annual Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 87, dated July 2, 2024, revealed that the resident was cognitively impaired, usually understood, able to sometimes understand others, required minimal assistance with care needs, had verbal and other behaviors, and had diagnoses that included Alzheimer's disease, dementia with agitation, and anxiety.
Physician's orders for Resident 87, dated May 13, 2024, included an order for medication monitoring of anti-anxiety medication every shift to monitor for side effects of medications and documentation of non-pharmacological interventions.
Physician's orders for Resident 87, dated June 7, 2024, included an order for the resident to receive 0.5 milligrams (mg) of Ativan (a psychotropic medication used to treat anxiety) every eight hours as needed for anxiety.
Review of the Medication Administration Record (MAR) for Resident 87 for June 2024 revealed that the resident was administered 0.5 mg of Ativan on the following dates and times: June 12 at 4:57 p.m., June 19 at 11:05 p.m., and June 20 at 7:45 p.m. There was no documented evidence that non-pharmacological behavioral interventions were attempted prior to administering Ativan on the above stated dates and times.
Physician's orders for Resident 87, dated July 15, 2024, included an order for the resident to receive 0.5 mg of Xanax (a psychotropic medication used to treat anxiety) every eight hours as needed for anxiety and/or agitation.
Physician's orders for Resident 87, dated August 5, 2024, included an order for the resident to receive 0.5 mg of Xanax every eight hours as needed for anxiety and/or agitation.
Physician's orders for Resident 87, dated August 18, 2024, included an order for the resident to receive 0.5 mg of Xanax every eight hours as needed for anxiety and/or agitation.
Review of the Medication Administration Record (MAR) for Resident 87 for July and August 2024 revealed that the resident was administered 0.5 mg of Xanax on the following dates and times: July 23 at 4:37 a.m., July 24 at 12:19 p.m., July 25 at 2:31 p.m., August 6 at 5:56 p.m., August 7 at 6:47 p.m., August 12 at 5:04 p.m., August 16 at 6:24 a.m., and August 18 at 6:25 a.m. and 8:58 p.m. There was no documented evidence that non-pharmacological behavioral interventions were attempted prior to administering Xanax on the above stated dates and times.
Interview with the Registered Nurse Assessment Coordinator on August 20, 2024, at 3:24 p.m. confirmed that non-pharmacological interventions should have been attempted prior to the administration of Ativan and Xanax to Resident 87 on the above stated dates and times.
28 Pa. Code 211.12(d)(5) Nursing Services.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected multiple residents
Based on review of policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to maintain an infection prevention and control program desig...
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Based on review of policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment to prevent the transmission of infections.
Findings include:
The facility's policy for linen management, dated July 1, 2024, revealed that soiled linens will be bagged at the point of use and placed in a soiled linen bin in the designated area.
A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 11, dated August 6, 2024, revealed that the resident was sometimes understood, could sometimes understand others, was cognitively impaired, and was dependent on staff for all care needs.
Observations of Resident 11's room on August 19, 2024, at 12:00 p.m. and 12:25 p.m. revealed a sign for contact precautions and to see the nurse for instructions. Interview with Licensed Practical Nurse 8 on August 19, 2024, at 12:10 p.m. regarding the sign revealed that Resident 11 was COVID-19 positive and was on droplet precautions (requiring a gown, gloves, N-95 mask and eye protection), not contact precautions. A tracking log for 2024 indicated that Resident 11 tested positive for COVID-19 (acute disease in humans caused by a coronavirus) on August 12, 2024. There was personal protective equipment (PPE) available on the door. There was no soiled bin for the used/contaminated PPE to be placed in. There was only one laundry basket that staff were moving from COVID-19 positive rooms as needed. The laundry basket had a lid, but there was no bag in it, which allowed the contaminated PPE to be exposed through the sides. Staff wheeled the laundry basket over to Resident 11's room so the used gown, gloves, and eye protection could be removed.
Interview with the Director of Nursing on August 21, 2024, at 4:12 p.m. confirmed that the correct transmission based precaution signs should have been posted, and that there should have been appropriate receptacles to remove soiled/used PPE when exiting the room of someone who is on droplet isolation.
Observations on August 19, 2024, at 12:38 p.m. revealed that Nurse Aide 13 carried dirty linens from one end of the hall to the middle of the hall and placed them in a linen bin.
Interview with Nurse Aide 13 on August 19, 2024, at 12:40 p.m. confirmed that she was carrying the linens from a droplet isolation room (prevent the spread of germs when they are able to be spread through the air) to a linen cart in the middle of the hallway and should have had a dirty linen bin available inside the droplet isolation room.
Interview with Nursing Home Administrator on August 21, 2024, at 10:40 a.m. confirmed that the isolation rooms should have had their own dirty linen bin in each room, and that Nurse Aide 13 should not have been carrying unbagged, dirty linens from a droplet isolation room through the hall.
28 Pa. Code 201.14(a) Responsibility of Licensee.
28 Pa. Code 201.18(e)(1) Management.
28 Pa. Code 211.12(d)(1)(5) Nursing Services.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0578
(Tag F0578)
Could have caused harm · This affected most or all residents
Based on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that the resident and/or resident representative had an opp...
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Based on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that the resident and/or resident representative had an opportunity to develop an advance directive (instructions regarding the provision of health care when the resident is incapacitated) or assist in formulating an advance directive for 12 of 45 residents reviewed (Residents 56, 57, 64, 66, 69, 71, 76, 77, 78, 80, 86, 89).
Findings include:
The facility policy regarding advance care planning meeting protocol, dated July 1, 2024, indicated that upon each resident's admission to the facility, the resident will meet with the appropriate member of the healthcare team to ensure their preferences (Living Wills, Medical [NAME] of Attorney, etc.) are recorded in their medical record. Information regarding Advance Directives is provided to the resident and their family by the facility during the meeting. The resident and/or representative will be given the opportunity to discuss their goals for care including their preference for advance care planning. In the event there are legal documents to be obtained, the resident, family and staff will coordinate as a team to obtain such documents and place them in the clinical record. Results of the advance care planning will be communicated to the resident's care providers and documented in the clinical record.
A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 56, dated July 10, 2024, revealed that the resident was cognitively intact, clearly understood, able to clearly understand others, and required supervision with care needs.
A quarterly MDS assessment for Resident 57, dated July 30, 2024, revealed that the resident was moderately cognitively impaired, was understood, able to understand others, and required assistance with care needs.
An admission MDS assessment for Resident 64, dated July 3, 2024, revealed that the resident was cognitively impaired, rarely understood, rarely able to understand others, and required assistance with care needs.
A quarterly MDS assessment for Resident 66, dated August 1, 2024, revealed that the resident was cognitively intact, clearly understood, able to clearly understand others, and required assistance with care needs.
A quarterly MDS assessment for Resident 69, dated July 8, 2024, revealed that the resident was cognitively intact, clearly understood, able to clearly understand others, and required assistance with care needs.
An admission MDS assessment for Resident 71, dated May 23, 2024, revealed that the resident was cognitively intact, usually understood, usually able to understand others, and required substantial assistance with care needs.
A quarterly MDS assessment for Resident 76, dated July 1, 2024, revealed that the resident was cognitively impaired, understood, able to understand others, and required moderate supervision with care needs.
A quarterly MDS assessment for Resident 77, dated July 19, 2024, revealed that the resident was cognitively intact, clearly understood, able to clearly understand others, and required assistance with care needs.
A quarterly MDS assessment for Resident 78, dated June 19, 2024, revealed that the resident was cognitively impaired, clearly understood, able to clearly understand others, and required supervision with care needs.
A quarterly MDS assessment for Resident 80, dated June 5, 2024, revealed that the resident was cognitively intact, understood, able to understand others, and required assistance with care needs.
An annual MDS assessment for Resident 86, dated July 22, 2024, revealed that the resident was cognitively intact, understood, able to understand others, and required assistance with care needs.
A quarterly MDS assessment for Resident 89, dated June 25, 2024, revealed that the resident was cognitively intact, understood, able to understand others, and was dependent on staff with care needs.
Review of the clinical records for Residents 56, 57, 64, 66, 69, 71, 76, 77, 78, 80, 86 and 89 revealed no documented evidence to indicate that the residents and/or their representative were informed of their rights to develop advance directives, no documented evidence that the residents and/or their representatives were provided the opportunity and assistance to formulate an advance directive, and no documented evidence that advanced directives were addressed with the residents and/or resident representatives periodically throughout their course of stay.
Interview with the Social Service Director on August 20, 2024, at 1:41 p.m. confirmed that there was no documented evidence in the clinical records of Residents 56, 57, 64, 66, 69, 71, 76, 77, 78, 80, 86 and 89 that indicated the residents and/or their representatives were informed of their rights to develop advance directives, no documented evidence that the residents and/or their representatives were provided the opportunity and assistance to formulate an advance directive, and no documented evidence that advanced directives were addressed with the residents and/or resident representatives periodically throughout their course of stay.
28 Pa. Code 201.29(a)(d) Resident Rights.
CONCERN
(F)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0804
(Tag F0804)
Could have caused harm · This affected most or all residents
Based on review of policies, as well as observations and interviews with residents and staff, it was determined that hot foods were not served at proper and palatable temperatures.
Findings include:
...
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Based on review of policies, as well as observations and interviews with residents and staff, it was determined that hot foods were not served at proper and palatable temperatures.
Findings include:
The facility's policy regarding food temperatures, dated June 1, 2024, indicated that the temperatures of hot foods were to be served at 135 degrees Fahrenheit (F) or above.
Observations of tray line for the lunch meal in the main kitchen on August 21, 2024, revealed that the Second Floor food cart left the kitchen at 12:28 p.m. and arrived on the Second Floor at 12:32 p.m. The last resident was served at 12:43 p.m. At 12:45 p.m. the temperature of the chicken breast was 124 degrees F. The chicken breast was lukewarm to taste and not appetizing.
Interview with Dietary Director on August 21, 2024, at 1:11 p.m. confirmed that the temperatures of hot foods should have been at 135 degrees F when served to residents.
28 Pa. Code 211.6(b) Dietary Services.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected most or all residents
Based on review of policies, as well as observations and staff interviews, it was determined that the facility failed to ensure that food was stored and served in accordance with professional standard...
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Based on review of policies, as well as observations and staff interviews, it was determined that the facility failed to ensure that food was stored and served in accordance with professional standards for food service safety. The facility failed to ensure that the kitchen and its equipment was clean; that food stored in the kitchen and pantries was labeled, dated and secured; that an ice cream freezer had a thermometer; that food was thawing properly; and that staff should wear hairnets that covered all of their hair.
Findings include:
The facility's policy regarding storage of perishable food and food safety, dated July 1, 2024, revealed that staff are to cover, label, and date unused portions and opened packages, thawing meat should be placed below other food items and never on the counter to thaw, and freezers will be equipped with an internal thermometer. The facility's policy regarding proper hygiene, dated July 1, 2024, revealed that sanitary practices were to be used during food preparation in the kitchen, and hair restraints were to be worn in a manner to cover all hair.
Observations in the kitchen on August 19, 2024, between 9:05 a.m. and 9:13 a.m. revealed a microwave with a white, creamy substance that covered approximately half of the glass plate inside; water was pooled on the floor under the coffee machine; a meat slicer and large mixer with pieces of dried food remnants on the blade; a white, powdery substance that was stuck on the bowl and parts of the mixer; and the ice cream freezer that had no thermometer inside. Observations of the kitchen floor revealed that there were cups, lids, straws and general debris under the coffee counter, sink and throughout the kitchen. Observations on the top shelf of the cooks prep area revealed one bag of powdered chicken gravy mix and a 16-ounce bag of marshmallows that were opened and undated and exposed to air.
Observations in the walk-in cooler on August 19, 2024, between 9:13 a.m. and 9:28 a.m. revealed 12 blueberry muffins, eight ham slices, five pounds of yellow cheese, and four pounds of shredded cheddar cheese that were opened and exposed to air and undated. There was a whip cream pipet that was opened and secured but had no opened date on the plastic wrap, and a pan of plastic covered watermelon chunks measuring approximately fifteen inches by twenty inches that was being stored under a shelf that contained a thawing 10-pound ham, two pounds each of ham and turkey slices, and 18 slices of bacon.
Observations in the walk-in freezer on August 19, 2024, at 9:34 a.m. revealed two pie crusts and 27 pieces of pork mic-rib sandwich meat that was opened and exposed to air and undated. Observations in the second floor pantry freezer on August 20, 2024, at 11:14 a.m. revealed two boxes of vanilla ice cream bars, one box of coconut ice cream bars, and a 14-ounce container of ice cream that were opened, undated and unlabeled.
Observations in the kitchen during tray line (plating of food for the next meal) on August 21, 2024, between 11:49 a.m. and 12:02 p.m. revealed that Dietary [NAME] 12, who was plating food, wore a hairnet with approximately two inches of hair tendrils down her neck and on the sides of her head exposed. Dietary Aide 11, who was pulling pork apart, wore a hairnet with approximately one inch of hair on her forehead and approximately three to four inches of hair on her neck exposed. Food Service Worker 12, who was scooping cottage cheese and fruit into bowls, wore a hairnet with approximately two to four inches of hair down the back of her head and one inch of hair tendrils on each side that was exposed and touching her collar.
Observations in the kitchen on August 21, 2024, on 12:17 p.m. revealed a puddle of water under the ice machine that extended out onto the floor of the kitchen and a 10-pound ham thawing on the prep area counter.
Interview with the Dietary Manager on August 22, 2024, at 11:20 a.m. confirmed that the above-mentioned kitchen and pantry concerns should not have occurred and that staff were to have their hair completely covered.
28 Pa. Code 211.6(f) Dietary Services.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0925
(Tag F0925)
Could have caused harm · This affected most or all residents
Based on observations, a review of clinical records, as well as staff interviews, it was determined that the facility failed to maintain an effective pest control program.
Findings include:
The facili...
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Based on observations, a review of clinical records, as well as staff interviews, it was determined that the facility failed to maintain an effective pest control program.
Findings include:
The facility's policy on pest control, dated July 1, 2024, indicated that the facility will maintain a pest control program and that treatment will be rendered as required to control insects.
Observations of the cooks prep area/sink in the kitchen on August 19, 2024, at 9:10 a.m. revealed approximately six flies and several gnats in the sink around the food prep area. There were also several gnats in the general area of the kitchen.
Interview with the Dietary Manager on August 19, 2024, at 9:20 a.m. revealed that she did realize that the flies and gnats were there and indicated that maintenance was aware and had a pest control company in several times; however, the problem remains.
Interview with the Maintenance Director on August 20, 2024, at 3:05 p.m. revealed that the pest control company was coming every other month, and they were last there June 20, 2024. He indicated that the pest control company generally comes between the 15th and 22nd of the month, and that they were due to come to the facility. Once he was made aware of the concern regarding the kitchen, he requested the company come to the facility that day, which was August 19, 2024. Floor and sink drains in the kitchen and washroom were treated. Recommendations by the pest control company included a thorough cleaning of the kitchen and dish area, eliminating all food debris, proper ventilation, and fly lights. The Maintenance Director indicated that the pest control company will now come monthly.
Interview with the Nursing Home Administrator on August 21, 2024, at 2:26 p.m. confirmed that flies and gnats should not be in the kitchen.
28 Pa. Code 207.2(a) Administrator's Responsibility.
28 Pa. Code 201.18(e)(2)(3) Management.
Jul 2024
16 deficiencies
1 IJ (1 affecting multiple)
CRITICAL
(K)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Immediate Jeopardy (IJ) - the most serious Medicare violation
Deficiency F0919
(Tag F0919)
Someone could have died · This affected multiple residents
Based on review of policy and clinical records, as well as observations and resident and staff interviews, it was determined that the facility failed to ensure that the call bell system was adequately...
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Based on review of policy and clinical records, as well as observations and resident and staff interviews, it was determined that the facility failed to ensure that the call bell system was adequately equipped to allow residents to call for staff assistance, by failing to ensure that the call bell system was working. This failure put 15 of 22 residents reviewed who need to utilize their call bell for staff assistance in an Immediate Jeopardy situation.
Findings include:
The facility's policy regarding resident communication system and call lights, dated April 30, 2024, revealed that it was the policy of the facility to provide residents with a means of communicating with staff. A call system is installed in each resident room and toilet/bath area. The facility will respond to resident needs and requests.
A review of Resident Council meeting minutes, dated April 2024, May 2024, and June 2024, revealed that the residents were concerned about the call bell wait time and that they felt the wait time for a call bell to be answered was excessive, sometimes up to an hour.
Observations on July 2, 2024, from 10:13 a.m. to 10:30 a.m. revealed that the residents' call lights were recessed in the ceiling above their room and not visible from a couple of rooms away. There was no sound activated when a call bell was pressed.
Interview with Licensed Practical Nurse 5 on July 2, 2024, at 10:23 a.m. revealed that she relies on the nurse aides to answer the call bells, and that she will answer them if she knows they are on. She said that they do not make a sound anywhere. She did not have any device on her that alerted her if a call bell was pressed.
Interview with Registered Nurse 6 on July 2, 2024, at 10:23 a.m. revealed that she is not sure where the call bells sound to. She said that the nurse aides are responsible for answering the call bells and that she does try to help. She is new to the facility and not aware of any device that the nursing staff carries to alert them of any call bell.
Interview with Nurse Aide 4 on July 2, 2024, at 10:30 a.m. revealed that she tries to watch for the lights above the resident's door ways to indicate that the resident's call bell is on. She said there is no sound, and she does not know of any device that she should carry that would alert her that the call bell is on. She said the resident's have complained to her that they have waited too long, but she does not know how long their call bells were actually on because they do not make a sound.
Interview with Nurse Aide 7 on July 2, 2024, at 10:38 a.m. revealed that the call bells do not make a sound anywhere in the hall or at the nurse's station, and she did not have any device that alerted her that the resident's call bell was on.
Interview with the Nursing Home Administrator (NHA) on July 2, 2024, at 2:53 p.m. revealed that, in the past, the staff were supposed to carry a pager that would alert them when a resident's call bell was pressed. She stated that, at some point, the staff stopped charging the pagers and stopped carrying them. She stated that she purchased mini kiosks for the staff to be able to sit in the hallways and do their charting so they could visualize the recessed light above the resident's door when the resident would press their call bell. She was not sure why the staff that were interviewed were not aware that they were to be charting in the hallways and watching for call bells to light up. She said she was aware that the call bells were not sounding at the nurse's station because the current system did not function that way. She said that there was a system where the staff wore a pager and it would alert them when a call bell was pressed and that the nurse aide would be alerted first, and then the nurses would be alerted if the nurse aides did not answer the bell in an allotted time. However, she stated the pagers were misplaced or not charged and the staff were not carrying them.
On July 3, 2024, at 10:46 a.m. the NHA was informed that the health and safety of residents were in Immediate Jeopardy due to registered nurses, licensed practical nurses, and nurse aides not knowing when the residents were calling for assistance. The NHA was provided with the IJ template at 10:46 a.m.
The facility submitted and implemented an immediate plan to ensure resident safety by providing each resident with a tap bell or a cow bell that, when sounded, staff could audibly hear. The facility also placed hall monitors in each of the four halls so that the residents' bells could be heard and staff would be alerted as to who needed assistance. Staff were educated regarding the temporary system. The facility was able to locate pagers, replace the batteries, and pass them out to staff for use. The pagers will be signed in and out each shift, and maintenance will replace the batteries once a month.
The Immediate Jeopardy was lifted on July 3, 2024, at 4:36 p.m. when it was confirmed that each resident had a tap bell or a cow bell that was audible to staff; that over 90 percent of the nursing staff received education regarding the temporary call bell system, with the remaining staff scheduled to receive the education prior to the start of their next shift; and that the facility contacted a contractor to purchase a new call bell system or change the current one to a system that makes sounds at a central location.
28 Pa. Code 207.2(a) Administrator's Responsibility.
28 Pa. Code 211.12(d)(5) Nursing Services.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0557
(Tag F0557)
Could have caused harm · This affected 1 resident
Based on clinical record reviews, observations, and resident and staff interviews, it was determined that the facility failed to treat residents with dignity by failing to answer call bells timely for...
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Based on clinical record reviews, observations, and resident and staff interviews, it was determined that the facility failed to treat residents with dignity by failing to answer call bells timely for one of 22 residents reviewed (Resident 17).
Findings included:
An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 17, dated April 17, 2024, indicated that the resident was moderately cognitively impaired, usually could make herself understood, had limited range of motion of her upper and lower extremities, and required assistance from staff for daily care tasks. The resident's care plan, dated April 11, 2024, indicated that the call bell was to be in reach at all times.
Observations on July 2, 2024, from 10:01 a.m. to 10:22 a.m. revealed that Resident 17's call bell light was lit but there was no sound. No staff responded to the resident's call light, although nurses were in the hallway passing medications until 10:22 a.m., at which time Nurse Aide 1 arrived and Resident 17 told her that she needed her lotion, her sheets re-adjusted, and re-positioned.
Interview with Resident 17 on July 2, 2024, at 10:22 a.m. revealed that she has to wait awhile for her call light to be answered, sometimes a couple of hours, and that it was worse on the night shift.
Interview with Registered Nurse 2 on July 2, 2024, at 12:41 p.m. confirmed that staff needed to answer residents' call lights within ten minutes or as soon as possible.
28 Pa. Code 201.29(j) Resident Rights.
28 Pa. Code 211.12(d)(5) Nursing Services.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and staff interviews, it was determined that the facility failed to provide a clean and homelike environme...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and staff interviews, it was determined that the facility failed to provide a clean and homelike environment in residents' rooms on one of two halls toured (200 hall).
Findings include:
Observations of resident rooms 211, 220, 223, and 230 on July 2, 2024, at 10:13 a.m., 12:10 p.m., and 12:38 p.m. revealed that there was food debris, food wrappers, used gloves, medication cups, and used tissues on the floor.
Interview with the Director of Housekeeping on July 2, 2024, at 10:15 a.m. revealed that the housekeeping department is short staffed and that the little staff she has are trying to keep up with the work. She stated that there are some residents that are [NAME] than others and need their rooms cleaned more often; however, she does not have the staff to get that done. She stated she works with one full time staff on the second floor, and she has them alternate the long side one day and the short side the next. She said it is not ideal, but it is all she can do. She stated that the residents' rooms that need cleaned should get cleaned.
Interview with the Nursing Home Administrator on July 2, 2024, at 2:53 p.m. revealed that the housekeepers should be cleaning the residents' rooms daily, but that the department is short staffed. She stated that there are residents that want their rooms cleaned daily; however, it is not able to be done.
28 Pa. Code 201.29(j) Resident Rights.
28 Pa. Code 207.2(a) Administrator's Responsibility.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Transfer Notice
(Tag F0623)
Could have caused harm · This affected 1 resident
Based on clinical record reviews and staff interviews, it was determined that the facility failed to notify the resident and legal guardian, in writing, regarding the reason for hospitalization for on...
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Based on clinical record reviews and staff interviews, it was determined that the facility failed to notify the resident and legal guardian, in writing, regarding the reason for hospitalization for one of 22 residents reviewed (Resident 2).
Findings include:
A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 2, dated April 18, 2024, indicated that the resident was cognitively impaired, required supervision from staff for her personal care needs, and had diagnoses that included dementia.
A nursing note for Resident 2, dated May 5, 2024, at 10:00 p.m., revealed that the resident's physical and verbal aggression had increased. The physician was notified, and the resident was transferred to the hospital.
There was no documented evidence that a written notice of Resident 2's transfer to the hospital was provided to the resident's responsible party regarding the reason for transfer.
Interview with the Nursing Home Administrator on July 2, 2024, at 2:30 p.m. confirmed that the facility did not provide a written notice to the resident or the resident's responsible party when a resident was transferred to the hospital.
28 Pa. Code 201.25 Discharge Policy.
28 Pa. Code 201.29(f)(g) Resident Rights.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0625
(Tag F0625)
Could have caused harm · This affected 1 resident
Based on review of clinical records and staff interviews, it was determined that the facility failed issue a bed hold notice at the time of an anticipated leave of absence from the facility for one of...
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Based on review of clinical records and staff interviews, it was determined that the facility failed issue a bed hold notice at the time of an anticipated leave of absence from the facility for one of 22 residents reviewed (Resident 2).
Findings include:
A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 2, dated April 18, 2024, indicated that the resident was cognitively impaired, required supervision from staff for her personal care needs, and had diagnoses that included dementia.
A nursing note for Resident 2, dated May 5, 2024, at 10:00 p.m. revealed that the resident's physical and verbal aggression had increased. The physician was notified, and the resident was transferred to the hospital.
There was no documented evidence that a bed-hold notice was issued to Resident 2 or his responsible party at the time of the transfer to the hospital.
Interview with the Nursing Home Administrator on July 3, 2024, at 4:30 p.m. confirmed that the facility did not provide a bed-hold notice to the Resident 2 or the resident's responsible party when he was transferred to the hospital.
28 Pa. Code 201.14(a) Responsibility of Licensee.
28 Pa. Code 201.18(b)(3) Management.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected 1 resident
Based on review of Pennsylvania's Nursing Practice Act, clinical record review, and staff interviews, it was determined that the facility failed to ensure that a professional (registered) nurse assess...
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Based on review of Pennsylvania's Nursing Practice Act, clinical record review, and staff interviews, it was determined that the facility failed to ensure that a professional (registered) nurse assessed a resident after a change in condition for one of 22 residents reviewed (Resident 8), and failed to clarify physician's orders for one of 22 residents reviewed (Resident 12).
Findings include:
The Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.11 (a)(1)(2)(4) indicated that the registered nurse was to collect complete and ongoing data to determine nursing care needs, analyze the health status of individuals and compare the data with the norm when determining nursing care needs, and carry out nursing care actions that promote, maintain, and restore the well-being of individuals.
A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 8, dated April 13, 2024, indicated that the resident was cognitively impaired, required supervision with personal hygiene care, and had diagnoses that included diabetes.
Review of a fall investigation for Resident 8, dated May 17, 2024, at 6:30 a.m., revealed that the resident fell out of bed and was observed on the floor on the left side of his bed, sitting on his buttocks. There was no documented evidence in the clinical record that a registered nurse assessment was completed at the time of the fall.
Interview with the Director of Nursing (DON) on July 2, 2024, at 3:24 p.m. confirmed that there was no documented evidence in Resident 8's clinical record to indicate that a registered nurse assessment was completed at the time of a fall on May 17, 2024.
An admission MDS assessment for Resident 12, dated May 10, 2024, indicated that the resident was cognitively intact, was dependent on staff for personal hygiene care needs, had diagnoses that included osteomyelitis (inflammation or swelling of bone tissue that is usually the result of an infection), and had received intravenous (IV- way of giving medication through a needle or tube inserted into a vein) medication.
Physician's orders for Resident 12, dated May 28, 2024, included an order for the Resident to receive 25 milligrams (mg) of Benadryl every six hours.
A nurse's note for Resident 12, dated May 28, 2024, at 9:10 a.m., revealed that the physician was aware of the resident's lip and tongue swelling and ordered 50 mg of Benadryl to be given every six hours as needed.
Interview with the DON on July 3, 2024, confirmed that the nurse's note regarding the Benadryl orders that were implemented on May 28, 2024, do not match the physician's orders and should have been clarified.
28 Pa. Code 211.12(d)(1)(5) Nursing Services.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
Based on review of clinical records and staff interviews, it was determined that the facility failed to follow physician's orders for three of 22 residents reviewed (Residents 2, 3, 12).
Findings incl...
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Based on review of clinical records and staff interviews, it was determined that the facility failed to follow physician's orders for three of 22 residents reviewed (Residents 2, 3, 12).
Findings include:
A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 2, dated April 18, 2024, indicated that the resident was cognitively impaired, exhibited physical behavior symptoms, wandered daily, required assistance with personal care needs, and had diagnoses that included dementia.
Physician's orders for Resident 2, dated May 2, 2024, included an order for the resident to have one-on-one supervision to monitor behaviors for 24 hours.
Review of the Medication Administration Record (MAR) for Resident 2, dated May 2024, revealed that one-on-one supervision was not done on the night shift of May 2, 2024.
Interview with the Director of Nursing (DON) on July 2, 2024, at 10:49 a.m. confirmed that there was no documented evidence that one-on-one supervision of Resident 2 was completed on May 2, 2024, as ordered.
A quarterly MDS assessment for Resident 3, dated April 1, 2024, revealed that the resident was cognitively impaired, wandered, and had diagnoses that included Parkinson's disease (a disorder of the central nervous system that affects movement, often including tremors) and anxiety. Physician's orders for Resident 3, dated May 20, 2024, included orders that the resident was to have one-on-one supervision at all times.
Review of the May 2024 MAR for Resident 3 revealed that one-to-one supervision was ordered for May 20, 2024, through May 30, 2024. However, one-to-one supervision was not provided for Resident 3 on May 21, 23 and 24, 2024, at 8:00 a.m.; and May 21, 23, 29 and 30, 2024, at 2:00 p.m.
Interview with the Nursing Home Administrator on July 3, 2024, at 3:46 p.m. confirmed that there was no documentation that one-on-one supervision of Resident 3 was completed on mentioned dates and times.
An admission MDS assessment for Resident 12, dated May 10, 2024, indicated that the resident was cognitively intact, was dependent on staff for personal hygiene care needs, had diagnoses that included osteomyelitis (inflammation or swelling of bone tissue that is usually the result of an infection), and had received intravenous (IV- way of giving medication through a needle or tube inserted into a vein) medication.
Physician's orders for Resident 12, dated May 17, 2024, included an order for the resident to receive 1 gram of vancomycin (an antibiotic medication) intravenously every 12 hours.
Physician's orders for Resident 12, dated May 20, 2024, included an order for the vancomycin to be held for one day and to have the pharmacy provide dosage orders for the vancomycin. There was no documented evidence that the facility notified that pharmacy of the need for vancomycin dosage orders until May 25, 2024.
Interview with the DON on July 3, 2024, confirmed that staff did not follow physician's orders to notify the pharmacy about dosing the vancomycin in a timely manner.
28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and resident and staff interviews, it was determined that the facility failed to ensure oxygen concentrato...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and resident and staff interviews, it was determined that the facility failed to ensure oxygen concentrators were functioning properly for four of 22 residents reviewed (Residents 13, 14, 15, 16).
Findings include:
A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 13, dated May 9, 2024, indicated that she was cognitively impaired, was dependent on staff for personal care needs, and had diagnoses that included chronic obstructive pulmonary disease (COPD - lung disease causing restricted airflow and breathing problems) and received supplemental oxygen therapy.
Observations on July 2, 2024, at 10:15 a.m. revealed that the oxygen concentrator (device used to provide supplemental oxygen to someone with difficulty breathing) being used by Resident 13 in her room was providing oxygen; however, it was producing a loud beeping sound approximately every fifteen seconds that could be heard from the hallway.
A clinical record review for Resident 14 revealed that the resident was readmitted to the facility on [DATE], with a diagnosis of congestive heart failure. A cognitive assessment, dated July 1, 2024, indicated the resident was cognitively intact.
Observations on July 2, 2024, at 10:32 a.m. revealed that the oxygen concentrator being used by Resident 14 in his room was providing oxygen; however, it was producing a loud beeping sound approximately every fifteen seconds that could be heard from the hallway.
Interview with Resident 14 on July 2, 2024, at 11:40 a.m. revealed that he believed his oxygen concentrator was beeping continuously since his readmission on [DATE].
Review of clinical records for Resident 15 revealed that she was admitted to the facility on [DATE], with diagnoses that included shortness of breath and pleural effusion (buildup of fluid between the layers of tissue that line the lungs). A cognitive assessment, dated June 28, 2024, indicated the resident was cognitively intact.
Observations on July 2, 2024, at 10:33 a.m. revealed that the oxygen concentrator being used by Resident 15 in her room was providing oxygen; however, it was producing a loud beeping sound approximately every fifteen seconds that could be heard from the hallway.
An annual MDS assessment for Resident 16, dated April 11, 2024, indicated that she had moderate cognitive impairment, was dependent on staff for personal care needs, and had diagnoses that included diabetes and COPD, and received supplemental oxygen therapy.
Observations on July 2, 2024, at 10:53 a.m. revealed that the oxygen concentrator being used by Resident 16 in her room was providing oxygen; however, it was producing a loud beeping sound approximately every fifteen seconds that could be heard from the hallway.
Interview with Licensed Practical Nurse 3 on July 2, 2024, at 11:01 a.m. revealed that oxygen concentrators beeping in the facility are a common occurrence. Maintenance will replace the beeping concentrators when requested, but it sometimes takes three to four attempts to get a concentrator that does not beep.
Interview with the Nursing Home Administrator on July 2, 2024, at 3:01 p.m. revealed that oxygen concentrators should not be making beeping noises while in use, and that she was in the process of ordering new oxygen concentrators.
28 Pa. Code 211.12(d)(5) Nursing Services.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0810
(Tag F0810)
Could have caused harm · This affected 1 resident
Based on review of policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that staff provided assistive devices to eat in acc...
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Based on review of policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that staff provided assistive devices to eat in accordance with the resident's care plan for one of 22 residents reviewed (Resident 17).
Findings include:
The facility's policy regarding adaptive equipment, dated April 30, 2024, indicated that adaptive equipment to meet residents' needs would be determined by therapy.
An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 17, dated April 17, 2024, indicated that the resident was moderately cognitively impaired, had limited range of motion of her upper extremities, and required partial assistance with eating after set up. An occupational therapy note, dated April 26, 2024, indicated that Resident 17 was to use foam built-up utensils for self-feeding.
Observations of Resident 17 during the lunch meal on July 2, 2024, at 12:31 p.m. revealed that the resident was in her room eating her meal using regular utensil, and did not have built-up utensils. The resident's meal ticket, dated July 2, 2024, indicated that she was to have utensils with red foam.
Interview with Registered Nurse 2 on July 2, 2024, at 12:44 p.m. confirmed that Resident 17 did not have built-up utensils for the meal, which was not in accordance with the meal ticket.
Interview with the Dietary Manager on July 3 2024, at 4:12 p.m. confirmed that if Resident 17's meal ticket indicated that the resident was to have had built-up utensils, they should have been provided on her tray.
28 Pa. Code 211.12(d)(3)(5) Nursing Services.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Administration
(Tag F0835)
Could have caused harm · This affected 1 resident
Based on review of job descriptions and the deficiencies cited during the current survey, it was determined that the Nursing Home Administrator (NHA) and the Director of Nursing (DON) failed to assume...
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Based on review of job descriptions and the deficiencies cited during the current survey, it was determined that the Nursing Home Administrator (NHA) and the Director of Nursing (DON) failed to assume responsibility for effective management of the facility to ensure that the facility was adequately equipped to allow residents to call for staff assistance through a communication system, which relays the call directly to a staff member or to a centralized staff work area from their rooms or bathrooms.
Findings include:
The job description for the NHA, dated May 15, 2023, indicated that the NHA would lead and direct the overall operations of the nursing facility in accordance with the community policies and procedures, customer and resident needs, and both state and federal guidelines.
The job description for the DON, dated June 17, 2024, indicated that the DON would organize, develop, manage, and direct the overall operations of the Nursing Service Department in accordance with the current federal, state and local standards, guidelines and regulations that govern the community.
The deficiencies cited under the Code of Federal Regulatory Groups for Long Term Care, 483.90(g)(1)(2) Resident Call System (F919) revealed that the NHA and DON failed to fulfill their essential job duties for ensuring the safety of residents.
Refer to F919.
28 Pa. Code 201.14(a) Responsibility of Licensee.
28 Pa. Code 201.18(b)(1)(e)(1) Management.
28 Pa. Code 211.12(d)(1)(5) Nursing Services.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Grievances
(Tag F0585)
Could have caused harm · This affected multiple residents
Based on review of facility policy, clinical records, and Resident Council meeting minutes, as well as observations and resident and staff interviews, it was determined that the facility failed to mak...
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Based on review of facility policy, clinical records, and Resident Council meeting minutes, as well as observations and resident and staff interviews, it was determined that the facility failed to make ongoing efforts to resolve resident grievances presented during the resident council meetings and for one of 22 residents reviewed (Resident 17).
Findings include:
The facility's grievance policy, dated April 30, 2024, indicated that the grievance official, or designee, would investigate the concern/grievance immediately, and that upon conclusion of the investigation, residents would be notified of the results.
Resident Council meeting minutes, dated April 2024, May 2024, and June 2024, revealed that the residents were upset regarding long call bell wait times, and that they were not getting the food items they were supposed to get for their meals.
Observations on July 2, 2024, from 10:01 a.m. to 10:22 a.m. revealed that Resident 17's call bell light was lit and ringing. No staff responded to the resident's call bell, although nurses were in the hallway passing medications until 10:22 a.m., at which time Nurse Aide 1 arrived and Resident 17 told her that she needed her lotion, her sheets re-adjusted, and re-positioned.
Interview with Resident 17 on July 2, 2024, at 10:22 a.m. revealed that she has to wait awhile for her call bell to be answered, sometimes a couple of hours, and that it was worse on the night shift.
Observations of the lunch meal on July 2, 2024, at 12:11 p.m. revealed that Residents 17, 18, 19, and 20 did not get the food that they ordered for their lunch meal. Resident 17 was missing tomato soup, Resident 18 was missing a roll/bread, Resident 19 was missing tomato soup, and Resident 20 did not receive his double portions.
Interview with the Nursing Home Administrator on July 2, 2024, at 2:53 p.m. confirmed that the residents' grievances presented in the council meetings in April 2024, May 2024, and June 2024 regarding call bell wait times and not receiving the correct food items on their meal trays have not been resolved satisfactorily and that they should have been.
An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 17, dated April 17, 2024, indicated that the resident was moderately cognitively impaired, usually could make herself understood, had limited range of motion of her upper and lower extremities, and required assistance from staff for daily care tasks.
Interview with Resident 17 on July 2, 2024, at 10:22 a.m. revealed that about a month and a half ago she was being bathed by staff and her privacy curtain was not pulled around the bed, the door to her room was kept open, and there were men visible in the hallway. She indicated that she filed a grievance; however, no one ever came to talk to her about it.
A review of the facility's grievance log for April 2024, May 2024, and June 2024 revealed that there was no documented evidence that a grievance was completed regarding Resident 17's concerns.
Interview with the Nursing Home Administrator on July 3, 2024, at 3:46 p.m. revealed that she was not able to find a grievance regarding Resident 17's concerns. She indicated that she talked with the resident's sister about the incident but should have completed a grievance according to the facility's policy.
28 Pa. Code 201.29(i) Resident Rights.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected multiple residents
Based on a review of clinical records, facility policy review, and resident and staff interviews, it was determined that the facility failed to ensure that residents were provided with showers as sche...
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Based on a review of clinical records, facility policy review, and resident and staff interviews, it was determined that the facility failed to ensure that residents were provided with showers as scheduled for one of 22 residents reviewed (Resident 16).
Findings include:
A facility policy for resident showers indicated that residents will be provided showers as per request or as per facility schedule protocols.
An annual MDS assessment for Resident 16, dated April 11, 2024, indicated that the resident was understood and could understand others, was dependent on staff for personal care needs, and had diagnoses that included diabetes.
A care plan for Resident 16, dated July 26, 2023, indicated that the resident preferred to have showers every Wednesday and Saturday during the second shift.
Review of bathing documentation for Resident 16, dated May 3, 2024, through July 3, 2024, indicated that the resident only received six showers during that time. There was no documented evidence that the resident was offered or refused showers twice weekly as per her care plan.
Interview with Resident 16 on July 3, 2024, at 3:56 p.m. revealed that she is supposed to get a shower every Wednesday and Saturday; however, there were times that staff told her they do not have time to give her a shower, and they gave her a bed bath instead. The resident revealed that she would prefer to get a shower twice a week instead of a bed bath.
Interview with the Director of Nursing on July 3, 2024, at 5:33 p.m. confirmed that there was no documented evidence that Resident 16 was offered or refused showers twice a week from May 3, 2024, through July 3, 2024, per the resident's care plan.
28 Pa. Code 211.12(d)(5) Nursing Services.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0692
(Tag F0692)
Could have caused harm · This affected multiple residents
Based on clinical record reviews and staff interviews, it was determined that the facility failed to ensure that there was timely physician notification and intervention for a significant weight loss ...
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Based on clinical record reviews and staff interviews, it was determined that the facility failed to ensure that there was timely physician notification and intervention for a significant weight loss for two of 22 residents reviewed (Residents 1, 16).
Findings include:
A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated May 9, 2024, indicated that the resident was severly cognitively impaired, was dependent on staff for daily care, and that he had diagnoses that included dementia. The resident's weight records revealed that he experienced a 17.5-pound weight loss from January 13, 2024, to March 25, 2024; and another 4.5 pound weight loss from April 2, 2024, to May 2, 2024. The resident's care plan, dated August 18, 2023, indicated that staff were to monitor the resident for malnutrition and significant weight loss of greater than 5 percent in one month, 7.5 percent in three months, or 10 percent in six months and notify the physician of the weight loss.
There was no documented evidence that the physician or the dietician was notified regarding Resident 1's weight changes or that any interventions were put into place to prevent further weight loss.
Interview with the Director of Nursing (DON) on May 22, 2024, at 2:59 p.m. confirmed that there was no documented evidence that any interventions to prevent further weight loss were implemented for Resident 56, including notifying the physician, addressing the possible need for an appetite stimulant, and obtaining weekly weights.
An annual MDS assessment for Resident 16, dated April 11, 2024, indicated that she had moderate cognitive impairment, was dependent on staff for personal care needs, and had diagnoses that included diabetes and COPD.
Review of the weight records for Resident 16 revealed that she experienced a 25.2-pound weight loss from April 2, 2024, to April 6, 2024, indicating an 8.16 percent weight loss in less than a month. She experienced a 42.7-pound weight loss from May 2, 2024, to June 6, 2024, indicating a 13.77 percent weight loss in a month. The resident had a 44-pound weight loss from December 22, 2023, to June 15, 2024, indicating a 14.19 percent weight loss in six months.
Review of the care plan for Resident 16, dated September 6, 2023, indicated that staff were to monitor the resident for malnutrition and significant weight loss of greater than 5 percent in one month, 7.5 percent in three months, or 10 percent in six months and notify the physician of the weight loss.
There was no documented evidence that the physician was notified regarding Resident 16's weight changes or that any interventions were put into place to prevent further significant weight loss.
Interview with the DON on July 3, 2024, at 5:33 p.m. confirmed that there was no documented evidence that the physician had been notified of Resident 16's significant weight loss as care planned and he should have been notified.
28 Pa. Code 211.12(d)(3)(5) Nursing Services.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Menu Adequacy
(Tag F0803)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the facility's written menus, observations, and staff interviews, it was determined that the facility failed ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the facility's written menus, observations, and staff interviews, it was determined that the facility failed to follow their planned menu for three of 22 residents reviewed (Residents 17, 18, 20).
Findings include:
The facility's written and posted menu for the lunch meal on July 2, 2024, revealed that the residents were to receive homemade meatloaf, mashed potatoes, green beans, cinnamon applesauce, milk, coffee, roll/bread, and margarine. The alternate was a ham and cheese sandwich, tomato soup, and hot tea.
An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 17, dated April 17, 2024, indicated that the resident was moderately cognitively impaired, had limited range of motion of her upper extremities, and required partial assistance with eating after set up. The resident's care plan, dated April 11, 2024, indicated that staff were to provide her diet per order, encourage intake, and to honor her dietary choices.
Observations of Resident 17 during the lunch meal on July 2, 2024, at 12:31 p.m. revealed that the resident was in her room eating her meal and she reported that she did not receive her tomato soup. The resident's meal ticket, dated July 2, 2024, indicated that she requested the tomato soup; however, there was no tomato soup on her meal tray.
Interview with Registered Nurse 2 on July 2, 2024, at 12:44 p.m. confirmed that Resident 17 did not have tomato soup on her meal tray, which was not in accordance with the meal ticket.
A quarterly MDS assessment for Resident 18, dated April 3, 2024, indicated that the resident was cognitively impaired, and that he was able to feed himself after his tray was set up for him. The resident's care plan, dated January 5, 2024, indicated that staff were to provide his diet per order, to encourage intake, and to honor his dietary choices.
Observations during the lunch meal on July 2, 2024 at 12:11 p.m. revealed that Resident 18 did not receive any bread or roll and he indicated at that time that he would like to have one.
According to Resident 20's clinical record, the resident was admitted to the facility on [DATE]. The resident's dietary assessment, dated June 26, 2024, indicated that the resident was requesting double portions.
Observations of Resident 20 on July 2, 2024 at 12:33 p.m. revealed that he did not receive double portions of the meatloaf, mashed potatoes, or green beans.
Interview with Nurse Aide 4 on July 2, 2024 at 12:11 p.m. and 12:33 p.m. confirmed that Resident 18 did not receive a roll/bread and should have, and that Resident 20 did not receive double portions of the meatloaf, mashed potatoes, and green beans and that he should have.
Interview with the Dietary Manager on July 3, 2024, at 4:12 p.m. confirmed that if food items were listed on the resident's meal ticket, they should have received the items on their meal tray.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0808
(Tag F0808)
Could have caused harm · This affected multiple residents
Based on a review of clinical records, observations, and resident and staff interviews, it was determined that the facility failed to ensure that a therapeutic diet was provided as ordered by the phys...
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Based on a review of clinical records, observations, and resident and staff interviews, it was determined that the facility failed to ensure that a therapeutic diet was provided as ordered by the physician for one of 22 residents reviewed (Resident 19).
Findings include:
Review of quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 19, dated June 1, 2024, indicated that the resident was cognitively intact and that she had diagnoses that included diabetes. A care plan, dated April 12, 2024, revealed that Resident 19 was to receive a low-sugar meal and that she prefers diet iced tea to drink.
Physician's orders for Resident 19, dated May 29, 2024, included an order for the resident to receive a low concentrated sweets, high protein, low carbohydrate diet.
Observations of Resident 19's meal tray on July 2, 2024, at 12:11 p.m. revealed that her tray ticket indicated that she was to have tomato soup, ham and cheese sandwich, cinnamon applesauce, coffee, milk, a mighty shake (special milk shake with added protein), and diet iced tea. There was no tomato soup on her tray, and she received two regular iced teas and not diet.
Interview with Resident 19 on July 2, 2024, at 12:11 p.m. revealed that she has not been getting diet iced tea, only regular tea, and that she does not usually get the food that she selects on her tray ticket. She said that she does drink the regular tea, even though her blood sugar levels will run high, because she is thirsty and wants the drink. She further said that she had asked for diet iced tea in the past and was told there was none, so she stopped asking for it.
Interview with Registered Nurse 2 on July 2, 2024, at 12:31 p.m. confirmed that Resident 19's tray ticket indicated that she was to have tomato soup and diet iced tea; however, she did not receive them. She further stated she should not drink the regular iced tea because of the amount of sugar in them.
Interview with the Nursing Home Administrator on July 2, 2024, at 2:53 p.m. revealed that the residents' diets should be followed according to the physician's orders and that the kitchen should supply the correct food items.
28 Pa. Code 201.29(j) Resident Rights.
28 Pa. Code 211.6(a) Dietary Services.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected multiple residents
Based on review of clinical records, as well as staff interviews, it was determined that the facility failed to maintain clinical records that were complete and accurately documented for one of 22 res...
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Based on review of clinical records, as well as staff interviews, it was determined that the facility failed to maintain clinical records that were complete and accurately documented for one of 22 residents reviewed (Resident 2).
Findings include:
A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 2, dated April 18, 2024, indicated that the resident was cognitively impaired, exhibited physical behavior symptoms, wandered daily, required assistance with personal care needs, and had diagnoses that included dementia. The resident had an MDS assessment, dated May 5, 2024, indicating that the resident was discharged with return anticipated.
A review of the census record for Resident 2 revealed that he was discharged on May 20, 2024.
A nursing note for Resident 2, dated May 5, 2024, at 10:00 p.m. revealed that the resident's physical and verbal aggression had increased, the physician was notified, and Resident 2 was transferred to the hospital.
A nursing note for Resident 2, dated May 14, 2024, at 3:33 p.m. revealed that the resident remained out of the facility related to an increase in aggressive behaviors that compromised the safety of the facility and that the interdisciplinary team would review the resident's plan of care upon his return to the facility. There was no further documentation in the resident's clinical record to indicate the discharge plan for Resident 2.
Interview with the Nursing Home Administrator on July 2, 2024, at 2:59 p.m. revealed that facility had communicated with the hospital regarding Resident 2's return to the facility and eventual discharge from the facility; however, there was no documentation in Resident 2's clinical record indicating that the facility was communicating with the hospital or that the resident had discharge plans. The Nursing Home Administrator confirmed that the resident's clinical record was incomplete.
28 Pa. Code 211.5(f) Clinical Records.
28 Pa. Code 211.12(d)(1)(5) Nursing Services.
Jun 2024
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Investigate Abuse
(Tag F0610)
Could have caused harm · This affected 1 resident
Based on clinical record reviews and staff interviews, it was determined that the facility failed to conduct a thorough investigation to rule out abuse or neglect for one of seven residents reviewed (...
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Based on clinical record reviews and staff interviews, it was determined that the facility failed to conduct a thorough investigation to rule out abuse or neglect for one of seven residents reviewed (Resident 7).
Findings include:
The facility's policy regarding abuse, dated January 1, 2024, indicated that the facility will investigate all allegations, suspicions and incidents of abuse, neglect, involuntary seclusion, intimidation, exploitation of residents, misappropriation property and injuries of unknown source.
A quarterly Minimum Data Set (MDS) assessment (a federally-mandated assessment of a resident's abilities and care needs) for Resident 7, dated April 1, 2024, revealed that the resident was cognitively impaired, required assistance from staff for daily care needs, and had a diagnosis of dementia.
A nursing note, dated April 14, 2024, at 5:35 a.m. revealed that Resident 7 entered another resident's room and was involved in an altercation that involved physical contact. The residents were separated and there were no injuries.
Witness statements, dated April 14, 2024, revealed that Resident 7 was heard yelling in another resident's room, was involved in an altercation, removed from the room, and escorted back to her room with no injuries noted.
Interview with Director of Nursing on June 18, 2024, at 1:35 p.m. revealed that the witness statements, dated April 14, 2024, were the only documentation related to the incident involving Resident 7. Additionally, the Director of Nursing confirmed that there was no documented evidence that the incident was thoroughly investigated to rule out possible abuse.
A nursing note for Resident 7, dated June 10, 2024, at 6:34 a.m., revealed that the resident woke up in the middle of the night and pushed the bedside table into roommate's leg repeatedly. The incident was not witnessed by staff. Resident 7 was assisted back to bed, emotional support was offered, and she was resting quietly in bed.
Witness statements, dated June 10, 2024, revealed that Resident 7 had pushed her bedside table in to the leg of her roommate and that the registered nurse was notified.
Interview with the Director of Nursing on June 18, 2024, at 1:35 p.m. revealed that the witness statements, dated June 10, 2024, were the only documentation related to the incident involving Resident 7. Additionally, the Director of Nursing confirmed that there was no documented evidence to indicate that the incident was thoroughly investigated to rule out possible abuse.
Interview with the Nursing Home Administrator on June 18, at 2:00 p.m. confirmed that incidents involving Resident 7 on April 14, 2024, and June 10, 2024, should have been thoroughly investigated to rule out abuse and they were not.
28 Pa. Code 201.18(e)(1) Management.
28 Pa. Code 211.12(d)(5) Nursing Services.
Apr 2024
6 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0558
(Tag F0558)
Could have caused harm · This affected 1 resident
Based on clinical record reviews and staff interviews, it was determined that the facility failed to accommodate residents' preferences regarding showers for two of nine residents reviewed (Residents ...
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Based on clinical record reviews and staff interviews, it was determined that the facility failed to accommodate residents' preferences regarding showers for two of nine residents reviewed (Residents 5, 8).
Findings include:
An annual Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 5, dated February 20, 2024, revealed that the resident was sometimes understood, sometimes understands, and had a diagnosis which included dementia and Alzheimer's disease. A care plan for the resident, dated November 29, 2023, revealed that she required assistance with care tasks and preferred to shower.
Nurse aide shower assignments for Resident 5, undated, revealed that the resident was to receive a shower every Tuesday and Saturday.
Shower records for Resident 5, dated February, March, and April 2024, revealed that on February 10, 17, 20, 24, and 27, 2024; March 16, 19, and 26, 2024; and April 2, 6, and 9, 2024, the resident received a bed bath and did not receive a shower as she preferred.
A quarterly MDS assessment for Resident 8, dated February 1, 2024, revealed that the resident was cognitively intact, sometimes understands, and had a diagnosis which included dementia. A care plan, dated July 3, 2023, revealed that Resident 8 preferred to shower.
Nurse aide shower assignments for Resident 8 revealed that the resident was to receive a shower every Monday and Thursday.
Shower records for Resident 8, dated February, March, and April 2024, revealed that the resident was not showered according to her preference on February 8, 12, 15, 19, 22, and 26; March 4, 7, 11, 18, 21, and 25; and April 1, 4, 8, 11, 15 and 18, 2024.
Interview with the Director of Nursing and the Assistant Director of Nursing April 18, 2024, at 5:25 p.m. confirmed that there was no documented evidence of why Resident 5 and 8 were provided bed baths instead of a shower as preferred.
28 Pa. Code 201.29(j) Resident Rights.
28 Pa. Code 211.12(d)(5) Nursing Services.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
Based on review of facility polices and clinical record reviews, as well as staff interviews, it was determined that the facility failed to develop a plan of care to address a resident's psychosocial ...
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Based on review of facility polices and clinical record reviews, as well as staff interviews, it was determined that the facility failed to develop a plan of care to address a resident's psychosocial well-being related to her fear and not feeling safe after a resident-to-resident incident for one of nine residents reviewed (Resident 7).
Findings include:
The facility's policy regarding care plan development, dated January 1, 2024, indicated that an interdisciplinary plan of care will be established for every resident and updated in accordance with state and federal regulatory requirements and on an as needed basis to meet the resident's medical, nursing, and mental and psychosocial needs.
An annual Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) assessment for Resident 7, dated March 19, 2024, revealed that the resident was cognitively intact, was understood and could understand, had no behaviors, and required assistance with care needs.
A nursing note for Resident 7, dated April 14, 2024, at 5:30 a.m., revealed that she reported she had laid down in bed after going into the restroom. She was adjusting the placement of her walker with one of her assistive devices and Resident 4 came out of the bathroom and into her room and walked over toward her. She told Resident 4 to go back to her own room, but the resident continued to walk toward her. Resident 4 accused Resident 7 of hitting her with the assistive device and grabbed her by the wrists and squeezed them. They were separated by one of the nurses. Upon assessment, Resident 7's right lateral wrist was noted to have a dark, pea-sized bruise with no open skin. She also reported some discomfort to her wrist.
Interview with Resident 7 on April 18, 2024, at 12:22 p.m. revealed that Resident 4 from next door came in a few nights ago and grabbed her when she was in bed. She stated that Resident 4 came in through the bathroom and told her to get out that this was her house and her bed. Resident 7 stated that Resident 4 still comes into her room, even though there is a stop sign on the bathroom door, and that she no longer feels safe. She stated that Resident 4 also came in her room and went through her closet and drawers.
There was no documented evidence to indicate that a care plan was developed to address Resident 7's psychosocial well-being related to her fear of not feeling safe after the resident-to-resident incidents.
Interview with the Director of Nursing on April 18, 2024, at 3:20 p.m. confirmed that there was no care plan in place to address Resident 7's psychosocial well-being related to her fear and not feeling safe after the resident-to-resident incidents.
28 Pa. Code 201.24(e)(4) admission Policy.
28 Pa. Code 211.12(d)(5) Nursing Services.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected 1 resident
Based on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that a resident's care plan was updated/revised to reflect ...
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Based on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that a resident's care plan was updated/revised to reflect the resident's specific behavioral intervention for one of nine residents reviewed (Resident 4).
Findings include:
The facility's policy regarding care plan development, dated January 1, 2024, indicated that an interdisciplinary plan of care will be established for every resident and updated in accordance with state and federal regulatory requirements and on an as needed basis to meet the resident's medical, nursing, and mental and psychosocial needs.
A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) assessment for Resident 4, dated April 1, 2024, revealed that the resident was cognitively impaired, walked independently without an assistive device, had wandering behaviors, and had a wander/elopement alarm used daily.
A nursing note on April 15, 2024, at 9:47 a.m. revealed that the interdisciplinary team reviewed the incident of Resident 4 going into Resident 7's room through a shared bathroom. A stop sign was to be placed on the opposite bathroom door and a sign with the resident's name on her side.
A psychosocial care plan to address Resident 4's wandering behavior, initiated on November 14, 2023, included interventions to assess whether the behavior endangers the resident and/or others and intervene if necessary; maintain a calm environment and approach to the resident; when resident begins to wander, provide comfort measures for basic needs (e.g., pain, hunger, toileting, too hot/cold, etc.). There was no documented evidence that Resident 4's care plan was revised to reflect the intervention for the stop sign.
Interview with the Director of Nursing on April 18, 2024, at 3:53 p.m. confirmed that Resident 4's care plan was not revised to reflect the intervention for the stop sign, and it should have been.
28 Pa. Code 201.24(e)(4) admission Policy.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0742
(Tag F0742)
Could have caused harm · This affected 1 resident
Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that a resident who displayed mental or psychosocial adjustment diff...
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Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that a resident who displayed mental or psychosocial adjustment difficulties received appropriate treatment and services to correct the problem for one of nine residents reviewed (Resident 2).
Findings include:
The facility's behavior policy, dated January 1, 2024, revealed that the goal of the facility was to improve management of behaviors and move closer to the goal of ending any inappropriate or unnecessary use of antipsychotic medications. The facility would assess and track a behavior(s) that negatively impacted each resident in regards to their quality of life.
An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 2, dated January 26, 2024, revealed that the resident was cognitively impaired, had physical behaviors, other behavioral symptoms not directed toward others, wandered, was receiving and antipsychotic and antidepressant medications, and had diagnoses that included dementia. Physician's orders, dated January 20, 2024, included orders for the resident to receive 25 milligrams (mg) of quetiapine (antipsychotic medication) twice a day, 5 mg of olanzapine (antipsychotic medication) every twelve hours as needed for agitation, and 10 mg of donepezil (medication used to treat dementia) at bedtime.
A nursing note, dated January 21, 2024, at 7:15 p.m., revealed that the resident was in a fight with Resident 9 on the third floor common area known as the alcove.
A psychiatric consult, dated January 25, 2024, revealed that the resident was seen for anxiety and dementia with behavioral disturbances. Recommendations were made to discontinue the resident's Seroquel (quetiapine) and Zyprexa (olanzapine), and to start 0.5 mg of Risperdal (antipsychotic medication) twice a day and 0.5 mg of Ativan (antianxiety medication) every eight hours as needed for 14 days. However, there was no documented evidence that the resident's Seroquel and Zyprexa were discontinued or that Risperdal and Ativan were started.
A nursing note, dated April 4, 2024, at 22:03 p.m., revealed that Resident 2 walked by and aggressively bumped into Resident 1 with his shoulder and knocked the other resident to the floor.
A psychiatric consult, dated April 5, 2024, revealed that the resident was seen for anxiety and other behavioral disturbances. Recommendations were made to discontinue the resident's Zyprexa and donepezil, and to start 125 mg of Depakote (mood stabilizer) at bedtime and 0.5 mg of Ativan every eight hours as needed. However, there was no documented evidence that the recommendations were initiated until April 10, 2024 (five days later).
A nursing note, dated April 10, 2024, at 9:50 a.m., revealed that the resident's wife called and asked if the resident's Depakote was ordered from the psychiatric visit on April 5, 2024. She was told that it was not ordered and requested the last psychiatric report be sent so they could see the recommendations.
Interview with the Director of Nursing on April 18, 2024, at 5:29 p.m. revealed that recommendation from the psychiatric consult on January 25, 2024, were missed and not implemented, and the recommendations from the psychiatric consult on April 5, 2024, were delayed and not initiated until April 10, 2024.
28 Pa. Code 201.18(b)(1) Management.
28 Pa. Code 211.12(d)(3)(5) Nursing Services.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0743
(Tag F0743)
Could have caused harm · This affected 1 resident
Based on clinical record reviews and facility reports, as well as staff interviews, it was determined that the facility failed to ensure that a resident did not display increased angry and aggressive ...
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Based on clinical record reviews and facility reports, as well as staff interviews, it was determined that the facility failed to ensure that a resident did not display increased angry and aggressive behaviors by not following care-planned interventions for one of nine residents reviewed (Resident 6), resulting in the resident hitting another resident, and failed to evaluate appropriate treatment and services to maintain the resident's highest practicable physical and mental well-being by failing to address a resident's fear and not feeling safe after a resident-to-resident incident for one of nine residents reviewed (Resident 7).
Findings include:
A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated March 29, 2024, revealed that the resident was sometimes understood, sometimes understands, exhibited wandering daily, and had a diagnosis which included Alzheimer's disease and dementia. A care plan for the resident, dated March 20, 2024, revealed that the resident exhibited wandering behaviors. Staff were to remove the resident from other resident's rooms and unsafe situations.
A quarterly MDS assessment for Resident 6, dated February 5, 2024, revealed that the resident was understood and could understand others. A care plan for the resident, dated August 15, 2023, revealed that the resident has attention-seeking behaviors towards males and requested a stop sign across the door to prevent visitors from coming into her room.
A nursing note for Resident 6, dated April 10, 2024, revealed that the licensed practical nurse on the third floor made the writer aware that this resident reported hitting another resident (Resident 1) with her back scratcher. The writer spoke with the resident, who reported that a confused male resident walked into her room, and she hit him on the wrist with her back scratcher. She said she told him to get out and hit him with it because she did not want him in there. The resident had no injury. Resident 6 was educated to ring or yell out for assistance if the other resident entered her room again and she verbalized understanding.
There was no documented evidence to indicate that the stop sign was across Resident 6's door to prevent Resident 1 from coming into her room.
Interview with the Director of Nursing on April 18, 2024, at 5:30 p.m. confirmed that there was no documented evidence to indicate that the stop sign was across Resident 6's door to prevent Resident 1 from coming into her room.
An annual MDS assessment for Resident 7, dated March 19, 2024, revealed that the resident was cognitively intact, was understood and could understand, had no behaviors, and required assistance with care needs.
A nursing note for Resident 7, dated April 14, 2024, at 5:30 a.m., revealed that she reported she had laid down in bed after going into the restroom and was adjusting the placement of her walker with one of her assistive devices. She said Resident 4 came out of the bathroom and into her room and walked over toward her. She told Resident 4 to go back to her room, but she continued to walk toward her and accused Resident 7 of hitting her with the assistive device. Resident 7 reported that Resident 4 grabbed her by the wrists and squeezed them. She reported they were separated by one of the nurses and upon assessment, Resident 7's right lateral wrist was noted to have a dark, pea-sized bruise with no open skin. She also reported some discomfort to her wrist.
Interview with Resident 7 on April 18, 2024, at 12:22 p.m. revealed that Resident 4 came in a few nights ago and grabbed her when she was in bed. Resident 7 stated she came in through the bathroom and told her to get out, that this was her house and her bed. Resident 7 stated that she still comes into her room, even though there is a stop sign on the bathroom door. She stated that Resident 4 also came in her room through the doorway to her room and went through her closet and drawers. Resident 7 stated that she does not feel safe ever since the incidents happened.
There was no documented evidence that the facility evaluated Resident 7 to address the resident's fear and not feeling safe after the resident-to-resident incidents.
Interview with the Director of Nursing on April 18, 2024, at 3:53 p.m. confirmed that there was no documented evidence that Resident 7 was assessed to address her fear and not feeling safe after the resident-to-resident incidents.
28 Pa. Code 201.14(a) Responsibility of Licensee.
28 Pa. Code 201.18(b)(1) Management.
28 Pa. Code 211.12(d)(3)(5) Nursing Services.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of clinical records and facility reports, as well as staff interviews, it was determined that the facility faile...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of clinical records and facility reports, as well as staff interviews, it was determined that the facility failed to ensure that the residents' environment remained safe for two of nine residents reviewed (Residents 2, 4) and failed to conduct a thorough investigation of resident-to-resident altercations to determine if care-planned interventions were followed for one of nine residents reviewed (Resident 6).
Findings include:
An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 2, dated January 26, 2024, revealed that the resident was cognitively impaired, had physical behaviors, wandered, had behavioral symptoms not directed toward others, was receiving antipsychotic and antidepressant medications, and had diagnoses that included dementia.
A behavior care plan for Resident 2, revised March 18, 2024, revealed that staff were to recognize/anticipate when the resident was becoming agitated so they could redirect and provide support; distract the resident from wandering; staff would talk to resident about personal topics including his dog, his time in the navy, wife and two sons, sports, and driving truck as a method to redirect him when he was wandering into other residents' rooms; provide resident with a portable music player to help with redirection and encourage a soothing environment; monitor the location of the resident frequently, document wandering behavior, and attempted diversional interventions; provide diversional activities: toileting, walking inside and outside, reorientation strategies including signs, pictures and memory boxes; avoid over-stimulation (e.g., noise, crowding, other physically aggressive residents); maintain a calm environment and approach to the resident; if the resident was looking for family/significant other, re-assure the resident that family/significant other knows where to find the resident; place the resident in a secure environment; remove the resident from other resident's rooms and unsafe situations; when the resident begins to wander, provide comfort measures for basic needs (e.g., pain, hunger, toileting, too hot/cold, etc.); use affirmative words as opposed to no, don't, or stop; validate his reality and do not attempt to bring him into our reality; and administer medications as ordered by physician.
A nursing note, dated January 21, 2024, at 7:15 p.m., revealed that the resident was in a fight with Resident 9 on the third floor common area known as the alcove. An interdisciplinary note, dated January 25, 2024, revealed that the residents' rooms were moved and Resident 2's Seroquel (anti-psychotic medication) was increased.
A nursing note, dated March 16, 2024, at 4:08 p.m., revealed that the resident was in the common area with other residents and punched Resident 8 on the right buttock and hip. There was no documented evidence that an interdisciplinary meeting was held to address the incident or changes made to protect other residents at that time. The resident's care plan, dated March 18, 2024, was updated to have staff move the resident to a quiet room until the episode was resolved, remove potentially harmful objects from the immediate environment, and protect other residents in the immediate area from harm.
A nursing note, dated March 19, 2024, at 10:58 p.m., revealed that the resident was observed wandering into other resident's rooms and becoming agitated when medical staff tried to redirect him. The resident would open closed doors and go into other residents' rooms, and tear down magnetic stop signs. Staff were unable to redirect the resident, as the behavior would continue again in just a few minutes and he continued to become increasingly agitated and standoffish with all medical staff.
A nursing note, dated April 4, 2024, at 22:03 p.m., revealed that Resident 2 walked by and aggressively bumped into Resident 1 with his shoulder and knocked the other resident to the floor. A facility event report, dated April 5, 2024, revealed that the resident would be referred to psychiatric services for a medication review. There was no documented evidence that any changes were made to Resident 2's behavior management plan.
Following the above incidents, there was no documented evidence that Resident 2's care-planned behavior interventions were revised when they were not effective, and no evidence that an individualized behavior management plan was developed in an attempt to prevent Resident 2's behaviors from affecting the safety of all other residents.
Interview with Nurse Aide 1 on April 18, 2024, at 12:20 p.m. revealed that Resident 2 wandered the unit a lot, would get agitated, hit other residents, shoulder checked another resident resulting in a fall for the other resident, and wandered into other resident rooms. She indicated that giving him something to do would help prevent him from wandering (such as rearranging the furniture in the alcove) and it really helped when his wife would come in to visit. She felt he wandered so much because he was trying to find his wife.
Interview with the Director of Nursing on April 18, 2024, at 5:29 p.m. confirmed that Resident 2 did have behaviors and that the resident's behavioral plan was not revised to include effective interventions that would ensure the safety and protection of other residents from Resident 2's aggressive behaviors.
A quarterly MDS assessment for Resident 4, dated April 1, 2024, revealed that the resident was cognitively impaired, walked independently without an assistive device, had wandering behaviors, had a wander/elopement alarm used daily, and had diagnosis including Parkinson's (a degenerative brain condition that affects muscle control and movement), dementia (progressive disease causing loss of cognitive functioning), and schizophrenia (a serious mental disorder that affects how people interpret reality).
A psychosocial care plan to address Resident 4's wandering behavior, initiated on November 14, 2023, included interventions to assess whether the behavior endangers the resident and/or others and intervene if necessary; maintain a calm environment and approach to the resident; when resident begins to wander, provide comfort measures for basic needs (e.g., pain, hunger, toileting, too hot/cold, etc.). A mood care plan to address Resident 4's physically abusive behaviors, initiated on April 15, 2024, included interventions to assess whether the behavior endangers the resident and/or others and intervene if necessary, avoid over-stimulation (e.g., noise, crowding,
other physically aggressive residents), maintain a calm environment and approach to the resident, and maintain a calm, slow, understandable approach with the resident.
A nursing note, dated March 3, 2024, at 12:14 a.m., revealed that Resident 4 was found in room [ROOM NUMBER] wandering and attempting to undress. She was extremely confused and was seen ten minutes earlier outside of her room stating she was looking for the bathroom. She was escorted to the bathroom. She then stated she was getting a bath and attempted to undress. It was explained to resident that it was the middle of night, and she agreed to return to bed. She was found later wondering in and out of rooms. She was helped back to her room and into bed but continued to wander and attempted to undress.
A nursing note on March 5, 2024, at 11:14 p.m. (recorded as late entry on March 7, 2024, at 5:15 a.m.) revealed that Resident 4 continued to wander without purpose on unit and was noted to be sitting on the roommate's bed and required verbal cues, much encouragement, and detailed instructions to stand and go to her own bed.
A nursing note on March 7, 2024, at 11:55 p.m. revealed that Resident 4 aimlessly wandered around the nursing unit, walked into other resident's rooms, and attempted to open closed doors.
A nursing note on March 21, 2024, at 1:54 p.m. revealed that social services and the registered nurse assessment coordinator spoke with Resident 4's son about a room change due to her increased behaviors. The son was agreeable to the room change to third floor closer to the nurse's station.
A nursing note for Resident 7, dated April 14, 2024, at 5:30 a.m., revealed that Resident 7 stated she had laid down in bed after going into the restroom and she was adjusting the placement of her walker with one of her assistive devices. She said Resident 4 came out of the bathroom door and into her room and walked over toward her. She said she told Resident 4 to go back to her room, but she continued to walk toward her, then Resident 4 reportedly accused Resident 7 of hitting her with the assistive device. Resident 7 reported that Resident 4 grabbed her by the wrists and squeezed them. She reported they were separated by one of the nurses. Upon assessment, Resident 7's right lateral wrist was noted to have a dark, pea-sized bruise with no open skin. She also reported some discomfort to her wrist.
A nursing note for Resident 4, dated April 14, 2024, at 5:35 a.m., revealed that Resident 4 was in Resident 7's room and grabbed onto Resident 7's bilateral wrists and squeezed them. Assessment of Resident 4 revealed no injuries.
A nursing note on April 15, 2024, at 9:47 a.m. revealed that the interdisciplinary team reviewed the incident of Resident 4 going into Resident 7's room through a shared bathroom. A stop sign was to be placed on the opposite bathroom door and a sign with the resident's name on her side. Resident 4 was unable to be reeducated due to dementia and psych diagnosis. Staff was to continue to provide support and redirection.
Interview with Resident 7 on April 18, 2024, at 12:22 p.m. revealed that Resident 4 next door came in a few nights ago and grabbed her when she was in bed. Resident 7 stated Resident 4 came in through the bathroom and told her to get out, that this was her house and her bed. Resident 7 stated that she still comes into her room, even though there is a stop sign on the bathroom door. She stated that Resident 4 also came in her room through the doorway to her room and went through her closet and drawers. Resident 7 stated that she does not feel safe ever since the incident happened.
There was no documented evidence that the interdisciplinary team assessed the effectiveness of the stop sign to prevent Resident 4 from wandering into Resident 7's room through the adjoining bathroom. There was no documented evidence that the interdisciplinary team addressed Resident 4's wandering into Resident 7's room through the doorway to her room, and no documented evidence that the interdisciplinary team addressed Resident 4's wandering into other resident's rooms. There was no documented evidence that an individualized behavior plan with individualized interventions was developed to prevent Resident 4's wandering and aggressive behaviors from affecting the safety of other residents.
Interview with Nurse Aide 1 on April 18, 2024, at 12:36 p.m. revealed that she had observed Resident 4 entering Resident 7's room since the incident, and she stated that Resident 4 goes into a lot of rooms.
Interview with the Director of Nursing on April 18, 2024, at 3:53 p.m. confirmed that Resident 4 does wander into other resident rooms, and there was no documented evidence that the intervention for the stop sign was assessed for effectiveness to ensure the safety and protection of Resident 7 and confirmed that there was no documented evidence that an individualized behavior plan with individualized interventions was developed to prevent Resident 4's behaviors from affecting the safety of other residents.
A quarterly MDS assessment for Resident 6, dated February 5, 2024, revealed that the resident was understood and could understand others. A care plan for the resident, dated August 15, 2023, revealed that the resident has attention seeking behaviors towards males, and requested a stop sign across the door to prevent visitors from coming into her room.
A note for Resident 6, dated April 10, 2024, revealed that the licensed practical nurse on the third floor made the writer aware that this resident reported hitting another resident with her back scratcher. The writer spoke with the resident, who reported that a confused male resident walked into her room, and she hit him on the wrist with her back scratcher. She said she told him to get out and hit him with it because she did not want him in there. The resident had no injury. The resident was educated to ring or yell out for assistance if the other resident enters her room again and she verbalized understanding.
However, there was no documented evidence to indicate that a thorough investigation was conducted to determine if the stop sign was in place across Resident 6's door to prevent visitors from coming into her room.
Interview with the Director of Nursing on April 18, 2024, at 5:30 p.m. confirmed that there was no documented evidence to indicate that an investigation was conducted to determine if the stop sign was in place across Resident 6's door to prevent visitors from coming into her room.
28 Pa. Code 201.14(a) Responsibility of Licensee.
28 Pa. Code 211.12(d)(5) Nursing Services.
Mar 2024
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Free from Abuse/Neglect
(Tag F0600)
Could have caused harm · This affected 1 resident
Based on review of policies, investigative reports, and residents' clinical records, as well as staff and family interviews, it was determined that the facility failed to ensure that residents were fr...
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Based on review of policies, investigative reports, and residents' clinical records, as well as staff and family interviews, it was determined that the facility failed to ensure that residents were free from neglect caused by a failure to follow a resident's care plan and transfer status for one of 10 residents reviewed (Resident 1).
Findings include:
The facility's current policy regarding abuse, neglect and exploitation indicated that neglect was the failure of the facility, its employees or service providers to provide goods and services to a resident that were necessary to avoid physical harm, pain, mental anguish, or emotional distress.
A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated February 9, 2024, revealed that the resident was severely cognitively impaired, required assistance from staff for transfers, and had diagnoses that included dementia. The resident's fall care plan, revised on February 15, 2024, indicated that she was a physical assist of two for transfers. A physical therapy discharge summary for Resident 1, dated February 15, 2024, revealed that on discharge Resident 1 required a physical assist of two for transfers.
A nursing note for Resident 1, dated February 25, 2024, revealed that while being transferred from her wheelchair she pulled her legs up at the knees. Resident 1 had to be placed back in the wheelchair and her right calf caught on the bracket where the foot pedal attaches causing a skin tear. The wound was cleansed, and a sterile dressing was applied.
The facility's investigation determined that Nurse Aide 1 transferred Resident 1 by himself. A witness statement, dated February 25, 2025, indicated that Resident 1 was changed and cleaned in bed. While sitting up in bed she was transferred to her wheelchair. Her legs were tucked up and her calf was cut on the right leg. The nurse was notified and first aid was completed. Resident 1 was harder to transfer when she tucked up.
Education paperwork provided by the facility, dated February 22, 2024, revealed that concerns were reported to the Director of Nursing and Nursing Home Administrator regarding Nurse Aide 1. It was reported that Nurse Aide 1 transferred a resident in a manner that was against their care plan and was not in line with the therapy recommendation. This could be an issue of safety and could cause the resident to have a fall or injury.
A nursing note for Resident 1, dated March 10, 2024, revealed that the skin tear on the right calf reopened and would care was ordered.
Observations of Resident 1 on March 20, 2024, revealed that she was visiting with a family member. She was sitting in her wheelchair, and there was a dressing applied to her right lower leg.
Interview with the Director of Rehab on March 20, 2024, at 3:27 p.m. confirmed that Resident 1 was a moderate assist of two staff for transfers.
Interview with Nurse Aide 1 on March 20, 2024, at 4:45 p.m. confirmed that he transferred Resident 1 by himself because he was not aware that she was a two-person physical assist. The education he received regarding the unsafe transfer with Resident 1 was dated February 22, 2024; however, he confirmed that the form was dated inaccurately.
Interview with the Director of Nursing on March 20, 2024, at 2:55, 3:45, and 4:45 p.m. confirmed that Nurse Aide 1 transferred Resident 1 by himself and that the resident required a two-person physical assist. The Director of Nursing also confirmed that the education was inaccurately dated for February 22, 2024, instead of February 25, 2024.
28 Pa. Code 201.14(a) Responsibility of Licensee.
28 Pa. Code 201.18(b)(1)(e)(1) Management.
28 Pa. Code 211.10(c)(d) Resident Care Policies.
28 Pa. Code 211.12(d)(1)(5) Nursing Services.
Jan 2024
5 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected 1 resident
Based on review of policies, clinical records, and investigation documents, as well as staff interviews, it was determined that the facility failed to ensure that staff reported allegations of sexual ...
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Based on review of policies, clinical records, and investigation documents, as well as staff interviews, it was determined that the facility failed to ensure that staff reported allegations of sexual abuse by one resident (Resident 7) towards two residents (Residents 8, 9) in a timely manner.
Findings include:
The facility's abuse policy, dated September 6, 2023, indicated that staff would report any incidents of suspected abuse immediately to the administrator/abuse coordinator. The administrator/abuse coordinator would immediately begin an investigation and notify the applicable local and state agencies in accordance with the procedures in the policy.
A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 7, dated October 23, 2023, indicated that the resident was sometimes understood and could sometimes understand others, required partial or moderate assist for personal hygiene needs, and had diagnoses that included heart failure and dementia with agitation.
A nurse's note for Resident 7, dated November 29, 2023, at 7:45 p.m. revealed that the resident had repeated deviant sexual behaviors of touching another resident, and that he needed to be moved to a different room. It further revealed that the physician ordered a medication to attempt to decrease his sexual desires.
A quarterly MDS assessment for Resident 8, dated December 14, 2023, indicated that the resident was sometimes understood and could sometimes understand others, required supervision or touch assist for personal hygiene needs, and had diagnoses that included Schizophrenia (affects a person's ability to think, feel, and behave clearly).
Interview with Licensed Practical Nurse 1 on January 2, 2024, at 3:30 p.m. revealed that she had witnessed Resident 7 inappropriately rubbing the groin area of Resident 8. Licensed Practical Nurse 1 reported the incident to administration and completed a written witness statement with details of the incident.
A quarterly MDS assessment for Resident 9, dated November 2, 2023, indicated that the resident was usually understood and could usually understand others, was dependent on staff for personal hygiene needs, and had diagnosis that included Alzheimer's disease.
A nurse's note for Resident 9, dated November 29, 2023, at 7:45 p.m., revealed that nursing had attempted to contact the resident's son to alert him of inappropriate touching that Resident 9 received from a male resident (Resident 7). They were unable to reach the son, and administration and the physician were aware.
There was no documented evidence that the incidents were reported to the Pennsylvania Department of Health or local agencies as required.
Interview with the Nursing Home Administrator on January 2, 2024, at 5:29 p.m. revealed that witness statements were obtained from staff regarding incidents of inappropriate touching from a male to female residents; however, they were misplaced and unable to be located. An incident report was completed in the clinical record but was retracted, and she was unsure why. The witness statements and incident reports were kept by a staff member who no longer worked at the facility and were not available.
28 Pa. Code 201.18(e)(1) Management.
28 Pa. Code 211.12(d)(5) Nursing services.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Investigate Abuse
(Tag F0610)
Could have caused harm · This affected 1 resident
Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to conduct a thorough investigation into incidents involving inappropriate sex...
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Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to conduct a thorough investigation into incidents involving inappropriate sexual behavior of one resident (Resident 7) towards two other residents (Residents 8, 9).
Findings include:
The facility's abuse policy, dated September 6, 2023, indicated that staff would report any incidents of suspected abuse immediately to administrator/abuse coordinator. The administrator/abuse coordinator will immediately begin an investigation and notify the applicable local and state agencies in accordance with the procedures in the policy. Once the administrator and Department of Health are notified, an investigation of the allegation or suspicion will be conducted. The investigation must be completed within five working days from the alleged occurrence.
A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 7, dated October 23, 2023, indicated that the resident was sometimes understood and could sometimes understand others, required partial or moderate assist for personal hygiene needs, and had diagnoses that included heart failure and dementia with agitation.
A nurse's note for Resident 7, dated November 29, 2023, at 7:45 p.m., revealed that the resident had repeated deviant sexual behaviors of touching of another resident, and that he needed to be moved to a different room. It further revealed that the physician ordered a medication to attempt to decrease his sexual desires.
A quarterly MDS assessment for Resident 8, dated December 14, 2023, indicated that the resident was sometimes understood and could sometimes understand others, required supervision or touch assist for personal hygiene needs, and had diagnoses that included Schizophrenia (affects a person's ability to think, feel, and behave clearly).
Interview with Licensed Practical Nurse 1 on January 2, 2024, at 3:30 p.m. revealed that she had witnessed Resident 7 inappropriately rubbing the groin area of Resident 8. Licensed Practical Nurse 1 reported the incident to administration and completed a written witness statement with details of the incident.
A quarterly MDS assessment for Resident 9, dated November 2, 2023, indicated that the resident was usually understood and could usually understand others, was dependent on staff for personal hygiene needs, and had diagnosis that included Alzheimer's disease.
A nurse's note for Resident 9, dated November 29, 2023, at 7:45 p.m., revealed that nursing had attempted to contact the resident's son to alert him of inappropriate touching that Resident 9 received from a male resident (Resident 7). They were unable to reach the son, and administration and the physician were aware.
There was no documented evidence that thorough investigations were completed regarding the two identified incidents of inappropriate sexual behaviors by Resident 7.
Interview with the Nursing Home Administrator on January 2, 2024, at 5:29 p.m. revealed that witness statements were completed from staff regarding incidents of inappropriate touching from Resident 7 to female residents; however, they were misplaced and unable to be located. An incident report was completed in the clinical record but was retracted, and she was unsure why. The witness statements and incident reports were kept by a staff member who no longer worked at the facility and were not available. The Nursing Home Administrator revealed that she was told the incidents included the male resident putting his hand on the knee or leg of female residents and did not feel at the time that it was a reportable incident requiring a full investigation.
28 Pa. Code 201.14(a) Responsibility of licensee.
28 Pa. Code 201.18(b)(1)(e)(1) Management.
28 Pa. Code 207.2(a) Administrator's responsibility.
28 Pa. Code 211.12(d)(3)(5) Nursing services.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected 1 resident
Based on a review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that residents were provided with showers as scheduled fo...
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Based on a review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that residents were provided with showers as scheduled for one of seven residents reviewed (Resident 6).
Findings include:
A facility policy for resident bathing and showering schedules indicated that residents will be bathed or showered according to their preference in order to maintain healthy hygiene. Each resident will be scheduled to receive bathing a minimum of two times per week unless they prefer less frequent. When the bath or shower is complete, the nursing assistant will document the activity.
An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 6, dated November 25, 2023, indicated that the resident was understood and was able to understand others, required set-up assistance with showers or baths, and had diagnoses that included Down's Syndrome (genetic disorder causing developmental and intellectual delays). A care plan for Resident 6, dated December 7, 2023, indicated that the resident preferred showers.
Review of bathing documentation for Resident 6 for November 20, 2023, through January 2, 2024, revealed that the resident only received three showers during that time. There was no documented evidence that the resident was offered or refused showers twice a week per policy and resident preference.
Interview with the Wound Nurse (LPN 2) on January 2, 2024, confirmed that there was no documented evidence that Resident 6 was offered or refused showers twice a week between November 20, 2023, and January 2, 2024, per the facility's policy.
Interview with the Nursing Home Administrator on January 2, 2024, at 5:39 p.m. confirmed that there was no documented evidence that Resident 6 was offered or refused showers twice a week from November 20, 2023, through January 2, 2024, per the facility's policy.
28 Pa. Code 211.12(d)(5) Nursing services.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
Based on review of clinical records, as well as staff interviews, it was determined that the facility failed to ensure that physician's orders for medications were followed for one of seven residents ...
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Based on review of clinical records, as well as staff interviews, it was determined that the facility failed to ensure that physician's orders for medications were followed for one of seven residents reviewed (Resident 3).
Findings include:
A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 3, dated September 5, 2023, revealed that the resident was cognitively impaired, required extensive assistance with daily care needs, and had diagnoses that included Huntingdon's Chorea (a neurological disease that causes uncontrollable movements, emotions and behaviors).
Physician's orders for Resident 3, dated August 21, 2023, included an order for the resident to receive 12 mg of Austedo (a drug used to treat uncontrollable movements caused by Huntingdon's Chorea) by mouth twice a day.
A neurology consultation for Resident 3, dated October 12, 2023, revealed that the neurologist increased the resident's Austedo to 24 mg by mouth twice daily.
There was no documented evidence in Resident 3's clinical record to indicate that the order to increase the Austedo was completed.
A review of Resident 3's Medication Administration Record for October 12, 2023, through January 4, 2024, revealed that the resident continued to receive Austedo 12 mg by mouth twice daily.
Interview with the Nursing Home Administrator on January 2, 2024, at 5:08 p.m. confirmed that Resident 3 did not receive Austedo as ordered by the physician.
28 Pa. Code 211.12(d)(1)(5) Nursing services.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0772
(Tag F0772)
Could have caused harm · This affected 1 resident
Based on review of clinical records and staff interviews, it was determined that the facility failed to obtain blood work as ordered by the physician for one of seven residents reviewed (Resident 4).
...
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Based on review of clinical records and staff interviews, it was determined that the facility failed to obtain blood work as ordered by the physician for one of seven residents reviewed (Resident 4).
Findings include:
An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 4, dated November 29, 2023, indicated that the resident was sometimes understood, could sometimes understand others, was dependent on staff for personal hygiene needs, and had diagnoses that included atherosclerotic heart disease (plaque buildup in the arteries).
Physician's orders for Resident 4, dated November 25, 2023, included an order for the resident receive 5 mg of warfarin (a blood thinning medication) at bedtime, and to obtain a PT/INR (protime and international normalized ratio - a blood test that measures the time it takes for blood to clot) on November 27, 2023, and to call the physician with the results for an order for the next warfarin dose.
There was no documented evidence that the PT/INR was obtained or that the physician was called for warfarin orders on November 27, 2023, as ordered.
Interview with the Director of Nursing on January 2, 2024, at 2:16 p.m. revealed that Resident 4 should have had a PT/INR test completed and the results called to the physician for warfarin orders. The lab was never notified to draw the blood on Resident 4; therefore, the PT/INR was not completed, the physician was not notified, and warfarin orders were not obtained. Warfarin use was discontinued on December 1, 2023, per recommendation by the cardiologist.
28 Pa. Code 211.12(d)(1)(5) Nursing services.
Nov 2023
8 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0675
(Tag F0675)
Could have caused harm · This affected 1 resident
Based on review of facility policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that residents were positioned appropriate...
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Based on review of facility policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that residents were positioned appropriately while eating for one of 13 residents reviewed (Resident 10).
Findings include:
The facility's policy regarding dining experience at mealtimes, dated July 1, 2023, indicated that positioning and assistance at mealtime must be appropriate for individual needs and that tray tables will be at the appropriate height and position.
A significant change Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 10, dated October 12, 2023, indicated that the resident was cognitively impaired and required staff to set her up for meals. The resident's care plan, dated October 12, 2023, indicated that the resident was at risk for nutritional problems, including weight loss.
Observations of Resident 10 on November 15, 2023, at 1:00 p.m. revealed that the resident was sitting in her specialized chair with her feet elevated and tight against the foot rest for positioning when her meal was served. Her tray was placed on an over-bed table in front of her and Nurse Aide 1 took the lids off the food and opened her drink. Nurse Aide 1 then told the resident to eat her lunch. The resident raised her arm up to reach her fork; however, the tray table was too far away from her. The resident tried again to raise her arm up to reach the tray and she could not. The resident then went to sleep and did not eat.
Interview with Licensed Practical Nurse 2 on November 15, 2023 at 1:30 p.m. confirmed that Resident 10 could not reach her tray and that it should have been pushed closer to her. She said that the resident usually feeds herself after her tray is set up for her. Licensed Practical Nurse 2 then pushed the tray towards Resident 10, woke her up, and encouraged her to eat. At that time the resident did not make an attempt to feed herself, so Licensed Practical Nurse 2 started to feed her. She had the kitchen send up some warm soup for the resident and the resident ate it.
Interview with the Nursing Home Administrator on November 15, 2023, at 2:45 p.m. confirmed that Resident 10 should have been positioned properly for her meal and that she should have been able to reach her food.
28 Pa. Code 211.10(a)(c)(d) Resident care policies.
28 Pa. Code 211.12(d)(1)(2)(5) Nursing services.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
Based on clinical record reviews, and staff interviews, it was determined that the facility failed to ensure that a safe environment was provided for one of 13 residents reviewed (Resident 1).
Finding...
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Based on clinical record reviews, and staff interviews, it was determined that the facility failed to ensure that a safe environment was provided for one of 13 residents reviewed (Resident 1).
Findings include:
The facility's policy regarding bedside care, dated July 1, 2023, revealed that the resident's care plan will be reviewed to assess for any special needs of the resident.
An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated August 16, 2023, indicated that the resident was sometimes understood and sometimes understands others, required the extensive assistance of two for ambulation and transfers, and extensive assistance of two for bathing and toileting.
A nursing note for Resident 1, dated October 6, 2023, revealed that the resident was found on the floor by her bed after the nursing assistant left the resident alone to change the bath water in the bathroom. The nursing assistant had been providing the resident with a bed bath and although the resident's care plan required two staff for care, she was the only staff in the room.
An incident report for Resident 1, dated October 6, 2023, at 4:53 p.m. revealed that the resident was trying to pick up a piece of tissue off the floor after being left alone by the nursing assistant.
Interview with the Director of Nursing on November 15, 2023, at 4:47 p.m. confirmed that there should have been two nursing assistants providing care to Resident 1 and the resident should not have been left alone at that time.
28 Pa. Code 201.14(a) Responsibility of licensee.
28 Pa. Code 211.12(d)(5) Nursing services.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Incontinence Care
(Tag F0690)
Could have caused harm · This affected 1 resident
Based on a review of facility policies and clinical record reviews, as well as observations and staff interviews, it was determined that the facility failed to provide timely incontinence care for one...
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Based on a review of facility policies and clinical record reviews, as well as observations and staff interviews, it was determined that the facility failed to provide timely incontinence care for one of 13 residents reviewed (Resident 10).
Findings include:
The facility's policy for perineal care, dated July 1, 2023, indicated that clinical staff would provide perineal care when necessary.
A significant change Minimum Data Set (MDS) assessment (a federally-mandated assessment of the resident's abilities and care needs) for Resident 10, dated October 12, 2023, indicated that the resident was cognitively impaired and was dependent on staff for daily care needs, including toileting. Resident 10's care plan, dated September 21, 2023, indicated that the resident was medicated with a diuretic (water pill) and that she has the potential for altered skin and that staff are to provide incontinence care and toileting as needed.
Observations of Resident 10 on November 15, 2023, at 12:20 p.m. revealed that the resident was seated in the dining area and that she was sleeping. At 12:27 p.m. the resident yelled out, Help me, I peed myself. The resident continued to say that she needed help. At 12:29 p.m. Nurse Aide 1 told the resident that the lunch trays were coming soon and that she would change her after the meal was over and she could lie down then. At 12:43 p.m. the resident was attempting to move in her chair with facial grimacing and saying, Ouch, ouch. At 12:57 p.m. the resident stated, Oh God, ouch, while moving in her chair. At 1:00 p.m. Nurse Aide 1 delivered the resident's tray to her and placed her tray in front of her. At 1:30 p.m. the resident was fed her lunch by Licensed Practical Nurse 2. At 1:43 p.m. the resident was saying, Ouch, ouch, when attempting to move around in her chair. At 2:12 p.m. Nurse Aide 1 asked the resident if she wanted to lie down. She then pushed the resident into her room and prepared the resident to stand. Nurse Aide 1 and Nurse Aide 5 were preparing her bed. Nurse Aide 1 was attempting to put the resident's slippers on her; however, the resident was yelling, Ouch, that hurts, stop it. Nurse Aide 1 told the resident that she needed good footwear on in order to stand. Nurse Aide 1 put the resident's slippers on; however, she put them on the wrong feet. She corrected that after she was told they were the wrong feet. The resident was assisted to stand, pivoted and then layed in the bed with her shirt and pants on. The slippers were removed from her feet and a wedge cushion was placed under the resident's right arm. Nurse Aide 5 then pulled the blankets over the resident, put the bed at a low height, and layed the fall mats down on both sides of the resident. The nurse aides moved the oxygen concentrator closer to the resident and assured her oxygen was in place. They then began to leave the room.
At 2:32 p.m. on November 15, 2023, Nurse Aide 1 was asked to check the resident to see if she was soiled before leaving the room. Nurse Aide 1 indicated that she changed her prior to lunch, but that she would check her. She and Nurse Aide 5 returned to the resident's bedside, pulled the blankets down, pulled the residents pants down, and then opened the brief which was fully soiled with urine. The resident's skin was visibly wet around the vaginal area and in the groin. Nurse Aide 1 then went to get a brief and Nurse Aide 5 grabbed some wet wipes to clean the resident with. The nurse aides proceeded to clean the resident and when they separated her legs they discovered that she had new skin breakdown in the groin area on both sides where the soaked brief was sitting against the skin. The skin was moist, reddened, and macerated. Nurse Aide 1 stated that the resident's skin was not like that two days ago when she changed her. Nurse Aide 1 left to go get the Licensed Practical Nurse 2 to look at the resident. Licensed Practical Nurse 2 stated at that time that the resident's skin was not like that yesterday when she received care and that she will call the provider to get a treatment ordered.
Interview with Nurse Aide 1 on November 15, 2023, at 2:48 p.m. revealed that she did not remember Resident 10 having told her that she had peed herself and needed changed before the trays arrived. She stated that she had been working since 3:00 a.m. that morning. When asked what her skin looked like earlier that day when she would have changed her, she did not reply.
Interview with Licensed Practical Nurse 2 on November 15, 2023, at 2:50 p.m. revealed that if a resident states they are soiled they should be changed or at least checked and that Resident 10 did not have any skin breakdown the day before. She stated that she was not sure when the last time Resident 10 had any incontinence care.
Interview with the Nursing Home Administrator on November 15, 2023, at 3:15 p.m. revealed that any time a resident states that they are soiled they should be checked, and that staff should have checked her when they laid her down without having been prompted to do so.
28 Pa. Code 211.12(d)(3)(5) Nursing services.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0757
(Tag F0757)
Could have caused harm · This affected 1 resident
Based on clinical record reviews and staff interviews, it was determined that the facility failed to ensure that the residents were free from unnecessary medications for one of 13 residents reviewed (...
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Based on clinical record reviews and staff interviews, it was determined that the facility failed to ensure that the residents were free from unnecessary medications for one of 13 residents reviewed (Resident 11).
Findings include:
A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 11, dated August 8, 2023, revealed that the resident was cognitively impaired and had diagnoses that included hypertension (high blood pressure).
Physician's orders, dated October 24, 2023, included an order for the resident to receive 100 milligrams (mg) of Aldactone (water pill) once a day. The order was entered in Resident 11's clinical record; however, this order was for another resident.
The Medication Administration Record (MAR) for October 2023 revealed that Resident 11 received Aldactone on October 25, 26, and 27, 2023.
A disciplinary action form, dated October 27, 2023, revealed that staff had transcribed the physician's order incorrectly (wrong person) and Resident 11 received Aldactone.
A nursing note, dated October 27, 2023, at 3:52 p.m. revealed that the resident's family was notified of the medication error, that the medication order was placed on the incorrect electronic medical record.
Interview with the Director of Nursing on November 15, 2023, at 4:07 p.m. confirmed that a new nurse had transcribed the physician's order wrong and no one checked it, and Resident 11 received the wrong medication.
28 Pa. Code 211.12(d)(3)(5) Nursing services.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected multiple residents
Based on observations and staff interviews, it was determined that the facility failed to provide a clean and homelike environment in residents' rooms for two of 13 residents reviewed (Residents 2, 7)...
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Based on observations and staff interviews, it was determined that the facility failed to provide a clean and homelike environment in residents' rooms for two of 13 residents reviewed (Residents 2, 7).
Findings include:
Observations of Resident 2 and 7's room on November 15, 2023 at 8:20 a.m. revealed that the resident's ceiling was stained, cracked and had visible paint peeling and damage along the seem of the wall and ceiling.
Interview with the Director of Maintenance on November 15, 2023 at 8:40 a.m. confirmed that Resident 2 and 7's ceiling was leaking water and damaged. He stated that when it rains heavily, as it had recently, the water pools up in a certain area of the roof and it needs to be swept off, or it will cause damage. He stated that he is one person and trying to get to everything that needs done in the large building. He stated that the ceiling repair has been on his list of things that needs done.
28 Pa. Code 201.29(j) Resident rights.
28 Pa. Code 207.2(a) Administrator's responsibility.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected multiple residents
Based on clinical record reviews, as well as staff and resident interviews, it was determined that the facility failed to ensure that residents were provided with showers/baths as scheduled for one of...
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Based on clinical record reviews, as well as staff and resident interviews, it was determined that the facility failed to ensure that residents were provided with showers/baths as scheduled for one of 13 residents reviewed (Resident 8).
Findings include:
An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 8, dated October 21, 2023, indicated that the resident was moderately cognitively impaired, was able to make herself understood, that it was very important to her to choose the type of bathing she wanted, and she required supervision with bath/shower.
A care preference sheet, dated October 16, 2023, revealed that Resident 8 preferred a bath in the morning three or more times a week.
Review of the resident's bathing records for October and November 2023 revealed that the resident received an other bath on October 16, 17, 18, 23 and 30, and November 2, 2023. There was no documented evidence that Resident 8 received a complete bed bath in October or November.
Interview with Registered Nurse 3 on November 15, 2023, at 4:58 p.m. confirmed that Resident 8 received a partial bed bath and did not receive a complete bed bath or have her hair washed.
28 Pa. Code 211.12(d)(5) Nursing services.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Pressure Ulcer Prevention
(Tag F0686)
Could have caused harm · This affected multiple residents
Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to follow recommendations from a wound consultation for one of 13 residents re...
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Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to follow recommendations from a wound consultation for one of 13 residents reviewed (Resident 3).
Findings include:
An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 3, dated October 3, 2023, indicated that he was cognitively intact, required substantial assistance for his care needs, and had pressure ulcers (skin breakdown caused by prolonged, unrelieved pressure). A care plan, dated October 3, 2023, indicated that wound dressings were to be applied as ordered.
A wound consultation for Resident 3, dated November 1, 2023 revealed that the resident had a Stage 3 (full thickness tissue loss) pressure sore on his left heel that measured 1.5 x 1.3 x 0.1 centimeters (cm). The plan was to cleanse the wound with normal saline (sterile salt and water), apply medical grade honey (honey-containing treatment used to heal wounds) to the base of the wound, and secure it with gauze daily and as needed. A wound consultation for Resident 3, dated November 8, 2023, revealed that the resident had a Stage 3 pressure sore on his left heel that measured 1.0 x 1.0 x 0.1 cm. The plan was to cleanse the wound with 0.125 percent Dakin's solution (antiseptic used to prevention wound infections), apply medical grade honey to the base of the wound, and secure it with gauze daily and as needed.
Physician's orders, dated September 26, 2023, included an order for Medihoney Gel to be applied every other day; however, there was no documented evidence that orders for the daily treatments of Medihoney or Dakin's were obtained.
Review of Resident 3's Treatment Administration Records (TAR's) for November 2023 revealed that the treatments to the left heel were documented as being completed every other day and not daily as recommended by the wound consultant, and there was no documented evidence that the wound was being cleansed with Dakin's solution every day as recommended on November 8, 2023.
Interview with Licensed Practical Nurse 4 (responsible for wound care) on November 15, 2023, at 3:12 p.m. confirmed that the treatments to Resident 3's left heel were not being completed as recommended by the wound consultant and should have been.
28 Pa. Code 211.12(d)(5) Nursing services.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0804
(Tag F0804)
Could have caused harm · This affected multiple residents
Based on review of policies, observations, and staff interviews, it was determined that the facility failed to serve food that was palatable and at proper temperatures.
Findings include:
The facility'...
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Based on review of policies, observations, and staff interviews, it was determined that the facility failed to serve food that was palatable and at proper temperatures.
Findings include:
The facility's policy regarding food temperatures, dated July 1, 2023, revealed that hot foods were to be plated at 135 degrees Fahrenheit (F) and were to be palatable at the point of delivery. The temperature of potentially hazardous cold foods were to be served at a temperature of 41 degrees Fahrenheit or below.
The posted menu for November 15, 2023, revealed that the lunch meal was corn chowder soup, soft beef tacos, churros, milk, and coffee.
A test tray for the lunch meal on the 300 nursing unit on November 15, 2023, revealed that the cart left the kitchen at 12:49 p.m., arrived on the nursing unit at 12:50 p.m., and the last resident was served at 1:09 p.m. The test tray was tasted at 1:10 p.m. and the soft beef taco was 119 degrees F and had excessive grease, the churro was hard and crunchy and tasted bland, and the milk was 60 degrees F and was not cold to taste.
Interview with the Dietary Manager on November 15, 2023, at 1:12 p.m. confirmed that the tacos and milk were not served at the proper temperatures and churro was not to be hard and crunchy.
28 Pa. Code 211.6(b) Dietary services.
Sept 2023
22 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0558
(Tag F0558)
Could have caused harm · This affected 1 resident
Based on review of policies and clinical records, as well as observations and resident and staff interviews, it was determined that the facility failed to ensure that call bells were within reach for ...
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Based on review of policies and clinical records, as well as observations and resident and staff interviews, it was determined that the facility failed to ensure that call bells were within reach for three of 41 residents reviewed (Residents 6, 65, 76).
Findings include:
A review of the facility's Resident Communication System and Call Light Policy, dated January 13, 2023, included that it is the policy of the facility to provide residents with a means of communicating with staff. A call system is installed in each resident room and toilet/bath areas. Each resident will be shown how to use the call bell.
A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's care needs and abilities) for Resident 6, dated August 2, 2023, revealed that the resident was understood and able to understand others, required extensive assistance from staff for personal care needs, was receiving supplemental oxygen, and had diagnosis that included chronic obstructive pulmonary disease (COPD - lung disease that causes difficulty breathing).
Observation of Resident 6 on September 7, 2023, at 9:14 a.m. revealed that the resident was lying in his bed in his room. Interview with the resident at that time revealed that he would like to have the head of his bed adjusted; however, his call bell was hanging on the wall behind his bed and not within reach.
An interview with Licensed Practical Nurse 1 on September 7, 2023, at 9:16 a.m. confirmed that the resident did not have a call bell within reach, and he should have.
Interview with the Director of Nursing on September 7, 2023, at 1:06 p.m. confirmed that the resident's call bell should be in reach at all times.
A quarterly MDS assessment for Resident 65, dated August 2, 2023, revealed that the resident was usually understood and could usually understand, did not walk, required extensive assistance for bed mobility and transfers, and had diagnoses that included chronic obstructive pulmonary disease, anxiety, and PTSD.
Observation of Resident 65 on September 7, 2023, at 8:49 a.m. revealed that Nurse Aide 3 and Nurse Aide 4 entered her room to boost her up in bed. Resident 65's call bell was on the floor behind her bed and not within her reach. Interview with Nurse Aides 3 and 4 at that time confirmed that the call bell should have been within Resident 65's reach.
Interview with the Director of Nursing on September 7, 2023, at 1:06 p.m. confirmed that the resident's call bell should be in reach at all times.
A current diagnosis list for Resident 76 revealed that he was admitted for respiratory failure, pneumonia, and end-stage renal disease.
A nursing note for Resident 76, dated September 6, 2023, indicated that he was a new admission from the hospital and was alert and oriented to person, place, and time. He was admitted for rehabilitation and planned to discharge home.
Observations in Resident 76's room on September 7, 2023, at 12:04 p.m. revealed that the resident was in bed and his call bell was on top of the bedside table on the right side of the bed, which was out of the resident's reach. Upon interview at that time, Resident 76 said he needed help because he could not find his television remote.
Interview with Licenced Practical Nurse 1 on September 7, 2023, at 12:06 a.m. confirmed that Resident 76's call bell was out of the resident's reach and was to be kept within his reach at all times. The television remote was attached to the call bell.
Interview with the Director of Nursing on September 7, 2023, at 1:06 p.m. confirmed that call bells should be within reach at all times.
28 Pa. Code 201.14(a) Responsibility of licensee.
28 Pa. Code 201.18(b)(1) Management.
28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Notification of Changes
(Tag F0580)
Could have caused harm · This affected 1 resident
Based on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that the physician was notified timely about abnormal blood...
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Based on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that the physician was notified timely about abnormal blood sugar results for four of 41 residents reviewed (Residents 7, 35, 53, 62).
Findings include:
The facility's policy regarding resident change in condition, dated January 13, 2023, indicated that the physician would be notified in a timely manner when a change in resident condition or an unusual incident involving the resident occurred. The physician's notification and intervention will be documented in the electronic medical record.
A quarterly MDS assessment (a mandated assessment of a resident's abilities and care needs) for Resident 7, dated July 18, 2023, revealed that the resident was understood and understands others, required assistance of staff for her daily care needs, had diagnoses that included diabetes, and received insulin (medication that lowers blood sugar levels).
Physician's orders for Resident 7, dated July 1, 2023, included an order for the resident to have her blood sugar checked before every meal and at bedtime and to notify the physician if the resident's blood sugar is less than 70 milligrams/deciliter (mg/dL) or greater than 400 mg/dL.
Review of Resident 7's Medication Administration Record (MAR) for September 2023 revealed that on September 1, 2023, at bedtime, the resident's blood sugar was 432 mg/dL. There was no documented evidence in the clinical record that the physician was notified about the resident's blood sugar being greater than 400 mg/dL.
Interview with the Nursing Home Administrator on September 7, 2023, at 3:07 p.m. confirmed that there was no documented evidence that the physician was notified about Resident 7's blood sugar of 432 mg/dL, as ordered.
A quarterly MDS assessment for Resident 35, dated June 16, 2023, revealed that the resident was rarely understood and rarely understands others, was dependent on staff for her daily care needs, had diagnoses that included diabetes, and received insulin (medication that lowers blood sugar levels).
Physician's orders for Resident 35, dated July 1, 2023, included an order for the resident to have her blood sugar checked twice a day and to notify the physician if the resident's blood sugar is less than 80 milligrams/deciliter (mg/dL) or greater than 350 mg/dL.
Review of Resident 35's MAR for July 2023 revealed that on July 22, 2023, at 6:00 a.m. the resident's blood sugar was 63 mg/dL, and on July 22, 2023, at 4:00 p.m. it was documented as low (less than 50 mg/dL). There was no documented evidence in the clinical record that the physician was notified about the resident's blood sugar being below 80 mg/dL on these dates and times.
Interview with the Director of Nursing on September 8, 2023, at 10:24 a.m. confirmed that there was no documented evidence that the physician was notified about Resident 35's low blood sugars, as ordered.
A quarterly MDS assessment for Resident 53, dated July 10, 2023, indicated that the resident was cognitively intact, required assistance from staff for her daily care tasks, and had diagnoses that included diabetes. Physician's orders for Resident 53, dated July 11, 2023, included an order for staff to check the resident's blood sugar twice a day on Monday, Wednesday and Friday, and to call the doctor if less than 70 milligrams (mg)/deciliter (d)L or greater than 300 mg/dL.
Review of Resident 53's MAR for August 2023 revealed that the resident's blood sugar on August 9, 2023, at 8:38 p.m. was low; on August 23, 2023, at 9:29 p.m. it was 377 mg/dL; and on August 28, 2023, at 5:21 a.m. it was 346 mg/dL. There was no documented evidence in the clinical record that the physician was notified of the low blood sugar or elevated blood sugar readings on these dates and times.
Interview with the Assistant Director of Nursing on September 7, 2023, at 2:29 p.m. confirmed that Resident 53's physician was not notified timely following her low blood sugar or elevated blood sugar readings and that he should have been.
An admission MDS assessment for Resident 62, dated August 7, 2023, indicated that the resident was alert and oriented, required minimal assistance from staff for her daily care needs, and had diagnoses that included diabetes. Physician's orders for Resident 62, dated August 1, 2023, included an order for the resident to have her blood sugar checked before meals and at bedtime and to notify the physician if the blood sugar is less than 70 or greater than 400.
A review of Resident 62's MAR for August 2023 revealed that the resident's blood sugar was high (greater than 450) on August 2, 2023, at 4:01 p.m.; high on August 3, 2023, at 8:36 p.m.; low (less than 50) on August 9, 2023, at 4:16 p.m.; and low on August 15, 2023. There was no documented evidence in the clinical record that the physician was notified of the blood sugar readings on these dates and times.
Interview with the Director of Nursing on September 7, 2023, at 12:16 p.m. confirmed that the physician was not notified regarding the blood sugar results that were less than 70 or greater than 400 for Resident 62 and that he should have been.
28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected 1 resident
Based on observations and staff interviews, it was determined that the facility failed to ensure a homelike environment related to uncomfortable sound levels for one of 41 residents reviewed (Resident...
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Based on observations and staff interviews, it was determined that the facility failed to ensure a homelike environment related to uncomfortable sound levels for one of 41 residents reviewed (Resident 23).
Findings include:
An annual Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 23, dated August 9, 2023, indicated that he was cognitively intact, required extensive assistance from staff for personal care needs, and had diagnoses that included diabetes and seizure disorder.
Observations on September 5, 2023, at 11:50 a.m.; September 6, 2023, at 11:40 a.m.; September 7, 2023, at 9:00 a.m. and 2:02 p.m.; and September 8, 2023, at 2:11 p.m. and 3:00 p.m. revealed that the oxygen concentrator (device used to provide supplemental oxygen to someone with difficulty breathing) being used by Resident 23 in his room was providing oxygen; however, it was producing a loud beep sound approximately every 30 seconds that could be heard in the hallway.
Review of the facility's maintenance work orders for August and September 2023 revealed no evidence of a report of a malfunctioning oxygen concentrator.
Interview with Resident 23 on September 6, 2023, at 11:40 a.m. revealed that he believed his oxygen concentrator was beeping because the filter needed changed and he was unsure if maintenance was aware of the problem.
Interview with Licensed Practical Nurse 1 on September 7, 2023, at 9:00 a.m. revealed that staff was aware of the beeping noise being made by the oxygen concentrator, but they were unsure why it was beeping, and that maintenance was also informed of the beeping sound but was also unsure why the oxygen concentrator was beeping.
Interview with the Maintenance Director on September 7, 2023, at 12:45 p.m. revealed that sometimes the oxygen concentrators beep because they need reset. If resetting the oxygen concentrator does not fix the problem, the oxygen concentrator can be replaced and the facility had plenty of working oxygen concentrators for resident use.
Interview with the Maintenance Director on September 8, 2023, at 2:45 p.m. confirmed that the oxygen concentrator should not be making a beeping sound and that he replaced the oxygen concentrator in Resident 23's room on September 8, 2023.
28 Pa. Code 201.18(e)(1) Management.
28 Pa. Code 201.29(j) Resident rights.
28 Pa. Code 207.2(a) Administrator's responsibility.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Grievances
(Tag F0585)
Could have caused harm · This affected 1 resident
Based on review of clinical records and grievance records, as well as resident and staff interviews, it was determined that the facility failed to make ongoing efforts to resolve a grievance regarding...
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Based on review of clinical records and grievance records, as well as resident and staff interviews, it was determined that the facility failed to make ongoing efforts to resolve a grievance regarding mechanical lifts.
Findings include:
Resident council meeting minutes, dated July 2023, indicated that the residents were frustrated with the mechanical lifts not working or having dead batteries frequently causing the residents to be stuck in bed.
A meeting with a group of residents on September 6, 2023, at 1:00 p.m. revealed that the residents are unable to get out of bed most weekends because the mechanical lift batteries are dead. They stated that they have requested more lift machines or more batteries in order to prevent this from happening again. They stated that this had been occurring since at least June 2023.
Interview with the Nursing Home Administrator on September 8, 2023, at 11:28 a.m. confirmed that staff were telling the residents they could not get out of bed because the lift machine batteries were dead. The staff were educated not to tell the residents they could not get out of bed because of dead lift batteries.
28 Pa. Code 201.29(i) Resident rights.
28 Pa. Code 211.12(d)(5) Nursing services.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected 1 resident
Based on review of Pennsylvania's Nursing Practice Act, facility policies, and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that an assessment wa...
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Based on review of Pennsylvania's Nursing Practice Act, facility policies, and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that an assessment was completed by a professional (registered) nurse after an injury occurred for one of 41 residents reviewed (Resident 23).
Findings include:
The Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.11 (a)(1)(2)(4) indicated that the registered nurse was to collect complete and ongoing data to determine nursing care needs, analyze the health status of individuals and compare the data with the norm when determining nursing care needs, and carry out nursing care actions that promote, maintain, and restore the well-being of individuals.
The facility's policy regarding resident change in condition, dated January 13, 2023, indicated that the nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status.
An annual Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 23, dated August 9, 2023, indicated that he was cognitively intact, required extensive assistance from staff for personal care needs, was dependent on staff for transfers to and from bed, and had diagnoses that included diabetes and seizure disorder.
A nurse's note for Resident 23, dated August 9, 2023, at 2:47 p.m. and an incident investigation report, dated August 9, 2023, at 2:40 p.m. revealed that while the resident was being transferred into his wheelchair, his right great toe was bumped against the lift. The physician was notified, the area was cleansed, and a dressing was applied. There was no documented evidence of a registered nurse assessment of the injured toe.
Interview with the Director of Nursing on September 7, 2023, at 1:05 p.m. confirmed that there was no documented evidence of a registered nurse assessment of Resident 23's right great toe after receiving an injury.
28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0675
(Tag F0675)
Could have caused harm · This affected 1 resident
Based on review of facility policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that residents were positioned appropriate...
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Based on review of facility policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that residents were positioned appropriately while eating for one of 41 residents reviewed (Resident 65).
Findings include:
The facility's policy regarding dining experience at mealtime, dated January 13, 2023, indicated that the resident should be comfortable, safe as possible, and position at mealtime must be appropriate for individual needs. Tray tables will be the appropriate height and position for those eating in bed.
A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 65, dated August 2, 2023, indicated that the resident was cognitively intact, dependent on two staff for daily care needs, and required supervision for eating. Resident 65 had a diagnosis of dysphagia (swallowing difficulties) and her care plan, dated August 8, 2023, indicated that the resident had swallowing difficulties and needs assistance or fed by staff.
Observations of Resident 65 on September 9, 2023, at 8:36 a.m. revealed that the resident was not in an upright position in her bed, with her tray table above her causing her to reach up and over the table to reach her breakfast. Speech Therapist 2 entered Resident 65's room to assist her with eating breakfast. She stated that she visits Resident 65 three times a week to assist her with meals.
Interview with Speech Therapist 2 on September 9, 2023, at 8:42 a.m. confirmed that Resident 65 was not in an upright position in her bed and that she should not have had to reach up and over the table to feed herself.
Interview with the Director of Nursing on September 9, 2023, at 1:06 p.m. confirmed that Resident 65 should have been in the upright position while eating.
28 Pa. Code 211.10(a)(d)(d) Resident care policies.
28 Pa. Code 211.12(d)(1)(2)(5) Nursing services.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
Based on review of policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that physician's orders were followed for one of 41...
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Based on review of policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that physician's orders were followed for one of 41 residents reviewed (Resident 39).
Findings include:
An annual Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 39, dated August 8, 2023, indicated that the resident was cognitively impaired and required extensive assistance from staff for her daily care tasks. Physician's order, dated August 23, 2023, included an order for the resident to have a glove on her right hand for pain.
Observations of Resident 39 on September 7, 2023, at 11:10 a.m. revealed that she was lying in bed awake and did not have a glove on her right hand.
Interview with Licensed Practical Nurse 5 on September 7, 2023, at 11:12 a.m. confirmed that Resident 39's glove was not on her right hand and that she was not sure why it was not.
Interview with the Assistant Director of Nursing on September 7, 2023, at 12:21 p.m. confirmed that Resident 39 should have had a glove on her right hand.
28 Pa. Code 211.12(d)(1)(5) Nursing services.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0688
(Tag F0688)
Could have caused harm · This affected 1 resident
Based on review of clinical records, observations, and staff interviews, it was determined that the facility failed to ensure that physician-ordered contracture management services were provided as ca...
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Based on review of clinical records, observations, and staff interviews, it was determined that the facility failed to ensure that physician-ordered contracture management services were provided as care planned for one of 41 residents reviewed (Resident 35).
Findings include:
A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 35, dated June 16, 2023, revealed that the resident was cognitively impaired, was dependent on staff for her daily care needs, and had diagnoses that included dementia and stroke.
Physician's orders for Resident 35, dated July 5, 2023, included an order for the resident to wear bilateral soft elbow splints while in bed for up to four hours as tolerated. Placement was to be checked every shift.
An activities of daily living (ADL- essential and routine tasks that most young, healthy individuals can perform without assistance) care plan for Resident 35, dated July 24, 2023, indicated that the resident was to wear bilateral soft elbow splints while in bed for up to four hours as tolerated.
Observations of Resident 35 on September 5, 2023, at 12:00 p.m. and September 7, 2023, at 2:03 p.m. revealed the resident lying on her back in bed with her elbows bent and hands resting on her chest.
There was no documented evidence in Resident 35's clinical record to indicate that the bilateral soft elbow splints were being offered or applied.
Interview with the Director of Nursing on September 8, 2023, at 2:15 p.m. confirmed that there was no documented evidence that the bilateral soft elbow splints for Resident 35 were being offered or applied.
28 Pa. Code 211.12(d)(5) Nursing services.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0760
(Tag F0760)
Could have caused harm · This affected 1 resident
Based on a review of facility policies, clinical records, and staff interviews, it was determined that the facility failed to ensure that it was free from significant medication errors for one of 41 r...
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Based on a review of facility policies, clinical records, and staff interviews, it was determined that the facility failed to ensure that it was free from significant medication errors for one of 41 residents reviewed (Resident 35).
Findings include:
The facility's policy for hypoglycemia (low blood sugar), dated January 13, 2023, indicated that insulin (used to lower blood sugar) dependent diabetics would be monitored for symptoms of hypoglycemia. A blood glucose of 60 mg/dL or less indicated a need for intervention.
A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 35, dated June 16, 2023, revealed that the resident was cognitively impaired, was dependent on staff for her daily care needs, and had diagnoses that included dementia and diabetes.
Physician's orders for Resident 35, dated June 23, 2023, included an order to administer 7 units of insulin lispro subcutaneously every Monday, Wednesday, and Friday at 6:00 a.m., hold if blood sugar was less than 100 milligrams/deciliter (mg/dL), and administer 13 units of insulin lispro subcutaneously before supper daily, hold if blood sugar was less than 100 mg/dL. Physician's orders, dated July 1, 2023, included an order for the resident to have her blood sugar checked twice a day and to notify the physician if the resident's blood sugar was less than 80 mg/dL or greater than 350 mg/dL.
A care plan for Resident 35, dated July 24, 2023, indicated that she had diabetes and should have her blood sugar checked as ordered and the physician notified if her blood sugar was less than 80 milligrams/deciliter (mg/dL) or greater than 350 mg/dL. It also included that she was to receive routine doses of fast acting insulin as ordered.
A review of the Medication Administration Record (MAR) for Resident 35 for July and August 2023 revealed that on July 22 at 6:00 a.m. the resident's blood sugar was 63 and 7 units of insulin lispro was administered between 7:00 a.m. and 9:00 a.m. On July 22 at 4:00 p.m. the resident's blood sugar was documented as low and 13 units of insulin lispro was administered between 5:00 p.m. and 6:00 p.m. On July 30 at 4:00 p.m. the resident's blood sugar was documented as 96 and 13 units of insulin lispro was administered between 5:00 p.m. and 6:00 p.m. On August 18 at 6:00 a.m. the resident's blood sugar was 99 and 7 units of insulin lispro was administered between 6:00 a.m. and 7:00 a.m. On August 18 at 4:00 p.m. the resident's blood sugar was documented as 98 and 13 units of insulin lispro was administered between 5:00 p.m. and 6:00 p.m. On August 25 at 6:00 a.m. the resident's blood sugar was 99 and 7 units of insulin lispro was administered between 6:00 a.m. and 7:00 a.m. Review of the resident's MAR also revealed that on August 5 and August 19 the resident was given 7 units of insulin lispro between 7:00 a.m. and 11:00 a.m.; however, there was no documented evidence of physician's orders to administer insulin in the morning on those dates.
An interview with the Director of Nursing on September 8, 2023, at 10:24 a.m. confirmed that insulin was given to Resident 35 on the above-mentioned dates and times, but according to physician's orders it should not have been given. The Director of Nursing also confirmed that insulin was given on August 5, 2023, and August 19, 2023, when there was no order for it to be given.
28 Pa. Code 211.12(d)(1)(5) Nursing services.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of facility policies, as well as observations and staff interviews, it was determined that the facility failed...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of facility policies, as well as observations and staff interviews, it was determined that the facility failed to ensure that medications were properly labeled and discarded when expired, and failed to label one multi-dose vial of Tubersol solution with the date it was opened in one of one medication rooms reviewed (second floor).
Findings include:
The facility's policy for medication storage guidance (for non-insulin injectable medications), dated [DATE], indicated that Tuberculin tests such as Aplisol injection or Tubersol injection (a solution injected under the skin to test for tuberculosis - a lung infection) were to be stored in the refrigerator at 36 to 46 degrees Fahrenheit (F). The medications should be dated when opened and discarded after 30 days. The facility should properly handle and dispose of any expired or unused product in accordance with facililty policy or local, state, and federal regulations.
Observations in the second floor medication room refrigerator on [DATE], at 10:21 a.m. revealed a container with one opened and undated multi-dose vial of Tubersol solution and ten sealed and unlabeled 75 milligram (mg) Oseltamivir Phosphate (antiviral mediation to treat influenza) capsules. Six of the capsules had a manufacturer's printed expiration date of [DATE]. Interview with Registered Nurse Unit Supervisor 7 at the time of observation and at 10:47 a.m. confirmed that the vial should have been dated with the date it was opened and the expired medication should have been discarded. Registered Nurse Unit Supervisor 7 further explained that the Oseltamivir Phosphate medication should have been labeled appropriately, since it was not an over-the-counter medication.
28 Pa. Code 211.9(h) Pharmacy services.
28 Pa. Code 211.12(d)(1)Nursing services.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0805
(Tag F0805)
Could have caused harm · This affected 1 resident
Based on clinical record reviews, observations, and staff interviews, it was determined that the facility failed to prepare food in an appropriate consistency to meet the resident's needs for one of 4...
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Based on clinical record reviews, observations, and staff interviews, it was determined that the facility failed to prepare food in an appropriate consistency to meet the resident's needs for one of 41 residents reviewed (Resident 65).
Findings include:
A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 65, dated August 2, 2023, indicated that the resident was cognitively intact, required extensive assistance of staff for daily care needs, required supervision for eating, and had diagnoses that included dysphagia (swallowing difficulties). A care plan for Resident 65, dated August 8, 2023, indicated that the resident had swallowing difficulties and was receiving a pureed diet.
Physician's orders for Resident 65, dated August 8, 2023, included an order for the resident to receive a pureed diet with honey thick liquids.
A review of a report from the Pennsylvania Department of Health Event Reporting System (ERS), dated August 27, 2023, at 6:15 p.m. revealed that Resident 65 had an episode of choking that required the Heimlich maneuver after she ate whole noodles that were not pureed as ordered.
A nurse's note for resident 65, dated August 27, 2023, at 6:15 p.m., revealed that the resident was eating dinner at the alcove and started to choke on a pasta noodle. The Heimlich maneuver was administered due to the resident not being able to clear her own airway, which successfully removed the noodle, and the resident was stabilized. A registered nurse assessment was completed. The resident's vital signs were stable, her lungs were diminished, which was baseline for resident, and her skin was warm and dry. The resident's tray card showed that the resident was to receive a pureed diet with nectar thick fluids, but the food was not pureed.
An interview with the Director of Nursing on September 7, 2023, at 1:06 p.m. confirmed that the ERS report was correct, and that the incorrect food consistency was given to the resident prior to her choking.
28 Pa. Code 211.12(d)(3) Nursing services.
28 Pa. Code 211.12(d)(5) Nursing services.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0810
(Tag F0810)
Could have caused harm · This affected 1 resident
Based on clinical record reviews, observations, and staff interviews, it was determined that the facility failed to ensure that residents were provided with assistive devices for eating for one of 41 ...
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Based on clinical record reviews, observations, and staff interviews, it was determined that the facility failed to ensure that residents were provided with assistive devices for eating for one of 41 residents reviewed (Resident 57).
Findings include:
The facility's policy regarding adaptive equipment, dated January 13, 2023, indicated that the primary therapist or assistant will issue and instruct the patient in adaptive equipment based upon patient's need. If the patient has difficulty comprehending, written instructions will be provided to family members and primary caregivers to increase carry over.
A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's care needs and abilities) for Resident 57, dated June 12, 2023, revealed that the resident was rarely understood and could rarely understand, was severely cognitively impaired, and required extensive assistance of one staff for eating. A care plan for impairment with self care, dated July 1, 2023, indicated that Resident 57 required total feeding assistance from staff.
A meal slip ticket, dated September 5, 2023, indicated in red capital letters that Resident 57 was to use a Teflon spoon.
Observations during the lunch meal on September 5, 2023, at 1:30 p.m. revealed that Nurse Aide 8 was providing total feeding assistance to Resident 57, and she did not have a Teflon spoon for her meal. Resident 57 was being fed with a metal spoon.
Interview with Nurse Aide 8 on September 5, 2023, at 1:30 p.m. confirmed that Resident 57 should have been provided a Teflon spoon, but the dietary department did not send one on the lunch tray.
Interview with the Rehabilitation Program Manager on September 7, 2023, at 10:28 a.m. confirmed that the Teflon spoon was ordered years ago, because Resident 57 bites down on the spoon. The spoon was ordered to protect her teeth, and Resident 57 should have had the spoon for the lunch meal.
28 Pa. Code 211.12(d)(3)(5) Nursing services.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected 1 resident
Based on review of clinical records, as well as resident and staff interviews, it was determined that the facility failed to maintain clinical records that were complete and accurately documented for ...
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Based on review of clinical records, as well as resident and staff interviews, it was determined that the facility failed to maintain clinical records that were complete and accurately documented for one of 41 residents reviewed (Resident 19).
Findings include:
A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 19, dated August 8, 2023, revealed that the resident was cognitively impaired, was dependent on staff for personal care needs, had an indwelling catheter (a thin tube inserted into the bladder to drain urine), and had diagnoses that included kidney disease.
Physician's orders for Resident 19, dated June 30, 2023, included an order for the resident to have a foley catheter (type of indwelling urinary catheter), 16 French (size of catheter), 10 milliliter (ml) balloon (volume capacity of balloon on the catheter tubing that prevents it from moving outside of the bladder) due to a pressure ulcer. Physician's orders, dated July 2, 2023, included an order to change the resident's foley catheter as needed using an 18 Fr, 10 ml balloon foley catheter.
Review of the Medication Administration Record (MAR) for Resident 19, dated July 2023, revealed that on the dates between July 15, 2023, and July 31, 2023, the resident had active orders for a size 16 Fr foley catheter and a size 18 Fr foley catheter. On July 22, 2023, the foley catheter was documented as being changed using an 18 Fr foley catheter; however, documentation on July 23-31, 2023, revealed that the resident had a size 16 Fr foley catheter.
An interview with the Director of Nursing on September 8, 2023, at 2:09 p.m. confirmed that Resident 19 had two different orders for her foley catheter in July 2023, and that documentation was inconsistent regarding what size foley catheter the resident had in place.
28 Pa. Code 211.5(f) Clinical records.
28 Pa. Code 211.12(d)(5) Nursing services.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
QAPI Program
(Tag F0867)
Could have caused harm · This affected 1 resident
Based on review of the facility's plans of correction for previous surveys, and the results of the current survey, it was determined that the facility's Quality Assurance Performance Improvement (QAPI...
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Based on review of the facility's plans of correction for previous surveys, and the results of the current survey, it was determined that the facility's Quality Assurance Performance Improvement (QAPI) committee failed to correct quality deficiencies and ensure that plans to improve the delivery of care and services effectively addressed recurring deficiencies.
Findings include:
The facility's deficiencies and plans of correction for a State Survey and Certification (Department of Health) surveys ending October 27, 2022; December 28, 2022; February 23, 2023; March 7, 2023; and May 30, 2023, revealed that the facility developed plans of correction that included quality assurance systems to ensure that the facility maintained compliance with cited nursing home regulations. The results of the current survey, ending September 8, 2023, identified repeated deficiencies related to quality of care and hand washing/hand hygiene.
The facility's plan of correction for a deficiency regarding notification, cited during the surveys ending December 28, 2022, and May 30, 2023, revealed that the facility developed a plan of correction that included completing audits and reporting the results of the audits to the QAPI committee for review. The results of the current survey, cited under F580, revealed that the facility's QAPI committee failed to successfully implement their plan to ensure ongoing compliance with regulations regarding notification.
The facility's plan of correction for a deficiency regarding quality of care, cited during the surveys ending October 27, 2023, and February 23, 2023, revealed that the facility developed a plan of correction that included completing audits and reporting the results of the audits to the QAPI committee for review. The results of the current survey, cited under F684, revealed that the facility's QAPI committee failed to successfully implement their plan to ensure ongoing compliance with regulations regarding quality of care.
The facility's plan of correction for a deficiency regarding safety and accidents, cited during the surveys ending March 7, 2023, and May 30, 2023, revealed that the facility developed a plan of correction that included completing audits and reporting the results of the audits to the QAPI committee for review. The results of the current survey, cited under F689, revealed that the facility's QAPI committee failed to successfully implement their plan to ensure ongoing compliance with regulations regarding safety and accidents.
The facility's plan of correction for a deficiency regarding significant medication errors, cited during the survey ending October 27, 2023, revealed that the facility developed a plan of correction that included completing audits and reporting the results of the audits to the QAPI committee for review. The results of the current survey, cited under F761, revealed that the facility's QAPI committee failed to successfully implement their plan to ensure ongoing compliance with regulations regarding significant medication errors.
The facility's plan of correction for a deficiency regarding safe storage and preparation of food, cited during the survey ending October 27, 2022, revealed that the facility developed a plan of correction that included completing audits and reporting the results of the audits to the QAPI committee for review. The results of the current survey, cited under F812, revealed that the facility's QAPI committee failed to successfully implement their plan to ensure ongoing compliance with regulations regarding safe storage and preparation of food.
The facility's plan of correction for a deficiency regarding infection control, cited during the survey ending October 27, 2022, revealed that the facility developed a plan of correction that included completing audits and reporting the results of the audits to the QAPI committee for review. The results of the current survey, cited under F880, revealed that the facility's QAPI committee failed to successfully implement their plan to ensure ongoing compliance with regulations regarding infection control.
Refer to F580, F684, F689, F761, F812, F880.
28 Pa. Code 201.14(a) Responsibility of licensee.
28 Pa. Code 201.18(e)(1) Management.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
Based on review of policies and clinical record reviews, as well as observations and staff interviews, it was determined that the facility failed to ensure that food was served to a resident in a sani...
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Based on review of policies and clinical record reviews, as well as observations and staff interviews, it was determined that the facility failed to ensure that food was served to a resident in a sanitary manner for one of 41 residents reviewed (Resident 8), and failed to use proper infection control practices during wound care for one of 41 residents reviewed (Resident 23).
Findings include:
The facility's policy regarding food production and safety, dated January 13, 2023, revealed that single-use gloves would be used when handling ready-to-eat food directly with hands to avoid cross-contamination.
A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's care needs and abilities) for Resident 8, dated August 29, 2023, revealed that the resident was usually understood and could usually understand, was severely cognitively impaired, and required supervision after set up of one staff for eating. Resident 8's care plan for impairment with self care, dated August 31, 2023, indicated that the resident had a potential nutrition problem related to chewing difficulties and a mechanically-altered diet.
Observations of the lunch meal on September 5, 2023, at 12:59 p.m. in the third floor dining room and lounge area revealed that Nurse Aide 8 provided assistance to set up the residents. With her bare hand, Nurse Aide 8 held down the bun of the roast beef sandwich to cut it with the knife, then using both bare hands she picked the sandwich up to pull the halves apart, and handed one half of the sandwich to Resident 8.
Interview with Nurse Aide 8 on September 5, 2023, at 1:30 p.m. confirmed that she was touching food with her bare hands but indicated that her hands were sanitized.
Interview with the Nursing Home Administrator on September 5, 2023, at 3:30 p.m. confirmed that all staff should have worn gloves to set up trays and should never use bare hands to touch food.
The facility's policy regarding hand hygiene, dated January 13, 2023, indicated that hand hygiene was to be performed after removing gloves and after contact with non-intact skin and/or wound dressings.
An annual MDS assessment for Resident 23, dated August 9, 2023, revealed that he was cognitively intact, required extensive assistance from staff for personal care needs, and had diagnoses that included diabetes and seizure disorder.
Physician's orders for Resident 23, dated August 31, 2023, included an order for the resident to receive Miconazole nitrate (used to treat fungal skin infections) cream to his left great toe and cover with a band aid every day for a fungal infection.
Observations on September 5, 2023, at 12:18 p.m. revealed that Licensed Practical Nurse 9 removed a soiled band aid from Resident 23's left great toe and did not remove her gloves and perform hand hygiene before cleansing the resident's toe and applying the ordered cream. The observation also revealed that Licensed Practical Nurse 9 applied the Miconazole cream directly to the resident's left great toe from the medication tube, touching the resident's toe with the tip of the medication tube.
Interview with Licensed Practical Nurse 9 on September 5, 2023, at 12:56 p.m. revealed that she should have removed her gloves and performed hand hygiene after removing the soiled band aid from Resident 23's left great toe and before applying the ordered cream and clean band aid, and that she should not have applied the Miconazole cream directly to the resident's toe from the medication tube, touching the resident's wound.
An interview with the Director of Nursing on September 5, 2023, at 3:15 p.m. confirmed that Licensed Practical Nurse 9 should have changed her gloves and performed hand hygiene between removing the soiled band aid and applying ordered cream and clean band aid, and that she should not have applied the Miconazole cream directly to Resident 23's toe.
28 Pa. Code 211.6(f) Dietary services.
28 Pa. Code 211.12(d)(1)(5) Nursing services.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0883
(Tag F0883)
Could have caused harm · This affected 1 resident
Based on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that each resident was assessed, offered and/or received th...
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Based on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that each resident was assessed, offered and/or received the pneumococcal immunizations for two of 41 residents reviewed (Residents 8, 11).
Findings include:
The facility's policy regarding pneumococcal vaccine, dated January 13, 2023, revealed that pneumococcal vaccinations will be offered to all residents and administered per provider orders.
A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 8, dated June 13, 2023, indicated that the resident was cognitively impaired and required assistance from staff for her daily care tasks. Section O0300 B (Pneumococcal Vacination) revealed that the resident was not up to date and that the resident was not offered the pneumococcal vaccine.
There was no documented evidence that the facility offered or administered the pneumococcal vaccines to the resident or that the resident refused the vaccination.
A quarterly MDS assessment for Resident 11, dated August 15, 2023, revealed that the resident was cognitively impaired and required assistance from staff for daily care needs. Section O0300 B (pneumococcal vaccination) revealed that the resident was not offered the pneumococcal vaccine.
There was no documented evidence in Resident 11's clinical record to indicate that the facility offered or administered the pneumococcal vaccines to the resident or that the resident refused the vaccination.
Interview with the Director of Nursing on September 8, 2023, at 11:37 a.m. confirmed that Residents 8 and 11 had no documented evidence that they were offered or refused the pneumococcal vaccination.
28 Pa. Code 201.14(a) Responsibility of licensee.
28 Pa. Code 201.18(b)(1) Management.
28 Pa. Code 211.12(d)(1)(5) Nursing services.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected multiple residents
Based on review of clinical records and facility investigation reports, as well as staff interviews, it was determined that the facility failed to complete safety assessments for five of 41 residents ...
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Based on review of clinical records and facility investigation reports, as well as staff interviews, it was determined that the facility failed to complete safety assessments for five of 41 residents reviewed (Residents 22, 40, 53, 73, 74) who used an air mattress.
Findings include:
An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 22, dated August 7, 2023, revealed that the resident was confused, required assistance from staff for his daily care needs, and was at risk for developing a pressure ulcer. Physician's orders, dated August 1, 2023, included an order for the resident to have an air mattress (an inflated mattress for pressure relief).
Observations on September 5, 2023, at 11:55 a.m. revealed that Resident 22 was lying in bed and the bed was equipped with an air mattress; however, there was no documented evidence that the use of an air mattress was assessed for potential safety hazards prior to being placed on Resident 22's bed.
A quarterly MDS assessment for Resident 40, dated August 18, 2023, revealed that the resident was severely cognitively impaired, required extensive assistance for daily care needs including bed mobility, and received hospice (end of life comfort care) services. Physician's orders for the resident, dated April 8, 2023, included an order for the resident's bed to be equipped with a 42-inch air force one mattress (an air mattress) with bolster overlay.
Observations on August 5, 2023, at 11:47 a.m. and September 7, 2023, at 11:27 a.m. revealed that Resident 40 was in bed sleeping; however, there was no documented evidence that the use of an air mattress was assessed for potential safety hazards prior to being placed on Resident 40's bed.
A quarterly MDS for Resident 53, dated July 10, 2023, revealed that the resident was alert and oriented, required minimal assistance from staff for daily care needs, and was at risk for pressure ulcer development. Physician's orders for Resident 53, dated July 4, 2023, included an order for the resident to have a Concord mattress (an air mattress).
Observations of Resident 53's bed on September 5, 2023, at 11:16 a.m. revealed that she had an air mattress; however, there was no documented evidence that the use of an air mattress was assessed for potential safety hazards prior to being placed on Resident 53's bed.
An admission MDS assessment for Resident 73, dated September 5, 2023, revealed that the resident required extensive assistance for care, had unhealed pressure ulcers, and was at risk for pressure ulcers. Physician's orders for Resident 73, dated August 30, 2023, included an order for the resident to have a Concord mattress (an air mattress).
Observations of Resident 73 on September 5, 2023, at 11:16 a.m. revealed that he was lying in bed on an air mattress; however, there was no documented evidence that the use of an air mattress was assessed for potential safety hazards prior to being placed on Resident 73's bed.
An admission MDS assessment for Resident 74, dated September 7, 2023, revealed that the resident required extensive assistance for care, had an unstageable pressure ulcer, and was at risk for pressure ulcers. Physician's orders for Resident 74, dated September 4, 2023, included an order for the resident to have a Concord mattress.
Observations of Resident 74 on September 6, 2023, at 9:33 a.m. revealed that the resident was lying in bed on an air mattress; however, there was no documented evidence that the use of an air mattress was assessed for potential safety hazards prior to being placed on Resident 74's bed.
Interview with the Assistant Director of Nursing on September 8, 2023, at 12:27 p.m. confirmed that there were no assessments for potential safety hazards prior to the air mattresses being placed on the resident's beds and there should have been.
28 Pa. Code 211.12(d)(3)(5) Nursing services.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0692
(Tag F0692)
Could have caused harm · This affected multiple residents
Based on clinical record reviews and family and staff interviews, it was determined that the facility failed to ensure that sufficient fluids were offered and/or consumed daily for one of 41 residents...
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Based on clinical record reviews and family and staff interviews, it was determined that the facility failed to ensure that sufficient fluids were offered and/or consumed daily for one of 41 residents reviewed (Resident 73), and failed to obtain weights as ordered for one of 41 residents reviewed (Resident 39).
Findings include:
An admission Minimum Data Set (MDS) assessment (a mandated assessment of a residents abilities and care needs) for Resident 73, dated September 5, 2023, revealed that she required extensive assistance for care, was frequently incontinent, and weighed 85 pounds. A care plan for Resident 73, dated August 30, 2023, indicated that staff were to monitor and document the resident's intake and output.
Review of Resident 73's intake and output record for August and September 2023 revealed that on August 29, 2023, the resident consumed 240 milliliters (ml) of fluids; on August 30, 2023, she consumed 387 ml; on August 31, 2023, she consumed 240 ml; on September 1, 2023, she consumed 303 ml; on September 2, 2023, she consumed 480 ml; on September 3, 2023, she consumed 1,030 ml; on September 4, 2023, she consumed 650 ml; on September 5, 2023, she consumed 890 ml; and on September 6, 2023, she consumed 320 ml.
An interview with Family Member 1 on September 7, 2023, at 11:34 a.m. revealed that Resident 73 is not able to give herself a drink and that staff must feed her all food and drink. She further stated that the resident did not get enough fluids offered to her each day.
An interview with the Dietician confirmed that Resident 73's intake records revealed that she was not offered or given enough fluids per day and that she should have more.
An interview with the Director of Nursing on September 7, 2023, at 1:38 p.m. confirmed that Resident 73 was not getting enough fluids offered to her.
An annual MDS assessment for Resident 39, dated August 8, 2023, indicated that the resident was cognitively impaired and required extensive assistance from staff for her daily care tasks. Physician's orders for Resident 39, dated July 5, 2023, included an order for the resident to be weighed every two weeks and for the physician to be notified of any gain greater than three pounds.
A review of Resident 39's weight logs for August and September 2023 revealed that she was not weighed on August 23 or September 6, 2023.
An interview with the Assistant Director of Nursing on September 8, 2023, at 12:24 p.m. confirmed that Resident 39 was not weighed per physician's orders and that she should have been.
28 Pa. Code 211.12(d)(3)(5) Nursing services.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0698
(Tag F0698)
Could have caused harm · This affected multiple residents
Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure communication between a dialysis provider and the nursing staff for ...
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Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure communication between a dialysis provider and the nursing staff for one of 41 residents reviewed (Resident 53).
Findings include:
The facility's policy regarding dialysis (mechanical cleansing of the blood to remove waste products when the kidneys are not functioning properly), dated January 13, 2023, indicated that facility staff would participate in ongoing communication with the dialysis center by using the dialysis communication form, which was filed in the resident's medical record.
A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 53, dated July 10, 2023, indicated that the resident was cognitively intact, required assistance from staff for her daily care tasks, and had diagnoses that included end-stage renal disease (the last stage of chronic kidney disease where the kidneys are only functioning at 10 to 15 percent of their normal capacity) with dependence on renal dialysis, and received dialysis treatments during the assessment period. The resident's care plan, dated June 30, 2023, revealed that the resident received dialysis related to renal failure, and that staff were to assist the resident in preparing for transport to dialysis every Tuesday, Thursday, and Saturday.
A review of Resident 53's clinical record revealed that the resident received dialysis every Tuesday, Thursday, and Saturday as ordered by the physician; however, there was no documented evidence that dialysis communication forms were completed per the facility's policy.
Interview with Resident 53 on September 7, 2023, at 10:29 a.m. revealed that she had not seen her dialysis communication book in a long time.
Interview with Licensed Practical Nurse 6 on September 7, 2023, at 10:30 a.m. confirmed that she could not find the dialysis communication book for Resident 53 and that she would have to start a new one.
Interview with the Director of Nursing on September 7, 2023, at 12:18 p.m. confirmed that there was no documented evidence that dialysis communication forms were completed for Resident 53 per the facility's policy.
28 Pa. Code 211.12(d)(3) Nursing services.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected multiple residents
Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to maintain accountability for controlled medications (drugs with the potentia...
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Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to maintain accountability for controlled medications (drugs with the potential to be abused) for one of 41 residents reviewed (Resident 19).
Findings include:
The facility's policy regarding controlled substance disposal, dated January 31, 2023, indicated that the destroying/disposal of controlled drugs should be conducted according to federal and state regulations. Destruction of controlled medications should be documented on the controlled medication count sheet and signed by the registered nurse and a witnessing licensed professional.
A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 19, dated August 8, 2023, revealed that the resident was cognitively impaired, received pain medication routinely and as needed, received an opioid (a controlled pain medication), and had diagnoses that included kidney disease.
Physician's orders for Resident 19, dated August 6, 2022, included an order for the resident to receive a 12 micrograms (mcg) Fentanyl (a narcotic pain patch) patch to be applied every three days for pain.
The Medication Administration Record (MAR) and a controlled drug count record (tracks each dose of a controlled medication) for Resident 19, both dated August and September 2023, revealed that a Fentanyl patch was applied to the resident on August 24, 27, and 30, and September 2 and 5, 2023. There was no documented evidence that two staff members signed that the old patch was destroyed after removal on these dates.
Interview with the Director of Nursing on September 8, 2023, at 2:09 p.m. confirmed that there were not two witness signatures for the destruction of Fentanyl patches on August 24, 27, and 30, and September 2 and 5, 2023.
28 Pa. Code 211.9(a)(h) Pharmacy services.
28 Pa. Code 211.12(d)(1)(5) Nursing services.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected multiple residents
Based on observations and staff interviews, it was determined that the facility failed to prepare and store ice under sanitary conditions for one of three ice machines and failed to ensure that food s...
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Based on observations and staff interviews, it was determined that the facility failed to prepare and store ice under sanitary conditions for one of three ice machines and failed to ensure that food stored in the main kitchen was sealed and not opened to air.
Findings include:
Observations of the second floor ice machine on September 8, 2023, at 1:43 p.m. revealed a dark, removable substance on the inside of the ice machine lid.
Interview with the Environmental Services Director on September 8, 2023, at 2:02 p.m. confirmed that the ice machine had a dark, removable substance inside the ice machine lid. He stated the machines were to be cleaned monthly and confirmed that the ice machine was in need of sanitizing.
The facility's policy regarding food storage, dated January 13, 2023, revealed that opened food must be labeled and dated when opened. Opened packages should be sealed and or covered. Food should be stored a minimum of six inches above the floor.
Observations in the kitchen's main freezer on September 5, 2023, at 9:40 a.m. revealed an opened bag of frozen sausage that was exposed to air, a box of frozen chicken, and a box of ice cream sitting on the floor of the freezer.
Interview with the Dietary Manager on September 5, 2023, at 9:40 a.m. confirmed that the sausage should not have been open and exposed to air and the boxes of chicken and ice cream should not have been on the floor of the freezer.
28 Pa. Code 211.6(f) Dietary services.
28 Pa. Code 207.4 Ice containers and storage.
MINOR
(B)
Minor Issue - procedural, no safety impact
Assessment Accuracy
(Tag F0641)
Minor procedural issue · This affected multiple residents
Based on review of the Resident Assessment Instrument User's Manual and clinical records, as well as staff interviews, it was determined that the facility failed to complete accurate Minimum Data Set ...
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Based on review of the Resident Assessment Instrument User's Manual and clinical records, as well as staff interviews, it was determined that the facility failed to complete accurate Minimum Data Set assessments for one of 41 residents reviewed (Resident 40).
Findings include:
The RAI User's Manual, dated October 2019, revealed that Sections H0100 through H0300 were to gather information on the use of bowel and bladder appliances and urinary and bowel continence. Section H0100 was to be coded for each appliance that was used at any time in the past seven days. Select none of the above if none of the appliances A-D were used in the past seven days. Section H0300 was to be coded nine (9), not rated if during the seven-day look-back period the resident had an indwelling bladder catheter (a tube held in the bladder to drain urine), or other types of catheters or no urine output for the entire seven days.
A quaterly MDS assessment for Resident 40, dated August 18, 2023, revealed that Section H0100Z was checked, indicating that the resident did not have an indwelling urinary catheter, and Section H0300 was coded with a three (3), indicating that the resident was always incontinent of urine.
Physician's orders for Resident 40, dated July 3, 2023, included an order for the resident to have the catheter tubing anchored and placement checked to ensure it was secured three times a day (once a shift). Review of Resident 40's treatment administration record for August 2023 revealed that he received catheter tubing and placement checks every shift during the review period.
Interview with the RNAC on September 8, 2023, at 2:28 p.m. confirmed that Resident 40 had an indwelling urinary catheter during the assessment period in August 2023, and that Section H0100 should have been coded with an A and not a Z. H0300 should have been coded with a nine (9) and not a three (3).
28 Pa. Code 211.5(f) Clinical records.
May 2023
3 deficiencies
1 Harm
SERIOUS
(G)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Actual Harm - a resident was hurt due to facility failures
Accident Prevention
(Tag F0689)
A resident was harmed · This affected 1 resident
Based on review of facility policies, clinical records, and facility investigative documents, as well as staff interviews, it was determined that the facility failed to ensure that each resident recei...
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Based on review of facility policies, clinical records, and facility investigative documents, as well as staff interviews, it was determined that the facility failed to ensure that each resident received adequate supervision and assistance devices to prevent accidents, by failing to ensure that care-planned interventions were in place for one of seven residents reviewed (Resident 7), resulting in a fractured tibia and fibula (lower leg bones) and a fracture of the fibular head (leg bone under knee cap) for the resident.
Findings include:
The facility's policy regarding fall investigations, dated April, 2023, indicated that the fall committee leader will be responsible for evaluating current interventions, updating fall care plans, and developing new interventions as appropriate.
A significant change Minimum Data Set (MDS) assessment (a federally-mandated assessment of a resident's abilities and care needs) for Resident 7, dated April 19, 2023, indicated that the resident could usually understand, was usually understood, required extensive assistance from staff for daily care, and had diagnoses that included dementia. Physician's orders for Resident 7, dated April 8, 2023, included an order for the resident to have an Air Force One Mattress with bolster overlay (specialty air mattress with built up sides).
Resident 7's care plan, dated April 20, 2022, revealed that she was to have constant supervision and be out of bed for her meals.
A nursing note for Resident 7, dated May 17, 2023 at 1:15 p.m., revealed that the resident was found on the floor lying on her back with her head at the bottom of the bed. The facility's investigation report, dated May 17, 2023, revealed that the resident was observed in bed eating her lunch five minutes prior to being found on the floor.
There was no documented evidence that Resident 7 was out of bed for her lunch meal or that she had constant supervision. There was no documented evidence that the resident was assessed for safety prior to the use of the air mattress, or that the air mattress was ruled out as a contributing factor in causing the resident to fall out of bed, or that the resident was assessed for safety with the air mattress after the fall.
A nursing note for Resident 7, dated May 17, 2023 revealed that the resident's left shin was discolored from a previous fall earlier that day. An x-ray for Resident 7, dated May 18, 2023, revealed that the resident had a fracture of the fibular head as well as the tibia and fibula.
Interview with the Director of Nursing on May 30, 2023, at 9:48 p.m. confirmed that the resident was in bed eating her lunch without supervision when she fell out of bed. The facility's investigation did not determine why the resident was in bed eating her lunch without supervision at the time of her fall, nor did the investigation rule out that the air mattress could have contributed to the resident's fall or if the resident was safe to remain on the air mattress after her fall.
28 Pa. Code 201.18(e)(1) Management.
28 Pa. Code 211.10(d) Resident care policies.
28 Pa. Code 211.12(d)(5) Nursing services.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Notification of Changes
(Tag F0580)
Could have caused harm · This affected 1 resident
Based on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that the resident's physician was notified timely about ele...
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Based on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that the resident's physician was notified timely about elevated blood sugar results for one of seven residents reviewed (Resident 2).
Findings include:
The facility's policy regarding physician notification, dated January 13, 2023, indicated that the physician would be notified in a timely manner when a change in resident condition or an unusual incident involving the resident occurred. The physician's notification and intervention will be documented in the electronic medical record.
An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 2, dated March 13, 2023, revealed that the resident was understood, understands, required extensive assistance for her daily care needs, had diagnoses that included diabetes, and received insulin (medication that lowers blood sugar levels).
Physician's orders for Resident 2, dated March 7, 2023, included an order for the resident to receive Novolog (Insulin) according to a sliding scale (the amount of insulin is based on the result of a fingerstick blood sugar test) before meals for diabetes. The sliding scale included giving 0 (zero) units of insulin for a blood sugar of 70-140 milligrams/deciliter (mg/dL); 3 units for a blood sugar of 141-180 mg/dL; 6 units of insulin for a blood sugar of 181-220 mg/dL; 9 units of insulin for a blood sugar of 221-260 mg/dL; 12 units of insulin for a blood sugar of 261-300 mg/dL; 18 units for a blood sugar of greater than 340 mg/dL and call the physician.
Resident 2's Medication Administration Record (MAR) for March 2023 revealed that on March 9, 2023, at 10:10 a.m. the resident's blood sugar was 363 mg/dL; on March 11, 2023, at 4:00 p.m. it was 368 mg/dL; on March 14, 2023, at 10:10 a.m. it was 403 mg/dL; and on March 21, 2023, at 10:10 a.m. it was 347 mg/dL. There was no documented evidence that the physician was notified about the resident's blood sugar being above 340 mg/dL on these dates and times.
Interview with the Director of Nursing on May 30, 2023, at 8:40 p.m. confirmed that there was no documented evidence that the physician was notified about Resident 2's elevated blood sugars, as ordered.
28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected 1 resident
Based on clinical record reviews and facility investigations, as well as staff interviews, it was determined that the facility failed to ensure that residents' clinical records were complete and accur...
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Based on clinical record reviews and facility investigations, as well as staff interviews, it was determined that the facility failed to ensure that residents' clinical records were complete and accurately documented for one of seven residents reviewed (Resident 2).
Findings include:
An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 2, dated March 13, 2023, revealed that the resident was understood, could understand, and required extensive assistance for her daily care needs
Physician's orders for Resident 2, dated March 7, 2023, included an order for the resident to receive a no added salt diet with regular texture, regular fluid consistency, and a fluid restriction of 2000 milliliters (ml).
Nurse Aide meal consumption documentation for Resident 2 for March, 2023 revealed that staff documented the resident was NPO (indicating that the resident was to receive nothing by mouth) on March 10, 2023, at 8:00 a.m.
Review of Resident 2's clinical record revealed no documented evidence that the resident was to be NPO for breakfast on March 10, 2023.
Interview with the Assistant Director of Nursing on May 30, 2023, at 8:35 p.m. confirmed that staff documented that Resident 2 was NPO on March 10, 2023, at 8:00 a.m. She indicated that she believes that there was an error in the documentation by the nurse aide, because the nurse aide also documented that the resident received 240 ml of fluid at that time.
28 Pa Code 211.5(f) Clinical records.
28 Pa. Code 211.12(d)(5) Nursing services.
Mar 2023
2 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected 1 resident
Based on review of policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to review and revise care plans for two of three residents re...
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Based on review of policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to review and revise care plans for two of three residents reviewed (Residents 1, 2).
Findings include:
The facility's policy regarding care plans, dated January 13, 2023, indicated that the resident's care plan will be updated when a change in condition occurs. Care plans that no longer reflect the current status of the resident are to be discontinued within the electronic record.
A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's care needs and abilities) for Resident 1, dated February 14, 2023, indicated that the resident was cognitively impaired, required limited assistance from staff with daily care tasks including transfers and ambulation (walking), had recent falls, and had diagnoses that included anxiety. A care plan, dated December 19, 2022, revealed that the resident was at risk for falls due to a history of falls, and staff were to anticipate and meet the resident's needs, encourage the resident to wear appropriate foot wear, have the area free of environmental factors, use a low bed, educate him not to self-transfer since he was non-compliant with transfers, have anti-skid tape on the right side of his bed, ensure the placement and function of his bed alarm, transfer with the minimum assist of one staff with a front-wheeled walker, and place a call don't fall sign in his room for safety.
A facility investigation, dated January 3, 2023, at 7:45 a.m. revealed that Resident 1 was observed lying on the floor in the doorway of the bathroom with his legs through the door. Staff were educated on not leaving high-risk fall residents alone in the bathroom. There was no documented evidence that the resident's care plan was revised to reflect that the resident was not to be left alone in the bathroom.
A fall investigation, dated February 3, 2023, at 2:50 p.m. revealed that Resident 1 was observed lying on the ground at the foot of the bed facing the doorway with his back against the wall and stated that he was going to the bathroom. The chair alarm was not sounding at the time of the fall and the resident stated that he turned off the chair alarm. The resident was assessed for injury and the chair alarm was on caregiver mode. However, there were no new interventions put into place to prevent the resident from transferring unassisted or turning off the alarm. There was no documented evidence that the resident's care plan was revised to reflect that the resident was to use a chair alarm.
Observations on March 7, 2023, at 3:18 p.m. revealed that Resident 1 was lying in bed and a chair alarm was attached to the regular chair that was in his room.
Interview with the Director of Nursing on March 7, 2023, at 3:32 p.m. and 4:04 p.m. confirmed that there was no documented evidence that the resident' care plan was updated to include the use of a chair alarm and not to be left alone in the bathroom, and should have been.
A quarterly MDS assessment for Resident 2, dated December 8, 2022, revealed that the resident rarely/never understood; rarely/never understands; required extensive assistance from staff for her bed mobility, eating, and personal hygiene; was totally dependent on staff for her transfers and toileting needs; and had diagnoses that included Cerebral Vascular Accident (CVA - commonly known as a stroke) and a history of Traumatic Brain Injury. A care plan for the resident, dated November 29, 2021, revealed that the resident was at risk for falls and was to have her bed at standard height with a pressure-redistribution mattress.
Observations of Resident 2 on March 7, 2023, at 11:15 a.m. revealed that the resident was lying in a low bed with bilateral assist rails, a bed alarm, and a concave mattress (a mattress that features concave sides, so the patient is encouraged to lie in the middle of it, thereby minimizing the possibility of falling).
As March 7, 2023, Resident 2's care plan still indicated that the resident had a pressure-redistribution mattress, and there was no documented evidence that the resident's care plan was revised to reflect that the resident was to have a concave mattress.
Interview with the Director of Nursing on March 7, 2023, at 2:54 p.m. confirmed that Resident 2 currently had a concave mattress, which was added as an intervention due to a fall that had occurred on February 18, 2023, and that the care plan should have been revised to reflect the change in the type of mattress.
28 Pa. Code 211.11(d) Resident care plan.
28 Pa. Code 211.12(d)(5) Nursing services.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
Based on review of policies, clinical records, and facility investigation reports, as well as staff interviews, it was determined that the facility failed to provide an environment that was free from ...
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Based on review of policies, clinical records, and facility investigation reports, as well as staff interviews, it was determined that the facility failed to provide an environment that was free from accident hazards and failed to ensure that assistance devices to prevent accidents were in place as care planned and ordered for one of eight residents reviewed (Resident 1) who was at risk for falls.
Findings include:
The facility's policy regarding falls, dated January 13, 2023, indicated that the facility was to promote resident safety by identifying residents at risk for falls, implementing resident-specific interventions to reduce the risk of falls, and conduct ongoing review of interventions to facilitate timely re-evaluation of safety strategies for effectiveness.
A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's care needs and abilities) for Resident 1, dated February 14, 2023, indicated that the resident was cognitively impaired, required limited assistance from staff with daily care tasks including transfers and ambulation (walking), had recent falls, and had diagnoses that included anxiety. A care plan, dated December 19, 2022, revealed that the resident was at risk for falls due to a history of falls, and staff were to anticipate and meet the resident's needs, encourage the resident to wear appropriate foot wear, have the area free of environmental factors, use a low bed, educate him not to self-transfer since he was non-compliant with transfers, have anti-skid tape on the right side of his bed, ensure the placement and function of his bed alarm, transfer with the minimum assist of one staff with a front-wheeled walker, and place a call don't fall sign in his room for safety.
A facility investigation, dated January 3, 2023, at 7:45 a.m. revealed that Resident 1 was observed lying on the floor in the doorway of the bathroom with his legs through the door. Staff were educated on not leaving high-risk fall residents alone in the bathroom.
Nursing notes, dated January 4, 2023, at 11:01 a.m., January 9, 2023, at 3:00 p.m. and January 11, 2023, at 3:05 p.m. revealed that the resident continued to be non-compliant with transfers and was educated multiple times on the importance of ringing the call bell for help. However, there were no new interventions put into place to prevent the resident from transferring unassisted.
A facility investigation, dated January 28, 2023, at 9:35 p.m. revealed that Resident 1 was observed lying on the floor with his legs pointed straight out, in between the bed and the closet, and his walker was in front of him. He was educated on the importance to ring for assistance when he needed help. A witness statement from Nurse Aide 1, dated January 28, 2023, revealed that Resident 1 was sitting in the dining area watching television and did not inform anyone when he wanted to go back to his room. He walked himself back to his room and tried to sit on his bed, but missed and fell. The resident's wife, who shares the room with him, was educated on the importance to ring the call bell for assistance.
A fall investigation, dated February 3, 2023, at 2:50 p.m. revealed that Resident 1 was observed lying on the ground at the foot of the bed facing the doorway with his back against the wall and stated that he was going to the bathroom. The chair alarm was not sounding at the time of the fall and the resident stated that he turned off the chair alarm. The resident was assessed for injury and the chair alarm was on caregiver mode. However, there were no new interventions put into place to prevent the resident from transferring unassisted or turning off the alarm.
A fall investigation, dated February 3, 2023, at 7:25 p.m. revealed that Resident 1 was lying on floor parallel with his bed and his bed alarm was going off. The resident had been educated to ring for assistance when getting out of bed, but his understanding was questionable due to dementia. However, there were no new interventions put into place to prevent the resident from transferring unassisted.
A fall investigation, dated February 9, 2023, at 2:36 p.m revealed that Resident 1 had an unwitnessed fall, was sitting next to the chair, and said he was coming back from the bathroom. The call bell was not on and the chair alarm was not sounding and was in caregiver mode. He stated that he missed the chair and landed on his buttocks. A communication to therapy was completed. The resident was unable to be re-educated and his spouse verbalized she would try to call when he needed to get up. However, there were no new interventions put into place to prevent the resident from turning the alarm off.
A fall investigation, dated February 19, 2023, at 5:45 p.m. revealed staff arrived to the resident's room with the bed alarm sounding and the resident lying on the floor. Staff educated the resident and his wife to ring the call bell for assistance. However, there were no new interventions put into place to prevent the resident from transferring unassisted.
Interview with the Director of Nursing on March 7, 2023, at 4:04 p.m. confirmed there was no documented evidence of new interventions implemented to prevent Resident 1 from transferring unassisted or turning the alarms off, and that re-educating the resident and his wife to ring the call bell for assistance was ineffective.
28 Pa. Code 211.12(d)(3)(5) Nursing services.
Feb 2023
5 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
Based on clinical record reviews and staff interviews, it was determined that the facility failed to develop comprehensive care plans that included specific and individualized preferences regarding ba...
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Based on clinical record reviews and staff interviews, it was determined that the facility failed to develop comprehensive care plans that included specific and individualized preferences regarding bathing/showering for two of 13 residents reviewed (Residents 7, 13).
Findings include:
A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 7, dated February 2, 2023, revealed that the resident was cognitively impaired and required extensive assistance from staff for personal hygiene and bathing.
Resident 7's inventory sheet, dated September 7, 2021, indicated that the resident likes to receive showers in the afternoon. Review of Resident 7's bathing records for January and February 2023 revealed that the resident received one shower in the last 30 days and four showers in the last 50 days. She had not refused any showers.
There was no documented evidence that the resident's care plan, which was updated on February 2, 2023, included the resident's preferences regarding bathing or showering.
An admission MDS assessment for Resident 13, dated January 27, 2023, revealed that the resident was alert and oriented and dependent on staff for transfers and bathing.
A bathing preference sheet, dated January 20, 2023, revealed that Resident 13 preferred to receive a shower. A review of Resident 13's bathing records for January and February 2023 revealed that she received a shower on January 27 and February 20, 2023. However, there was no documented evidence that the resident's current care plan included the resident's preference for receiving a shower.
Interview with the Director of Nursing on Feburary 20, 2023, at 5:34 p.m. confirmed that Resident 7's and 13's care plans were not individualized regarding the residents preference for receiving a shower or bath, and it should have been.
28 Pa. Code 211.11(d) Resident care plan.
28 Pa. Code 211.12(d)(5) Nursing services.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility fail...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to complete neurological assessments after a fall for one of 13 residents reviewed (Resident 2).
Findings include:
The facility policy regarding neurological assessments, dated February 7, 2023, indicated that for the first hour staff were to assess the resident every 15 minutes, then assess the resident every hour two times, then assess the resident every two hours two times, and then assess the resident every four hours to complete a 24-hour period.
A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 2, dated [DATE], indicated that the resident was cognitively impaired, required assistance from staff for his daily care tasks, including bed mobility and transfers, and had diagnoses that included a stroke, Parkinson's disease (brain disorder that causes unintended or uncontrollable movements), and traumatic brain injury (results from a violent blow or jolt to the head).
A nursing note, dated February 15, 2023, at 1:00 a.m. revealed that Resident 2 was observed lying on the fall mat beside his bed. He stated that he rolled out of bed.
A fall investigation report for Resident 2, dated February 15, 2023, revealed that the resident's fall at 12:40 a.m. was unwitnessed and neurological checks (a thorough assessment to assess mental status, cranial nerves, motor and sensory function, as well as reflexes to determine if there has been a change in mental or physical function) were started.
Neurological checks for Resident 2, dated February 15, 2023, revealed that staff obtained initial neurological checks at 12:45 a.m. and then at 1:00 a.m. and 1:15 a.m., then at 2:30 a.m. and 3:30 a.m., and then at 5:30 a.m. and 7:30 a.m. There was no documented evidence that a neurological check was completed every four hours at 11:30 a.m. There was no documented evidence that neurological checks for the first hour were completed every 15 minutes at 1:30 a.m. and 1:45 a.m., and every four hours at 11:30 a.m., per the facility policy.
A nursing note, dated February 15, 2023, at 12:30 p.m. and 12:40 p.m. revealed that the resident was observed in his wheelchair unresponsive and not breathing. Staff transferred the resident to his bed and started CPR (cardio-pulmonary resuscitation); however, the resident ceased to breathe.
Interview with the Director of Nursing on Feburary 20, 2023, at 2:30 p.m. confirmed that there was no documented evidence that Resident 2 had neurological checks completed per the facility policy.
28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Pressure Ulcer Prevention
(Tag F0686)
Could have caused harm · This affected 1 resident
Based on review of clinical records, as well as staff interviews, it was determined that the facility failed to ensure that pressure ulcer care/prevention treatments were proved as ordered for one of ...
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Based on review of clinical records, as well as staff interviews, it was determined that the facility failed to ensure that pressure ulcer care/prevention treatments were proved as ordered for one of 13 residents reviewed (Resident 1).
Findings include:
A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated December 6, 2022, revealed that the resident was cognitively impaired, was dependent on staff for daily care needs, was at risk for pressure ulcer (skin impairment caused by pressure) development, and had one Stage 2 (damage to the top two layers of skin) facility-acquired pressure ulcer, one Stage 4 (deep wounds that may impact muscle, tendons, ligaments, and bone) pressure ulcer present on admission, and one deep tissue injury (DTI- pressure-related injury to tissues under intact skin) present on admission.
Physician's orders for Resident 1, dated December 7, 2022, included an order for the resident to have her right flank (side) wound cleansed with Dakin's solution (used to treat or prevent infections), the wound bed covered with
Dakin's moistened gauze, and then covered with a dry dressing attached with tape every shift.
Physician's orders for Resident 1, dated December 7, 2022, included an order for the resident to have the wound on her sacrum (area around the base of the spine) irrigated with Dakin's solution, collagen powder (used to promote wound healing) applied to the wound base, the wound packed with Dakin's moistened kerlix (roll of woven gauze) and covered with a dry dressing fixed with tape every day and evening shift.
Physician's orders for Resident 1, dated January 19, 2023, included an order for the resident to have the wound on her sacrum irrigated with Dakin's solution, the wound packed with Dakin's moistened kerlix and covered with a dry dressing fixed with tape daily on every shift.
Physician's orders for Resident 1, dated February 3, 2023, included an order for the resident to have the wound on her sacrum irrigated with normal saline and patted dry, exufiber ag (product used to help support a moist wound healing environment) applied to the wound bed and covered with dry dressing and tape on day shift every two days.
Physician's orders for Resident 1, dated December 2, 2022, included an order for the resident to have Skin Prep (used to form a protective film or barrier on the skin) applied to the DTI on her left heel and left open to air every day and evening shift.
Physician's orders for Resident 1, dated February 3, 2023, included an order for the resident to have the wound on her left heel cleansed with normal saline, exufiber ag applied to the wound bed, and covered with a foam dressing on day shift every two days.
Physician's orders for Resident 1, dated October 10, 2022, included an order for the resident to have Triad Hydrophilic Wound Dress Paste (helps block bacteria from contact with a wound and promotes wound healing) applied to the buttock's peri wound every shift.
A review of Treatment Administration Records (TAR) for Resident 1 for December 2022, January 2023, and February 2023 revealed that there was no documented evidence that the treatment to the resident's right flank wound was completed as ordered on December 19, 2022, evening shift; December 24, 2022, evening shift; December 25, 2022, evening shift; December 31, 2022, evening shift; January 7, 2023, daylight shift; January 13, 2023, daylight shift; January 18, 2023, evening shift; February 5, 2023, daylight shift; February 7, 2023, evening shift; February 11, 2023 daylight shift; February 12, 2023, daylight shift; February 13, 2023, evening shift; and February 17, 2023 evening shift.
There was no documented evidence that the treatment to the resident's sacrum wound was completed as ordered on December 19, 2022, evening shift; December 24, 2022, evening shift; December 25, 2022, evening shift; December 31, 2022, evening shift; January 7, 2023, day shift; January 13, 2023, day shift; January 18, 2023, evening shift; February 5, 2023, day shift; and February 11, 2023, day shift.
There was no documented evidence that the treatment to the resident's heel was completed as ordered on December 19, 2022, evening shift; December 24, 2022, evening shift; January 7, 2023, day shift; January 18, 2023, evening shift; and February 5, 2023, day shift. There was no documentation that the Triad Hydrophilic Wound Dress Paste was applied to the resident's buttocks as ordered on December 3, 2022; December 24, 2022; December 25, 2022; January 2, 2023; January 13, 2023; January 18, 2023; and February 5, 2023.
An interview with the Director of Nursing on February 20, 2023, at 3:28 p.m. confirmed that there was no documented evidence that wound treatments were completed as ordered for Resident 1 on the above dates and times.
28 Pa. Code 211.12(d)(5) Nursing services.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0725
(Tag F0725)
Could have caused harm · This affected 1 resident
Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to have sufficient nursing staff to provide showers as scheduled for three of ...
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Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to have sufficient nursing staff to provide showers as scheduled for three of 13 residents reviewed (Residents 7, 11, 13).
Findings include:
The facility's policy regarding bathing/showering, dated February 7, 2023, indicated that all residents will be provided a shower at least one time weekly.
A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 7, dated February 2, 2023, revealed that the resident was cognitively impaired and required extensive assistance from staff for personal hygiene and bathing.
Resident 7's inventory sheet, dated September 7, 2021, indicated that the resident likes to receive showers in the afternoon. Review of Resident 7's bathing records for January and February 2023 revealed that the resident received one shower in the last 30 days and four showers in the last 50 days. She had not refused any showers.
A quarterly MDS for Resident 11, dated January 9, 2023, revealed that the resident was cognitively intact and required extensive assistance from staff for personal hygiene and bathing.
Resident 11's care plan, dated June 6, 2020, revealed that the resident preferred showers twice a week on Sunday and Wednesday night shift. However, the resident's bathing records for December 2022 and January and Feburary 2023 revealed that staff provided zero showers, instead of the 23 showers he should have received during that time.
Interview with Resident 11 on February 20, 2023, at 4:30 p.m. revealed that staff did not know his shower date. He preferred showers but was not offered showers. He stated staff told him they did not have time to provide him a shower.
An admission MDS assessment for Resident 13, dated January 27, 2023, revealed that the resident was alert and oriented and dependent on staff for transfers and bathing. A bathing preference sheet, dated January 20, 2023, revealed that Resident 13 preferred to receive a shower. A review of Resident 13's bathing records for January and February 2023 revealed that she received a shower on January 27 and February 20, 2023. There was no documented evidence that she received a shower weekly on February 3 and 17, 2023.
Interview with Nurse Aide 1 on February 20, 2023, at 2:50 p.m. revealed that there was not enough staff and they did not always have time to get showers done for residents who were dependent for transfers and required two staff members.
Interview with Nurse Aide 2 on February 20, 2023, at 2:57 p.m. revealed that she is not able to get her work done, she is not able to get the resident's showers done, turning and repositioning is not always done, and the care is not quality care because staff are rushed.
Interview with the Nursing Home Administrator and Director of Nursing on February 23, 2023, at 11:34 a.m. revealed that their staff were in need of time management skills in order to get their tasks done and they were working on education for them so that staff could get their showers and other tasks done.
28 Pa. Code 201.18(e)(1) Management.
28 Pa. Code 211.12(d)(5) Nursing services.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected multiple residents
Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that dependent residents were provided with the necessary services t...
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Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that dependent residents were provided with the necessary services to maintain personal hygiene by failing to provide showers as scheduled for three of 13 residents reviewed (Residents 7, 11, 13).
Findings include:
The facility's policy regarding bathing/showering, dated February 7, 2023, indicated that all residents will be provided a shower at least one time weekly.
A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 7, dated February 2, 2023, revealed that the resident was cognitively impaired and required extensive assistance from staff for personal hygiene and bathing.
Resident 7's inventory sheet, dated September 7, 2021, indicated that the resident likes to receive showers in the afternoon. Review of Resident 7's bathing records for January and February 2023 revealed that the resident received one shower in the last 30 days and four showers in the last 50 days. She had not refused any showers.
A quarterly MDS for Resident 11, dated January 9, 2023, revealed that the resident was cognitively intact and required extensive assistance from staff for personal hygiene and bathing.
Resident 11's care plan, dated June 6, 2020, revealed that the resident preferred showers twice a week on Sunday and Wednesday night shift. However, the resident's bathing records for December 2022 and January and Feburary 2023 revealed that staff provided zero showers, instead of the 23 showers he should have received during that time.
Interview with Resident 11 on February 20, 2023, at 4:30 p.m. revealed that staff did not know his shower date. He preferred showers but was not offered showers. He stated staff told him they did not have time to provide him a shower.
An admission MDS assessment for Resident 13, dated January 27, 2023, revealed that the resident was alert and oriented and dependent on staff for transfers and bathing. A bathing preference sheet, dated January 20, 2023, revealed Resident 13 preferred to receive a shower. A review of Resident 13's bathing records for January and February 2023 revealed that she received a shower on January 27 and February 20, 2023. There was no documented evidence that she received a shower weekly on February 3 and 17, 2023.
Interview with the Director of Nursing on February 20, 2023, at 5:30 p.m. confirmed that Residents 7, 11, and 13 did not get their showers per the facility policy or resident preference.
28 Pa. Code 211.12(d)(5) Nursing services.
Dec 2022
2 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Notification of Changes
(Tag F0580)
Could have caused harm · This affected 1 resident
Based on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that the resident's representative/interested family member...
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Based on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that the resident's representative/interested family member was notified timely about changes in the resident's condition and/or physician's orders (new treatments) for one of five residents reviewed (Resident 3).
Findings include:
The facility's policy regarding resident representative notification, dated May 23, 2022, revealed that it is the policy of this facility to notify the resident's representative of any significant change in the resident's status or condition, to include but not limited to, a decline in condition, health, and unusual incident or accident. Notification of the resident's representative will occur between 7:00 a.m. and 10:00 p.m. unless the resident requires transfer/emergency medical treatment. Two attempts of notification for each significant change in the resident's status/condition will be documented in the medical record. Documentation of the notification will be completed in the electronic medical record.
A Significant Change in Condition Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 3, dated October 3, 2022, revealed that the resident was cognitively impaired. The resident's clinical record revealed that Resident Family Member 1 was listed as the resident's Power of Attorney (POA), emergency contact #1 and staff were able to release medical information to her.
A progress note for Resident 3, dated November 9, 2022, revealed that the resident's right eye had dry drainage to her eyelashes, the eye was slightly red, and the sclera (the white outer layer of the eyeball) was dark pink. The physician was made aware and a new order was received to start Gentamicin Opthalmic (antibiotic used to treat certain eye infections) drops.
A progress note for Resident 3, dated November 17, 2022, revealed that the resident was noted to have Moisture Associate Skin Damage (MASD - the general term for inflammation or skin erosion caused by prolonged exposure to a source of moisture) with two small open areas to her bilateral buttocks that were approximately 0.5 centimeter (cm) by 0.5 cm. A new order was received for the resident to receive Triad paste (a paste that contains a combination of medications to be applied to a wound) to the area. A message was sent to the wound nurse to evaluate.
There was no documented evidence that Resident 3 had instructed the facility to not contact her POA/responsible party/interested family member, and no documented evidence that Resident Family Member 1 was notified about the above changes in the resident's condition and physician's orders/new treatments.
Interview with the Assistant Director of Nursing on December 28, 2022, at 12:50 p.m. confirmed that there was no documented evidence that Resident 3 instructed the facility to not contact her responsible party and no documented evidence that the resident's responsible party was notified about the above changes in the resident's condition and physician's orders.
28 Pa. Code 211.12(d)(5) Nursing services.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Free from Abuse/Neglect
(Tag F0600)
Could have caused harm · This affected 1 resident
Based on review of policies, clinical records, and investigation documents, as well as staff interviews, it was determined that the facility failed to ensure that residents were free from abuse for on...
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Based on review of policies, clinical records, and investigation documents, as well as staff interviews, it was determined that the facility failed to ensure that residents were free from abuse for one of five residents reviewed (Resident 2).
Findings include:
The facility's abuse policy, dated May 23, 2022, indicated that no resident in the facility would be physically, verbally, mentally, or sexually abused; neglected; have their property misappropriated; suffer from corporal punishment or involuntary seclusion; or be exploited by anyone. The facility will report all alleged violations involving abuse, neglect, exploitation, or mistreatment immediately, but not later than two hours to the facility administrator, the Pennsylvania Department of Health, and the Area Agency on Aging.
A Comprehensive Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 2, dated December 25, 2022, indicated that the resident was severely cognitively impaired, required extensive assistance with daily care needs, had physical and verbal behaviors, had rejected care, and had diagnosis that included dementia.
A facility investigation document, dated December 15, 2022, at 10:25 a.m. revealed that Licensed Practical Nurse (LPN) 1 reported to the Director of Nursing that he slapped Resident 2 on the left cheek. LPN1 was immediately escorted from the facility and placed on unpaid leave pending an investigation. The alleged abuse was reported to the resident's physician and family, and further investigation was initiated. The investigation also revealed that Resident 2 was not a credible witness and when assessed, did not recall the event.
A written statement from LPN 1, dated December 15, 2022, revealed that on December 15, 2022, he entered Resident 2's room to administer medication. LPN 1 asked the resident if she would take her medicine and she opened her mouth and accepted one half of the medication. She stated that she hated it, and LPN 1 asked the resident if she would accept the rest of her medication. He administered the rest of the medication and Resident 2 spit the medication into his face. As a knee jerk reaction, he slapped the resident lightly, without intent. LPN 1 looked at Resident 2's cheek and there was no red mark. He immediately regretted his actions and notified the Director of Nursing. The written statement also revealed that Resident 2 was scratching at staff who were present in her room at the time.
A written statement from Occupational Therapist (OT) 2, undated, revealed that on December 15, 2022, at 9:45 a.m. she was in Resident 2's room providing therapy along with Physical Therapy Assistant (PTA) 3 when LPN 1 entered the room to administer medication. OT 2 reported that the resident accepted two bites of medications that were crushed and then spit the medication out onto LPN 1 and OT 2. She turned her head away from the resident and heard a short slap noise. LPN 1 left the room and OT 2 turned to PTA 3 and confirmed with her that LPN 1 had just slapped the resident on the cheek. No redness was noted, and the resident was moved to an activity area.
A written statement from PTA 3, undated, revealed that she was in Resident 2's room assisting OT 2 with transferring the resident. The resident was sitting on the edge of the bed when LPN 1 entered the room to give medication that was crushed in pudding to the resident. LPN 1 gave a bite of medication to the resident, who stated, I don't like this, and she was using vulgar and profane words and was attempting to pinch staff who were present in the room. The resident was redirected, and LPN 1 gave the resident a second bite of medication. Resident 2 spit the medication out onto LPN 1, OT 2, and PTA 3. LPN 1 reacted with an open-hand slap across the resident's cheek that was audible. LPN 1 left the room, and OT 2 and PTA 3 reported the event to the Director of Nursing.
A review of education records for the facility revealed that LPN 1 received training on Preventing, Recognizing and Reporting Abuse on December 12, 2022, training on Dementia Care and Resident's Rights on October 2, 2022, and training on the Elder Justice Act on March 24, 2022.
An interview with the Assistant Director of Nursing on December 28, 2022, at 1:00 p.m. confirmed that on December 15, 2022, LPN 1 reported to the Director of Nursing that he slapped Resident 2 across the cheek. LPN 1 was immediately escorted from the building and placed on unpaid leave pending results of an investigation and has not worked in the facility since the incident. An investigation was initiated, and all required agencies were notified. The facility's plan was to terminate LPN 1 from his position; however, as of December 28, 2022, LPN 1 had not been officially terminated.
42 CFR 483.13 - Resident Behavior and Facility Practices, 10-1-1998 edition.
28 Pa. Code 201.14(a) Responsibility of licensee.
28 Pa. Code 201.18(b)(e)(1) Management.
28 Pa. Code 201.29(a)(j) Resident rights.
28 Pa. Code 211.12(d)(5) Nursing services.
Oct 2022
11 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0557
(Tag F0557)
Could have caused harm · This affected 1 resident
Based on clinical record reviews, as well as observations and staff interviews, it was determined that the facility failed to enhance each resident's dignity by answering call bells timely for one of ...
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Based on clinical record reviews, as well as observations and staff interviews, it was determined that the facility failed to enhance each resident's dignity by answering call bells timely for one of 45 residents reviewed (Resident 41).
Findings include:
An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 41, dated September 19, 2022, revealed that the resident was able to make her needs known and required extensive assistance from staff for her daily care tasks. A care plan for the resident, dated September 13, 2022, revealed that she had a self-care performance deficit related to impaired balance. Staff was to encourage the resident to use the call bell to call for assistance. A care plan, dated September 19, 2022, revealed that she had limited physical mobility related to weakness.
Observations on October 27, 2022, at 11:15 a.m. revealed that the call bell light for Resident 41 was on. There were no staff in the facility's COVID unit where the resident was located. There were three staff working on the second floor unit that was adjacent to the COVID unit. Licensed Practical Nurse 3 entered the COVID unit at 12:00 p.m. and answered the resident's call bell light at that time.
Interview with Licensed Practical Nurse 3 on October 27, 2022, at 12:08 p.m. confirmed that staff on the second floor unit were responsible for answering the call bells on the COVID unit. She indicated that they carry a beeper to indicate when a resident's call bell is activated. She confirmed that her beeper showed that Resident 41's call bell had been activated but was showing the wrong time when it was activated. She indicated that the resident had dropped her charger as the reason for her placing her call bell on.
Interview with the Assistant Director of Nursing on October 27, 2022, confirmed that staff were to answer residents' call bells as soon as possible.
28 Pa. Code 201.29(j) Resident rights.
28 Pa. Code 211.12(d)(5) Nursing services.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0583
(Tag F0583)
Could have caused harm · This affected 1 resident
Based on review of clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that each resident's personal privacy was maintained for one of ...
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Based on review of clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that each resident's personal privacy was maintained for one of 49 residents reviewed (Resident 39).
Findings include:
A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 39, dated September 13, 2022, revealed that the resident was understood and could understand, and required supervision or limited assistance from staff for her daily care tasks.
Observations on the second floor on October 24, 2022, at 10:40 a.m. revealed that an unattended medication cart was sitting outside of the nursing station, across from the central bathing room. The computer screen on the cart was visible, exposing Resident 39's personal and medication information to any residents and staff who passed by it. Licensed Practical Nurse 2 returned to the medication cart at 10:42 a.m. and prepared another resident's medications.
Interview with Licensed Practical Nurse 2 on October 24, 2022, at 10:48 a.m. confirmed that she should have closed the computer screen so that Resident 39's information was not visible when she left the medication cart unattended.
Interview with the Director of Nursing on October 25, 2022, at 1:30 p.m. confirmed that when staff leave the area of the medication cart, the computer screen should be locked or minimized to prevent the residents' information from being viewed.
28 Pa. Code 201.29(j) Resident rights.
28 Pa. Code 211.5(b) Clinical records.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Assessments
(Tag F0636)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the Resident Assessment Instrument User's Manual and clinical records, as well as staff interviews, it was de...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the Resident Assessment Instrument User's Manual and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that comprehensive admission Minimum Data Set assessments were completed in the required timeframe for two of 45 residents reviewed (Residents 44, 62).
Findings include:
The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which provides instructions and guidelines for completing required Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2019, indicated that an admission MDS assessment was to be completed no later than 14 days following admission (admission date + 13 calendar days).
An admission MDS assessment for Resident 44, dated August 31, 2022, revealed that the resident was admitted to the facility on [DATE], and the resident's admission MDS assessment was dated as completed on September 8, 2022, which was 16 days after admission.
An admission MDS assessment for Resident 62, dated August 31, 2022, revealed that the resident was admitted to the facility on [DATE], and the resident's admission MDS assessment was dated as completed on September 8, 2022, which was 16 days after admission.
Interview with the Registered Nurse Assessment Coordinator (RNAC - a registered nurse who is responsible for the completion of MDS assessments) on October 27, 2022, at 9:43 a.m. and 10:05 a.m. confirmed that the admission MDS assessments for Residents 44 and 62 were completed late.
28 Pa. Code 211.5(f) Clinical records.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Assessment Accuracy
(Tag F0641)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the Resident Assessment Instrument User's Manual and clinical records, as well as staff interviews, it was de...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the Resident Assessment Instrument User's Manual and clinical records, as well as staff interviews, it was determined that the facility failed to complete accurate comprehensive Minimum Data Set assessments for four of 45 residents reviewed (Residents 36, 54, 62, 69).
Findings include:
The Resident Assessment Instrument (RAI) User's Manual, which gives instructions for completing Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated [DATE], indicated that Section P0200B was to capture the use of chair alarms and P0200E was to capture the use of wander/elopement alarms. The sections were to be coded zero (0) for not used, one (1) for used less than daily, or two (2) for used daily.
Current physician's orders for Resident 36, included orders for the resident to use a wanderguard alarm and chair alarm. Resident 36's Treatment Administration Records (TAR) for [DATE] indicated that the resident used a wanderguard alarm and chair alarm from [DATE] through 31, 2022. A quarterly MDS assessment for Resident 36, dated [DATE], revealed that Section P0200B and P0200E were coded with a zero (0), indicating that the resident did not use a wanderguard alarm or chair alarm.
The RAI User's Manual, dated [DATE], indicated that Section O0100 was to capture a resident's special treatments, procedures, and programs. Section O0100H was to be coded for receiving IV (intravenous) medications. Column (1) was to be checked if IV medications were received while not a resident of the facility within the last 14 days, and column (2) was to be checked if IV medications were received while a resident of the facility within the last 14 days.
Physician's orders for Resident 54, dated [DATE], included an order for the resident to receive 600 milligrams (mg) of Zyvox (antibiotic) Solution intravenously every 12 hours for 14 days for a urinary tract infection. The resident's Medication Administration Records (MAR's) for [DATE] indicated that the resident received Zyvox intravenously from [DATE]-27, 2022. A quarterly MDS assessment for Resident 54, dated [DATE], revealed that Section O0100H, Column 2, was not checked to indicate that the resident received an IV medication during the 14-day assessment period.
Interview with the Registered Nurse Assessment Coordinator (RNAC - a registered nurse who is responsible for the completion of MDS assessments) on [DATE], at 10:18 a.m. confirmed that the above MDS assessments for Residents 36 and 54 were not accurate.
The RAI User's Manual, dated October, 2019, indicated that Section C of the MDS was to be completed for each resident to identify his/her cognitive status. Section C0100 was to be coded No (0) or Yes (1) depending on whether a Brief Interview for Mental Status (BIMS) should be attempted with the resident and coded in Sections C0200 through C0500. The instructions for determining if a BIMS interview should be attempted indicated that if the resident was at least sometimes understood (verbally or in writing) then the BIMS interview was to be attempted with the resident. If the resident was rarely/never understood, then the BIMS interview was not to be attempted, and a Staff Assessment of Mental Status was to be completed instead and coded in Sections C0600 through C1000. The RAI User's Manual also indicated that if a resident did not answer a question, then the question should be coded as a zero for an incorrect answer. If there were no responses, or the responses were nonsensical, then the BIMS interview was to be stopped after Section C0300 (day of the week), a dash was to be coded in the remaining sections of the individual interview, a (99) was to be entered in Section C0500, and then a Staff Assessment of Mental Status was to be completed instead and coded in Sections C0600 through C1000.
A quarterly MDS assessment for Resident 62, dated [DATE], revealed that Sections C0200 through C0400 were all coded with a zero (0), indicating that the resident did not answer or answered incorrectly. Section C0600 (asking whether the staff assessment for mental status should be completed) was coded (0) No, and the Staff Assessment of Mental Status (Sections C0700 through C1000) was not completed.
Interview with the Social Worker (who was responsible for completing Section C of the MDS) on [DATE], at 2:49 p.m. confirmed that Resident 62 was unable to complete the BIMS interview due to not answering questions C0200 to C0300. She indicated that she was aware that the resident was nonverbal and unable to be understood and that the Staff Assessment was to be completed if the resident's responses were nonsensical or if the resident did not answer, and that it was a clerical error as C0600 was coded (0) no.
The RAI User's Manual revealed that Section A2100 was to capture the discharge status of the resident by checking the appropriate type of discharge from the facility from the types listed, (1) home/community, (2) another nursing home or swing bed, (3) acute hospital, (4) psychiatric hospital, (5) inpatient rehabilitation facility, (6) ID/DD facility, (7) hospice, (8) deceased , (9) long term care hospital, and (99) other.
A nursing note for Resident 69, dated [DATE], indicated that the resident was discharged from the facility and that he planned to stay at his niece's house that evening.
A discharge tracking MDS for Resident 69, dated [DATE], revealed that section A2100 (discharge status) indicated (3) that he was discharged to an acute care hospital.
Interview with the Assistant Director of Nursing on [DATE] confirmed that Resident 69's MDS was coded incorrectly for [DATE], and that it should have been coded (1) as a discharge to home.
28 Pa. Code 211.5(f) Clinical records.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Pressure Ulcer Prevention
(Tag F0686)
Could have caused harm · This affected 1 resident
Based on clinical record reviews, observations, and staff interviews, it was determined that the facility failed to ensure that treatments for pressure ulcers were provided as ordered by the physician...
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Based on clinical record reviews, observations, and staff interviews, it was determined that the facility failed to ensure that treatments for pressure ulcers were provided as ordered by the physician for one of 45 residents reviewed (Resident 62).
Findings include:
A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 62, dated October 5, 2022, indicated that the resident was severely cognitively impaired, had no speech, required extensive assistance with bed mobility, did not ambulate (walk) during the review period, required extensive assistance for transfers, and had a Stage 4 pressure ulcer (wound caused by pressure). A care plan for Resident 62, created on October 12, 2022, revealed that the resident had a deep tissue injury (DTI-a serious type of pressure injury that begins in the muscle closest to the bone) on the left heel related to immobility.
A therapy progress note for Resident 62, dated September 14, 2022, indicated that the resident was seen for skilled services for passive range of motion of the bilateral lower extremities to improve positioning, to decrease the risk of skin break down and contracture (deformity and rigidity of joints). Physician's order for Resident 62, dated September 14, 2022, indicated that the resident was to wear Posey boots (pressure-relieving foam boots to help prevent heel and toe ulcers) on both feet when in bed, as tolerated, and skin checks were to be performed every shift. Physician's orders for Resident 62, dated October 12, 2022, included an order for skin prep (protective wipe) to be applied to the heels twice a day, leave open to the air.
A nursing note for Resident 62, dated October 12, 2022, revealed that the resident was assessed by a registered nurse regarding an area that was found on the left heel and that foam boots were already in place as ordered. A wound note, dated October 12, 2022, indicated that Resident 62 had a new DTI and orders were in place to treat. The resident has been ordered bilateral Posey boots to assist with pressure off loading. The resident was non-verbal with a flat affect (no facial expressions).
Observations on October 26, 2022, at 4:01 p.m. revealed that Resident 62 was lying in bed and her heels were not elevated. The resident's left heel was in direct contact with the mattress and her right heel was crossed over the top of the left ankle. Resident 62's Posey boots were on the chair beside the bed.
Interview with Licensed Practical Nurse 7 on October 26, 2022, at 4:03 p.m. confirmed that Resident 62 was not wearing her Posey boots as ordered and did not know why.
Interview with the Director of Nursing on October 27, 2022, at 11:19 a.m. and 11:34 a.m. confirmed that Resident 62 should have been wearing her Posey boots while in bed, that there was no documented evidence to indicate that she was not tolerating the boots, and that the left heel should have been elevated off the mattress.
28 Pa. Code 211.12(d)(1)(5) Nursing services
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected 1 resident
Based on review of clinical records and interviews with staff, it was determined that the facility failed to maintain clinical records that were complete for one of 45 residents reviewed (Resident 27)...
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Based on review of clinical records and interviews with staff, it was determined that the facility failed to maintain clinical records that were complete for one of 45 residents reviewed (Resident 27).
Findings include:
An admission Minimum Data Set (MDS) assessment (mandated assessment of a resident's abilities and care needs) for Resident 27, dated August 23, 2022, revealed that the resident was understood and could understand, required extensive assistance for all care, and had a diagnosis of diabetes (a group of diseases that result in too much sugar in the blood). A care plan for the resident, dated August 25, 2021, indicated that the resident had diabetes and that staff were to administer medications as ordered by the physician.
Physician's orders for Resident 27, dated October 6, 2022, included an order for the resident to receive 13 units of Insulin Glargine (a long-acting type of insulin) one time per day. If the blood sugar level was less than 100 milligram/ deciliter (mg/dL) staff were to administer six units of Insulin Glargine. The order was discontinued on October 19, 2022.
Physician's orders for Resident 27, dated October 19, 2022, included an order for the resident to receive 14 units of Insulin Glargine one time per day. If the blood sugar level was less than 100 milligram/deciliter (mg/dL) then staff were to administer seven units of Insulin Glargine.
Resident 27's Medication Administration Records (MARs) for October 2022 revealed that on October 15, 2022, the blood sugar level was documented as 89 mg/dL; on October 18, 2022, the blood sugar level was documented as 99 mg/dL; on October 20, 2022, the blood sugar level was documented as 93 mg/dL; and on October 25, 2022, the blood sugar level was documented as 91 mg/dL. The Insulin Glargine was signed as given; however, there was no documented evidence in Resident 27's clinical record to indicate the amount of Insulin Glargine that was given on the above dates.
Interview with the Director of Nursing on October 26, 2022, at 12:30 p.m. and on October 27, 2022, at 9:00 a.m. confirmed that there was no documented evidence in Resident 27's clinical record to indicate the amount of Insulin that was administered on the above dates.
28 Pa. Code 211.5(f) Clinical records.
28 Pa. Code 211.12(d)(5) Nursing services.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0885
(Tag F0885)
Could have caused harm · This affected 1 resident
Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that residents and/or the resident's responsible parties were notifi...
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Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that residents and/or the resident's responsible parties were notified about positive COVID-19 laboratory test results.
Findings include:
The facility's policy regarding notification, dated May 23, 2022, indicated that the facility would notify the resident representative of any significant change in resident status/condition and it would be documented in the medical record of the notification.
A diagnosis record for Resident 25, dated October 21, 2022, included the diagnosis of COVID-19. A nursing note for Resident 25, dated October 21, 2022, revealed that during routine testing the resident tested positive for COVID-19. A care plan for the resident, dated October 21, 2022, indicated that the family was to be notified of the suspected infection.
There was no documented evidence that the resident and/or the resident's responsible parties were notified of the positive COVID-19 laboratory test results for the resident on the above date or by 5:00 p.m. the following day.
Interview with the Assistant Director of Nursing on October 27, 2022, at 2:33 p.m. confirmed that there was no documented evidence that the family was notified of the positive COVID results and that they should have been notified. She further indicated that notification should be documented and/or if the resident does not want anyone else notified.
An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 70, dated October 19, 2022, revealed that the resident was understood, could understand, and required extensive assistance from staff for her daily care tasks. A care plan for the resident, dated October 21, 2022, revealed that if the resident was positive for COVID-19, staff were to notify the physician, Medical Director, Director of Nursing, Infection Preventionist, and family of the suspected infection.
A nursing note for Resident 70, dated October 21, 2022, revealed that during routine outbreak testing, the resident tested positive for COVID-19. The resident was notified that it would be necessary to move her to the Red Zone due to her positive COVID status. Resident 70 was agreeable and the physician was notified of the positive results.
There was no documented evidence that the resident's responsible parties were notified of the positive COVID-19 laboratory test results for the resident on the above date or by 5:00 p.m. the following day.
Interview with the Assistant Director of Nursing/Infection Preventionist on October 27, 2022, at 2:35 p.m. confirmed that there was no documented evidence that the resident and/or the residents' responsible parties were notified of the positive COVID-19 laboratory test results on the above dates or by 5:00 p.m. the following day.
28 Pa. Code 201.14(a) Responsibility of licensee.
28 Pa. Code 201.18(e)(1)(2)(3) Management.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected multiple residents
Based on facility policy and clinical record reviews, as well as observations and staff interviews, it was determined that the facility failed to ensure that weekly wound assessments were completed fo...
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Based on facility policy and clinical record reviews, as well as observations and staff interviews, it was determined that the facility failed to ensure that weekly wound assessments were completed for one of 45 residents reviewed (Resident 13).
Findings include:
A facility policy regarding wound care, dated July 18, 2022, indicated that the wound care coordinator would be responsible for completing weekly evaluations, measurements, and descriptive information on all pressure, vascular, arterial, stasis, eviscerated, dehisced incision, and diabetic ulcers. All other wounds and changes in skin conditions will be assessed by the registered nurse and communicated to the physician for appropriate treatment.
A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 13, dated August 3, 2022, indicated that the resident was cognitively intact, required extensive assistance with all care, was at risk for pressure ulcers, was occasionally incontinent of urine, and always incontinent of stool. A care plan for Resident 13, dated August 7, 2018, revealed that the resident had an active buttock wound. Physician's orders for Resident 13, dated March 12, 2022, indicated that the resident was to be provided wound care to the right buttock with an application of nystatin zinc compound cream (used to treat fungal infection and diaper rash) covered with non-adherent pads every evening and as need for dislodgement.
A nursing note for Resident 13, dated September 2, 2022, indicated that a skin and wound assessment was completed and that treatment and monitoring would continue.
Interview with Resident 13 on October 24, 2022, at 12:13 p.m. revealed that there was still a wound that was being treated with a patch.
Observations of Resident 13's wound care by the Licensed Practical Wound Nurse on October 26, 2022, at 3:43 p.m. revealed that the resident currently had two open areas on the right buttocks.
There was no documented evidence in the clinical record that weekly wound assessments were completed on Resident 13 after September 2, 2022.
Interview with the Director of Nursing (DON) on October 26, 2022, at 2:50 p.m. confirmed that there was no documented evidence that wound assessments were completed on Resident 13 after September 2, 2022, and that the Certified Registered Nurse Practitioner (CRNP-a registered nurse with advanced training who can diagnose and treat patients) was responsible for overseeing the Licensed Practical Wound Nurse.
Interview with Licensed Practical Wound Nurse on October 27, 2022, at 11:27 a.m. revealed that Resident 13 has chronic issues on the buttocks with moisture-associated skin damage that open and close frequently and that the weekly wound assessments were completed. However, the assessments were not documented due to having to juggle the tasks of being the restorative nurse and the wound nurse.
28 Pa. Code 211.12(d)(1)(5) Nursing services
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected multiple residents
Based on a review of facility policies, manufacturer's directions, and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that medicat...
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Based on a review of facility policies, manufacturer's directions, and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that medications were properly labeled and dated in one of the three medications carts (third floor short hall), and failed to label two multi-dose vials of Tubersol solution with the date they were opened in one of two medication rooms reviewed (Second floor).
Findings include:
The facility's policy for medication administration (vials, ampules and pens of injectable medications), dated May 23, 2022, indicated that after removing an insulin pen from the refrigerator for the first use, indicate both the first date used and the expiration date. The clinical drug information instructions for a Breo Illipta inhaler (used to treat chronic obstructive respiratory disease), dated 2022, indicated that once opened to throw away any part not used after six weeks or when the indicator reads zero, whichever comes first. The clinical drug information instructions for Fluticasone/Salmeterol (Advair Diskus) inhalation powder, dated 2022, indicated that the inhaler should be thrown away when the counter dose reaches zero, one month after opening the pouch, or after the expiration date, whichever comes first. The clinical drug information instructions for Insulin Glargine (long acting insulin), dated 2022, indicated that after the first use, store at room temperatures for up to 28 days and throw away any part not used after 28 days. The clinical drug information instructions for insulin Aspart (short acting insulin), dated 2022, indicated that after opening, throw away any part not used after 28 days.
Observations of the third floor short hall medication cart on October 25, 2022, between 1:01 p.m. and 1:33 p.m. revealed an undated Breo Illipta inhaler for Resident 19 and an undated Breo Illipta inhaler for Resident 59, an undated Fluticasone/Salmeterol (Advair diskus) inhaler (used to treat asthma- shortness of breath/wheezing) for Resident 30, a Wixela 110/50 inhaler (used to treat asthma- shortness of breath/wheezing) without a resident's name on it, an undated Glargine insulin pen for Resident 69, and an undated Aspart insulin pen for Resident 69.
Interview with Licensed Practical Nurse 1 on October 25, 2022, at 1:33 p.m. confirmed that the medications listed were in use and that the items were not dated when opened and should have been. She further indicated that she was unaware of who was receiving the Wixela and that it should have been labeled with the resident's name and date of when it was opened.
Interview with the Director of Nursing on October 25, 2022, at 2:23 p.m. confirmed that medications should be labeled with the resident's name and that all multidose medications should be labeled with a date when opened.
The manufacturer's instructions for Tubersol (a solution injected under the skin to test for tuberculosis - a lung infection) indicated that after opening, throw away any part not used after 30 days.
Observations of the Second Floor medication room refrigerator on October 26, 2022, at 8:31 a.m. revealed a container with two opened and undated multi-dose vials of Tubersol solution. Interview with Licensed Practical Nurse 2 at the time of observation confirmed that the vials should have been dated with the date they were opened.
28 Pa. Code 211.9(h) Pharmacy services.
28 Pa. Code 211.12(d)(1)Nursing services.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected multiple residents
Based on review of policies, as well as observations and staff interviews, it was determined that the facility failed to store food in accordance with professional standards of food service safety by ...
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Based on review of policies, as well as observations and staff interviews, it was determined that the facility failed to store food in accordance with professional standards of food service safety by failing to properly seal, label and date refrigerated foods.
Findings include:
The facility's policy regarding food storage, dated July 18, 2022, revealed that date marking was a system that assisted in identifying when food was prepared/received and when it was to be used/discarded. All food was to be date marked and labeled upon receipt when a commercially prepared item was opened (milk, cheese, etc.), when purchased foods were removed from their original container or packaging, and when leftovers were stored.
Observations in the reach-in refrigerator on October 24, 2022, at 8:31 a.m. revealed that there was a package of provolone cheese and American cheese slices that were open to air and not dated or labeled, and a package containing sliced turkey, a package containing bologna, and two peanut butter and jelly sandwiches wrapped in cellophane that were not labeled or dated.
Interview with the Dietary Director on October 24, 2022, at 8:31 a.m. confirmed that all food in the refrigerators were to be labeled and dated.
28 Pa. Code 211.6(f) Dietary services.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected multiple residents
Based on review of established infection control guidelines, the facility's policies and documents, and residents' clinical records, as well as observations and staff interviews, it was determined tha...
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Based on review of established infection control guidelines, the facility's policies and documents, and residents' clinical records, as well as observations and staff interviews, it was determined that the facility failed to follow infection control guidelines from the Centers for Medicare/Medicaid Services (CMS), the Centers for Disease Control (CDC), and the Pennsylvania Department of Health (PA DOH) to reduce the spread of infections and prevent cross-contamination during the COVID-19 pandemic, failed to ensure that appropriate signage was posted for a resident with special infection control isolation needs for one of 45 residents reviewed (Resident 13), and failed to use proper infection control practices during incontinent care for two of 45 residents reviewed (Residents 15, 22).
Findings include:
Pennsylvania Health Alert Network (PAHAN)-663 regarding Interim Infection Prevention and Control Recommendations for Healthcare Settings during the COVID-19 Pandemic, dated October 4, 2022, revealed Implement Source Control Measures: Source control refers to use of respirators or well-fitting facemasks or cloth masks to cover a person's mouth and nose to prevent spread of respiratory secretions when they are breathing, talking, sneezing, or coughing. People, particularly those at high risk for severe illness, should wear the most protective form of source control they can that fits well and that they will wear consistently. Source control options for Healthcare Professional (HCP) include National Institute for Occupational Safety and Health (NIOSH) -approved particulate respirator with N95 filters or higher; a respirator approved under standards used in other countries that are similar to NIOSH-approved N95 filtering facepiece respirators (note: these should not be used instead of a NIOSH-approved respirator when respiratory protection is indicated); a barrier face covering that meets ASTM F3502-21 requirements including Workplace Performance and Workplace Performance Plus masks; or a well-fitting facemask. When used solely for source control, any of the options listed above could be used for an entire shift unless they become soiled, damaged or hard to breathe through. If they are used during the care of a patient for which a NIOSH-approved respirator or facemask is indicated for personal protective equipment (PPE) (e.g., NIOSH-approved N95 or equivalent or higher-level respirator during the care of a patient with SARS-CoV-2 infection, facemask during a surgical procedure or during care of a patient on Droplet Precautions), they should be removed using proper doffing technique and discarded after the patient care encounter and a new one should be donned. When SARS-CoV-2 Community Transmission levels are high, source control is recommended for everyone (e.g. staff, patients, visitors, etc.) in a healthcare setting when they are in areas of the healthcare facility where they could encounter patients. Personal Protective Equipment: HCP who enter the room of a patient with suspected or confirmed SARS-CoV-2 infection should adhere to Standard Precautions and use a NIOSH-approved N95 or equivalent or higher-level respirator, gown, gloves, and eye protection (i.e., goggles or a face shield that covers the front and sides of the face). This is also known as Transmission-based Precautions for COVID-19.
The facility's policy regarding COVID-19 Response Plan, dated May 23, 2022, revealed that staff were to be educated on the proper use of PPE and application of standard, contact, droplet, and airborne precautions, including eye protection. Red Zone (COVID Care Unit) - Use standard and transmission based precautions. A N95 mask, gowns, gloves, and eye protection or face shield must be worn.
Interview with the Nursing Home Administrator and Director of Nursing on October 24, 2022, at 8:30 a.m. revealed that a portion of the second floor had COVID-positive residents and that it was designated as the facility's Red Zone. The Nursing Home Administrator and Director of Nursing confirmed that staff in the Red Zone were to wear N95 masks, eye protection, and gowns.
Observations on the Second Floor on October 27, 2022, at 9:45 a.m. revealed a sign indicating that the area was a Red Zone. A sign on the double doors indicated that staff were to don a gown, a N95 mask, an ear-looped mask, goggles or face shield, and gloves.
Observations in the Red Zone on October 27, 2022, at 10:38 a.m. revealed that Laundry Worker 4 entered the Second Floor Red Zone wearing only a surgical mask and a gown while delivering laundry into the resident rooms. Interview at the time of observation revealed that she was not aware if she needed to wear goggles or a face shield. She indicated that she could not find another mask other than the the surgical mask that she was wearing.
Interview with the Assistant Director of Nursing on October 27, 2022, at 2:35 p.m. confirmed that staff should have been wearing goggles/face shield and a N95 mask when in the Red Zone.
The facility's policy regarding care of residents with a multidrug resistant organism (MDRO), dated May 23, 2022, revealed that a sign would be placed at the entrance of the known infected resident's room instructing people to stop at the nurse's station before entering.
A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 13, dated August 3, 2022, indicated that the resident was cognitively intact and required extensive assistance of one staff person for bed mobility and transfers. The resident's care plan, revised January 27, 2022, indicated that the resident was to have contact isolation due to a buttock wound with methicillin-resistant Staphylococcus aureus (MRSA - multidrug resistant organism). Physician's orders for Resident 13, dated March 7, 2022, included an order to apply nystatin/zinc compound cream to the right buttock wound and cover with non-adherent pads every evening. An interview with Resident 13 on October 24, 2022, at 12:13 p.m., confirmed that he still had an open area on his buttocks and currently received treatment.
Observations of wound care for Resident 13, on October 26, 2022, at 3:43 p.m. revealed that the resident had two open areas on the right buttock. Observations of the resident's room on October 24, 2022, at 12:13 p.m.; October 26, 2022, at 8:50 a.m.; and October 27, 2022, at 1:40 p.m. revealed that there was no sign at the entrance of the room to stop at the nurses' station.
Interview with the Assistance Director of Nursing/Infection Preventionist on October 27, 2022, at 10:40 a.m. indicated that she was unaware that Resident 13's chronic wound was open again, and that there should be a green circle dot on the name plate outside of the room to inform staff that the resident was on transmission precautions, and that there should also be a sign instructing people to stop at the nurses' station.
The facility's policy regarding hand hygiene, dated May 23, 2022, indicated that hand hygiene (whether or not gloves were worn) was to be performed after contact with body fluids, mucous membranes, secretions, or excretions.
An annual Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 22, dated August 12, 2022, indicated that the resident was cognitively intact, required the extensive assistance of one staff for toileting, that she was always incontinent of urine, and was on a diuretic medication. The resident's care plan, dated September 18, 2021, indicated that the resident's peri-area was to be cleaned with each incontinent episode.
Observations on October 24, 2022, at 11:30 a.m. revealed that Resident 22 activated the call bell, and stated, I always go after I take my water pill. The resident had been incontinent of urine and at 11:32 a.m., Nurse Aide 6 donned gloves and cleaned the resident, then applied a new brief without removing her gloves and performing hand hygiene. Nurse Aide 6 did not remove her gloves until she was finished providing care and had removed the trash bag.
A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 15, dated August 2, 2022, indicated that the resident was severly cognitively impaired, required the extensive assistance of one staff for toileting, and that she was always incontinent of urine and stool. The resident's care plan, dated February 5, 2021, indicated that the resident's peri-area was to be cleaned with each incontinent episode
Observations of Resident 15 on October 24, 2022 at 11:41 a.m. revealed that the resident had been incontinent of bowel. Nurse Aide 6 donned gloves and cleaned the resident, then applied a new brief without removing her gloves and performing hand hygiene. Nurse Aide 6 did not remove her gloves until she had finished providing care and had removed the trash bag.
Upon interview with Nurse Aide 6 on October 24, 2022, at 11:51 a.m. she indicated that she should have changed gloves and completed hand hygiene between dirty and clean tasks for Resident 15 and 22.
Interview with the Assistance Director of Nursing/Infection Preventionist on October 25. 2022, at 3:01 p.m. confirmed that hand hygiene and glove changes should have been completed after providing incontinent care and before placing clean briefs on Residents 15 and 22.
28 Pa. Code 211.12(d)(1)(5) Nursing services.
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated
K - Pattern
L - Widespread
Actual Harm
G - Isolated
H - Pattern
I - Widespread
Potential for Harm
D - Isolated
E - Pattern
F - Widespread
No Harm (Minor)
A - Isolated
B - Pattern
C - Widespread
Questions to Ask on Your Visit
- "What changes have you made since the serious inspection findings?"
- "Why is there high staff turnover? How do you retain staff?"
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • Licensed and certified facility. Meets minimum state requirements.
Concerns
- • Multiple safety concerns identified: 1 life-threatening violation(s), Special Focus Facility, 3 harm violation(s), $106,485 in fines. Review inspection reports carefully.
- • 131 deficiencies on record, including 1 critical (life-threatening) violation. These warrant careful review before choosing this facility.
- • $106,485 in fines. Extremely high, among the most fined facilities in Pennsylvania. Major compliance failures.
- • Grade F (0/100). Below average facility with significant concerns.
Bottom line: This facility is on CMS's Special Focus list for poor performance. Consider alternatives strongly.
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About This Facility
What is Midtown Oaks Health & Rehab Center's CMS Rating?
MIDTOWN OAKS HEALTH & REHAB CENTER does not currently have a CMS star rating on record.
How is Midtown Oaks Health & Rehab Center Staffed?
Staff turnover is 57%, which is 11 percentage points above the Pennsylvania average of 46%. High turnover can affect care consistency as new staff learn residents' individual needs. RN turnover specifically is 72%, which is notably high. RNs provide skilled clinical oversight, so turnover in this role can affect medical care quality.
What Have Inspectors Found at Midtown Oaks Health & Rehab Center?
State health inspectors documented 131 deficiencies at MIDTOWN OAKS HEALTH & REHAB CENTER during 2022 to 2025. These included: 1 Immediate Jeopardy (the most serious level, indicating potential for serious harm or death), 3 that caused actual resident harm, 126 with potential for harm, and 1 minor or isolated issues. Immediate Jeopardy findings are rare and represent the most serious regulatory concerns. They require immediate corrective action.
Who Owns and Operates Midtown Oaks Health & Rehab Center?
MIDTOWN OAKS HEALTH & REHAB CENTER is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility is operated by SABER HEALTHCARE GROUP, a chain that manages multiple nursing homes. With 120 certified beds and approximately 95 residents (about 79% occupancy), it is a mid-sized facility located in ALTOONA, Pennsylvania.
How Does Midtown Oaks Health & Rehab Center Compare to Other Pennsylvania Nursing Homes?
Compared to the 100 nursing homes in Pennsylvania, MIDTOWN OAKS HEALTH & REHAB CENTER's staff turnover (57%) is significantly higher than the state average of 46%.
What Should Families Ask When Visiting Midtown Oaks Health & Rehab Center?
Based on this facility's data, families visiting should ask: "What changes have been made since the serious inspection findings, and how are you preventing similar issues?" "How do you ensure continuity of care given staff turnover, and what is your staff retention strategy?" "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" These questions are particularly relevant given the facility's Immediate Jeopardy citations and the facility's high staff turnover rate.
Is Midtown Oaks Health & Rehab Center Safe?
Based on CMS inspection data, MIDTOWN OAKS HEALTH & REHAB CENTER has documented safety concerns. Inspectors have issued 1 Immediate Jeopardy citation (the most serious violation level indicating risk of serious injury or death). The facility is currently on the Special Focus Facility watch list (a federal program monitoring the lowest-performing 1% of nursing homes nationwide). The facility has a 0-star overall rating and ranks #100 of 100 nursing homes in Pennsylvania. Families considering this facility should ask detailed questions about what corrective actions have been taken since these incidents.
Do Nurses at Midtown Oaks Health & Rehab Center Stick Around?
Staff turnover at MIDTOWN OAKS HEALTH & REHAB CENTER is high. At 57%, the facility is 11 percentage points above the Pennsylvania average of 46%. Registered Nurse turnover is particularly concerning at 72%. RNs handle complex medical decisions and coordinate care — frequent RN changes can directly impact care quality. High turnover means new staff may not know residents' individual needs, medications, or preferences. It can also be disorienting for residents, especially those with dementia who rely on familiar faces. Families should ask: What is causing the turnover? What retention programs are in place? How do you ensure care continuity during staff transitions?
Was Midtown Oaks Health & Rehab Center Ever Fined?
MIDTOWN OAKS HEALTH & REHAB CENTER has been fined $106,485 across 3 penalty actions. This is 3.1x the Pennsylvania average of $34,144. Fines at this level are uncommon and typically indicate a pattern of serious deficiencies, repeated violations, or failure to correct problems promptly. CMS reserves penalties of this magnitude for facilities that pose significant, documented risk to resident health or safety. Families should request specific documentation of what issues led to these fines and what systemic changes have been implemented.
Is Midtown Oaks Health & Rehab Center on Any Federal Watch List?
MIDTOWN OAKS HEALTH & REHAB CENTER is currently on the Special Focus Facility (SFF) watch list. This federal program identifies the roughly 1% of nursing homes nationally with the most serious and persistent quality problems. SFF facilities receive inspections roughly twice as often as typical nursing homes. Factors in this facility's record include 1 Immediate Jeopardy finding and $106,485 in federal fines. Facilities that fail to improve face escalating consequences, potentially including termination from Medicare and Medicaid. Families considering this facility should ask for documentation of recent improvements and what specific changes have been made since the designation.